The role of partial laryngeal resection in current management of laryngeal cancer: a collective review

Current Status of Partial Laryngeal Surgery for Advanced Laryngeal Cancer: When and Why?

PURPOSE OF REVIEW

This paper aims to evaluate the evolution and current status of partial laryngeal surgery in the treatment of advanced laryngeal cancer (LC). Specifically, recent progress in the selection of both patients and tumors, together with surgical and rehabilitation innovations, have contributed to balancing oncological control with the maintenance of quality of life in naïve and radiorecurrent patients. The main aspect is represented by the recognized role of open partial horizontal laryngectomies (OPHLs) in this new era of laryngeal cancer treatment.

RECENT FINDINGS

Recent advancements highlight OPHLs' efficacy for conservative management of intermediate to advanced stages of LC. Innovations such as supratracheal partial laryngectomy have expanded surgical options, offering a modular approach to complex cases. Improved understanding of tumor biology, enhanced imaging techniques, and more precise preoperative planning have led to better patient outcomes, emphasizing the importance of a conservative function-preserving surgical treatment. These advancements reflect a broader trend towards individualized treatment plans that prioritize both survival and quality of life. OPHLs play an important role in current management of intermediate/advanced LC, effectively balancing oncological control with the preservation of laryngeal functions. Critical factors include meticulous patient and tumor selection, the impact of surgical and technological refinements on functional outcomes, and the necessity of a multidisciplinary approach in treatment planning. Current evidence justifies the use of these interventions in many intermediate T-stage laryngeal tumors, even at risk of upstaging on pathological examination. The oncological results, the preservation of laryngeal function and the laryngectomy-free survival achieved with OPHLs appear to be highly competitive with those of non surgical organ-preservation protocols, aiming to introduce a new standard in the LC treatment.

Frozen Section Evaluation for Surgical Margins in Laryngeal Squamous Cell Carcinoma: Is it a Reliable Method for Partial and Total Laryngectomies?

BACKGROUND

In this study, we aimed to compare the accuracy of frozen section evaluation in partial and total laryngectomies performed to treat laryngeal squamous cell carcinoma .

METHODS

A retrospective study was conducted to evaluate the efficacy and accuracy of frozen section analysis for laryngeal squamous cell carcinoma of 65 patients, operated at a tertiary hospital. Two groups were recruited according to the surgical procedure.

RESULTS

The sensitivity and specificity of frozen section diagnosis in laryngeal cancer were 20% and 99.73%, respectively. For partial laryngectomy, the sensitivity was 16.66% and specificity was 100%. For total laryngectomy, sensitivity was 22.2% and specificity 99.13%. Discordances between the initial frozen section diagnosis and the subsequent permanent section diagnosis were found in 13 (3.35%) pairs (3.37% partial laryngectomy and 3.33% total laryngectomy).

CONCLUSION

Our study shows that the surgical method applied has no effect on discordances. However, sampling errors are likely to be more common in partial laryngectomy procedures. It should be kept in mind that the sensitivity of frozen section evaluation is low.

Risk of Recurrence in Laryngeal Cancer

A cohort study was undertaken to analyze the risk of recurrence among 1616 patients with primary squamous cell carcinoma of the larynx from 1983 to 2010 at a single, tertiary academic center in Oslo, Norway. The cohort was followed from the date of diagnosis to September 2011. Competing risk regression analysis assessed the association between various risk factors and the risk of recurrence, where death was considered a competing event. Recurrence was observed in 368 patients (23%) during the study period. The majority (71%) of recurrences involved the location of the primary tumor. The overall risk of recurrence during the first three years after initiating treatment was 20.5%. Increased risk of recurrence was observed in patients with supraglottic cancer, younger patients, those with T2–T3 tumors and in patients treated in the earlier part of the study period. Significant factors for recurrence in glottic carcinomas were age, treatment in the earlier part of the study and T-status, whereas age was a significant factor in supraglottic cancer. N-status appeared less significant. In conclusion, follow-up of laryngeal squamous cell carcinoma should place particular emphasis on the site of the primary tumor, younger patients, cases of supraglottic cancer and T2-T4 primary tumors, especially during the first three years after treatment. More studies are needed to assess the impact of surgical versus non-surgical treatment, and eventually the significance of recurrence, for disease-specific and overall survival in cases of advanced laryngeal squamous cell carcinoma.

Laser carbon dioxide cordectomy versus open surgery in the treatment of glottic carcinoma: Our results

OBJECTIVE: To analyze oncologic results in patients with glottic cancers treated respectively, by laser CO2 or open surgery, taking into account specific-disease survival, rate of locoregional recurrences, and their salvageability.

STUDY DESIGN: Retrospective study of 198 patients treated from January 1993 to June 2002 in the department of otorhinolaryngology at a Catholic university in Rome.

METHODS: Glottic carcinoma were treated by laser CO2 cordectomy in 132 patients (group 1) and by open surgery in 66 patients (group 2). The statistical analysis was performed by Kaplan Meyer method, log rank test, and x 2 , test.

RESULTS: The log-rank test points out significant differences between the 2 groups regarding specific-disease survival; no differences were found for disease-free survival. Within group 1, 16 patients developed local failure, which was retreated in 6 cases with laser surgery; in 9 (6.8%) with total laryngectomy, only 1 case was inoperable. In this group, 10 patients (62.5%) were salvaged. Within group 2, 18 patients developed local recurrences, which was retreated in 14 (21.21%) cases with total laryngectomy; the other 4 cases were not suitable for surgery. Of these 18, 8 patients (44.5%) were salvaged.

CONCLUSIONS AND SIGNIFICANCE: Our results show significant differences between the 2 groups concerning the specific-disease survival and the salvageability of local recurrences. In fact, in group 1 we found a higher salvage rate and a lower incidence of total laryngectomy. As already suggested, laser therapy leaves the laryngeal cartilaginous framework intact, avoiding the spread of the tumor out of laryngeal organ and resulting in a more favorable oncologic outcome.

The role of primary surgical treatment in young patients with squamous cell carcinoma of the larynx: a 20-year review of 34 cases

Background

The aim of this study was to investigate the clinical patterns in young Chinese patients (less than 40 years old) with laryngeal squamous cell cancer (LSCC) and the outcome of primary open surgery.

Methods

Thirty-four young patients, with histologically confirmed LSCC between 1985 and 2005 at Qilu Hospital and Affiliated Hospital of Weifang Medical College, who underwent primary open surgery were retrospectively evaluated according to the clinical patterns in comparison with 374 non-young patients (older than 40 years). The Kaplan-Meier method was used to calculate the survival rate. The relevance of smoking, tumor location, tumor-node-metastasis (TNM) staging, lymph node involvement, tumor size, and histological differentiation to overall survival was tested by multivariate analysis.

Results

There was a significantly higher rate of smoking (p = 0.020) in the non-young patients compared to the young patients, but no significant difference was observed in alcohol consumption, tumor location, tumor size, TNM staging, lymph node metastasis, histological grade, and 5-year overall survival.

One-year survival rates were 100 %, 3-year survival rates were 79.41 %, and 5-year survival rates were 67.65 %. In the multivariate analysis, lymph node involvement (p = 0.006), tumor stage (p = 0.022), and tumor size (p = 0.004) proved to be significant predictors of overall survival.

Conclusions

The incidence of smoking was significantly higher in non-young patients compared to young patients. Primary surgery with or without radiotherapy may provide a value treatment option for young LSCC. Nodal status, tumor stage, and tumor size were the primary determinants of overall survival in multivariate analysis. These data may provide useful information for counseling and treatment planning.

Study of the Histopathologic Characteristics and Surface Morphologies of Glottic Carcinomas With Anterior Vocal Commissure Involvement

This article explores the features and the role of the anterior vocal commissure (AVC) structure and the surface morphologies of glottic carcinomas with AVC involvement to provide a reference for the selection of transoral carbon dioxide (CO2) laser surgery. A total of 31 cases of glottic carcinomas with AVC involvement from May 2012 to January 2014 were included. All patients underwent electronic laryngoscopic examinations and computed tomography scans to determine the surface morphology. After surgery, the tumor specimens were resected integrally, and axial serial sections parallel to the plane of vocal cords were taken to explore the features and possible invasion paths of the glottic carcinomas with AVC involvement. The rates of involvement of the supraglottis and subglottis were 71.4% and 14.8%, respectively, via the AVC. The involvement of the superficial layer of the unilateral or bilateral vocal cords without involvement of the vocal muscle in the AVC region (IVM) or the cartilage was present in 15 cases (48.4%). The involvement of the superficial layer of the unilateral and bilateral vocal cords occurred in 16 cases (51.6%) with the IVM in 13 cases and the involvement of the intermediate lamina of the thyroid cartilage (ITC) in 8 cases. The involvement of the ITC was associated with the involvement of the vocal muscle of the AVC region (P < 0.05). Among the pushing carcinomas, 15 of 21 (71.4%) presented with well-defined tumor mass, and 8 of 10 (80.0%) infiltrating carcinomas presented with multiple tumor nests that were often surrounded by fibrosis (P < 0.05). The AVC is an important path of invasion of subglottic in glottic carcinomas but less so for suparglottic. The Broyles' ligaments acted as a barrier against the spread of the tumors to the thyroid cartilage, but this role was obviously weaken by the involvement of the vocal muscle of the AVC region. The infiltrating carcinomas presented with multiple tumor nests in fibrous tissue. When CO2 laser microsurgery is considered as a treatment option, these facts should be kept in mind.

Different spectral hounsfield unit curve and high-energy virtual monochromatic image characteristics of squamous cell carcinoma compared with nonossified thyroid cartilage

BACKGROUND AND PURPOSE

The attenuation of normal nonossified thyroid cartilage can be similar to that of head and neck squamous cell carcinoma on CT. We compared dual-energy CT spectral Hounsfield unit attenuation characteristics of nonossified thyroid cartilage with that of squamous cell carcinoma to determine the optimal virtual monochromatic image reconstruction energy levels for distinguishing tumor from normal nonossified thyroid cartilage.

MATERIALS AND METHODS

Dual-energy CT scans from 30 patients with histopathology-proved squamous cell carcinoma at different primary sites (laryngeal and nonlaryngeal) and 10 healthy patients were evaluated. Patients were scanned with a 64-section single-source scanner with fast-kilovolt (peak) switching, and scans were reconstructed at different virtual monochromatic energy levels ranging from 40 to 140 keV. Spectral attenuation curves of tumor and nonossified thyroid cartilage were quantitatively evaluated and compared. Any part of the tumor invading the cartilage, when present, was excluded from ROI analysis to avoid cross-contamination from areas where there could be a mixture of cartilage and invading tumor.

RESULTS

Normal nonossified thyroid cartilage had a characteristic, predictable spectral attenuation curve that was different from that of tumors. The greatest difference in attenuation of nonossified cartilage compared with tumor was on virtual monochromatic images of ≥95 keV (P < .0001), with sharp contrast between the relatively high attenuation of nonossified cartilage compared with that of tumor.

CONCLUSIONS

Head and neck squamous cell carcinoma has significantly different attenuation on virtual monochromatic images of ≥95 keV, compared with nonossified thyroid cartilage.

Site-wise Differences in Adequacy of the Surgical resection Margins in Head and Neck Cancers

Adequacy of surgical resection decided by the margin status is important in attaining a good local control and better survival in Head and neck Cancers. Conventionally, a measured distance between the tumor edge and the cut edge of the specimen is taken as the margin. A margin more than 5  millimeter (mm) is considered clear, less than 5 mm is close and less than one mm is denoted as involved. The concept of this adequacy varies between the different sites and subsites in head and neck. The purpose of this paper is to review the current evidence that describes the adequacy of surgical margin status and their variability among the sites and sub-sites in the head and neck.

CO(2) laser therapy in Tis and T1 glottic cancer: indications and results

BACKGROUND

Laser cordectomy for glottic cancer is still hampered by recurrence, which is more frequent upon anterior commissure (AC) involvement. Analysis of results may be a step to improve the efficacy of this therapy for early glottic cancer.

METHODS

In all, 81 patients who underwent surgery with CO(2) laser for Tis and T1, AC0 to AC2 glottic carcinoma were followed up to 55 months.

RESULTS

The incidence of recurrence increased significantly with T and AC classifications. The disease-free interval decreased with increasing T and AC classifications and with increasing severity of histology, but only the AC classification appeared significant. Recurrences occurred in 5 of 35 patients upon type I and type II cordectomy, in 16 of 24 patients upon type V cordectomy, and never upon type III and IV cordectomy.

CONCLUSIONS

Type I to type IV cordectomy, when indicated, can achieve radical treatment of most T1 glottic cancer. Type V cordectomy requires that any suspicion of cartilage invasion, even microscopic, be excluded.

Organ preservation surgery for laryngeal cancer

The principles of management of the laryngeal cancer have evolved over the recent past with emphasis on organ preservation. These developments have paralleled technological advancements as well as refinement in the surgical technique. The surgeons are able to maintain physiological functions of larynx namely speech, respiration and swallowing without compromising the loco-regional control of cancer in comparison to the more radical treatment modalities. A large number of organ preservation surgeries are available to the surgeon; however, careful assessment of the stage of the cancer and selection of the patient is paramount to a successful outcome. A comprehensive review of various organ preservation techniques in vogue for the management of laryngeal cancer is presented.

Status of primary tumour surgical margins in squamous head and neck cancer: prognostic implications

PURPOSE OF REVIEW

To look at the current published literature on squamous-cell carcinoma of the head and neck, at the microscopic level, and the implications of molecular and genetic research.

RECENT FINDINGS

The goal of surgical treatment is still complete eradication of the primary tumour with a 'safe margin'. To achieve this 'safe margin' is not always possible, however. Currently, there is no agreed consensus as to how to submit tissue for frozen section, or how to define a 'clear margin'. Histopathologically, there are two margins requiring analysis, the mucosal margin and the 'deep margin'. Margins declared histopathologically 'tumour free' can be found to be positive for malignant/premalignant cells when molecular markers are applied. When the presence of genetically altered cells is suggested in the margins, there is an increased risk of a recurrent or new tumour. There is limited application of such knowledge and further trials are awaited.

SUMMARY

Standard histopathology has limitations for examining surgical margins. The probability of recurrent malignant disease is explained and this is much increased when molecular markers are identified in the resected margins. Further studies are required.

Clinical Analysis of 74 Cases of Laryngeal Cancer who Underwent Frontolateral Partial Vertical Laryngectomy-Usefulness of Salvage Surgery after Failure of a Full Course of Radiotherapy-

This study was designed to analyze the surgical (postoperative course, mortality, morbidity), oncological (local control, survival rate) and functional (maximum phonation time: MPT) results of frontolateral partial vertical laryngectomy (FLPVL), in order to evaluate the advantages and disadvantages of salvage FLPVL after a full course of radiotherapy (FRT). A retrospective analysis of the results in the 74 patients (of whom 61 had previously received FRT) was undertaken. The median follow up was 68 months (range 12-290 months). No significant influence of the prior FRT was noted on the deglutition, respiration, or duration of hospitalization. The frequency of complications after discharge, but not of that during hospitalization was significantly higher in the prior FRT group. Speech (MPT) was significantly shorter (poor effect) in the prior FRT group with standard extirpation. Recurrence developed in 8 patients: in the larynx only in 7 cases, and in both the larynx and neck in the remaining one case. One patient with control of the primary showed relapse in the neck and lung. Subsequent surgery was successful in salvaging 5 of the 8 cases with local failure. One died refusing TL, and two because of uncontrolled neck recurrence. Hence, the overall laryngeal preservation rate following salvage FLPVL was 85% (52/61). Salvage FLPVL results in good tumor control and incompletely satisfactory functional results and may be recognized as a safe procedure.

Prognostic factors of glottic carcinomas treated with radiation therapy: value of the adjacent sign on radiological examinations in the sixth edition of the UICC TNM staging system

PURPOSE

To evaluate the predictive value of the adjacent sign, the tumor adjacent to the thyroid cartilage on radiologic examinations, in the new sixth edition of the International Union Against Cancer (UICC) staging system of glottic carcinoma.

METHODS AND MATERIALS

Between 1989 and 1998, 130 patients with T1-2N0 glottic squamous cell carcinoma, classified according to the fifth edition of the UICC staging system and evaluated by computed tomography or magnetic resonance imaging, were treated with radiation therapy (RT). Factor analysis included clinical, radiologic, and treatment characteristics. Tumors with the adjacent sign, considered representative of paraglottic space invasion with or without minor thyroid cartilage erosion, were retrospectively classified as T3-stage tumors by the UICC sixth edition.

RESULTS

The 5-year local control rate after RT was 76%. Univariate analysis showed that the T stage according to the UICC fifth edition, supraglottic extension, subglottic extension, tumor size, adjacent sign, total dose, fraction size, field size, and overall treatment time were significant factors for the local control rate. Multivariate analysis confirmed the adjacent sign as the only independent predictor. According to the UICC sixth edition, the 5-year local control, laryngeal preservation, cause-specific survival, and overall survival rates of the T3 (adjacent sign-positive) vs. T1 and T2 (adjacent sign-negative) lesions were 37% vs. 87% (p < 0.0001), 47% vs. 95% (p < 0.0001), 75% vs. 99% (p < 0.0001), and 54% vs. 81% (p = 0.0180), respectively.

CONCLUSION

Factor analysis confirmed the adjacent sign as an independent prognostic factor. The UICC sixth edition appears to identify correctly patients with T3 lesions as a high-risk group.

Advanced laryngeal carcinoma: surgical and non-surgical management options

This article discusses the surgical and non-surgical management of advanced laryngeal cancers.

Prognostic evaluation in supracricoid partial laryngectomy with cricohyoidopexy

Identification of prognostic factors related to supracricoid partial laryngectomy may optimise indications for this surgical technique. We analysed several clinical and histopathological variables in a series of 81 patients treated with SPL at our department. Attention was focused on neoplastic spread of the anterior commissure, thyroid cartilage and prelaryngeal soft tissue of the neck. Statistical analysis (Kaplan-Meier method and Cox regression test) showed a significant decrease in survival for prelaryngeal soft tissue invasion. Due to the fact that the survival rate is not modified by the anterior commissure and thyroid cartilage infiltration, the prognostic value of prelaryngeal invasion is extremely relevant. Therefore, we suggest the oncological value of SPL even in cases of invasion of the anterior commissure or thyroid cartilage, but not beyond the outer perichondrium.

Embryological study of the glottic site and clinical implications

The development of the glottic site, in particular of its ventral area, was studied to better understand the spreading pathways of T1, T2 cancer. Serial sections of larynges from human embryos, fetuses and adults were observed. A dorsal, a ventral and an intermediate compartment were found on the basis of their maturation schedule. A commissure muscle which develops in the anterior one third of the glottic site and wraps the connection system of vocal ligaments was recognized. The inferior paraglottic space, the compartment structures and the localization of superficial and deep blood vessels and of glands in the ventral compartment and the components of Broyles ligament were studied during ontogenesis. The compartments identified here have clinical and oncological relevance. Their detailed knowledge offers a prerequisite for planning and performing compartment conservative surgery in T1, T2 cancer, based on their spreading pathways.

Más de cinco décadas de laringectomía horizontal supraglótica (técnica de alonso)

In this paper we attempt to prove the relevance of the Spanish and Iberoamerican contribution, in the expansion and development of Alonso's technique for surgical treatment of supraglottic cancer, that began in Spain and South America in the fifties. We mention the most important authors and their ideas, and we explain their contribution to this surgical procedure which has been remained forgotten in the latest publications.

Risk factors and prognosis of anterior commissure versus posterior commissure T1-T2 glottic cancer

For better understanding of the causation and behavior of T1-T2 commissural glottic laryngeal tumors, we retrospectively analyzed risk factors and outcome related to T class and type of therapy for tumors involving the anterior (184 cases) or the posterior (60 cases) commissure. The patients' smoking habits and alcohol consumption were similar, regardless of involved subsite. The disease-free interval was longer after surgery than after radiotherapy. The survival rates after recovery upon relapse were similar among subsites, T classes, and types of therapy. In anterior commissure tumors, the larynx remained preserved more frequently after partial laryngeal resection than after radiotherapy, and was more frequently preserved the lower the T class. In posterior commissure tumors, larynx preservation was less frequent and apparently independent of type of therapy or T class. In conclusion, smoking and alcohol consumption play similar pathogenetic roles in either subsite; partial laryngeal resection gave a higher rate of laryngeal preservation than did radiotherapy; and anatomic peculiarities of the subsites influence tumor behavior.