The place of conservation surgery for T3 laryngeal carcinomas with fixation.

Although the traditional surgical treatment of T3 laryngeal carcinomas is total laryngectomy, we have obtained favorable survival results for selected cases with partial laryngectomy, as exemplified in the literature. Extending the indications up to ultimate limits by partial, but radical surgical techniques is the recent trend in the world, for the conservation surgery of laryngeal cancers. The primary treatment of T3 laryngeal cancers, instead of irradiation, should be surgical and, for select cases partial laryngectomy, depending on laryngeal embryological development and lymphatic drainage, may be carried out. We have performed partial laryngectomy with elective or therapeutic and radical or modified radical neck dissection for 43 T3 laryngeal carcinomas at the Department of Otolaryngology, Istanbul Medical Faculty, University of Istanbul in the years 1978-1991 and obtained 2, 3, and 5 years of survival rates, which are 89, 79.4, and 73%, respectively.     

Cricohyoidopexy (CHP) and Cricohyoidoepiglottopexy (CHEP). Indication,complications, functional und oncological results

BACKGROUND: Subtotal laryngectomy with Cricohyoido(epiglotto)pexy (CHEP and CHP) is a commonly used surgical procedure in France, Italy and North America, but it is rarely carried out in Germany,where most laryngeal carcinomas staged T1-T3 are resected endoscopically or with total laryngectomy. OBJECTIVE: To identify indications for the CHEP and CHP in a setting that uses endolaryngeal procedures as a standard approach to organ preserving surgery in laryngeal cancer patients. PATIENTS: Nineteen patients with primary (n=15) or recurrent (n=4), supra- or transglottic carcinoma or carcinoma of the anterior commissure staged (r)T1b-4N0-2cM0 were treated with subtotal laryngectomy with CHEP (with or without neck dissection/radiotherapy) between October 1997 and June 1999. RESULTS: Undisturbed deglutition without aspiration and respiration without tracheotomy was achieved in 17/19 patients.Three patients showed temporary pneumonia from aspiration and two patients needed further treatment for endolaryngeal synechia. Three patients died of unrelated causes. Four patients were diagnosed with local recurrence: Two of them died from tumor, two patients had curative total laryngectomy as salvage surgery.Fourteen patients are living free of disease 24-40 months after therapy. CONCLUSION: CHEP is a subtotal laryngectomy with increased postoperative morbidity, but good functional results.Assuming a scrupulous indication for the extended tumors the oncological results of the CHEP are satisfying, too.     

喉环上部分切除术及其疗效

目的 探讨喉癌行喉次全切除术并重建喉功能的术式及其疗效。方法 １９７８～１９９８年行喉次全切除环－舌骨固定术或环－舌骨－会厌固定术２９例,其中男１８例,女１１例;年龄最大７０岁,最小３８岁,平均５５．４岁。按１９８７年ＵＩＣＣ分期,全部均为Ｍ０,声门上型１０例（Ｔ２Ｎ０ ３例、Ｔ２Ｎ１ １例、Ｔ３Ｎ０ ３例、Ｔ３Ｎ１ ２例,Ｔ３Ｎ２ １例）,声门型１９例（Ｔ２Ｎ０ １２例、Ｔ２Ｎ１ １例、Ｔ３Ｎ０     

Supracricoid laryngectomy with cricohyoidoepiglotto-pexy or cricohyoido-pexy: experience on 32 patients

OBJECTIVE: Supracricoid laryngectomy (SCL) with Cricohyoidoepiglotto-pexy (CHEP) or Cricohyoido-pexy (CHP) is an organ preservation surgery indicated for early and selected advanced laryngeal cancers. To verify the clinical usefulness of supracricoid laryngectomy versus total laryngectomy, a retrospective review was conducted. METHODS: We summarized the clinical and postoperative data of 32 patients who received SCL over the past 9 years (1997-2005). Five-year survival rate of the SCL patient group (29 cases) was compared with that of the patient group receiving total laryngectomy (35 cases) within the same period. RESULTS: Wound infection was detected in 12 patients (38%). Those with severe infection, which required surgical intervention, included two cases of ruptured pexis and two cases showing cricoid cartilage necrosis induced by Forestier disease. There were two T4 cases that resulted in extensive excision. In one case, excision involved the posterior part of the cricoid cartilage resulting in insufficient closure of the neoglottis; the patient received total laryngectomy 30 months after SCL-CHEP because of persistent aspiration of liquid diet. In the other T4 case, the tumor invaded the thyroid and arytenoid cartilages but not the cricoid cartilage. Reposition of the remaining corniculate cartilage resulted in sufficient closure of the neoglottis; this patient subsequently acquired satisfactory laryngeal function. The 5-year overall survival rate was 86% for SCL group and 61% for the total laryngectomy group (limited to Stages III and IV glottic cancers). The causes of the four deaths were distant metastasis, neck metastasis, and intercurrent disease, respectively. Two patients are alive with distant disease. CONCLUSION: Through our experience in this series, the functional and oncological results of SCL showed certain advantages over those of total laryngectomy. Particularly, the clinical impact of SCL-CHEP was impressive; this technique needs is recommended to both head and neck surgeons and patients.     

Supracricoid partial laryngectomies after failure of radiation therapy

BACKGROUND: Conservation of laryngeal function is a key surgical objective in cases of limited recurrence after previously irradiated T1b or T2 glottic carcinoma. Only a few articles have mentioned the use of supracricoid partial laryngectomies (SCPL) to treat recurrent T1/T2 tumors that cannot be managed with vertical partial laryngectomy. OBJECTIVES: To evaluate oncologic and functional results of SCPL in selected cases of T1/T2 glottic carcinoma recurrence after primary irradiation therapy. METHOD: Between 1986 and 2000, 23 selected patients (T1b, 12 cases; T2, 11 cases) underwent SCPL as salvage treatment: cricohyoidepiglottopexy (CHEP) in 18 cases and cricohyodopexy (CHP) in 5 cases. RESULTS: The mean cannulation time was 28 (14-90) days. The mean nasogastric feeding tube time for CHP and CHEP was 55 (28-96) days and 21 (9-45) days, respectively. Four (17.4%) patients had major swallowing recovery problems. Three patients died in the postoperative period, one of intercurrent disease and two because of aspiration pneumonia. Six (26.08%) patients relapsed and underwent total laryngectomy. Three were subsequently controlled. The T stage was correlated with the onset of a new recurrence (P = .0258). The surgical margins were not correlated with recurrence (P = .0741). At 3 and 5 years, the global survival rate was 82.9% and 69.04%. The success rate for oncologic control and oncologic control with organ preservation was 74% and 66.6%, respectively. CONCLUSION: In selected cases of limited recurrence after radiation therapy for T1/T2 vocal cord carcinomas, SCPL can be an alternative to total laryngectomy when partial vertical surgery appears unsuitable.     

Partial laryngeal surgery in recurrent carcinoma

With the growing acceptance of nonsurgical therapies for laryngeal squamous cell carcinomas (LSCCs), it has become important to delineate surgical salvage strategies for disease recurrences. Total laryngectomy is often recommended, but appropriately selected laryngeal recurrences may be treated successfully with partial laryngeal surgery: laryngeal function can be preserved with oncological efficacy. The main available studies dealing with partial laryngeal surgery in recurrent carcinoma were critically reviewed. The most appealing feature of salvage transoral laser surgery (TLS) is the opportunity to make tumor-tailored excisions without any reconstructive limitations and retaining the option to switch to open partial laryngectomy. A recent detailed review of 11 series found a pooled local control rate of 57% after a first TLS procedure. Supracricoid laryngectomy (SCL) seems to achieve good local control rates in selected cases of recurrent supraglottic-glottic carcinoma: one review considering seven series calculated that 85% of the patients treated with salvage SCL after radiotherapy experienced no local recurrence; and total laryngectomy after failure of salvage SCL afforded an overall local control rate of 65%. Neck dissection is mandatory in all cases of local LSCC recurrence with evidence of neck metastases, and routine elective neck dissection is recommended for recurrent supraglottic and transglottic cancers.     

The intraoperative management of the thyroid gland during laryngectomy

The standard of care of laryngeal cancer surgery is wide field excision of the larynx combined with ipsilateral thyroid lobectomy. A retrospective review of 247 laryngectomies performed between 1979 and 1989 was undertaken to determine specific intraoperative indications for thyroid gland removal. The incidence of thyroid disease in our patients with laryngeal cancer was compared to the normal population. Eight percent of thyroid specimens removed during laryngeal cancer surgery demonstrated invasion by squamous cell carcinoma. All patients having thyroid invasion had T3 or T4 laryngeal lesions that were stage IV at the time of surgery. All these lesions were found to have transglottic growth and laryngeal cartilage invasion by the pathologist. All of these patients also had abnormal thyroid glands intraoperatively and laryngeal cartilage destruction that was evident intraoperatively. Total thyroidectomy with bilateral paratracheal and pretracheal lymph node dissection is indicated when squamous cell carcinoma of the larynx involves the thyroid gland. Prophylactic ipsilateral thyroid lobectomy and isthmusectomy is warranted for large laryngeal cancers (T3, T4) that involve the anterior commissure, the subglottic area, or extend transglottically. Routine thyroid gland removal is not indicated for the majority of laryngeal cancers that do not meet the aforementioned criteria. Finally, abnormal thyroid histopathology was diagnosed in 37% of the surgical thyroid gland specimens removed during laryngectomy.     

CO<Subscript>2</Subscript> laser treatment of laryngeal stenoses after reconstructive laryngectomies with cricohyoidopexy,cricohyoidoepiglottopexy or tracheohyoidoepiglottopexy

Supracricoid laryngectomy with cricohyoidopexy (CHP) or cricohyoidoepiglottopexy (CHEP) is a conservative laryngeal surgery tailored to T1b-T2-T3 glottic-supraglottic carcinomas. Tracheohyoidopexy (THP) and tracheohyoidoepiglottopexy (THEP) allow a chance of conservative surgery also for selected transglottic carcinomas. These techniques are comprehensively named reconstructive laryngectomies (RLs). Post RL laryngeal stenosis not due to carcinoma persistence or recurrence is an unusual occurrence. The aim of the present study has been to analyse retrospectively and describe the treatment of the cases of laryngeal stenosis after RL, which occurred in Vittorio Veneto Otolaryngological Department in a 6 year period. In the period between 1999 and 2004, 225 patients underwent RL in our Department. In 18 of them (8%) a laryngeal stenosis after RL was diagnosed. The same evidence was shown in 2 patients who underwent RL in other Institutions. All patients underwent CO₂ laser surgical treatment of the laryngeal stenosis. The 14 patients who underwent RL-CHEP, the 5 patients who underwent THEP and the patient who underwent CHP were treated on average with CO₂ laser 1.2 (range 1–2), 4.2 (range 2–7), and 2 times, respectively. Decannulation was possible in all patients but one after CO₂ laser treatment of the stenosis in a mean period of 3.4 months. Laryngeal stenoses after RLs can be successfully treated with CO₂ laser excision with a very limited morbility. The only reasonable contra-indication to CO₂ laser excision could be a cranio-caudal length of the laryngeal stenotic tract longer than 1 cm: in this occurrence diagnosed after THP or THEP, an external surgical approach could be preferred.     

喉水平垂直部分切除术治疗晚期喉癌

目的　评价喉水平垂直部分切除术治疗晚期 (T3 ,T4 )喉癌的效果。方法　回顾性分析1984～ 1994年采用该术式治疗的 5 7例T3 、T4 病例的生存率和喉功能保留情况。结果　本组病例 3年生存率为 70 % (40 / 5 7) ,5年生存率为 6 4% (32 / 5 0 )。本组患者均保留了发音功能 ,需带管呼吸者 4例 ,拔管率为 93% (5 3/ 5 7) ,经过鼻饲和使用带气囊气管套管锻炼 ,患者均可经口进食。清楚死亡原因的病例共 14例 :局部复发死亡 4例 ,颈淋巴结转移死亡 4例 ,远隔转移死亡 4例 ,非肿瘤原因死亡 2例。失访 4例。结论　只要适应证选择的合理 ,该术式对一部分T3 、T4 喉癌的治疗即可根治肿瘤 ,又可保留喉的功能 ,单纯的高龄因素不是该术式的禁忌证。     

Is routine bilateral neck dissection absolutely necessary in the management of N0 neck in patients with supraglottic carcinoma?

The supraglottic larynx has a rich lymphatic network that places patients with supraglottic laryngeal carcinomas at high risk for early dissemination of the disease into the cervical lymphatics. Therefore, elective neck treatment of clinically N0 neck in patients with supraglottic carcinomas is widely accepted as a standard approach. However, the issue whether elective neck treatment should routinely be directed on both sides of the neck is still controversial. The present study is aimed at determining whether T2–T4 stage supraglottic carcinomas require bilateral neck dissection in the management of N0 necks. We designed a prospective study on 72 patients with N0 supraglottic laryngeal carcinoma. Patients were divided into three groups according to the site and extension of the primary tumors. Group I consisted of 21 patients with lateralized (clear lateral) lesion reaching but not crossing the midline. Group II comprised 25 patients with cancer largely involving one side and crossing to the midline. Group III included 26 patients with carcinoma equally involving both sides of the larynx or growth into the midline larynx. All patients underwent bilateral lateral neck dissection in conjunction with various types of laryngectomies selected to the status of the primary. Of the 72 patients, 16 were found to have occult regional metastases in pathologic examination (9 pN1, 4 pN2b, 3 pN2c). The prevalence of occult metastases proportionally increased with T stage from 8.3 to 22.7 and 31.2%, respectively, for T2, T3 and T4. Bilateral neck metastases were found in 2 of 26 patients (7.7%) with central lesions. There was only one patient (4%) with both ipsilateral and contralateral lymph node metastasis in group II. None of the 21 patients with lateral lesion (group I) had contralateral neck metastasis. Routine bilateral elective neck dissection may not be a part of the surgical procedure in all supraglottic laryngeal carcinoma patients. Bilateral neck dissection should be preferred for cases with central tumors and lateral tumors with positive nodes in the ipsilateral side of the neck.     

Transoral CO<Subscript>2</Subscript> laser management for selected supraglottic tumors and neck dissection

This study aimed to evaluate transoral laser resection as a method of choice for conservation surgery for supraglottic laryngeal carcinoma in carefully selected patients. Between 1987 and 2006, 55 patients with early supraglottic carcinoma were selected for transoral laser surgery. The outcome of the endoscopic CO₂ laser resection and larynx-sparing functional results without tracheotomy was evaluated. Fifty-five patients with T1, T2 supraglottic carcinomas underwent transoral CO₂ laser resection and seven patients with manifest neck metastasis required a neck dissection at one session with additional postoperative radiation therapy. There was no need for tracheotomy; deglutition was moderately disturbed. Forty of the 55 (73%) patients had no signs of recurrence to date. Fifteen patients with local recurrences underwent salvage therapies: six repeated laser excisions, three radiotherapies, four supraglottic laryngectomies and two total laryngectomies. Laser-specific survival is 84% and larynx preservation is 96%. The overall 5-year-survival after salvage treatment is 98%. Development of late metastasis required five radical neck dissections (RND) and radiation therapy. The results indicated that transoral laser resection can control early supraglottic cancer in selected patients and can be combined with simultaneous neck dissection with less morbidity than “open surgery”.     

Transoral videolaryngoscopic surgery for oropharyngeal,hypopharyngeal, and supraglottic cancer

In this retrospective cohort study, we evaluated the oncological and functional outcomes of transoral videolaryngoscopic surgery (TOVS). Using distending laryngoscope and videolaryngoscope, wide operative field and working space could be obtained and tumor could be resected in en bloc. Sixty patients with T1, T2, and selected T3 laryngeal or pharyngeal squamous cell carcinomas (Stage I: n = 17, Stage II: n = 16, Stage III: n = 7, Stage IV: n = 20 cases) were enrolled and followed up for at least 24 months or until the patient’s death. Fifty-three patients underwent initial treatment, and seven patients had recurrent cancer after chemoradiation. In principle, node-positive patients underwent a simultaneous neck dissection. Patients with multiple nodal metastases or a positive surgical margin received postoperative radiotherapy. For initial treatment, the 5-year overall survival and disease-specific survival rates were 77 and 95 %, respectively. For supraglottic and hypopharyngeal cancers, the 5-year laryngeal preservation rates were 89 and 96 %, respectively. For salvage surgery, the overall survival, disease-specific survival, and laryngeal preservation rates were 75, 75, and 80 %, respectively. The median times before patients could resume eating and swallowing a soft diet were 6 and 9 days, respectively. The patients’ Functional Outcome Swallowing Scale stages were 0–2 in 93.3 % of the cases and 3 or 4 in 6.7 % of the cases. A percutaneous endoscopic gastrostomy was indicated for 1 (1.7 %) patient. Four (6.7 %) patients received transient tracheostomy. TOVS is a satisfactory and minimally invasive treatment option for laryngeal and pharyngeal cancers.     

喉水平垂直部分切除术治疗晚期喉癌

目的 评价喉水平垂直部分切除术治疗晚期（Ｔ３,Ｔ４）喉癌的效果。方法 回顾性分析１９８４～１９９４年采用该术式治疗的５７例Ｔ３,Ｔ４病例的生存率和喉功能保留情况。结果 本组病例３年自下而上率为７０％（４０／５７）,５年生存率为６４％（３２／５０）。本组患者均保留了发音功能,需带管呼吸者４例,拔管率为９３％（５３／５７）,,经过鼻饲和使用带气囊气管套管锻炼,患者均可经口进食。清楚死亡原因的病例共１５     

Limited Surgery for Cancer of the Larynx and Hypopharynx: Options and Consequences

We reviewed surgical options for laryngeal preservation (limited surgery) in laryngeal and hypopharyngeal cancers and the consequences of the options. Of 44 patients with laryngeal cancer, 11 (25%) received limited surgery and 33 (75%) received total laryngectomy. The survival rates were 91% for the limited surgery group and 73% for the total (radical) surgery group. Of 31 patients with hypopharyngeal cancer, 7 (23%) received limited surgery and 24 (77%) received total laryngopharyngectomy. The survival rates were 53% for the limited surgery group and 40% for the total (radical) surgery group. The survival rates associated with limited surgery were thus better than those for total (radical) surgery for cancers of both the larynx and hypopharynx. This was attributed to the limited surgery group comprising well-selected patients with confined lesions. Organ preservation surgery should be technically simple, reliable in terms of its functional impact and, above all, should not jeopardize the patient's survival. Supracricoid subtotal laryngectomy with cricohyoidoepiglottopexy or cricohyoido-pexy has great potential for laryngeal preservation and will become the major limited surgery modality for treating cancer of the larynx. Limited surgery, however, needs to be performed with great care and is indicated only for very well-selected patients with cancer of the hypopharynx.     

Limited surgery for cancer of the larynx and hypopharynx: options and consequences

We reviewed surgical options for laryngeal preservation (limited surgery) in laryngeal and hypopharyngeal cancers and the consequences of the options. Of 44 patients with laryngeal cancer, 11 (25%) received limited surgery and 33 (75%) received total laryngectomy. The survival rates were 91% for the limited surgery group and 73% for the total (radical) surgery group. Of 31 patients with hypopharyngeal cancer, 7 (23%) received limited surgery and 24 (77%) received total laryngopharyngectomy. The survival rates were 53% for the limited surgery group and 40% for the total (radical) surgery group. The survival rates associated with limited surgery were thus better than those for total (radical) surgery for cancers of both the larynx and hypopharynx. This was attributed to the limited surgery group comprising well-selected patients with confined lesions. Organ preservation surgery should be technically simple, reliable in terms of its functional impact and, above all, should not jeopardize the patient's survival. Supracricoid subtotal laryngectomy with cricohyoidoepiglottopexy or cricohyoido-pexy has great potential for laryngeal preservation and will become the major limited surgery modality for treating cancer of the larynx. Limited surgery, however, needs to be performed with great care and is indicated only for very well-selected patients with cancer of the hypopharynx.     

头颈部鳞癌颈淋巴结隐匿性转移

目的 探讨头颈部鳞癌隐匿性颈淋巴结转移的特点和规律。方法 对111例头颈部鳞癌N_0M_0患者的颈淋巴结清扫标本进行切片观察。结果 隐匿性转移总体发生率为26.12％(29/111)。其中口腔癌18.75％(15/80),口咽癌25.00％(1/4),下咽癌54.54％(6/11),喉癌43.75％(7/16)。原发癌临床分期、肿瘤细胞分化程度是影响颈淋巴结隐匿性转移的重要因素。111例N_0M_0患者5年生存率为66.7％,其中pN~-为74.39％(61/82),pN~ 为44.82％(13/29)。结论 对临床T_3和T_4期、癌组织分化程度低和深度浸润的cN_0头颈部鳞癌应行选择性颈清扫术以治疗颈淋巴结隐匿性转移并提高患者的生存率。     

The value of ultrasound examination in preoperative neck assessment and in early diagnosis of nodal recurrences in the follow-up of patients operated for laryngeal cancer

The purpose of this study was to prove the superiority of ultrasound (US) examination of the neck in comparison to palpation, to reveal unpalpable nodes (pN0) before surgery, and to allow for the early detection of nodal recurrences in patients with laryngeal cancers. In all, 1,120 patients with laryngeal cancers were operated on between 1990 and 1997. All underwent palpation and neck US before surgery. In the pN0 group US revealed enlarged lymph nodes in 261/505 cases, of which 63 (24.14%) were confirmed as metastatic by histology. All 1,120 patients underwent regular postoperative US follow-up. Nearly 5,000 US examinations were performed; 136 patients who developed nodal recurrences had surgical salvage procedures. In this group 61 patients had small, nonpalpable lesions, and 46 patients discrete and slight changes in scarred necks. In this latter group of 117 patients with nonpalpable lesions, 105 cases were histologically confirmed as metastatic. In postoperative check-ups, metastases were suspected in sonographically detected subclinical nodes, but the US scans obtained were difficult to interpret. In these cases, because of the dynamics of lesion changes, US was repeated two to three times at 10- to 14-day intervals. This reappraisal enabled us to exclude malignancy in regressing nodes, as well as to obtain the stable picture of scar, and support a diagnosis while the lesion grew larger or a central area of low attenuation or hypoechogenic echos appeared in the nodal capsule. Successful radical reoperation for tumor was done on110 patients; 78 patients underwent successful salvage surgery after an early US diagnosis. The sonographic-surgical correlation was nearly 95% and the sonographic-histological correlation was 90%. The follow-up period was 1–49 months. In all preoperative assessments US was found to be a valuable tool in the staging of laryngeal cancer and planning the extent of surgery. Close follow-up with US after radiotherapy and initial operation was essential for the early detection of tumor recurrences, making surgical salvage still feasible. Received: 26 September 1998 / Accepted: 13 April 1999     

Quality of life in patients with laryngeal carcinoma after radical neck dissection

In modern oncology quality of life (QL) in patients treated for neoplasmatic disease, has become a parameter of equal importance to other values of treatment success, such as 5-years survival, mean survival and disease free survival. The presence of cervical adenopathy and qualification for total laryngeal surgery and radical neck dissection is a source of deep additional mental experiences in patients with laryngeal carcinoma. The aim of this study was the objective establishment of QL in 70 patients treated in ENT Department University Medical in ?ód? who underwent total laryngectomy and radical neck dissection, estimation of QL in various phases after treatment (in period of 6 months, from 6 to 12 months, and 1 year after surgery) and comparison of QL of patients after laryngeal surgery and QL of patients after surgery and radiotherapy. In order to evaluate quality of life the EOTRC QLQ-30, EOPRTC QLQ-H&N35 and HAD scale were used. It was stated, that the most difficult time for patients after radical neck dissection is the first 6 months after surgery, and the quality of life in patients after surgery and radiotherapy was lower than that of other patients in period of observation.     

环状软骨上喉次全切除术及疗效分析

目的探讨环状软骨上喉次全切除术(简称环上喉次全切除术)的可行性及其疗效。方法回顾性分析1990—2001年43例行环上喉次全切除术的T1b～T4及术后放疗后复发的喉癌患者,声门上癌16例,声门癌21例,声门下癌2例;外院术后复发3例,放疗后复发1例。临床分级:T1b6例,T213例,T316例,T44例。应用3种不同的环上喉次全切除术进行治疗(17例行环上喉次全切除环舌骨固定术,24例行环上喉次全切除环舌骨会厌固定术,2例采用环上喉次全切除气管环舌骨会厌固定术)。16例患者辅以放疗。结果KaplanMeier法统计生存率,随诊中位时间57个月。全组总的3年累积生存率为90.7%,5年累积生存率83.7%。术后拔管率为95.3%(41/43)。保留双侧杓状软骨的拔管时间为14d,保留单侧杓状软骨的拔管时间为43d。术后8周评价误咽发生率为14.0%(6/43),切除会厌增加了术后的误咽及拔管时间(P<0.05)。结论环上喉次全切除术是一种在肿瘤根治和喉功能保全上能达到临床应用水平的术式。     

Surgical treatment of the neck in cancer of the larynx

Current concepts in management of the clinically negative and clinically positive neck in laryngeal cancer are reviewed. Occult disease in the neck not detected by physical and radiographic examination may also be difficult to identify on routine histologic examination. Immunohistochemistry or molecular analysis may detect metastatic involvement not apparent by light microscopy. The surgeon should be aware of the relatively high incidence of micrometastases in patients with laryngeal cancer to establish optimal treatment approaches. Elective treatment of the neck is recommended for supraglottic tumors staged T2 or higher, and glottic or subglottic tumors staged T3 or higher. The neck may be treated electively by either surgery or irradiation, but irradiation is best reserved for cases where that modality is employed for the primary tumor. Elective neck dissection provides important information for prognostic purposes and therapeutic decisions, by establishing the presence, number, location and nature of occult lymph node metastases. The selective lateral neck dissection (levels II, III and IV), unilateral or bilateral, is the procedure of choice for elective treatment. Paratracheal nodes (level VI) should be dissected in cases of advanced glottic and subglottic cancer. Complete radical or functional neck dissections are excessive in extent, as levels I and V are almost never involved. Sentinel lymph node biopsy may fail to detect tumor on frozen section examination or may not reveal 'skip' metastases. The clinically involved neck is usually treated by complete radical or functional neck dissection of levels I through V. Selective neck dissection has been employed successfully in selected cases, particularly for N1 or occasionally N2 nodal involvement. The selective neck dissection can be extended to include structures at risk. More advanced disease has been treated in this manner often in association with adjuvant chemotherapy and/or irradiation. While the benefit of adjuvant treatment is difficult to assess, it appears most useful in cases with extranodal spread of disease, a factor associated with the worst prognosis.