Research Article
Outcome of Supraglottic Horizontal Laryngectomy
Felipe Guilherme da Silva Souza1, José Luiz Ortiz Bogado1 and Rogério Aparecido Dedivitis2*
1Department of Head and Neck Surgery, Hospital Ana Costa, Brazil
2Department of Head and Neck Surgery, Hospital das Clínicas, Brazil
*Corresponding author: Rogério Aparecido Dedivitis, Department of Head and Neck Surgery, Hospital das Clínicas, Santos, 1045- 000, São Paulo, Brazil
Published: 06 Jul 2017
Cite this article as: da Silva Souza FG, Bogado JLO,
Dedivitis RA. Outcome of Supraglottic
Horizontal Laryngectomy. Clin Surg.
2017; 2: 1537.
Abstract
Introduction: Nowadays the main objective on treatment for laryngeal carcinomas is to achieve
function preservation in addition to cancer cure. The Horizontal Supraglottic Laryngectomy shows
adequate outcome in both.
Objective: Evaluate the outcome in a group of consecutive patients undergoing HSGL.
Methods: Between 1997 and 2016, 15 patients treated for supraglottic and base of the tongue
Squamous Cell Carcinoma (SCC) with HSGL were retrospectively studied.
Results: There were 9 patients with T2 and 6 with T3 tumors. Among these, 3 patients had clinical
negative neck disease. All patients underwent HSGL. Ten patients were submitted to bilateral
radical neck dissection, where as 4 patients were submitted to ipsilateral radical and contra lateral
neck dissection. Adjuvant radiotherapy was given to all patients. The follow up ranged from 12 to
60 months. Five-year disease-specific survival and loco regional control were 73.3%. All patients
recovered a close to normal function after the treatment. A median of 16 days (7–60) was necessary
to recover a close to normal diet. Decannulation took a median of 17 days (8–65). One patient
died from aspiration. There was no permanent tracheostomy or total laryngectomy for functional
purposes.
Conclusion: HSGL remains an adequate therapeutic alternative for supraglottic SCC. Good
laryngeal function recovery is the rule.
Keywords: Laryngeal neoplasms; Laryngectomy; Carcinoma; Squamous cell; Radiotherapy;
Adjuvant; Retrospective Studies
Introduction
Laryngeal cancer is the second most common type of head and neck cancer worldwide [1].
The supraglottis represents the primary tumor site from 30% to 40% of laryngeal carcinoma
cases, however, in certain geographic regions it tends to be the most frequently implicated subsite
[2]. Due to its rich lymphatic drainage system and the relatively late appearance of symptoms,
diagnosis is often made at a more advanced stage; hence, prognosis has traditionally been poorer
for supraglottic carcinomas, compared to glottic lesions [1,3]. Nevertheless, the goal of treatment
for early supraglottic carcinomas currently is to achieve function preservation in addition to cancer
cure [4-6].
Justo Alonso first described the technique of Horizontal Supra Glottic Laryngectomy (HSGL)
[7], in 1946. The original surgery allows the resection of supraglottic tumors that are placed anteriorly
to the arythenoids without compromising the vocal folds. Modifications to the original technique
included avoiding the temporary pharingostoma [8] by performing primary closure without the
skin graft [9] and preserving the hyoid bone, based on larynx embriology studies, which support the
compartimentalization of the organ in independent parts [10]. The understanding of the anatomy of
the supraglottic larynx and possible avenues of tumour extension, together with the observation that
cancer in early stages tends to remain localized within the boundaries of the supraglottis, formed the
basis of the HSGL [11].
It is a surgical technique that allows the appropriate resection of the tumor, reestablishing
swallowing function and maintains breathing function through its natural way and a good
phonation [12]. It is indicated for supraglottic tumors with mobile vocal folds and arythenoids,
as well as tumors which extend to the aryepiglottic fold or to the cranial part of the vestibulary
folds through the posterior epiglottic wall and additionaly to tumors compromising the base of the
tongue through the anterior epiglottic wall. It can be recommended for tumors affecting the medial wall of the pyriform recess, one arythenoid, laryngeal ventricle and
cranial wall of the vocal fold [13].
In recent years, partial laryngectomy by laser microsurgery and
through robotic surgery have become a recognized alternative to
transcervical approach for supraglottic laryngeal cancer treatment.
The oncological results are comparable to those achieved by classic
supraglottic laryngectomy; despite this, the endoscopic and robotic
approaches offer several advantages, such as avoiding tracheotomies,
reducing the incidence of pharyngocutaneous fistula, allowing a faster
swallowing rehabilitation, preventing aspiration pneumonia and
shortening hospitalization [14-17]. The objective of this article is to
analyse the oncological results of a series of patients who underwent
HSGL.
Table 1
Methods
Fifteen consecutive medical records of patients who underwent HSGL at the Departments of Head and Neck Surgery of Irmandade da Santa Casa de Misericórdia de Santos and Hospital Ana Costa, Santos, from January, 1997 to December, 2015 were retrospectively reviewed. Demographic data, clinical condition, tumor site and staging, surgical procedure, complications, oncological results and the need for tracheotomy and feeding tube were evaluated. Besides technical indications shown above, we also consider pulmonary conditions, not age alone, one of the indications criteria for HSGL.
Results
The 15 medical records were retrospectively reviewed. Age varied
from 42 to 68 years (median, 57). Twelve patients were men; 14 were
chronic smokers; and 11 were alcohol users. The main complaints
were dysphagia and foreign body sensation in the throat. There
were 11 supraglottic tumors and 4 of the base of the tongue, being 9
patients staged as T2 and 6 as T3. Three patients had clinical negative
neck – Table 1.
All patients underwent bilateral neck dissection and its extesion
was based in the clinical staging and intraoperative findings. When
evaluating clinical and pathological staging, we notice that there was a
clinical under evaluation of the neck. In four cases there was the need
for total resection of one arythenoid – Table 1. All patients underwent
postoperative radiotherapy, whose dosis varied from 5,500 to 7,020
cGy (median, 7,020 cGy), due to pathological neck staging [14] or
primary tumor margins [1].
The follow up varied from 12 to 60 months. Seven patients were
alive and without evidence of disease; 2 patients died of a second
primary tumor (esophagus and lung); 1 patient died of another cause
(cardiopathy); 1 patient died due to aspiration; and 4 patients died of
the diesease, being 1 with a distant metastasis and 3 with locoregional
recurrence. Thus, specific survival rate and its locoregional control
were of 73.3% in five years.
All patients were decannulated, within 8 to 65 days (average, 17
days) and feeding tube was also removed in all cases, within 7 to 60 days
(average, 16 days). In cases which the primary tumor compromised
the base of the tongue, decannulation and feeding tube removal
occurred later (after 4 weeks). No definitive tracheotomy or total
laryngectomy for functional reasons were necessary. Unfortunatelly,
1patient removed the feeding tube precociously by himself, despite
advice from the medical staff and eventually died due to aspiration.
Discussion
In the past two decades organ preservation has been a major
target for clinical research in head and neck cancer. Since the first
total laryngectomy was undertaken in 1873, efforts have been made
to avoid removing the entire larynx. The objective of conservation
laryngeal surgery was designed to be oncologically sound, however,
also to be voice saving and to avoid morbidity [18]. Nowadays, the
treatment of supraglottic carcinoma is still a controversial issue. Two
accepted oncological treatments have been currently established,
namely standard supraglottic laryngectomy and radiotherapy or
both options may be utilized [19]. Early or moderately advanced
supraglottic carcinoma may be treated successfully with either
supraglottic laryngectomy or radiotherapy [20].
Supraglottic partial laryngectomies require the resection of
natural protective barriers, such as epiglottis, aryepiglottic folds
and false vocal folds; this could lead towards penetration and/or
aspiration in either latent or clinical manifestation. Moreover, surgical resection extended to the tongue base and/or arytenoid cartilage
could expose patients to major risk of swallowing disturbances [21].
For infiltrative tumors staged as T2 and T3 or with extension to the
valecula or the base of the tongue with laryngeal mobility preserved,
HSGL is recommended, since the patient’s clinical status allows
[22]. Contraindications include extension to the ventricles, anterior
commisure, paraglottic spaces and thyroid cartilage [23].
After HSGL, patients have an increased risk for deglutition and
aspiration, as they may not be able to put the tongue base over the
laryngeal entrance during swallowing, especially if the surgical
defect of the tongue base has increased. However, the duration until
nasogastric tube removal had a highly significant association with
the tongue base infiltration width. The radiologically determined
infiltration height of the base of the tongue width and area are
useful tools for surgical planning as they can be used to predict
postoperative swallow function. Thereby, in a patient group with the
tongue base infiltration area <6.20 cm2, 50% of the nasogastric tubes
were removed after 4 days (95% CI 0–8.6 days). In patients with base
of the tongue infiltration area >6.20 cm2, 50% of the nasogastric tubes
were removed after 22 days (95% CI 6.8–37.2 days) [24].
Free mobility of the vocal folds is an essential element to
conventional HSGL. Dysphonia comes from vocal fold submucosa
infiltration, probably demanding a wider resection [25]. Invasion of
preepiglottic space is a diagnostic problem. It should be suspected in
cases of infiltration through the thyrohyoid membrane and can be
shown by imaging methods and fine needle aspirative punction with
cytopathological evaluation [26].
The modern armamentarium of organ preservation treatment
for supraglottic cancer includes Transoral CO2 Laser Microsurgery
(TLM), open partial laryngectomy and radiotherapy with or without
concomitant chemotherapy, in single or combined modality schemes.
For accurately staged cases, the outcome of organ-preservation
treatment modalities should be comparable with results achieved by
total laryngectomy [6]. Moreover, important functions of the larynx,
including respiration, safe deglutition and phonation, can be retained
with organ-preservation treatment, with significant positive impact
on the patient’s quality of life [27].
TLM was introduced in laryngeal cancer surgery by Strong
and Jacko [28] in 1972. Vaughan [29] first described supraglottic
cancer excision with laser in 1978. Nowadays, TLM represents a
minimally invasive surgical approach which allows tumors to be
removed with limited sacrifice of healthy tissue and with retention of
organ function. Functional results of TLM are generally considered
superior to those obtained with open approaches and in many cases
comparable to radiotherapy. Other advantages of TLM include low
morbidity and mortality, avoidance of tracheotomy, shorter periods
of hospitalization and lower costs. In addition, TLM has repeatedly
demonstrated cure rates for supraglottic cancer comparable with
those of open surgery or primary radiotherapy[6].
Supraglottic tumors may be removed through HSGL with a
caudal margin which can be measured in millimeters and still be
adequate. It is shown that recurrences happen almost invariably in
the base of the tongue, not in its caudal margin [30]. However, frozen
section control is recommended as an indicator for further resection,
although frozen sections do not always correlate with permanent
pathology [31]. Nevertheless, local control is excellent, varing from
70% to 100% [32].
Supraglottis contains a rich lymphatic net. Therefore, tumors
developing in this area frequently produce neck metastasis – 48%
in a series of 932 patients [33]. Due to the large variation and
intercommunication of these lymphatic vesses, it is impossible to
predict the exact location of the metastasis. It is now widely accepted
that the clinically no neck should always be included in the primary
treatment plan of supraglottic lesions [34-36]. Such a tactic is based
on the knowledge that supraglottic cancer, even during early local
stage, is characterized by a significant incidence of occult metastases
in the neck [37,38]. Moreover, it has been previously shown that the
survival of patients with supraglottic cancer is largely determined
by this high rate of cervical node metastases and failure in the neck
is generally the most likely cause of treatment failure [34,37]. The
procedure is performed ipsilateral to the lesion in laterally localized
tumors and bilaterally in the rest of the cases.
Five year survival rate is strictly attached to neck staging, as was
verified in an analysis of 10,989 cases of 23 different oncological
treatment centers [39]. N0 43%; N1 30%; N2 25% and N3 10%.
Regional control of supraglottic tumors varies in the literature from
76 to 96% [32]. Neck recurrences are more common among N2 and
N3 patients, especially when there is capsular rupture and extranodal
spread [40]. On the other hand, rarely can salvage surgeries be
successfully performed for recurrences. Cartilage infiltration
influences local control (p=0.03) and specific disease survival rates
(p=0.06), showing worst survival when neck lymph nodes are
compromised (p=0.15) and in extralaryngeal tumor extension cases
(p=0.1). The systematical neck bilateral lateral neck dissection (II, III
and IV) is not only therapeutic, but also diagnostic.
Second primary tumor is a possible failure cause, happening
mainly in lungs and being diagnosed in imaging methods as a routine
[41]. In a retrospective 268 series of cases, multivariate analysis has
shown that N3 neck staging (p=0.0003) and locally T4 staged tumors
(p=0.004) are two independent predictive parameters of reduced
specific disease free survival rate [11].
In a series of 41 patients who underwent HSGL, 87.8% did not
show complications. There has been 3 cases of fistula. Functional
results were good, with 100% of satisfactory phonation and swallowing
after the second or third postoperative week [42]. Decannulation
can be postponed due to arythenoid edema when patients are also
treated with radiotherapy. Pulmonary function must be compatible
with the procedure. Preoperative functional evaluation is highly
recommended [43].
Conclusion
The HSGL remains as a therapeutic option for the supraglottic carcinoma, allowing good reestablishment of laryngeal function.
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