Carcinoma of the laryngeal margin

Open Partial Laryngectomies: History of Laryngeal Cancer Surgery

Historically, surgery was the first-choice therapy for early, intermediate and advanced laryngeal squamous cell carcinoma (LSCC). Partial laryngeal surgery has evolved in recent decades and was influenced by many historic events and the development of new technologies. Partial laryngectomies may be performed by open, endoscopic or transoral robotic approaches. In this historic paper, we describe the evolution of open partial laryngectomy techniques, indications and surgical outcomes. Since the first partial laryngectomy in 1788, many U.S., U.K. and European surgeons, including Henry Sands, Jacob da Silva Solis-Cohen and Theodor Billroth, performed this surgical procedure under local anesthesia for tuberculosis, cancer or syphilis. Partial laryngectomy gained reputation in the medical community in 1888 due to the laryngeal cancer and death of the prince of Prussia, Frederick III. Frederick III’s death represented the turning point in the history of partial laryngectomies, calling attention to the importance of semiotics, biopsy and early diagnosis in laryngeal cancers. Hemi-laryngectomy was indicated/proposed for lateral laryngeal tumors, while thyrotomy was indicated for cancers of the middle part of the vocal fold. The second landmark in the history of partial laryngectomies was the discovery of cocaine, novocaine and adrenaline and the related development of local anesthetic techniques, which, together with the epidemiological and hygienic advances of the 19th century, allowed for better perioperative outcomes. General anesthesia was introduced in the second part of the 20th century and further improved the surgical outcomes. The diagnosis of laryngeal cancer was improved with the development of X-rays and direct laryngoscopies. The 20th century was characterized by the development and improvement of vertical partial laryngectomy procedures and the development of horizontal partial laryngectomies for both supraglottic and glottic regions. The history and the evolution of these techniques are discussed in the present historical paper.

Platin-based exclusive chemotherapy for selected patients with squamous cell carcinoma of the larynx and pharynx

BACKGROUND

The current study was conducted to determine the long-term outcomes of patients with squamous cell carcinoma of the larynx and pharynx who were treated with platin-based exclusive chemotherapy (EC) after they achieved a complete clinical response (CCR) to induction chemotherapy.

METHODS

One hundred forty-two who achieved a CCR after platin-based induction chemotherapy were treated exclusively with additional chemotherapy, and 98.6% were followed for a minimum of 3 years or until death. Thirty-five patients had >10 years of follow-up.

RESULTS

The survival rates at 1 year and 5 years were 95.8% and 61.2%, respectively. The main causes of death were metachronous second primary tumors (n = 27) and intercurrent disease (n = 21). Death related to EC was not encountered, and only 2 patients (1.4%) had grade 4 toxicity. In multivariate analysis, primary tumor arising outside the glottic larynx (P = .0001) and a Charlson comorbidity index >1 (P = .0001) were associated with a statistically significant reduction in survival. The 1-year and 5-year Kaplan-Meier local control estimates were 76.1% and 50.7%, respectively. Salvage treatment resulted in an observed final local control rate of 93% that varied from 97.2% in patients who had glottic cancer to 88.7% in patients who had tumor originating from other sites (P = .097). Combined chemotherapy with cisplatin and 5-fluorouracil (PF) allowed for the successful modulation of local therapy in 54.9% of patients.

CONCLUSIONS

For selected patients, EC may provide long-term, durable disease control. For patients who developed recurrent disease after EC, this approach did not diminish survival and maintained function in the majority of patients. Future work should be directed toward select markers of response to PF chemotherapy with which to identify those patients who are suited optimally for this approach.

Supraglottic hemipharyngolaryngectomy for the treatment of T1 and T2 carcinomas of laryngeal margin and piriform sinus

BACKGROUND

We evaluated the functional and oncologic results of supraglottic hemipharyngolaryngectomy as treatment for T1 and T2 lateral laryngeal margin and piriform sinus carcinomas.

METHODS

Eighty-seven patients underwent this surgical treatment. The disease was classified T1 in 14 of these cases (16.1%) and T2 in 73 cases (83.9%). The nodal status indicated 39 cases of N0 (44.8%), 18 cases of N1 (20.7%), 28 cases of N2 (32.2%), and two cases of N3 (2.2%). With regard to the N0 cases, 15 (38.4%) were positive at the histologic examination. Within the N+ group, 52.1% involved capsular rupture.

RESULTS

Two patients died of complications during the postoperative period. The mean duration of nasogastric tube feeding was 20 days. Six patients (7.27%) had feeding resumption problems. All patients were decanulated after a mean period of 16 days. All patients underwent postoperative radiation therapy, except two with T1N0N- disease and three who had previously undergone this treatment. The 5-year actuarial survival rate was 60.3% (T1, 83.3%; T2, 49.9%). The rates of local and regional recurrence, second primary cancer, and metastasis were 19.5%, 24.1%, and 28.1%, respectively. The infringement of the pharyngoepiglottic fold was significantly correlated with locoregional recurrence. The survival rate was significantly correlated with the nodal status and extracapsular spread.

CONCLUSIONS

Initial staged cancers of the laryngeal margin and piriform sinus can be successfully managed with conservative surgery called supraglottic hemipharyngolaryngectomy combined with nodal neck dissection. Postoperative radiation therapy is still recommended in most cases because of the high recurrence potential and prevalence of secondary regional cancers. This combined treatment seems to be a suitable therapeutic choice in the treatment of patients with T1 and T2 carcinomas of the laryngeal margins and piriform sinus.

Lateral supraglottic pharyngo-laryngectomy with arytenoidectomy

BACKGROUND

Supraglottic laryngectomy for tumors of the epilarynx requiring arytenoid cartilage resection is frequently associated with problems in relearning to swallow, and aspiration is frequent. We propose a surgical procedure in which a local flap is used to close the pharyngeal defect.

METHODS

An apron skin incision is used to expose the hyoid bone and strap muscles. The median raphe is opened, and the hyoid bone is cut along the midline and released on its posterior surface. The thyrohyoid and stemothyroid muscles ipsilateral to the tumor are separated, with the perichondrium from the thyroid cartilage. This forms a continuous flap that includes the suprahyoid muscles and hemihyoid bone, together with the strap muscles and thyroid lobe that will be used for closure.

RESULTS

Thirty-three patients with T1-T3 carcinomas of the laryngeal margin, with extension to one arytenoid in all cases and to the pyriform fossa in 14, underwent this procedure. Only 5/33 (15%) patients had locoregional recurrences. Visceral metastases occurred in 11/33 (33%) patients, and second primary tumors were diagnosed at the time of surgery or during follow-up in 9/33 (27%) patients. Three-year and 5-year actuarial survival rates were 57% and 51%, respectively. Despite the need for radiotherapy in 26 patients, functional success was obtained in 26/33 cases (79%).

CONCLUSION

This technique provided good tumor control and a high rate of satisfactory functional results. It can be applied to patients with tumors of the lateral margin which unilaterally extend to the aryepiglottic fold, the arytenoid, and the medial well of the pyriform fossa.

Topographic classification, clinical characteristics, and diagnostic delay of cancer of the larynx/hypopharynx in Torino, Italy

The case series of a population-based case-control study of laryngeal and hypopharyngeal cancers in Torino, Italy, included 281 men with clinical and anamnestic data. Two hundred fifteen, 28, and 38 cancers originated from the endolarynx, epilarynx, and hypopharynx, respectively. Regions invaded by the tumor were divided into 26 subsites. A classification based on the number of invaded subsites was proposed, which agreed well with the T classification of the TNM system. Cancers originating from the hypopharynx invaded more subsites than cancers from the endolarynx, and among the latter, supraglottic were more invasive than glottic lesions. The number of invaded subsites was strongly associated with nodal involvement. Among symptoms at onset of disease and at diagnosis, patients with endolaryngeal lesions reported dysphonia and dyspnea more frequently, and patients with lesions from other regions had a higher prevalence of dysphagia, odynophagia, otalgia, and adenopathia. Clinical and epidemiologic results of this study suggest considering the endolarynx, epilarynx, and hypopharynx as separate anatomic entities. Diagnostic delay was not associated with tumor size and showed a negative trend with involvement of cervical lymph nodes, suggesting that stage at diagnosis is due to intrinsic differences in tumor aggressiveness.

Supracricoid hemilaryngopharyngectomy. Analysis of 240 cases

The supracricoid hemilaryngopharyngectomy consists of resection of the supracricoid hemilarynx and ipsilateral pyriform sinus. Two hundred forty patients underwent this procedure from 1964 through 1983. Two hundred twenty-two patients had no airway impairment, and 204 recovered normal deglutition. The local recurrence rate was 5.2%. Indications for the procedure are carcinoma of the supracricoid upper part of the pyriform sinus and carcinoma of the lateral laryngeal margin with normal vocal cord mobility.