Long-term follow—up of cartilaginous tumors of the larynx

Background: Cartilaginous tumors of the larynx are uncommon. A literature review disclosed approximately 250 cases since 1816; the cricoid cartilage is the most common site. The rarity of these tumors has made for limited experience and, as a consequence, our knowledge is incomplete. Objective: To report surgical results as well as long—term follow—up on 6 patients with cartilaginous tumors of the larynx. Design: A 28—year retrospective study with the patients followed-up from 6 to 28 years (average, 17.8 years). Methods: Six adult white male patients with cartilaginous tumors of the larynx: 4 low-grade chondrosarcoma (1 of the thyroid and 3 of the cricoid) and 2 chondroma of the cricoid. Surgical treatment included total laryngectomy of the thyroid and 1 of the cricoid chondrosarcoma, and conservation surgery of the other 4 cricoid tumors: the 2 patients with chondrosarcoma had total resection of the cricoid cartilage with thyrotracheal anastomosis, and the 2 patients with chondroma had local tumor resection using a laryngofissure approach. Results: The margins of the specimen were negative for tumor in the 6 patients. On follow-up, none of the patients had regional or distant metastasis or tumor—related death. One of the patients with cricoid chondrosarcoma developed recurrence 8 years after conservation surgery, and required a total laryngectomy for salvage. Survival rate tumor-free at 5 years was 100% and at 10 years 67%, co-morbidity being responsible for the decrease in survival rate. Conclusions: Based on this small series of patients, the long—term follow—up of benign and low—grade malignant tumors suggests that the surgical approach and prognosis does not depend on histologic distinction and, importantly, underdiagnosed malignancy on tumor sampling and recurrent chondrosarcoma, managed with salvage surgery, have no adverse impact on patient survival. Total resection of the cricoid cartilage with thyrotracheal anastomosis over a stent proved an alternative surgical technique in chondrosarcoma who otherwise would have been treated by total laryngectomy. (Otolaryngol Head Neck Surg 2001;124:634-40.)     

Chondrosarcoma of the larynx: a clinicopathologic study of 111 cases with a review of the literature

Chondrosarcomas of the larynx are rare tumors accounting for about 0.5% of all laryngeal primary tumors. A total of 111 laryngeal chondrosarcoma cases, diagnosed between 1970 and 1997, were retrieved from the Otorhinolaryngic-Head & Neck Tumor Registry of the Armed Forces Institute of Pathology. There was a 3.6:1 male/female ratio of patients 25-91 years of age (mean, 64.4 years). Patients presented most frequently with hoarseness (n = 72 patients) present for a mean of 28.2 months. The majority of tumors involved the cricoid cartilage (n = 77) with a mean size of 3.5 cm. All tumors were invasive and malignant by radiology and/or histology (into bone within the ossified laryngeal cartilages in 52 tumors). Most tumors were low-grade lesions: grade 1 (n = 51), grade 2 (n = 54); there were six grade 3 tumors. An associated benign chondroma with (n = 41 tumors) or without ischemia (n = 24 tumors) was noted. All patients had surgery and five had radiation therapy. Wide excision or voice-sparing surgery was used in 73 patients, whereas 37 patients had a laryngectomy. Recurrences occurred in 20 (18%) patients, 10 of whom underwent salvage laryngectomy. At the last follow-up, 102 patients had no evidence of disease (alive or dead, mean 11.2 years) and five patients had evidence of disease (alive, one patient, 6.5 years; dead, four patients, mean 6.4 years). The six patients with high-grade chondrosarcoma were all without disease at the last follow-up (mean, 15.1 years). There was no difference in clinical outcome based on grade (p = 0.210), location (p = 0.078), or treatment (p = 0.607) but was worse for patients with a myxoid-type chondrosarcoma (p = 0.044). Primary laryngeal chondrosarcomas are typically low- to moderate-grade lesions involving the cricoid cartilage, frequently associated with a chondroma. They usually portend an excellent overall long-term prognosis with initial conservative voice-sparing surgery.     

Chondrosarcoma of the larynx: a case presentation

The chondrosarcoma of the larynx is an exceptionally rare tumour. It appears mainly in white men in their 7th decade. The most significant clinical manifestation is hoarseness accompanied at times by stridor. It involves mainly the cricoid cartilage and the treatment of choice is surgical excision. A case of a large tumour of the cricoid cartilage is described. The diagnostic work-up consisted of two minor operations for biopsies and an MRI scan prior to the patient being treated with total laryngectomy.     

Experience with primary neoplasms of the trachea and carina

From 1963 to 1983, 44 patients presented with a primary tracheal neoplasm that was amenable to surgical treatment. Forty-two of the 44 tumors were malignant. Thirty-three patients were managed by resection and primary anastomosis. The following resections were done: trachea only, 12; trachea plus carina, 13; trachea plus cricoid cartilage, four; and trachea plus larynx, four. There were two operative deaths in these 33 patients. Prosthetic reconstruction with heavy-duty Marlex mesh was done in six patients. Three of the six died of erosion of the innominate artery during the postoperative period. In three patients with nonresectable tumors, a silicone-coated Montgomery T-tube provided transient but worthwhile palliation. In two patients with nonobstructive adenoid cystic carcinoma involving the subglottis, irradiation was chosen as the initial treatment, since resection would necessitate laryngectomy. Resection, including laryngectomy, may be required in the future. The following points are emphasized: (1) A majority of operable neoplasms can be resected through a cervical collar incision and median sternotomy. Median sternotomy is the optimal operative exposure in most neoplasms necessitating resection of the carina. (2) Partial resection of the cricoid with sparing of the recurrent laryngeal nerves and larynx is possible in some patients with primary malignant tumors involving the proximal trachea and subglottic region. (3) In patients with adenoid cystic carcinoma, resection may afford excellent, long-term palliation even when the resection is incomplete. Pulmonary metastases are common in patients with adenoid cystic tumors. However, they usually progress slowly, may remain asymptomatic for many years, and are not necessarily a contraindication to resection of the primary tumor even when they are synchronous. Our experience suggests that adjunctive radiotherapy is beneficial in patients with adenoid cystic carcinoma.     

Laryngotracheal reconstruction in subglottic stenosis: an ancient problem still present.

BACKGROUND: Subglottic stenosis is an ancient but persistent problem as a cause of airway obstruction. The etiology and the results of surgical treatment with thyrotracheal anastomosis were reviewed. METHODS: Fifty-six patients with subglottic stenosis were studied. All were subjected to laryngotracheal reconstruction by thyrotracheal anastomosis with partial resection of the cricoid. RESULTS: Of all 56 cases of subglottic stenosis, 48 (86%) had history of previous tracheal intubation, and only 8 (14%) had different non-neoplastic obstructive processes such as scleroma, direct injury, hamartoma, and amyloidosis. Immediate results were good in all cases. After 1 year follow-up, results of thyrotracheal anastomosis were successful in 44 (91%). In 4 other cases a restenosis was observed. Eight patients were lost to follow-up. CONCLUSIONS: Subglottic stenosis is still frequent after tracheal intubation, but other causes must be considered. Laryngotracheal reconstruction with thyrotracheal anastomosis with partial cricoid resection was feasible with good results in 91% of the cases with follow-up, but this procedure must be performed by a skilled surgical team.     

Laryngotracheoplastic resection for primary tumors of the proximal airway

BACKGROUND: Primary tumors of the airway with proximity to vocal cords and recurrent laryngeal nerves can be resected with sparing of the larynx. Long-term data on survival and local recurrence after laryngotracheal resection are scarce. METHODS: We conducted a retrospective study of laryngotracheal resection and reconstruction for primary tumors of the airway since 1972. RESULTS: Twenty-five patients aged 15 to 77 years presented with adenoid cystic carcinomas (n = 9), squamous cell carcinomas (n = 6), and other airway tumors (n = 10). Subglottic resection consisted of anterior cricoid in 5 patients; posterior cricoid mucosa in 9 patients, with resection of the posterior cricoid plate in 3 patients; lateral resection in 7 patients; and combined anterior and posterior elements in 4 patients. Vascularized trachea was tailored to reconstruct the defect. Seven patients without hoarseness required resection of the recurrent laryngeal nerve, and 4 other patients with hoarseness did not. There were no operative deaths. Two (8.0%) patients who had received prior high-dose cervical radiation had anastomotic separation, one requiring laryngectomy. One patient needed permanent tracheostomy, and temporary (<2 months) airway tubes were used in 5 patients. Sixteen patients received postoperative radiation. Median follow-up was 101 months. Four (16%) patients died of disease. Overall survival at 5 and 10 years was 79% and 64%, respectively. No patient underwent laryngectomy for recurrence. CONCLUSION: Laryngotracheal resection and immediate reconstruction for subglottic tumors is achieved with good preservation of voice, low morbidity, and no compromise of long-term survival.     

Chondrosarcoma of the larynx: a report of two cases and a review of the literature

Chondrosarcoma of the larynx: a report of two cases and a review of the literature. This paper describes two cases of low-grade laryngeal chondrosarcoma. In both cases, the tumours were located on the cricoid, and could be visualized with a CT scan and magnetic resonance imaging. The diagnosis was made by a deep wedge biopsy with a CO2 laser, and after subtotal supracricoid laryngectomy. Most of the reported cases have been successfully managed by voice-sparing surgery, but the two cases reported here, needed more radical treatment.     

Conservation laryngeal surgery versus total laryngectomy for radiation failure in laryngeal cancer

BACKGROUND: Total laryngectomy is the standard of care for surgical salvage of radiation failure in laryngeal cancer. However, the role of conservation laryngeal surgery in this setting remains unclear. The objective was to compare the efficacy of conservation versus total laryngectomy for salvage of radiation failure in patients who initially presented with T1 or T2 squamous cancer of the larynx. METHODS: A 21-year retrospective analysis of patients who received surgery at a single comprehensive cancer center after definitive radiation therapy is reported. At recurrence, the patients were reevaluated and then underwent a total laryngectomy or, if possible, a conservation laryngeal procedure. The charts of 105 patients who failed radiation treatment for primary laryngeal cancer and who subsequently underwent surgical salvage were reviewed for this study. Eighty-nine were male (84.8%). The mean age was 60.3 years. The median follow-up time after surgery was 69.4 months. Most patients with recurrence after radiotherapy required total laryngectomy (69.5%; 73/105). Conservation laryngeal surgery was performed for 32 patients (31.5%). Concomitant neck dissections were performed on 45 patients (45.5%). RESULTS: In 14 patients, local or regional recurrence developed after salvage surgery: 9 patients after total laryngectomy (12.3%; 9/73), and 5 patients (15.6%; 5/32) after conservation laryngeal surgery. This difference was not statistically significant, nor was there a difference in disease-free interval for the two procedures (p = .634, by log-rank test). Distant metastasis developed in 13 patients. Most developed in the setting of local and/or regional recurrence, but distant metastasis occurred as the only site of failure in 6 of the patients who had undergone total laryngectomy but in 1 of the conservation surgery patients treated for a supraglottic laryngeal cancer. The overall mortality for patients who underwent total laryngectomy was also higher: 73.74% (54/73) versus 59.4% (19/32) for patients who underwent a conservation approach (p = .011 by log-rank test). CONCLUSIONS: Although conservation laryngeal surgery was possible in a few patients with local failure after radiotherapy, conservation laryngeal surgery is an oncologically sound alternative to total laryngectomy for these patients.     

Tracheal chondrosarcoma

Tracheal chondrosarcomas are rare, with only 14 cases previously documented. We report a case of chondrosarcoma of the trachea and review other published cases. Our patient was a 34-year-old man who began to feel shortness of breath 8 months after initial hemoptysis. Transverse and coronal computed tomography demonstrated a tumor that was obstructing nearly 80% of the tracheal lumen at the thoracic inlet. A bronchoscopic biopsy specimen led to an initial diagnosis of chondroma. Five tracheal rings from the third to the seventh including the tumor were completely resected, and an end-to-end anastomosis was performed. The histological diagnosis of the surgical specimen showed it to be a chondrosarcoma. The patient was alive without recurrence at 6 years 4 months after surgery. Because recurrence after incomplete resection and malignant transformation can occur with chondromas, radical resection of the trachea is recommended for all cartilaginous tumors of the trachea.     

Salvage laryngectomy and pharyngocutaneous fistulae after primary radiotherapy for head and neck cancer: a national survey from DAHANCA

OBJECTIVE: In 1998, the Danish Society for Head and Neck Oncology decided to conduct a nationwide survey at the five head and neck oncology centers with the aim of evaluating the surgical outcome of salvage laryngectomy after radiotherapy with special emphasis on identifying factors that could contribute to the development of pharyngocutaneous fistulae. PATIENTS: A total of 472 consecutive patients undergoing postirradiation salvage laryngectomy in the period July 1, 1987-June 30, 1997 were recorded at the five head and neck oncology centers in Denmark. Age ranged from 36 to 84 years, median 63 years, 405 men and 67 women. Primary tumor site was glottic larynx (n = 242), supraglottic larynx (n = 149), other larynx (n = 45), pharynx (n = 27), and other (n = 9). All patients had received prior radiotherapy. RESULTS: Median time between radiotherapy and laryngectomy was 10 months (range, 1-348 months). A total of 89 fistulae lasting at least 2 weeks were observed, corresponding to an overall average fistulae risk of 19%. The number of performed laryngectomies per year decreased linearly (from 58 to 37), whereas the annual number of fistulae increased slightly (from 7 to 11), which meant that the corresponding estimated fistulae risk increased significantly from 12% in 1987 to 30% in 1997. Other significant risk factors for fistulae in univariate analysis included younger patient age, primary advanced T and N stage, nonglottic primary site, resection of hyoid bone, high total radiation dose, and large radiation fields. Multiple logistic regression analysis of these parameters suggested that nonglottic tumor site, late laryngectomy period (1987-1992 vs 1993-1997), and advanced initial T stage were independent prognostic factors for fistulae risk. Surgical parameters like resection of thyroid/tongue base/trachea or radiotherapy parameters like overall treatment time or fractions per week did not influence fistulae risk. CONCLUSIONS: The risk of fistulae is especially high in patients initially treated with radiotherapy for nonglottic advanced stage tumors. A significant decrease in the number of performed salvage laryngectomies over the 10 years was seen. Over the same time period, the annual number of fistulae remained almost constant. The resulting more than doubling of fistulae rate could thus in part be explained by less surgical routine.     

Management of advanced glottic carcinomas

One hundred twenty-eight patients with T3 or T4 glottic cancers were treated by initial surgery; 59 had a total laryngectomy and 69 had total laryngectomy with regional node dissection. Fifty-eight percent of the total laryngectomy group and forty-nine percent of the total laryngectomy with neck dissection group remained free of disease for 5 or more years. Forty-seven percent (60 of 128 patients) treated surgically developed regional recurrences requiring further treatment. Nine patients had evidence of widespread metastases, leaving 51 suitable for salvage radiotherapy. Twenty-three percent (12 of 51 patients) were salvaged with radiotherapy given for postoperative recurrences. Twenty-five patients received an initial 6,600 rads to larynx and neck with curative intent, 28 percent of whom remained free of disease for 5 or more years. Seventeen percent of patients were salvaged with one laryngectomy for persistent or recurring tumors. Initial total laryngectomy gave better survival figures for advanced glottic carcinoma.     

Current trends in the treatment of cancer of the larynx.

The case histories of 250 patients with cancer of the larynx presenting to the Peter MacCallum Hospital, the Alfred Hospital and the Royal Melbourne Hospital in the ten-year period 1966 to 1975 have been reviewed to determine: The results of primary irradiation treatment of T1N0 and T2N0 glottic cancer; The comparative results of primary irradiation plus salvage surgery as compared with primary radical surgery for T3N0 glottic and supraglottic cancer; and The surgical morbidity of secondary salvage laryngectomy following irradiation as compared with that of primary total laryngectomy. These findings are compared with those of a previous study of cancer of the larynx for the period 1956 to 1965.     

Results of hemilaryngectomy in primary surgical treatment of laryngeal carcinoma

Hemilaryngectomy is the resection of a true anatomic half of the larynx with preservation of the cricoid cartilage. We present a retrospective study of 438 patients with glottic carcinoma, treated with hemilaryngectomy, at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia between 1988 and 1997. The patients with positive margins (19.4% of all) were postoperatively irradiated. Local recurrences of carcinoma were found in 17.3% of subjects, and regional recurrences in 16.4% of subjects. Those patients were treated with total laryngectomy or radical neck dissection, and with radiotherapy. 5-years survival rate in our patients was 79%. Hemilaryngectomy provided acceptable percent of local and regional recurrences, and good functional results: respiration, swallowing and voice quality. Therefore it could be the first choice surgery technique in treatment of T2 laryngeal carcinoma.     

Primary Sarcomas of the Larynx: A Clinicopathologic Study of 27 Cases

Primary sarcomas of the larynx are rare and are associated with diagnostic and treatment challenges. Studies of these tumors are limited, and most examples have been reported as small series. To further increase our understanding of laryngeal sarcomas, we reviewed our experience of an adult cohort. A retrospective search for laryngeal sarcomas from our pathology archives and consultation files of one of the authors was performed. We studied 27 primary laryngeal sarcomas that included 25 males, and 2 females, with a mean age of 60 years (range 33–85). The cases included conventional chondrosarcoma (16), well-differentiated liposarcoma (2), clear cell chondrosarcoma (1), leiomyosarcoma (2), high grade myxofibrosarcoma (2), high grade myofibroblastic sarcoma (1), low-grade myofibroblastic sarcoma (1), malignant granular cell tumor (1), and Kaposi sarcoma (1). Data on treatment and follow-up was available in 17 and 16 cases, respectively. 12 patients underwent partial laryngeal resection; five had total laryngectomy, and the patient with Kaposi sarcoma received combined highly active antiretroviral therapy and chemotherapy. Three patients developed local recurrence, and two patients developed metastases. The remaining patients with follow up had a favorable outcome and were disease-free after treatment. The important differential diagnosis of spindle cell sarcoma is sarcomatoid squamous cell carcinoma, and their distinction often requires extensive sampling of the mucosal surface and immunohistochemical analysis. The mainstay of treatment for laryngeal sarcomas is surgical removal, with the extent dictated by tumor type and grade. Adjuvant therapy is reserved for high-grade sarcomas and may be given in a neoadjuvant or adjuvant setting.     

Laryngeal chondrosarcoma: gross pathological, histologic and electron microscopic characteristics

Chondrosarcoma is an uncommon cartilaginous tumour of the upper respiratory tract, and its morphology and clinical course vary widely. Few reports have evaluated the clinicopathological findings of this tumour in the larynx. This paper reports on a low-grade chondrosarcoma in a 44-year-old woman who required laryngectomy for cure. The gross pathological, histologic and electron microscopic features of the tumour are analysed with respect to its clinical course, using histopathological criteria.     

Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves.

Resections at the cricoid level pose the problems of damage to the recurrent laryngeal nerve and loss of circumferential cartilaginous support. Strictures within the cricoid ring have usually been managed with keels or stents, whereas neoplasms have been managed by laryngectomy. This paper reports on 6 patients with lesions involving the cricoid who were successfully treated by segmental tracheal resection and removal of all but a thin shell of posterior cricoid plate. The distal trachea was anastomosed at the subglottic level within 1 cm. or less of the vocal cords. Two patients had traumatic transection at the cricotracheal level with disruption of cricoid cartilage and avulsion of both recurrent nerves. Of the other 4 patients with tracheal lesions involving the cricoid, 2 had postintubation strictures, another had chemical burns, and the fourth had adenoid cystic carcinoma. Primary healing and good clinical results were obtained in all 6 patients. In the 4 patients with intact recurrent nerves, nerve function was preserved. This technique provides a method for resection and reconstruction in one stage for selected lesions at the cricoid level.     

Chondrosarcoma of the larynx: Challenges in diagnosis and management

Chondrosarcoma is a rare neoplasm of the larynx with approximately 200 cases reported in the literature. The infrequent occurrence of this neoplasm, and its indolent pattern of growth, can result in a delayed or missed diagnosis, thereby jeopardizing the preservation of laryngeal function. Four cases of chondrosarcoma of the larynx are presented demonstrating the challenges in the diagnosis and management of this neoplasm. Conservation surgery remains the mainstay of therapy aiming towards preservation of the framework and function of the larynx. Two innovative reconstructive techniques are presented which made conservation laryngeal surgery possible in two of the four patients. Indeed, surgical resection with sound oncologic principles must be applied and total laryngectomy may be necessary. On rare occasion radiotherapy may be used, although its value remains controversial. © 1994 John Wiley & Sons, Inc.     

髋部骨肿瘤的全髋关节置换和保肢

目的：研究髋部骨肿瘤的全髋关节置换和保肢疗效。方法：总结分析29例29髋髋部骨肿瘤病例，男18例，女11例，年龄32－67岁，平均43．7岁。骨巨细胞瘤14例，软骨肉瘤4例，骨成纤维细胞瘤2例，骨肉瘤4例，复发性软骨瘤2例，骨囊肿骨折3例，27例采用肿瘤型人工全髋关节假体置换，2例采用人工半骨盆全髋关节假体置换。股骨切除长度14－21cm。结果：29例均安全渡过围手术期，获平均4年10个月随访，除2例髋骨肿瘤人工半骨盆全髋置换术后分别于2年后急性肺炎和1年7个月肿瘤复发转移死亡外，其余27例均存活，并从事家务和工作，结论：根据髋骨肿瘤的类型，切除后选择适当假体和治疗方法，对重建髋关节功能、保留肢体是安全可行的。     

Strategy of the surgical treatment of primary tumors of the spine

The surgical treatment of the primary spinal tumors is started after the analysis of the following data: --location of the tumor, --pathological identification after the biopsy examination, --staging of the lesion according to Enneking. In case of benign tumors it is possible to realize: a total resection by morcellement until healthy margins in case of chondroma or osteochondroma, intralesional excision until healthy borders in case of osteoid osteoma, total excision by partial anterior or posterior vertebrectomy (with previously embolization) according to the location (body or neural arch resection) in case of giant cells tumour or aneurysmal bone cyst. In case of malignant tumors, the total resection is an absolute goal when the feasability occurs (total vertebrectomy), in case of chordoma, chondrosarcoma and malignant giant cells tumours; the stabilization surgery is indicated without attempt of total tumor removal because others means are availables and/or accurates (radio and/or chemotherapy) in cases of Ewing's sarcoma, plasmocytoma and lymphoma.