Conservative surgery for laryngeal chondrosarcoma: a review of the most recently proposed approaches

Treatment strategy in laryngeal chondrosarcoma: a multicenter study of 43 cases

PURPOSE

Laryngeal chondrosarcoma is a rare tumor that mostly affects the cricoid cartilage. The aim of this study was to compare outcomes between the various treatments of this pathology as there are no official guidelines for this pathology.

METHODS

A retrospective analysis of the pathology database of nine French tertiary care centers was conducted. Outcomes of patients treated by total laryngectomy were compared with those treated by more conservative approaches (endoscopic debulking, median thyrotomy, partial laryngectomy). Two Kaplan-Meier survival analyses were performed: one to assess the overall survival rate and the other to assess laryngeal preservation over time.

RESULTS

A total of 43 patients were enrolled: 12 with total laryngectomy as the initial treatment, and 31 who initially underwent laryngeal-preserving treatment. With conservative treatment, laryngeal function was preserved in 96% and 75% of patients at 1 and 5 years, respectively. Conservative treatment did not reduce the overall survival rate.

CONCLUSION

These results suggest that laryngeal preservation should be considered as the initial treatment in cases of laryngeal chondrosarcoma.

Hemicricoidectomy with modified rotational thyro-crico-tracheal anastomosis: a newborn in the family of crico-tracheal resection and anastomosis techniques

Objective

The aim of the present study is to describe our novel surgical technique of hemicricoidectomy and reconstruction with modified rotational thyro-crico-tracheal anastomosis for the treatment of non-squamous cell subglottic tumours. The procedure has been defined as Type E crico-tracheal resection and anastomosis (CTRA) following the University of Brescia (C)TRA classification introduced elsewhere.

Methods

A detailed anatomical step-by-step dissection was reproduced and illustrated on a cadaveric laryngo-tracheal specimen. Moreover, oncological and functional outcomes of the first 5 patients who underwent Type E CTRA at our Institution between October 2016 and September 2022 are described.

Results

Three patients underwent Type E CTRA for cricoid chondrosarcoma (CS) and 2 patients for subglottic adenoid cystic carcinoma (ACC). No post-operative complication was reported. All patients maintained intact oral intake and an intelligible voice at discharge. All but one patient with obstructive sleep apnoea hypopnea syndrome and lung comorbidity were successfully decannulated before discharge. At the last follow-up (April 2023), one patient experienced local recurrence of CS that was still amenable to conservative treatment by transoral debulking, while the remaining patients were free of disease.

Conclusions

With the proper indications, Type E CTRA is a feasible and effective conservative surgical technique for selected non-squamous cell subglottic tumours.

Establishing safe high hydrostatic pressure devitalization thresholds for autologous head and neck cancer vaccination and reconstruction

High hydrostatic pressure specifically devitalizes cells and tissues without major changes in their molecular structure. Hence, high hydrostatic pressure may enhance the development of whole-cell anti-tumor vaccines, representing tumor heterogeneity and thus (neo-) antigen diversity. Moreover, safe devitalization of tumor-infiltrated supporting tissue may facilitate reimplantation for functional reconstruction. However, precise high hydrostatic pressure thresholds for safe cancer cell killing are unknown. Here, we show that high hydrostatic pressure of at least 450 MPa is necessary to safely devitalize head and neck squamous cell cancer. A pressure of 300 MPa, which has been used frequently in cancer vaccine preparation, resulted in partial devitalization with 27% live cells in flow cytometry and 4% remaining autofluorescence in cell culture after one week. The remaining cells could form vital tumors in the chorioallantoic membrane assay. In contrast, 450 MPa killed all cells in vitro and prevented tumor outgrowth in ovo. The effectiveness of 450 MPa was attributed to the induction of DNA double-strand breaks, independent of apoptosis, autophagy, or methuosis. Furthermore, 450 MPa continued to induce immunogenic cell death. Our results demonstrate that 450 MPa of high hydrostatic pressure induces safe and sustained devitalization of head and neck cancer cells and tissues. Because of the heterogeneity in pressure resistance, we propose our approach as a starting point for determining the precise thresholds for other cancer entities. Further studies on head and neck cancer should focus on immunological co-cultures, combinations of immune checkpoint inhibition, and accurate anatomical reconstruction with pressure-treated autografts.

A Rare Case of Aggressive Metastatic Laryngeal Chondrosarcoma Presenting as Bilateral Necrotizing Pneumonia

Laryngeal chondrosarcomas are rare tumors that account for only 0.2% of malignant tumors of the larynx. Approximately 80% of these tumors are low grade and well differentiated and are associated with a good long-term prognosis. Herein, we report a case of a 77-year-old male presenting with acute hypoxic respiratory failure that required intubation and mechanical ventilation. Chest CT showed multiple pulmonary nodules and cavities. He then required a tracheostomy, and a soft tissue mass in the subglottic mass was discovered. A laryngoscopy-guided excisional biopsy of the mass was performed. Histopathological examination confirmed the diagnosis of laryngeal chondrosarcoma. Clinicians should consider metastatic laryngeal chondrosarcoma as a differential diagnosis for lung cavities. Overall, we believe this to be the first case of aggressive laryngeal chondrosarcoma with mediastinal and pulmonary metastasis mimicking necrotizing pneumonia.

The glottic-subglottic laryngectomy: Surgical technique, oncological, and functional outcomes

OBJECTIVES

The aim of this article was to describe the surgical technique and report the oncological and functional outcomes of the partial glottic-subglottic laryngectomy (GSL).

METHODS

A retrospective review of the clinical charts of patients who underwent GSL for laryngeal cancer from 1989 to 2020 at the Otolaryngology Unit of the Vittorio Veneto Hospital, a referral center for laryngeal cancer treatment.

RESULTS

The present article considered 36 patients who were submitted to GSL for laryngeal cancer. The pathological exam found squamous cell carcinoma (SCC) in 16 cases, adenoid-cystic carcinoma (ACC) in 9 cases, laryngeal chondrosarcoma in 8 cases, 1 giant cell carcinoma, 1 carcinosarcoma, and 1 metastasis of colon adenocarcinoma. Considering the 16 SCC cases we observed a recurrence rate of 31%, the overall survival (OS) and disease-specific survival (DSS) were 75%. The 9 ACC cases had a recurrence rate of 23% and OS/DSS of 88%. In the 8 chondrosarcomas no relapses were reported and the OS/DSS were 100%. Among the patients without recurrence of the disease, a definitive decannulation was achieved in 21 cases (75%).

CONCLUSIONS

The GSL represents a valid alternative to total laryngectomy in selected cases of laryngeal cancer involving the glottic and subglottic regions.

Organ Preservation Strategies in Laryngeal Chondrosarcoma

OBJECTIVES/HYPOTHESIS

Laryngeal chondrosarcoma (LC) is a rare, slowly growing malignancy. The preferred treatment is laryngeal preservation surgery (LPS). Some patients may require multiple interventions or total laryngectomy (TL). We investigated risk factors for retreatment and TL, and assessed the impact of LPS on oncological and functional outcomes.

STUDY DESIGN

Case series METHODS: We searched our institution database for LC. Tumor grading, localization, and margin status were tested as predictors of recurrence and organ preservation.

RESULTS

We included 21 patients (seven females, mean age 58 ± 12 years). LPS was applied in 20 (95.2%) of them as a primary procedure. Six patients were treated by transoral approach and 14 received "open-neck" LPS. Fifteen (71.4%) were operated only once, while six patients underwent a total of 15 adjunctive procedures. Additional operations were always performed for recurrence of tumors localized within the cricoid plate. The histological grading was G1 in 81% and G2 in 19%. However, two patients with a primary G1 LC showed a G2 recurrence. Reoperations for recurrence were more frequent among patients with G2 in respect to G1 histology (83% vs. 7%, P < .001). Fifty percent of G2 LC and 8% of G1 underwent TL (P < .05). Margin status had no influence on recurrence rate.

CONCLUSIONS

Patients with G2 LC have more recurrences requiring surgery and a higher incidence of TL. Cricoid plate localization is relevant for organ preservation. Margin status signals possible disease persistence, without influencing the need for future surgeries. Need for reoperation entails a risk of not being able to maintain organ functionality.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Clinicopathologic characteristics of laryngeal chondrosarcoma: An analysis of the National Cancer Database

OBJECTIVES

Laryngeal Chondrosarcoma (LC) is a rare malignancy with limited studies documenting its clinicopathologic characteristics and treatment options. This study reports demographic and clinical determinants of outcomes for this rare tumor.

METHODS

The National Cancer Database (NCDB) was queried for cases of LC reported from 2004-2016. 274 cases that met inclusion criteria were analyzed for demographic and clinicopathologic characteristics. Kaplan-Meier (KM) and Cox proportional hazard analyses were conducted to identify variables that impacted the overall survival of these patients.

RESULTS

LC was found to be more common in males (74.8%). The mean age of patients was 61.8 years and 92.3% of the patients were white. 91.3% of patients were treated with only surgical resection, most commonly: partial laryngectomy (31.6%), total laryngectomy (25.7%), and local resection (22.4%). 98.8% of patients had no evidence of nodal disease and 99.6% of patients did not have distant metastasis at presentation. KM analysis revealed a 5-year overall survival (5YOS) of 89.0%. Age, insurance status, facility type, and surgery type were significant predictors of 5YOS (p<0.05). On Cox Proportional Hazard analysis, private insurance significantly improved survival (HR 0.21; p = 0.048) while increasing age was a poor prognostic indicator (HR 1.10; p = 0.004).

CONCLUSION

The majority of LC patients present with no nodal involvement or distant metastasis at diagnosis, and overall this tumor has a favorable prognosis. Increasing age was found to be a poor prognostic factor while private insurance status was associated with improved survival.

Functional optimisation in chondrosarcoma of the subglottis: a novel surgical approach

Chondrosarcoma of the larynx is rare accounting for approximately 1% of laryngeal cancers; clear cell subtype is a rare variant. Given the low risk of occult nodal disease, they present a unique opportunity to maximise tissue preservation in order to optimise both recovery and long-term functional outcomes. We present a case of laryngeal clear cell chondrosarcoma causing critical airway obstruction. An emergency tracheostomy was performed and mapping biopsies were taken. The tumour originated from the cricoid and extended into both arytenoid superstructures precluding cricotracheal resection. A modified narrow-field laryngectomy was performed, preserving all pharyngeal mucosa and neurovascularly intact infrahyoids. Organ preservation surgery is preferred in the management of laryngeal chondrosarcoma. If laryngectomy is required, the surgeon must ensure that all uninvolved, functional tissue is preserved carefully to improve swallow and voice outcomes postoperatively. We describe a novel technique used to achieve this outcome.

Prognostic factors for laryngeal sarcoma and nomogram development for prediction: a retrospective study based on SEER database

Background

Laryngeal sarcoma is an extremely rare malignant tumor of larynx and usually reported as case reports or small series. At present, there is no research based on big data about the prognostic factors affecting laryngeal sarcoma. Our study aimed to investigate the prognostic survival factors of laryngeal sarcoma and develop a comprehensive nomogram for predicting the survival of laryngeal sarcoma.

Methods

Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database to find patients diagnosed with laryngeal sarcoma from 1998 to 2016. The data were obtained using SEER Stat 8.3.5 software, collated, and analyzed by Excel 2016 software and SPSS (v25.0). Kaplan-Meier curves were used for survival analysis. The variables obtained by univariate analysis were introduced into the Cox proportional hazard model for multivariate analysis. The risk factors affecting the prognosis of laryngeal sarcoma were obtained (P<0.05 indicated statistical significance). The independent prognostic factors of laryngeal sarcoma were integrated and used to construct a nomogram.

Results

A total of 381 patients with laryngeal sarcoma were included. The median age of diagnosis was 67 years. The proportion of patients who had received surgical treatment was 62.73%, while 22.31% of patients had received no surgery. The 1-, 3-, 5-, and 10-year survival rates were 87%, 76%, 61%, and 45%, respectively. The median survival time was 102.35 months. Univariate analysis showed that increased age, primary site, pathology, pathological grade, and surgical treatment were significantly correlated with patient survival time and were risk factors for the patients' prognosis. Race, gender, and even lymph node metastasis were not significantly correlated with patient prognosis. The risk factors obtained from the univariate analysis were incorporated into the Cox risk model for multivariate analysis, the independent risk factors for prognosis of patients were: age (HR 1.569, 95% CI: 1.358–1.813, P<0.005), pathology (HR 0.834, 95% CI: 0.734–0.948, P<0.005), pathological grade (HR 1.433, 95% CI: 1.164–1.764, P<0.001), surgical treatment (HR 0.778, 95% CI: 0.696–0.870, P<0.000), primary site was excluded (P=0.092). We included all the risk factors from the multi-factor analysis to construct a nomogram, and the C-index value was 0.73, indicating that it was well-calibrated in the medium and long term.

Conclusions

Laryngeal sarcoma is a rare malignant tumor of the larynx, which most often affects people between the ages of 50 and 79 and males. Our study shows that age, pathology, pathological grade, surgical treatment may be the risk factors for patients’ prognosis. Based on this, we constructed a nomogram model with a prediction accuracy of 73% that could help clinicians make decisions on an individual basis.

High-grade chondrosarcoma of the larynx: treatment and management

We present a case of an 88-year-old man with high-grade chondrosarcoma of the larynx. The patient presents with a history worsening dysphonia and dyspnoea treated with antibiotic and corticosteroid therapy as it was a bronchopneumonia. Thanks to fibrolaryngoscopy, radiological imaging and final biopsy with immunohistochemistry, we have done differential diagnosis with the others sarcomas of the larynx. The histological diagnosis and the correct grading are essential for treatment and management of the pathology. The best treatment is primary surgical resection with negative margins. Chemoradiotherapy may provide some benefit if there are margin positive resections or with palliative intent. In our case, we performed only surgery treatment and a close follow-up at 1-3-6 months and after every 6 months. After 18 months from surgery, there are no signs of recurrence of disease.

Differing characteristics of cartilaginous lesions of the larynx

Introduction

The tissues of the laryngeal region only rarely harbor primary cartilaginous lesions, and squamous cell carcinoma remains the most frequently encountered malignant tumor in this area.

Materials and Methods

We reviewed the salient histological features of cartilaginous laryngeal lesions to provide differential diagnostics and guidelines for distinguishing the benign from the malignant ones.

Results

Cartilaginous neoplasms of the larynx include chondroma and chondrosarcoma. Among the overarching group of all forms of laryngeal sarcoma, chondrosarcoma forms the most common entity in the larynx, followed by rhabdomyosarcoma. Cartilaginous tumors comprise about 0.1%–1% of all laryngeal neoplasms with chondrosarcomas being more frequently encountered than chondromas. Several neoplasms earlier reported as giant-cell tumors of the larynx would most likely, using current terminology, be classified as cases of undifferentiated pleomorphic sarcoma (previously known as malignant fibrous histiocytoma, giant-cell variant) or aneurysmal bone cyst.

Conclusion

When true laryngeal sarcomas do exist, they may prove to be challenging lesions both for the pathologist and the treating clinician. The diagnostic problems are mainly a result of the infrequent exposure of clinicians and diagnosticians to these lesions.

Laryngeal chondrosarcoma, case report and literature review

INTRODUCTION

Chondrosarcoma constitutes 0.2% of all malignant tumors of the larynx. Many surgeons treat it with total laryngectomy due to the limited experience with this neoplasm because its rarity, and although several conservative approaches have been proposed, the data of these techniques are limited and based on retrospective series.

PRESENTATION OF CASE

A 52-year-old male with a transglottic submucosal tumor and glottic stenosis in fiberoptic examination showed by tomography a laryngeal tumor that infiltrates vocal cords, glottis, cricoid and thyroid cartilage of 3 × 2.7 × 4 cm. Patient was submitted to total laryngectomy with selective bilateral neck dissection because obstructive tumor. Pathology reported a cricoid cartilage tumor consistent with grade 2 chondrosarcoma.

DISCUSSION

Biopsy by laryngoscopy is considered the standard procedure for the diagnosis of laryngeal tumors, however the need for general anesthesia and the difficulty in intubation in some patients with large tumors make difficult to obtain an adequate biopsy in some cases with submucosal tumor. Conservative surgeries should be individualized based on the size and location of the tumor as well as on the patient's general conditions. Radical treatment is recommended for high-grade and large tumors in which conservative surgery would destabilize the cricoid ring.

CONCLUSION

There is no diagnostic and treatment approach established for laryngeal chondrosarcoma, we believe that percutaneous biopsy would be the diagnostic test of choice because it is less invasive and has a high sensitivity and specificity; it could also identify patients who are candidates for conservative surgeries.

Transoral robotic surgery for the treatment of laryngeal chondrosarcoma: A case report

IMPORTANCE

Transoral robotic surgery has revolutionized the practice of head and neck surgery over the past decade, with indications now expanding to include laryngeal pathology. Although laryngeal chondrosarcoma is a rare entity, trends in otolaryngology literature suggest that it can frequently be managed with conservative approaches. We hope to inspire other head and neck surgeons to consider transoral robotic surgery for the treatment of such tumors so that outcomes data can be collected and studied.

OBSERVATION

An 87-year-old male presented with a left-sided supraglottic mass that was found incidentally on imaging performed for an unrelated reason. Flexible fiberoptic laryngoscopy revealed a cystic-appearing supraglottic mass with near complete obstruction of the glottis airway. Internal review of the imaging demonstrated a 3.5 by 2.3 by 2.8 cm centrally hypodense lesion with a rim of calcification in the left paraglottic space, with resultant narrowing of the laryngeal airway.

INTERVENTION

The patient underwent awake tracheostomy and transoral robotic subtotal resection of the mass using the Da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). The vocal folds, ventricular mucosa, and arytenoid cartilage were grossly preserved. Final pathology revealed a low-grade cartilaginous neoplasm consistent with low-grade chondrosarcoma.

CONCLUSIONS AND RELEVANCE

Chondrosarcoma of the larynx is a rare entity that accounts for roughly 1% of laryngeal neoplasms. Recent trends in otolaryngology literature and practice suggest that low-grade chondrosarcomas can be effectively treated with organ-preserving, conservative surgery. Transoral robotic surgery offers numerous advantages over both open and endoscopic approaches. To our knowledge, this is the first report in the literature describing the successful use of transoral robotic surgery for the resection of a laryngeal chondrosarcoma.