Rationale behind thyroidectomy in total laryngectomy: analysis of endocrine insufficiency and oncological outcomes

Extent of thyroidectomy and paratracheal lymph node dissection in total pharyngolaryngectomy for pyriform sinus cancer, and recurrence, survival, and postoperative hypoparathyroidism: A multicenter retrospective study

BACKGROUND

Total pharyngolaryngectomy (TPL) is standard treatment for hypopharyngeal cancer. However, extensive thyroidectomy and paratracheal nodal dissection (PTND) can cause hypoparathyroidism. We sought to determine the optimum extent of resection.

METHODS

We analyzed the clinicopathological information of 161 pyriform sinus cancer patients undergoing TPL from 25 Japanese institutions. Rates of recurrence and risk factors for hypoparathyroidism, as well as incidence of pathological contralateral level VI nodal metastasis and stomal recurrence, were investigated.

RESULTS

The extent of thyroidectomy and nodal dissection were not independent risk factors for recurrence. Incidences of contralateral level VI nodal involvement and stomal recurrence were 1.8% and 1.2%, respectively. Patients undergoing hemithyroidectomy/ipsilateral PTND did not develop stomal recurrence and had the lowest incidence of hypoparathyroidism. Prognosis in patients without tracheostomy prior to hemithyroidectomy/ipsilateral PTND was comparable to that with more extensive resections.

CONCLUSIONS

Hemithyroidectomy/ipsilateral PTND may be sufficient for pyriform sinus cancer cases without tracheostomy.

Incidence of Post Total Laryngectomy Hypothyroidism: Effects of Thyroid Gland Surgery and Post-Operative Radiotherapy

To record the incidence of hypothyroidism in patients after total laryngectomy, whether with or without postoperative radiation therapy and to analyze the effect of hemithyroidectomy for the development of hypothyroidism. A retrospective study included patients who underwent total laryngectomy (with or without hemithyroidectomy) between 2018 and 2021 for laryngeal carcinoma and/or received postoperative radiotherapy. Thirty-six (45%) of the 80 enrolled patients developed hypothyroidism after a median follow-up of 16 months. In this study, adjuvant radiation and central neck dissection were found to be significantly linked with developing post-operative hypothyroidism (p values: 0.001, 0.007, respectively). The incidence of hypothyroidism in patients treated for laryngeal carcinoma is high, especially after combination treatment of surgery and radiotherapy.

Intraoperative Autofluorescence Imaging for Parathyroid Gland Identification during Total Laryngectomy with Thyroidectomy

OBJECTIVE

Hypoparathyroidism is a known complication of total laryngectomy, although parathyroid preservation and/or reimplantation are not routine. Autofluorescence is a new technique for identifying parathyroid glands intraoperatively. The aim of this study was to evaluate the feasibility of autofluorescence in this context.

MATERIALS AND METHODS

A retrospective study of patients undergoing total laryngectomy/pharyngectomy with concomitant thyroidectomy using the Fluobeam^® (Fluoptics, Grenoble, France) and frozen section of a parathyroid fragment in case of reimplantation. The rates of identification using autofluorescence, reimplantation, and hypoparathyroidism were evaluated.

RESULTS

Eighteen patients (16 males, median age 67) underwent total laryngectomy/pharyngectomy with total thyroidectomy (n = 12) or hemithyroidectomy (n = 6). A median of 2 parathyroid glands were identified per patient. Ninety-two percent were identified by autofluorescence before visualisation. All parathyroids were reimplanted due to devascularization. Temporary hypoparathyroidism occurred in nine patients, and was permanent in one patient. After 34 months of median follow-up (range 1-49), no tumor recurrence was observed in the reimplantation sites.

CONCLUSIONS

To our knowledge, this is the largest study to evaluate autofluorescence during total laryngectomy with thyroidectomy. No tumor recurrence occurred in the sites of parathyroid reimplantation.

[Overview of thyroid gland involvement and its prognostic value on advanced laryngeal cancer]

Laryngeal cancer is the second most common malignancy in the head and neck region. The guidelines recommend prophylactic thyroidectomy for patients with advanced laryngeal cancer, but its prognostic value remains elusive. In this review, the incidence, risk factors, prognostic value of thyroid invasion in patients with laryngeal cancer were reviewed. The effect of prophylactic thyroidectomy on the outcome of advanced laryngeal cancer patients was also discussed.

Frequency of Thyroid Gland Invasion by Laryngeal Squamous Cell Carcinoma: The Role of Subglottic Extension

Introduction  Management of the thyroid gland during laryngectomy has been controversial. The primary tumor may invade the thyroid gland by direct invasion or lymphovascular spread. Hypothyroidism and hypoparathyroidism are potential risks when lobectomy or total thyroidectomy are performed simultaneously.

Objective  To report the frequency of thyroid gland involvement by primary laryngeal squamous cell carcinoma in patients undergoing laryngectomy and to identify possible risk factors for thyroid gland involvement so that judicious excision of thyroid gland can be attained.

Methods  We performed a retrospective review of 9 years. Data was collected from medical records of patients dated from December 2009 to October 2018. All patients with laryngeal cancer who underwent laryngectomy with lobectomy or total thyroidectomy were included in the present study.

Results  We reviewed 151 laryngectomy records. A total of 130 surgeries included the thyroid gland with the excised specimen and were available for analysis. There were 124 males and 6 females. The mean age was 59.4 years old. The glottis was the most common subsite involved, in 70 patients, followed by 38 transglottic, 16 supraglottic and 03 subglottic tumors. On histology, 12 out of 130 excised thyroid glands were involved by squamous cell carcinoma. Only subglottic involvement ( p  = 0.01) was significantly associated with thyroid gland invasion (TGI). Type of laryngectomy, subsite of the primary tumor, thyroid cartilage involvement, neck nodal metastases, and perineural and lymphatic invasion by the primary tumor were not associated with TGI.

Conclusion  Only subglottic involvement is associated with TGI; therefore, preoperative and intraoperative assessment is necessary prior to considering excision of the thyroid gland.

Routine thyroidectomy with total laryngectomy: Is it really indicated? A randomized controlled trial

Background

We investigated the incidence of thyroid gland invasion in patients with advanced laryngeal carcinoma who were treated with total laryngectomy, also the impact of different preoperative and intraoperative predictors on thyroid gland invasion. Moreover, the impact of thyroid gland preservation on the locoregional tumor control and the recurrence rates after surgery were investigated.

Materials and methods

This study was conducted over 5 years on 100 patients with advanced laryngeal carcinoma who underwent total laryngectomy. The adopted protocol in our hospital is to perform an ipsilateral thyroid lobectomy if there is subglottic extension, thyroid or cricoid cartilage invasion or true invasion of the thyroid gland. The patients of the study were divided into thyroid sparing and thyroid sacrificing groups. The two groups were compared in terms of demographic data, tumor characteristics, incidence of postoperative hypothyroidism and tumor recurrence.

Results

There was no significant difference between groups regarding the tumor profile. Regarding local tumor spread, the only two subsites that showed significant difference is anterior commissure and thyroid cartilage invasion. In the thyroid sacrificing group, invasion of the thyroid gland was proved histopathologically in only one patient. Postoperatively, the incidence of hypothyroidism was significantly higher in the thyroid sacrificing group. However, there was no statistically significant difference between the two groups regarding the incidence of tumor recurrence.

Conclusion

The incidence of thyroid gland invasion by an advanced laryngeal carcinoma is low. Preservation of the thyroid gland during laryngectomy to reduce the risk of thyroid dysfunction does not affect the oncological control.

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Thyroid gland invasion incidence in advanced laryngeal carcinoma is low.

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Thyroid gland Preservation during laryngectomy does not affect the oncological control.

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There was no statistically significant difference between the thyroid sparing and thyroid sacrificing group regarding the incidence of recurrence. Due toding author”. Due toding author".

Hypocalcaemia in pharyngolaryngectomy: Preservation or autotransplantation of parathyroid glands

OBJECTIVE

To describe transient and permanent hypocalcaemia following partial and total pharyngolaryngectomy with parathyroid gland preservation or autotransplantation.

METHODS

Thirty patients underwent partial or total pharyngolaryngectomy by a single surgeon during the period 2009-2020. Intraoperative parathyroid gland preservation or autotransplantation (where the gland appeared devascularized) was routinely performed. Calcium levels performed on day 1, 3 months, and at 12 months postoperatively were collected. Rates of transient and permanent hypocalcaemia were calculated.

RESULTS

A total of 13% of patients had transient hypocalcaemia, and 10% permanent hypocalcaemia. Rates of transient and permanent hypocalcaemia in total pharyngolaryngectomy were 14% and 14%, respectively. Partial pharyngectomy hypocalcaemia rates were 13% for transient and 0% for permanent. The majority of patients underwent salvage surgery for oncological resection, often following radiotherapy (63%). Ipsilateral hemithyroidectomy was preferred to total (57% vs 7%), with high rates of concurrent neck dissection (67%) and reconstruction (87%).

CONCLUSION

This data supports preservation or autotransplantation of parathyroid glands as a means of reducing permanent postoperative hypocalcaemia.

LEVEL OF EVIDENCE

Level IV, case series, retrospective.

The prognostic value of thyroid gland invasion in locally advanced laryngeal cancers

BACKGROUND

Locally advanced laryngeal cancers can spread to the thyroid gland by direct invasion of cricothyroid membrane. The prevalence of thyroid gland invasion (TGI) and the predictive factors of TGI were well described in literature. However, the association of TGI with survival was undetermined yet.

OBJECTIVES

The aim of this study is to analyze the effects of TGI on survival rates in patients with locally advanced laryngeal cancer.

MATERIALS AND METHODS

Medical records of 91 patients who underwent total laryngectomy with thyroidectomy were retrospectively reviewed. Demographical, clinical, and histopathological characteristics of the patients were noted. Kaplan-Meier test was used for survival analysis.

RESULTS

Histopathology reports revealed the prevalence of TGI as 14.3% (13/91). Survival analyses showed that TGI did not affect recurrence free (p = .078) and overall (p = .080) survival rates.

CONCLUSIONS

Thyroid gland invasion is one of the characteristic features of locally aggressive laryngeal tumors. In this study, TGI is not a statistically significant prognostic factor that has impact on survival of the patients with locally advanced laryngeal cancer.

Incidence of thyroid gland invasion in advanced laryngeal cancers and its impact on disease-specific survival; a retrospective review at a tertiary care center

Background: Incidence of thyroid gland invasion in advanced laryngeal cancers is low. Ipsilateral or total thyroidectomy along with total laryngectomy has been controversial and there has been no consensus over the management of thyroid gland in advanced laryngeal cancers.Objective: To determine the frequency of thyroid gland invasion in locally advanced laryngeal squamous cell carcinoma and the risk factors associated with it.Material and methods: A retrospective review of patients with laryngeal squamous cell carcinoma operated at our center between January 2011 and December 2018 was carried out. Patients undergoing upfront or salvage laryngectomy with or without neck dissection along with hemi or total thyroidectomy were included. Histopathology reports were reviewed to record the involvement of thyroid gland.Results: Invasion of thyroid gland by squamous cell carcinoma larynx was seen in 10 (10.9%) patients out of 92. All of the cases showed direct extension of the tumor. Trans-glottic, subglottic, and tumors with extra laryngeal spread were found to be significantly associated with thyroid gland invasion. Patients with thyroid gland invasion showed higher rate recurrence.Conclusion and significance: Incidence of thyroid gland invasion in squamous cell carcinoma larynx is low, allowing us not to address thyroid routinely in patients undergoing total laryngectomy for laryngeal carcinoma.

Systematic review of incidence, risk factors, prevention and treatment of post-laryngectomy hypoparathyroidism

Purpose

Post-laryngectomy hypoparathyroidism is associated with significant short- and long-term morbidities. This systematic review aimed to determine incidence, risk factors, prevention and treatment of post-laryngectomy hypoparathyroidism.

Methods

Medline, EMBASE and the Cochrane library were searched for relevant articles on hypocalcaemia and/or hypoparathyroidism after laryngectomy or pharyngectomy. Two authors independently screened titles and abstracts from the search. Data from individual studies were collated and presented (without meta-analysis). Quality assessment of included studies was undertaken. The review protocol was registered in the PROSPERO database (CRD42019133879).

Results

Twenty-three observational studies were included. The rates of transient and long-term hypoparathyroidism following laryngectomy with concomitant hemi- or total thyroidectomy ranged from 5.6 to 57.1% (n = 13 studies) and 0 to 12.8% (n = 5 studies), respectively. Higher transient (62.1–100%) and long-term (12.5–91.6%) rates were reported in patients who had concomitant oesophagectomy and total thyroidectomy (n = 4 studies). Other risk factors included bilateral selective lateral neck dissection, salvage laryngectomy and total pharyngectomy. There is a lack of data on prevention and management.

Conclusion

Hypoparathyroidism occurs in a significant number of patients after laryngectomy. Patients who underwent laryngectomy with concomitant hemithyroidectomy may still develop hypoparathyroidism. Research on prevention and treatment is lacking and needs to be encouraged.