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Alsup NA, Farsi S, Blevins SK, Giese R, King D, Sunde J, Vural E, Moreno M. Elective Neck Dissection in Patients Undergoing Salvage Laryngectomy: Outcomes, Complications, and Considerations. Cureus 2024; 16:e60222. [PMID: 38868267 PMCID: PMC11168787 DOI: 10.7759/cureus.60222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2024] [Indexed: 06/14/2024] Open
Abstract
Objective In this study, we sought to identify the predictors for occult nodal disease (OND) and compare oncologic outcomes in patients undergoing elective neck dissection (END) at the time of salvage laryngectomy (SLE) versus the observation group. Methods A retrospective chart review was conducted involving all patients with clinically node-negative (cN0) necks who underwent SLE at a tertiary academic center over 12 years. A total of 58 patients met the inclusion criteria and were divided into two groups: END (n=39) and observation (n=19). Primary endpoints were OND, regional recurrence-free survival (RRFS), and disease-specific survival (DSS). Univariate analysis was performed to establish the association between variables with Fisher's exact test and Mann-Whitney U test. Survival analysis was performed with the log-rank test. Results The cohort comprised 46 (79.3%) males and 12 (20.7%) females, with a mean age of 60 years. Pathological nodal disease was identified in five of 71 (7%) examined neck dissection specimens, with positive nodes found in levels II through IV. The only statistically significant predictor of OND was the rT3/rT4 stage (p=0.017). There were no differences in perioperative complications, RRFS (p=0.216), or DSS (p=0.298) between the END and observation groups. Conclusions In cN0 necks, the advanced recurrent T-stage (rT3-rT4) is a predictor for OND. As OND was found involving levels II, III, and IV in this study's specimens, formal lateral neck dissection should be the procedure of choice if END is to be performed alongside SLE. While END did not show a significantly higher morbidity profile versus conservative management in this cohort, the procedure did not improve loco-regional control or survival, even when stratifying by tumor stage.
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Affiliation(s)
- Nickolas A Alsup
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Soroush Farsi
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Sydney K Blevins
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Rachel Giese
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Deanne King
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Jumin Sunde
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Emre Vural
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Mauricio Moreno
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
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Pujol A, León X, Holgado A, Valero C, Kolanczak K, Quer M, Virós D. External validation of the GETTEC algorithm for elective neck dissection in patients candidates for salvage total laryngectomy. Oral Oncol 2024; 149:106686. [PMID: 38218021 DOI: 10.1016/j.oraloncology.2024.106686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/06/2024] [Accepted: 01/07/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVE To perform an external validation of the algorithm for elective treatment of the lymph node areas proposed by GETTEC for patients candidates to salvage total laryngectomy after radiotherapy. This algorithm is based on the initial lymph node status, local extension of the recurrence and time to recurrence. MATERIAL AND METHODS Retrospective study performed in 151 patients treated with salvage total laryngectomy without clinical or radiological evidence of regional involvement at the time of diagnosis of recurrence (rcN0). The percentage of patients with occult lymph node metastases was calculated according to the algorithm proposed by GETTEC. RESULTS A total of 14.6 % (n = 22) of the patients had occult lymph node metastases. Patients with locally advanced recurrences (rcT4) had a higher risk of occult lymph node metastases. There were no significant differences in the risk of occult lymph node metastases according to initial lymph node status or time to recurrence. When applying the algorithm proposed by GETTEC, there were no significant differences in the percentage of occult lymph node metastases between the group of patients who were candidates for follow-up (14.4 %) and those candidates for elective neck dissection (14.9 %) (P = 0.940). According to our results, patients who were candidates for an elective neck dissection were those with tumors located in the supraglottis or rcT4 glottic tumors. CONCLUSION Our results do not validate the algorithm proposed by GETTEC for the management of the lymph nodes in rcN0 patients who are candidates for salvage total laryngectomy after radiotherapy.
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Affiliation(s)
- Albert Pujol
- Otorhinolaryngology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier León
- Otorhinolaryngology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain; UVIC. Universitat Central de Catalunya, Vic, Spain.
| | - Anna Holgado
- Otorhinolaryngology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Valero
- Otorhinolaryngology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Katarzyna Kolanczak
- Otorhinolaryngology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miquel Quer
- Otorhinolaryngology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain
| | - David Virós
- Otorhinolaryngology Department, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain
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Šifrer R, Strojan P, Tancer I, Dolenc M, Fugina S, Zore SB, Aničin A. The Incidence and the Risk Factors for Pharyngocutaneous Fistula following Primary and Salvage Total Laryngectomy. Cancers (Basel) 2023; 15:cancers15082246. [PMID: 37190174 DOI: 10.3390/cancers15082246] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/26/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
The pharyngocutaneous fistula (PCF) is the most common complication following a total laryngectomy (TL) with a wide range of incidence and various potential risk factors. The aim was to analyse the incidence and potential risk factors for PCF formation in a large study set collected over a longer period of time. In the retrospective study at the Department of Otorhinolaryngology and Cervicofacial Surgery of Ljubljana, 422 patients who were treated for head and neck cancer by TL between 2007 and 2020 were included. The comprehensive clinicopathologic data were collected including potential risk factors related to the patient, disease, surgical treatment and post-operative period for the development of fistulae. The patients were categorized into a group with the fistula (a study group) and one without it (a control group). The PCF then developed in 23.9% of patients. The incidence following a primary TL was 20.8% and 32.7% following salvage TL (p = 0.012). The results demonstrated that surgical wound infection, piriform sinus invasion, salvage TL, and total radiation dose were determined as independent risk factors for PCF formation. A diminishing surgical wound infection rate would contribute to a further reduction of the PCF rate.
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Affiliation(s)
- Robert Šifrer
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Primož Strojan
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- Department of Radiation Oncology, Institute of Oncology, Zaloška 2, 1000 Ljubljana, Slovenia
| | - Ivana Tancer
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia
| | - Maja Dolenc
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia
| | - Simon Fugina
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia
| | - Sara Bitenc Zore
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia
| | - Aleksandar Aničin
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
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Gross JH, Patel MR, Switchenko JM, Chan TG, Baddour HM, Kaka A, Boyce BJ, Saba NF, Beitler JJ, El-Deiry M. Oncologic Outcomes After Clinically Node-Negative Salvage Laryngectomy. JAMA Otolaryngol Head Neck Surg 2023; 149:24-33. [PMID: 36394866 PMCID: PMC9673019 DOI: 10.1001/jamaoto.2022.3597] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/20/2022] [Indexed: 11/19/2022]
Abstract
Importance Controversy exists regarding management of the clinically node-negative neck in patients with recurrent larynx or hypopharynx cancers who received total laryngectomy after definitive radiation with or without chemotherapy. Objective To explore clinical and oncologic outcomes after elective neck dissection vs observation in patients who received clinically node-negative salvage total laryngectomy. Design, Setting, and Participants This cohort study was performed from January 2009 to June 2021 at a single, high-volume tertiary care center. Follow-up was conducted through June 2021 for all patients. Survival outcomes were based on at least 2 years of follow-up. Patients aged 18 years or older with recurrent, clinically node-negative larynx or hypopharynx tumors after definitive nonsurgical treatment who were treated with a salvage total laryngectomy were included. Data were analyzed from October 2021 through September 2022. Exposures Elective neck dissection. Main Outcomes and Measures Presence and location of occult nodal metastasis in electively dissected necks, along with differences in fistula rates and overall and disease-free survival between patients receiving elective neck dissection vs observation. Results Among 107 patients receiving clinically node-negative salvage total laryngectomy (median [IQR] age, 65.0 [57.8-71.3] years; 91 [85.0%] men), 81 patients underwent elective neck dissection (75.7%) and 26 patients underwent observation (24.3%). Among patients with elective neck dissection, 13 patients had occult nodal positivity (16.0%). Recurrent supraglottic (4 of 20 patients [20.0%]) or advanced T classification (ie, T3-T4; 12 of 61 patients [19.7%]) had an occult nodal positivity rate of 20% or more, and positive nodes were most likely to occur in levels II and III (II: 6 of 67 patients [9.0%]; III: 6 of 65 patients [9.2%]; VI: 3 of 44 patients [6.8%]; IV: 3 of 62 patients [4.8%]; V: 0 of 4 patients; I: 0 of 18 patients). There was a large difference in fistula rate between elective neck dissection (12 patients [14.8%]) and observed (8 patients [30.8%]) groups (difference, 16.0 percentage points; 95% CI, -3.4 to 35.3 percentage points), while the difference in fistula rate was negligible between 50 patients undergoing regional or free flap reconstruction (10 patients [20.0%]) vs 57 patients undergoing primary closure (10 patients [17.5%]) (difference, 2.5 percentage points; 95% CI, -12.4 to 17.3 percentage points). Undergoing elective neck dissection was not associated with a clinically meaningful improvement in overall or disease-free survival compared with observation. Recurrent hypopharynx subsite was associated with an increased risk of death (hazard ratio, 4.28; 95% CI, 1.81 to 10.09) and distant recurrence (hazard ratio, 7.94; 95% CI, 2.07 to 30.48) compared with glottic subsite. Conclusions and Relevance In this cohort study, patients with recurrent supraglottic or advanced T classification tumors had an increased occult nodal positivity rate, elective neck dissection was not associated with survival, and patients with recurrent hypopharynx subsite were more likely to have a distant recurrence and die of their disease. These findings suggest that underlying disease pathology rather than surgical management may be associated with survival outcomes in this population.
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Affiliation(s)
- Jennifer H. Gross
- Department of Otolaryngology–Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mihir R. Patel
- Department of Otolaryngology–Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey M. Switchenko
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Tyler G. Chan
- Emory University School of Medicine, Atlanta, Georgia
| | - H. M. Baddour
- Department of Otolaryngology–Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Azeem Kaka
- Department of Otolaryngology–Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Brian J. Boyce
- Department of Otolaryngology–Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nabil F. Saba
- Department of Otolaryngology–Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jonathan J. Beitler
- Department of Otolaryngology–Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mark El-Deiry
- Department of Otolaryngology–Head and Neck Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Wong SNS, Lau FTY, Chung JCK, Tsang RKY. Retrospective Review on Role of Neck Dissection in Laryngectomy of Patients With N0 Laryngeal Carcinoma. OTO Open 2022; 6:2473974X221127903. [PMID: 36171806 PMCID: PMC9511344 DOI: 10.1177/2473974x221127903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/04/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives The primary objective is to evaluate the incidence of occult nodal metastasis in patients undergoing total laryngectomy with cN0 disease. Other objectives are to compare the survival between different treatments of the neck, identify possible associated risk factors, and evaluate the effectiveness of elective neck dissection in this population with regards to oncological outcomes. Study Design Retrospective review. Setting Tertiary hospitals in Hong Kong. Methods Retrospective study was performed on patients who underwent total laryngectomy from 2008 to 2017 in New Territories West and Hong Kong West Clusters of the Hospital Authority of Hong Kong as primary or salvage treatment for cN0 squamous cell carcinoma (SCC) of the larynx. Incidence of neck dissection, incidence of nodal involvement, possible predictors, and oncological outcomes were analyzed. Results Seventy-seven patients were included, of whom 61 underwent either ipsilateral or bilateral neck dissection. Most (90.1%) of the patients with total laryngectomy done had locally advanced disease. Overall occult nodal metastasis rate was 20.6%, and only 3.8% of them had contralateral nodal metastasis. Occult nodal metastasis was significantly less in salvage laryngectomy (P = .045), while midline involvement and pT3/4 disease seem to be predictors for contralateral nodal metastasis. Conclusion There is significantly lower incidence of occult nodal metastasis in cN0 laryngeal SCC in the salvage setting, and occult contralateral nodal metastasis is not common in the cohort. Neck dissection during a salvage laryngectomy for cN0 disease could be avoided while contralateral neck dissection might be considered in cases of locally advanced disease with midline involvement.
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Affiliation(s)
- Stephanie Nga-sze Wong
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR
| | - Felix Tak-yin Lau
- Department of Otolaryngology, Yan Chai Hospital, Tsuen Wan, Hong Kong SAR
| | - Joseph Chun Kit Chung
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR
| | - Raymond King-yin Tsang
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR
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Long-term olfactory dysfunction following coronavirus disease 2019 infection, routine neck dissection at salvage laryngectomy, parotid incidentalomas, and prescribing intranasal steroids in HIV infection. The Journal of Laryngology & Otology 2021; 135:753-754. [PMID: 34448688 DOI: 10.1017/s0022215121002218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Kumari A, Rao NP, Patnaik U, Malik V, Tevatia MS, Thakur S, Jaydevan J, Saxena P. Management outcomes of mucormycosis in COVID-19 patients: A preliminary report from a tertiary care hospital. Med J Armed Forces India 2021; 77:S289-S295. [PMID: 34334896 PMCID: PMC8313063 DOI: 10.1016/j.mjafi.2021.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/05/2021] [Indexed: 12/13/2022] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) continues to be a significant health problem worldwide. The unprecedented surge of mucormycosis in patients with COVID-19 is a new emerging challenge. Although a few studies documenting high incidence of mucormycosis in COVID -19 patients have recently emerged in literature, data pertaining to treatment outcomes in such cohorts is lacking. Here, we report our experience in management of mucormycosis in COVID-19 patients at our tertiary care centre. Method The clinical, imaging, histopathological and treatment data of 20 patients with mucormycosis (in setting of COVID-19) was analysed. Results 35% and 65 % of cases developed mucormycosis in setting of active and recovered COVID-19 infections respectively. Diabetes mellitus was documented in 80% cases, with 55% demonstrating HbA1c >10%. Steroid was administered in 80% during COVID-19 illness. Imaging demonstrated paranasal sinus (PNS), orbital and intracranial extension in 100%, 55% and 20% patients respectively. All received amphotericin and underwent endoscopic debridement, 20% underwent orbital decompression and 5% maxillectomy with orbital exenteration. 6/20(30%) patients died (4 with rhino-orbito-cerebral disease, 1 with extensive orbito-maxillary involvement and 1 sino-nasal disease). All 6 patients received steroids and documented poor glycaemic control. Conclusion The strong association of hyperglycemia and steroid intake with mucormycosis in COVID-19 cases warrants judicious use of corticosteroids and optimal glycaemic control. Our study highlights that good clinical outcome can be achieved in invasive mucormycosis provided prompt treatment is instituted with aggressive surgical debridement and antifungal medication.
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Affiliation(s)
- Abha Kumari
- Classified Specialist (ENT), Command Hospital (Southern Command), Pune, India
| | | | - Uma Patnaik
- Senior Advisor & Head (ENT), Command Hospital (Southern Command), Pune, India
| | - Virender Malik
- Classified Specialist (Imaging & Intervention Radiology), Army Institute of Cardio Thoraicic Sciences, Pune, India
| | | | - Shivali Thakur
- Graded Specialist (ENT), Command Hospital (Southern Command), Pune, India
| | - Jijesh Jaydevan
- Resident (ENT), Command Hospital (Southern Command), Pune, India
| | - Pavitra Saxena
- Resident (ENT), Command Hospital (Southern Command), Pune, India
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Mucormycosis-A serious threat in the COVID-19 pandemic? J Infect 2021; 83:237-279. [PMID: 34029629 PMCID: PMC8139429 DOI: 10.1016/j.jinf.2021.05.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 12/14/2022]
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