Reconsidering a paradigm: the spread of supraglottic carcinoma to the glottis

Transcervical Conservation Laryngeal Surgery: An Anatomic Understanding to Enhance Functional and Oncologic Outcomes

The goal of this review is to facilitate an improved understanding of the indications and contraindications to transcervical conservation laryngeal surgery in the treatment of glottic and supraglottic carcinoma. An overview of seminal anatomic principles is presented to provide guidance for clinicians contemplating open partial laryngectomy options.

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.

Organ preservation surgery for laryngeal cancer

The open organ preservation surgical procedures are an important part of the head and neck surgeon's armamentarium for treating laryngeal cancer. The principles of organ preservation surgery as they apply to laryngeal cancer must be thoroughly appreciated and strictly applied for oncologic and functional success. The selection of eligible patients for these procedures is an art and requires a keen clinical acumen. The vertical partial laryngectomy and supraglottic laryngectomy have defined clinical applications that are relatively well accepted. The supracricoid laryngectomy continues gaining acceptance as a means of treating more extensive glottic and transglottic lesions while maintaining physiologic speech and swallowing without the need for a permanent tracheostoma. The inability to include and use the open surgical organ preservation approaches in the organ preservation paradigm for larynx cancer severely limits the patient's treatment options. Total laryngectomy and medical organ preservation protocols may not be acceptable to the patient from a quality-of-life standpoint. Therefore, it is incumbent upon the head and neck surgeon to have a thorough understanding of all the options available for treatment in the organ preservation paradigm for laryngeal cancer. These options must be skillfully evaluated as they relate to the patient's disease process and confidently used to provide the best oncologic and functional outcome.

Cancer spread in the larynx: a pathologic basis for conservation surgery

BACKGROUND

Previous pathologic studies of the spread of laryngeal carcinoma have drawn inferences about the site of origin of tumors, their mechanisms of growth, or the role of structures as potential barriers to tumor spread. Most of the information is based on the study of advanced or recurrent tumors and is difficult to apply to conservation surgical technique. We carried out a systematic analysis of a wide range of laryngeal tumors with the aim of providing a basis for conservation surgery.

METHODS

We analyzed tumor invasion of the laryngeal spaces and the laryngeal framework in relation to the mucosal tumor extent by axial sectioning of 80 sequential partial and total laryngectomy specimens.

RESULTS

Invasion of a particular laryngeal space could be accurately predicted by mucosal tumor extent and vocal cord mobility. Invasion of the laryngeal framework was associated with tumor extension to the ventricle, subglottis, or pyriform fossa. The thyroid cartilage and the cricothyroid space and ligament were the most frequent sites of invasion.

CONCLUSIONS

The mucosal distribution of a tumor and observation of vocal cord mobility can be used to determine accurately the extent of tumor invasion of the laryngeal spaces and framework and therefore the extent of resection necessary.

Barrier between the supraglottis and the glottis: myth or reality?

Controversial opinions on the existence of a "barrier" between the supraglottic and glottic regions of the larynx are reported. Even if the two areas have different embryological derivations, there is no anatomic evidence of a "barrier" that could prevent supraglottic cancer from extending downward to the glottis. Numerous adequate pathologic studies, including whole organ sections, confirm that for advanced cancers, anatomic compartments delimiting the spread of the neoplastic process from the supraglottis to the glottis do not exist. Therefore, supraglottic laryngectomy should be performed not on the basis of embryological considerations, but on the basis of the actual extension of the neoplastic lesion.

Glottic-supraglottic barrier: fact or fantasy?

An anatomic structure that might act as a barrier between the glottic and supraglottic areas has never been demonstrated in whole organ serial section studies. Nevertheless, most squamous cell carcinomas arising on the supraglottic mucosa remain confined above the ventricle, and this fact is reflected in the high rate of local control obtained by surgeons performing horizontal supraglottic laryngectomy: 80.6% to 98%. Whole organ sections of laryngectomy specimens suggest that a tumor situated above and below the glottic level may have arrived there not by crossing the ventricle, but by encircling it. In so doing, part of the tumor is visible posterior to the ventricle or on the arytenoid cartilage-a finding that contraindicates conventional supraglottic laryngectomy, with or without limited mobility of the true vocal cord.