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

A spectrum of treatment plans and surgical procedures is available for management of early and moderately advanced laryngeal cancer. While the approach of chemotherapy and irradiation, or irradiation alone, followed by total laryngectomy for failure is often employed in practice by present day clinicians, the options of conventional conservation surgery (CCS), transoral endoscopic laser surgery (TLS) and supracricoid partial laryngectomy (SCPL) provide a wide choice of treatments that may help attain the goal of cure with preservation of laryngeal function and integrity of the airway. While CCS has been supplanted for many early-stage lesions by TLS and for more advanced stages by SCPL, centres throughout the world have reported favourable results with CCS, which is often modified to include resection of more extensive tumours than was previously possible. During the past decade a number of extended CCS procedures have been developed for management of glottic tumours involving both vocal cords and the anterior commissure, the paraglottic space and with vocal cord fixation, and for supraglottic tumours involving the glottis or hypopharynx. TLS has proved an effective, minimally invasive and functionally satisfactory procedure for management of suitable T1 and T2 glottic cancers, and stage I-III supraglottic cancers. The procedure may be effectively employed in combination with neck dissection and postoperative radiotherapy when necessary, particularly for moderately advanced supraglottic carcinomas. SCPL has proven effective in management of glottic and supraglottic cancers of all stages, even with involvement of paraglottic space and thyroid cartilage, provided at least one arytenoid unit can be preserved with clear margins. Invasion of cricoid cartilage is the most significant limitation for this procedure. All three surgical approaches have been employed for irradiation failure, but with greatly increased failure and complication rates compared with the results of treatment of non-irradiated patients. Thus a decision to treat laryngeal cancer initially with irradiation may preclude a satisfactory result from partial laryngectomy should radiation fail. The treatment of laryngeal cancer should be individualized according to the size and extent of the tumour, the age and physical condition of the patient, and the skill and experience of the surgeon with various treatment modalities and surgical procedures.     

Current trends in initial management of laryngeal cancer: the declining use of open surgery

The role of open surgery for management of laryngeal cancer has been greatly diminished during the past decade. The development of transoral endoscopic laser microsurgery (TLS), improvements in delivery of radiation therapy (RT) and the advent of multimodality protocols, particularly concomitant chemoradiotherapy (CCRT) have supplanted the previously standard techniques of open partial laryngectomy for early cancer and total laryngectomy followed by adjuvant RT for advanced cancer. A review of the recent literature revealed virtually no new reports of conventional conservation surgery as initial treatment for early stage glottic and supraglottic cancer. TLS and RT, with or without laser surgery or CCRT, have become the standard initial treatments for T1, T2 and selected T3 laryngeal cancer. Photodynamic therapy (PDT) may have an emerging role in the treatment of early laryngeal cancer. Anterior commissure involvement presents particular difficulties in application of TLS, although no definitive conclusions have been reached with regard to optimal treatment of these lesions. Results of TLS are equivalent to those obtained by conventional conservation surgery, with considerably less morbidity, less hospital time and better postoperative function. Oncologic results of TLS and RT are equivalent for glottic cancer, but with better voice results for RT in patients who require more extensive cordectomy. The preferred treatment for early supraglottic cancer, particularly for bulkier or T3 lesions is TLS, with or without postoperative RT. The Veterans Administration Study published in 1991 established the fact that the response to neoadjuvant CT predicts the response of a tumor to RT. Patients with advanced tumors that responded either partially or completely to CT were treated with RT, and total laryngectomy was reserved for non-responders. This resulted in the ability to preserve the larynx in a significant number of patients with locally advanced laryngeal cancer, while achieving local control and overall survival results equivalent to those achieved with initial total laryngectomy. Following this report, similar “organ preservation” protocols were employed in many centers. By 2003, results of the RTOG 93-11 trial, utilizing CCRT as initial treatment, were published, demonstrating a higher rate of laryngeal preservation with this protocol. Surgery was reserved for treatment failures. This concept changed the paradigm for management of advanced laryngeal cancer, greatly reducing the number of laryngectomies performed. While supracricoid laryngectomy has been employed for selected patients, total laryngectomy is the usual procedure for salvage of failure after non-surgical treatment.     

环状软骨上喉次全切除术后喉功能探讨

目的 探讨环状软骨上喉次全切除术后喉功能的恢复。方法 分析2002-2004年行环状软骨上喉次全切除术21例喉癌患者,其中声门型14例,行环状软骨-舌骨-会厌固定术：声门上型7例,行环状软骨-舌骨固定术。结果 术后30-45天拔管,平均拔管时间为36．4天,拔管率为90．5％（19／21）;大多患者术后有误咽,经训练后全部恢复正常饮食及发音功能但有不同程度的嘶哑。结论 环状软骨上喉次全切除术是保留喉功能的有效术式。     

Transglottic carcinoma: a histopathological study of 64 cases]

Sixty-four cases of the transglottic carcinoma treated with surgical operations at our hospital were reviewed. The anatomical sites and the serial sections of the tumour specimens were observed. It indicated that 42 cases were proved to be supraglottic carcinomas; 7 glottic; 5 subglottic. Ten cases had no definite primary sites. There was no T1 lesion and only one pT2 lesion. 98.4% of the specimens showed pT3-pT4. 75% specimens lesions greater than or equal to 2 cm. Thus we suggest that the so called transglottic carcinoma should be regarded as an advanced lesion of the laryngeal cancers. The advanced cancers can spread into the paraglottic space and invade the laryngeal frame-works as a special pathological features. The paper also discussed the primary site of the transglottic lesion. We think that it is reasonable to classify the laryngeal cancers into supraglottic, glottic and subglottic categories. The idea to classify tumours that originate in the ventricle into an independent type, i.e. transglottic carcinoma, will wait for further discussions.     

Supracricoid Laryngectomy With Cricohyoidopexy (CHP) in the Treatment of Laryngeal Cancer: A Functional and Oncologic Experience

Subtotal laryngectomy with cricohyoidopexy (CHP) results in a satisfactory cure rate in selected T1b, T2, and T3 supraglottic and glottic cancers. The clinical, oncologic, and functional results of this type of surgery have led to an ever-increasing number of patients undergoing this procedure. This study involved 70 patients operated on from 1984 to 1993 using this surgical procedure. This report also discusses the clinical (cTNM) and pathologic (pTNM) classifications of CHP cases. Fifty-two of these patients were evaluated after a follow-up of more than 3 years. Lymph node treatment protocol comprised 51 functional ipsilateral neck dissections (FNDs), 9 bilateral FNDs, 1 radical ipsilateral dissection, and 1 radical ipsilateral and contralateral FND. There were 6 recurrences (5 local, 1 neck); after CHP physiologic deglutition was recovered in most of the patients (95.5%), and all but 6 (92%) were decannulated. Results were excellent after phoniatric rehabilitation. This surgical procedure may be indicated for selected laryngeal cancers and allows for the preservation of laryngeal functions even when the neoplastic lesions are advanced. However, care must be taken when evaluating the infiltration of the paraglottic space, as that infiltration represents the main cause of failure in this type of surgery.     

环状软骨上喉次全切除术及其疗效

目的 探讨环状软骨上喉次全切除术的可行性及其适应证。方法 选择自１９８８～１９９６年不宜行常规水平或垂直半喉部分切除术的Ｔ２和Ｔ３喉鳞癌患者２１例行环状软骨上喉次全切除术。声门上型９例,声门型１０例,跨声门型２例。临床分级：Ｔ２期１６例,Ｔ３期５例。手术切除范围;舌骨、甲状软骨板、会厌前间隙和声门旁间隙,保留环状软骨和至少一侧杓状骨或部分正常会厌软骨。吹功能重建主要采用环状软骨舌根（会厌舌根）吻合     

Plattenepithelkarzinome an der vorderen Kommissur

Summary Sixty-one glottic and 57 supraglottic advanced carcinomas of the larynx were investigated histologically by serial coronal sections. Twenty-nine glottic cancers spreading out more horizontally also rose from the anterior commissure. Seven supraglottic and 24 glottic carcinomas with a vertical extension to the sub- or supraglottic space involved the anterior commissure or the anterior subglottic wall secondary. After a short introduction in the actually known principles of the anatomy of laryngeal cancer the behaviour of squamous cell carcinomas at the anterior commissure was reported.Carcinomas of the anterior commissure have a high tendency to involve the anterior subglottic wall. Tumour growth in this area is the most important condition for penetration of the laryngeal framework. Nearly all these cancers broke through the lower frontal ossified part of the thyroid cartilage without or including the cricothyroid membrane. Therefore glottic cancers with subglottic spread also preferred this direction to the prelaryngeal space. The importance of further histological findings for the technique of partial laryngectomy is discussed.More than the half of the investigated carcinomas were treated by a planned preoperative irradiation of 3.000 rad. By comparison with the posterior region the frontal areas of these tumours showed microscopically a lower visible response to the radiotherapy. In our opinion this indicates that radiation failure in carcinomas of the anterior commissure is caused by the usually applied cross field radiation technique.     

Supracricoid partial laryngectomy with cricohyoidopexy

The supracricoid partial laryngectomy (SCPL) with cricohyoidopexy (CHP) is an alternative to total laryngectomy in the treatment of selected glottic and supraglottic cancers. It consists of the resection of the true cords, false cords, thyroid cartilage and epiglottis, while the cricoid cartilage and at least one of the two arytenoid cartilages are spared. Reconstruction is performed by securing the cricoid cartilage to the hyoid bone. Careful patient selection is of paramount importance for the success of this procedure. In general, the indications for SCPL with CHP include selected supraglottic and glottic tumors that do not involve the subglottis or the arytenoid cartilages. When properly performed, the speech and swallowing function is preserved in a high percentage of patients. The specific indications and the surgical technique are presented here.     

The role of laser microsurgery in the treatment of laryngeal cancer

PURPOSE OF REVIEW: Transoral laser microsurgery has developed in recent years into a surgical method that combines a minimally invasive approach with the surgical precision of laser and microscope. The outcomes of laser microsurgical treatment of laryngeal carcinomas are reviewed and compared with the results of competitive standard procedures. RECENT FINDINGS: Laser microsurgery is widely acknowledged to have advantages in the treatment of early glottic carcinoma. In the treatment of glottic carcinoma causing impaired mobility or fixation of the vocal cord the role of laser surgery has not yet been definitively assessed. Based on published results, primary laser therapy can achieve local tumor control with a functional residual larynx in approximately 70-80% of cases. In patients with early or moderately advanced supraglottic carcinoma, laser microsurgery is comparable to open supraglottic laryngectomy in terms of local control and survival. With regard to organ preservation, laser microsurgery is comparable to open supraglottic laryngectomy but superior to radiotherapy. Microsurgery can preserve functionally important structures, allowing for early swallowing rehabilitation while avoiding tracheotomy. SUMMARY: This review elucidates the role of laser microsurgical partial resections of the larynx in comparison with other treatment modalities.     

Feasibility of supracricoid laryngectomy based on pathological examination

Partial horizontal supracricoid laryngectomy with cricohyoidopexy at the Department of Otolaryngology, Medical University of Białystok, involves resection of the entire thyroid cartilage with the pre-epiglottic and paraglottic spaces. Experience has shown that this technique will permit adequate phonation, respiration and deglutition in selected advanced cases of supraglottic and glottic carcinoma. The purpose of this study was to verify histologically the indications for this surgery by examining sections of whole-organ laryngeal specimens. Post-laryngectomy specimens from 90 patients with otherwise previously untreated supraglottic (48), transglottic (22) and glottic (20) carcinomas were reviewed retrospectively. The majority (66) of the specimens were staged as pT₄. Findings showed that 22 of the specimens analyzed (mostly supraglottic tumors) could have been eradicated by supracricoid laryngectomy alone. The present study confirmed the principles of supracricoid laryngectomy for selected large tumors. Received: 4 June 1997 / Accepted: 23 September 1997     

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。     

环状软骨上喉部分切除术的探讨

目的　通过对 18例喉癌患者的手术治疗 ,就环状软骨上喉部分切除术的有关问题进行探讨。方法　声门癌T1N0 M0 1例 ,T2 N0 M0 9例 ,T3N0 M0 2例 ,跨声门癌T3N1M0 3例 ,T3N2 M0 1例 ,T2 N0 M0 放射治疗后复发 1例 ,声门下癌T4N0 M0 1例 ;应用三种不同的环状软骨上喉部分切除术技术进行治疗。结果　 3年生存率 94 .4 %。所有患者均于术后第 7～ 4 2天 (平均 17天 )拔除气管套管 ,拔管率 10 0 % ;所有患者均在术后第 14～ 3 0天 (平均 2 2天 )拔除鼻饲管。术后所有患者均完全恢复了喉的发声、呼吸、吞咽及维持声门下压的生理功能。术后的发音情况也令人满意。结论　环状软骨上喉部分切除术打破了以往根据喉癌肿瘤临床分期决定喉部分切除与否的传统观点 ,为喉癌的手术治疗提出了一条新的术式。它在保证完整、安全有效地切除喉肿瘤病灶的同时 ,更加考虑到患者术后的功能及生存质量的改善 ,同时又能达到喉全切除术同样的局部控制率 ,值得推广应用     

环状软骨上喉次全切除术后喉功能的临床分析

目的分析喉鳞状细胞癌患者接受环状软骨上喉次全切除(supracricoid partial laryngectomy,SCPL)术后喉功能的情况。方法回顾性分析2000~2006年采用SCPL治疗喉鳞状细胞癌患者38例,其中声门上型17例,声门型21例;术后辅助放射治疗8例,剂量累计为60~65 Gy。对切除(或)保留会厌、保留一侧(或)双侧杓状软骨患者术后呼吸、发音、吞咽功能分别进行评估。所得结果运用统计学方法进行检验。结果所有患者随访至今,无失访;3年生存率81.6%,5年生存率73.7%。其中声门上型喉癌3年生存率76.5%,5年生存率64.7%;声门型喉癌3年生存率85.7%,5年生存率81.0%。所有患者均拔除气管套管,拔管率为100%。切除会厌和一侧杓状软骨患者的误咽评分、平均气管套管拔除时间、平均鼻饲胃管拔除时间和平均住院天数均高于其他组,差异具有统计学意义;而呼吸、发音评估各组之间比较差异无统计学意义。结论 SCPL对喉癌治疗和喉功能保留有积极意义,临床分析表明会厌和一侧杓状软骨切除对于患者远期喉功能恢复无影响。     

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open vs. laser microsurgical approaches for partial resections of the larynx are described, oncological as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.     

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.     

环状软骨上喉部分切除术斩探讨

目的 通过对１８例喉癌患者的手术治疗，就环状软骨上喉部分切除术的有关问题进行探讨。方法 声门癌Ｔ１ＮｏＭｏ１例，Ｔ２ＮｏＭｏ９例，Ｔ３ＮｏＭｏ２例，跨声门癌Ｔ３Ｎ１Ｍｏ３例，Ｔ３Ｎ２Ｍｏ１例，Ｔ２ＮｏＭｏ放射治疗后复发１例，声门下癌Ｔ４ＮｏＭｏ１例；应用三种不同的环状软骨上喉部分切除术技术进行治疗。结果 ３年生存率９４．４％。所有患者均于术后第７￣４２天（平均１７天）拨除气管套管，拨管率１００％；     

Supracricoid Partial Laryngectomy After Failed Laryngeal Radiation Therapy

Twelve patients managed with supracricoid partial laryngectomies(SCPLs) after failed laryngeal radiation therapy (RT) were evaluated. None of the recurrent tumors were amenable to vertical or horizontal partial laryngectomy. Results were analyzed for tracheostomy decannulation, oral alimentation, morbidity, local control, and survival. Major complications included perichondritis (2 patients), laryngeal stenosis (2 patients), and pneumonia from aspiration (1 patient). Mucocutaneous fistula and cricoarytenoid joint ankylosis were not encountered. Margins of resection were uninvolved in all cases. The Kaplan-Meier 3-year actuarial survival and local control estimate was 83.3%. Salvage total laryngectomy allowed for an overall 100% local control rate and a 75% laryngeal preservation rate. This preliminary report suggests that, in patients with failed laryngeal RT not amenable to vertical or horizontal partial laryngectomy, the SCPL procedures should be discussed before advocating salvage total laryngectomy. Further series analyzing the role and limitations of the various SCPL procedures after failed laryngeal RT are warranted.     

Phonatory mechanisms after vertical partial laryngectomy with glottic reconstruction by false vocal fold flap

A prospective randomized study was designed to compare phonatory mechanisms in patients treated with frontolateral partial laryngectomy (FLPL) with or without glottic reconstruction with false vocal fold (FVF) mucosal flap. Objective voice assessment was based on computerized acoustic recordings and videolaryngostroboscopy performed before, 1 year after, and 2 years after surgery. Phonatory mechanisms were studied according to the surgical technique and correlated with acoustic recordings. The results showed that supraglottic structures participated in laryngeal closure and voice production in 80% of cases in which a standard FLPL was performed. The FVF mucosal flap was involved in both laryngeal closure and voice production in 54% of patients treated with glottic reconstruction. The type of laryngeal closure (glottic or supraglottic) statistically influenced the acoustic measurements. As glottic closure is more frequent in patients treated with glottic reconstruction, the authors recommend performing reconstruction of the glottis with an FVF mucosal flap when an FLPL is indicated.     

El papel actual de la cirugía parcial como estrategia de preservación funcional en el carcinoma de laringe

With the current advances and recent organ preservation protocols for intermediate or advanced stage laryngeal cancer, based on chemotherapy, the role of surgery seemed replaced except for surgical rescue of tumours not responding to these treatments, total laryngectomy being the surgical option. This type of non-surgical treatment is offered as a strategy for organ preservation, as opposed to total laryngectomy. However, we believe that there are two organ-preservation strategies, surgical and non-surgical. A wide spectrum of surgical techniques is available and such techniques lead to excellent results, both oncological and functional (speech and swallowing). The aim of this paper is to present options for organ-preserving surgery for laryngeal cancer. A review of surgical techniques available for functional preservation in cancer of the larynx at intermediate or advanced stage is presented. In addition to classic approaches such as vertical partial laryngectomy and horizontal or supraglottic laryngectomy, options for conservative laryngeal surgery have improved significantly over the past two decades. Minimally invasive surgery, transoral laser surgery, and supracricoid partial laryngectomy have become important laryngeal preservation approaches for patients with laryngeal cancer. Surgery must define its role in the multidisciplinary treatment of advanced cancers of the larynx, which at present often favours (chemo)radiotherapy protocols.     

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.