pT3 N0 Laryngeal Squamous Cell Carcinoma: Oncologic Outcomes and Prognostic Factors of Surgically Treated Patients

Lymph Node Yield/Ratio, Neutrophil-Lymphocyte Ratio: Prognostic Factors in cN0 Laryngeal Carcinoma

OBJECTIVES

The aim of this study was to investigate the role of lymph node yield (LNY), lymph node ratio (LNR), and neutrophil to lymphocyte ratio (NLR) as prognostic factors, their impact on survival in patients with advanced laryngeal squamous cell carcinoma (LSCC).

METHODS

This multicentric retrospective study included 195 patients with clinical N0 advanced laryngeal carcinoma who underwent total laryngectomy and/or total pharyngolaryngectomy over 5 years. The number of lymph nodes extracted (LNY) and the number of positive nodes were counted. The lymph node ratio "LNR" was calculated as follows: (positive nodes /LNY). Moreover, neutrophil to lymphocyte ratio (NLR) was calculated and documented for analysis.

RESULTS

The mean 5-years DFS and overall survival (OS) was 33 and 35 months. The following were statistically significant factors negatively associated with overall survival; LNR (p = 0.047), NLR > 7 (p = 0.05), preoperative tracheostomy (p = 0.016), infiltrated safety margin (p = 0.01), postoperative radiotherapy (p < 0.001), N stage (p = 0.019), and unilateral neck dissection (p = 0.03). On the other hand, DFS was negatively associated with LNR (p = 0.001), N stage (p = 0.001), and infiltration of the surgical margins (p = 0.001).

CONCLUSION

LNY and LNR are both linked to survival outcomes following neck dissection in patients with clinical N0, locally advanced laryngeal carcinoma, where higher LNY and lower LNR correlated with improved survival and could be easily incorporated into cancer staging systems to aid in the prognostic stratification of patients. Additionally, NLR could act as a cost-effective inflammatory biomarker predicting poor prognosis in LSCC.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:2037-2043, 2025.

Opportunities and limits of open partial horizontal laryngectomies for naïve T3-T4a laryngeal cancer: a systematic review and meta-analysis

Background

The present systematic review aims to investigate the survival rates and surgical outcomes of patients with treatment-naïve, intermediate (T3) to early advanced (T4a) laryngeal squamous cell carcinoma (LSCC) managed with open partial horizontal laryngectomies (OPHLs).

Methods

A systematic literature search was conducted in PubMed, Embase, and Scopus for studies published between January 2000 and December 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Inclusion criteria were: patients with histopathological confirmed LSCC; tumor classified as T3 or T4a stage according to the American Joint Committee on Cancer (AJCC) staging system; having undergone OPHL as the primary treatment without any prior therapy; availability of at least one of the following outcomes: overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), local control (LC), locoregional control (LRC), laryngectomy-free survival (LFS), and laryngo-esophageal dysfunction-free survival (LEDFS).

Results

A total of 16 studies were deemed eligible for the qualitative analysis. The cumulative number of patients was 1473. The sample size ranged from 17 to 390 patients. The follow-up period ranged from 0 to 198 months. In patients treated with OPHL for T3, the overall five-year pooled proportions were OS 0.82, DSS 0.88, DFS 0.80, and LFS 0.86, whereas for the T4a case series, they were OS 0.77, DSS 0.89, DFS 0.74, and LFS 0.78.

Conclusions

OPHL for selected T3 and low extralaryngeal volume T4a LSCC can guarantee a high rate of oncological success. Accurate patient selection is paramount to differentiate advanced diseases that is amenable to conservative surgery.

Impact of neck dissection in cN0 patients undergoing primary or salvage total laryngectomy

INTRODUCTION

It is debatable whether neck dissection is necessary in patients with advanced laryngeal carcinoma who are clinically node-negative (cN0). We assessed the effect of neck dissection on overall survival in patients with cN0 undergoing primary or salvage laryngectomy.

MATERIALS AND METHODS

A retrospective evaluation of cN0 patients who underwent primary or salvage total/pharyngolaryngectomy at a French tertiary facility in 2008-2018, with or without neck dissection, was carried out. Patients were divided into two groups: primary (n = 65) and salvage (n = 84).

RESULTS

Comparing subglottic (HR = 3.978; p = 0.023) and hypopharyngeal (HR = 2.958; p = 0.018) malignancies to other tumor subsites, the mortality rates were greater. The primary group had a greater rate of occult metastases (23.07% vs. 14.28%; p = 0.089) than the salvage. The average lymph node ratio was significantly different between the treatment groups (0.05 ± 0.04 vs. 0.17 ± 0.33; p = 0.004). If LNR > 0.05, we found poor survival rates (p < 0.001). Although performing a neck dissection during the primary treatment increased the 5-year OS rate (Yes 89.5% vs. No 83.3%; p = 0.062), there was no discernible difference in the salvage group (Yes 80.3% vs. No 78.6%; p = 0.806; Log-rank p > 0.05). For the predicted survival variables, no significant relationships were detected in the Cox regression analysis (all p-values > 0.05).

CONCLUSION

Although the primary group had a greater frequency of occult metastases, neither the primary group's survival outcomes nor those of the salvage laryngectomy cases were significantly affected by neck dissection. LNR and the location of the tumor were important variables that could affect survival and the choice to do a neck dissection.

Ten-Year Outcome After Supracricoid Partial Laryngectomy in cT3M0 Laryngeal Squamous Cell Carcinoma-A STROBE Analysis

OBJECTIVES

The aim of this study was to document 10-year outcomes after supracricoid partial laryngectomy (SCPL) in selected cT3M0 laryngeal squamous cell carcinoma (SCC) patients.

METHODS

This real-life retrospective observational study analyzed an inception cohort of 168 patients with isolated, untreated, selected cT3M0 laryngeal SCC, that were consecutively managed by SCPL during the period 1973-2013, and followed up until death or for a minimum of 10 years in 92% of cases at a single French academic and tertiary referral care center. Prior induction chemotherapy, arytenoid cartilage removal, level II-IV neck dissection, and postoperative radiation therapy were performed on 148, 77, 136, and 27 patients, respectively. The main objective was to determine 10-year actuarial local control and laryngeal preservation estimates. Secondary objectives included 10-year actuarial survival and cause-of-death analysis, and assessment of correlations between endpoints and clinical variables. The significance threshold was set at p < 0.005.

RESULTS

Ten-year actuarial local control, laryngeal preservation, and survival estimates were 90%, 85%, and 52%, respectively. Salvage treatment resulted in an overall 99% local control rate. Metachronous second primary cancer, intercurrent disease without evidence of SCC, SCPL-related death, and uncontrolled local recurrence accounted for 31%, 26%, 7%, and 2% of causes of death. On univariate analysis, overall local recurrence and laryngeal preservation rates varied significantly, from 5% to 54% and 90% to 46% when resection margins were R0 and R1, respectively.

CONCLUSION

The present study highlighted successful 10-year outcomes after SCPL, providing further evidence in favor of its integration into the conservative armamentarium for endolaryngeal cT3 SCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4557-4563, 2024.

Effect of Aging on Long-Term Functional Outcomes After Open Partial Laryngectomy

OBJECTIVE

Open partial horizontal laryngectomies (OPHLs) represent a comparable alternative to total laryngectomy and nonsurgical protocols in selected cases. While short-term functional outcomes of OPHLs have been widely investigated, few have focused on the effect of aging on residual laryngeal structures.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care academic center.

METHODS

Patients who underwent OPHLs after at least 1 year follow-up and optimal functional rehabilitation were included in the study. Swallowing function was assessed according to PAS (Penetration aspiration scale) and Pooling scores. Spectrogram analysis of voice was conducted according to Yanagihara classification and acoustic parameters were also recorded. Subjective questionnaire data about phonation and swallowing were also recorded. Data obtained were compared among patients according to age at time of surgery, evaluation and duration of follow-up.

RESULTS

Ninety-seven patients were enrolled with a mean age at surgery and evaluation of 63 and 70 years old, respectively. Median follow-up length was 5 years. OPHL type II was mostly performed. No significant correlation was observed between most of the analyzed variables and patient's age at the time of surgery and at the time of evaluation. Some acoustic parameters were negatively correlated with follow-up length, while Jitter, NHR (Noise-Harmonic Ratio), and Global grade and Roughness were significantly higher in patients >65 years old.

CONCLUSION

Patients who complete rehabilitation reach equally good results as their younger peers with stability over time. Finally, the effects of aging on residual larynx are of minor entity compared to the nonoperated patients.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Current Status of Partial Laryngeal Surgery for Advanced Laryngeal Cancer: When and Why?

PURPOSE OF REVIEW

This paper aims to evaluate the evolution and current status of partial laryngeal surgery in the treatment of advanced laryngeal cancer (LC). Specifically, recent progress in the selection of both patients and tumors, together with surgical and rehabilitation innovations, have contributed to balancing oncological control with the maintenance of quality of life in naïve and radiorecurrent patients. The main aspect is represented by the recognized role of open partial horizontal laryngectomies (OPHLs) in this new era of laryngeal cancer treatment.

RECENT FINDINGS

Recent advancements highlight OPHLs' efficacy for conservative management of intermediate to advanced stages of LC. Innovations such as supratracheal partial laryngectomy have expanded surgical options, offering a modular approach to complex cases. Improved understanding of tumor biology, enhanced imaging techniques, and more precise preoperative planning have led to better patient outcomes, emphasizing the importance of a conservative function-preserving surgical treatment. These advancements reflect a broader trend towards individualized treatment plans that prioritize both survival and quality of life. OPHLs play an important role in current management of intermediate/advanced LC, effectively balancing oncological control with the preservation of laryngeal functions. Critical factors include meticulous patient and tumor selection, the impact of surgical and technological refinements on functional outcomes, and the necessity of a multidisciplinary approach in treatment planning. Current evidence justifies the use of these interventions in many intermediate T-stage laryngeal tumors, even at risk of upstaging on pathological examination. The oncological results, the preservation of laryngeal function and the laryngectomy-free survival achieved with OPHLs appear to be highly competitive with those of non surgical organ-preservation protocols, aiming to introduce a new standard in the LC treatment.

Primary Total Laryngectomy for Endolaryngeal cT3-4M0 Squamous Cell Carcinoma: A STROBE Analysis

OBJECTIVES

To document 10-year oncologic outcome of primary total laryngectomy (TL) for patients with cT3-4M0 endolaryngeal squamous cell carcinoma (SCC).

STUDY DESIGN

Observational inception cohort of 531 patients with isolated untreated endolaryngeal cT3-4M0 SCC review over 40 years using STROBE guideline. 94% of patients were followed until death or for a minimum of 10 years.

SETTING

Academic tertiary referral care center.

METHODS

All patients underwent primary TL. Prior tracheotomy, induction chemotherapy, thyroid gland resection, level II-IV neck dissection, level VI dissection, and postoperative radiation therapy were associated in 6%, 40%, 43%, 89%, 47%, and 74% of cases, respectively: The main objective was to determine the 10-year actuarial local control estimate. Accessory objectives comprised screening for clinical variables increasing the risk of local recurrence, and analysis of long-term oncologic consequences of local recurrence.

RESULTS

The 10-year actuarial local control estimate was 89.7%. Local recurrence was salvaged in 11% of cases, resulting in 92% overall local control. On multivariate analysis, none of the study variables correlated with local recurrence. Local recurrence resulted in significantly reduced nodal control, distant metastasis control, and survival. Postoperative complications, persistent index SCC, intercurrent disease, and metachronous second primary cancer accounted for respectively 3%, 37%, 33%, and 28% of the 334 deaths noted during the 10 years following TL.

CONCLUSION

The present study underscored the long-term oncologic efficacy of primary TL, the dangers of local recurrence, the key role of local control for survival, and the importance of a long-term oncologic watch policy.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2288-2294, 2024.

Prognostic analysis of surgical treatment for T3 glottic laryngeal cancer based on different tumor extension patterns

BACKGROUND AND OBJECTIVES

To investigate the prognostic impact of different tumor invasion patterns in the surgical treatment of T3 glottic laryngeal cancer.

METHODS

We conducted a retrospective analysis of clinical data of 91 patients with T3 glottic laryngeal cancer.

RESULTS

We found that the posterior invasion being significantly associated with involvement of the lamina of cricoid cartilage (P < 0.001), arytenoid cartilage (P = 0.001), and subglottic (P = 0.001). There was no statistical difference in survival outcomes between the total laryngectomy (TL) group and the partial laryngectomy (PL) group, but in the PL group, tumors with anterior invasion were associated with a better 5-year DFS than tumors with posterior invasion (HR: 4.681, 95% CI: 1.337-16.393, P = 0.016), and subglottic involvement was associated with worse LRRFS (HR: 3.931, 95% CI: 1.054-14.658, P = 0.041). At the same time, we found that involvement of the lamina of cricoid cartilage was an independent risk factor for postoperative laryngeal stenosis in PL patients (HR: 11.67, 95% CI: 1.89-71.98, P = 0.008).

CONCLUSION

Selectively performed PL can also achieve favorable oncological outcomes comparable to those of TL. Posterior invasion and subglottic involvement are independent prognostic factors for recurrence after PL in T3 glottic laryngeal cancer, and involvement of the lamina of cricoid cartilage is associated with postoperative laryngeal stenosis. The tumor invasion pattern of patients with laryngeal cancer should be further subdivided to allow for selection of a more individualized treatment plan.

Multicentric Study on Oncological Outcomes and Prognostic Factors of Open Partial Horizontal Laryngectomies

Objective: In recent years, the number of open preservation surgeries for the treatment of laryngeal Cancer has increased. This surgery aims to maintain laryngeal function and ensure oncological radicality, thereby avoiding a total laryngectomy (TL) that could significantly impact the patient's quality of life. The purpose of this study was to assess the oncologic results of OPHL I and II and to identify prognostic factors that could impact patient survival and local failure rates. Methods: This study was conducted on 182 patients with laryngeal squamous cell carcinoma treated with OPHLs between 2005 and 2015. The survival rates of a group of patients treated with TL between 2004 and 2014 were taken into consideration to compare survival outcomes. Results: The disease-specific survival in pT2 and pT3 tumors in relation to the type of surgery showed no statistically significant difference between OPHLs and TL (P = .54 and P = .63, respectively). The 5-year T-recurrence-free survival showed that pT4 tumors, perineural/vascular positive invasion, and OPHL IIb + ARY-treated tumors were associated with a higher risk of tumor recurrence (P < .0001, P = .0005 and P = .016 respectively). Conclusions: OPHLs represent an excellent alternative to TL considering the characteristics of the tumor and the general conditions of the patient.

[Prognostic impact of different tumor invasion patterns in the surgical treatment of T3 glottic laryngeal cancer]

Objective:To investigate the prognostic impact of different tumor invasion patterns in the surgical treatment of T3 glottic laryngeal cancer. Methods:A retrospective analysis was conducted on the clinical data of 91 patients with T3 glottic laryngeal cancer. Results:Among the 91 patients, 58 cases （63.7%） had anterior invasion and 33 cases （36.3%） had posterior invasion. The posterior invasion was significantly correlated with invasions of the dorsal plate of cricoid cartilage （P<0.001）, arytenoid cartilage （P= 0.001）, and subglottic region（P = 0.001）. There was no statistical difference in survival outcomes between the total laryngectomy group and the partial laryngectomy group. But in the partial laryngectomy group, the 5-year disease-free survival（DFS） of patients with anterior invasive tumors was better than that of patients with posterior invasion tumors （HR: 4.681, 95%CI 1.337-16.393, P=0.016）, and subglottic invasion was associated with worse loco-regional recurrence-free survival（LRRFS）（HR: 3.931, 95%CI 1.054-14.658, P=0.041）. At the same time, we found that involvement of the dorsal plate of cricoid cartilage was an independent risk factor for postoperative laryngeal stenosis in partial laryngectomy patients （HR:11.67, 95%CI 1.89-71.98,P=0.008）. Conclusion:Compared with total laryngectomy, selected partial laryngectomy can also achieve favorable oncological outcomes. Posterior invasion and subglottic extension are independent prognostic factors for recurrence of partial laryngectomy in T3 glottic laryngeal cancer, and the involvement of the dorsal plate of cricoid cartilage is associated with postoperative laryngeal stenosis. The tumor invasion pattern of laryngeal cancer should be further subdivided in order to select a more individualized treatment plan.

Functional reconstruction of the unilateral supraglottis and piriform sinus with a triple chimeric superficial circumflex iliac artery perforator flap after supraglottic laryngectomy: A case report

Preservation of laryngeal functions after supraglottic laryngectomy depends on both the extent of surgical resection and the type of reconstruction. Any reconstructive modality faces the challenges of preserving voice and swallow function due to the complex and dynamic anatomy of the larynx. In this report, we present a case in which the entire affected unilateral supraglottis and piriform sinus were functionally reconstructed using a triple chimeric superficial circumflex iliac artery perforator (SCIP) free flap. An extended unilateral supraglottic laryngectomy and neck dissection were performed in a 78-year-old male patient presenting with a supraglottic cT4a cN0 cM0 laryngeal cancer. The resulting defect was reconstructed using a triple chimeric SCIP flap from the right inguinal region intended to reconstruct the different affected compartments. It was based on three perforators and consisted of a 4 cm × 3 cm fascial flap from the external oblique muscle and two fasciocutaneous paddles measuring 6 cm × 2 cm and 3 cm × 4 cm. The arterial and venous vessels were anastomosed to the superior thyroid artery and internal jugular vein. The fascial flap was used to reconstruct the aryepiglottic fold. The smaller fasciocutaneous paddle was utilized to reconstruct the affected piriform sinus and former thyroid cartilage compartment, while the larger fasciocutaneous paddle served as a monitor skin flap. The postoperative recovery was uneventful. Laryngeal functions including voice and deglutition were well-preserved after 4 months of rehabilitation. The patient showed no signs of chronic aspiration or tumor recurrence 6 and 12 months postoperatively. The pliable and versatile triple chimeric SCIP flap provides a useful free flap option for a tailored functional reconstruction after an extended supraglottic laryngectomy. Restoration of larynx elevation and mobility with the presented technique substantially improves swallow rehabilitation while preserving the voice.

Partial laryngectomy for naïve pT3N0 laryngeal cancer: Systematic review on oncological outcomes

The first aim was to define the oncologic outcomes of open partial laryngectomy (OPL) in naïve pT3 laryngeal cancer. The second aim was to analyze the outcomes after OPL versus total laryngectomy (TL). A literature search was conducted in three databases (MEDLINE, EMBASE, and Cochrane Library) until January 2022. In 805 patients treated with OPL, 5-year OS, DSS, DFS and LFS were 80.5% (95% CI 70.6-87.6), 83.4% (95% CI 75.7-89), 77.4% (95% CI 66.3-85.7) and 77.9% (95% CI 68.7-85), respectively. Three articles compared TL versus OLP: 5-year OS, DSS and DFS risk difference were 0.100 (95% CI -0.092 to 0.291), 0.067 (95% CI -0.085 to 0.220) and 0.018 (95% CI -0.164 to 0.201) respectively. OPL for selected pT3 laryngeal cancer is able to guarantee a high percentage of oncological success. Accurate patient selection is of utmost importance to differentiate advanced disease amenable to conservative surgery.

The role of adjuvant therapy in pT4N0 laryngectomized patients: Multicentric observational study

BACKGROUND

To retrospectively evaluate oncological outcomes in two groups of patients with pT4aN0 glottic SCC treated with total laryngectomy (TL) and neck dissection (ND) who underwent postoperative radiotherapy or exclusive clinical and radiological follow-up.

METHODS

It includes patients with pT4N0 glottic SCC who underwent TL and unilateral or bilateral ND with or without PORT. Divided in two comparison groups: the first group underwent adjuvant RT (TL-PORT); the second group referred to clinical and radiological follow-up (TL).

RESULTS

PORT was associated with a better OS while no differences were found in terms of DSS. A better local control is achieved when PORT is administered while no differences in terms of regional and distant control rates were found. Bilateral ND positively impacts on the regional control while the PNI negatively impact the regional control.

CONCLUSIONS

A tailored PORT protocol might be considered for pT4N0 glottic SCC treated with TL and ND, both considering the ND's extent and presence of PNI.

Paraglottic Space Invasion in Glottic Laryngeal Cancer: A Clinical‐Pathological Study

OBJECTIVE

This study aims to prospectively compare endoscopic, radiological, and pathological features of a cohort of patients with glottic laryngeal squamous cell carcinoma (LSCC) undergoing open partial horizontal laryngectomy (OPHL) type II/III or total laryngectomy to better understand the reliability of preoperative endoscopy and computed tomography (CT) to predict the inferior paraglottic space (iPGS) involvement.

METHODS

We prospectively compared the endoscopic, radiological, and pathological findings in patients with glottic LSCC who underwent OPHL II/III, or total laryngectomy.

RESULTS

Endoscopy achieved a diagnostic accuracy of 87.2% for the anterior iPGS (iPGSa) and 86.1% for the posterior iPGS (iPGSp). There was no statistically significant difference in terms of histopathologic iPGSa involvement between reduced (85%-17/20 pts) and absent (92%-24/26 pts) vocal cord mobility (p = 0.39). CT alone did not improve the diagnostic performance of the endoscopy, reaching a diagnostic accuracy of 62.9% and 73.7% for the iPGSa and iPGSp, respectively. When endoscopy and CT were combined, the diagnostic performance improved for the iPGSp, achieving a sensitivity (Se), specificity (Spe), positive predictive value (PPV), and negative predictive value (NPV) of 100%, 89.8%, 68.7%, and 100%, respectively. On the contrary, the combination of CT and endoscopy improved only the Se and NPV for the iPGSa with respect to the sole endoscopic assessment.

CONCLUSIONS

Whenever motility impairment is present, a histopathologic invasion of the iPGS should be suspected. Endoscopic assessment of laryngeal motility achieved a satisfactory value of Se, Spe, PPV, and NPV in predicting the involvement of the iPGS. CT scan is still the mainstay imaging technique in the clinical staging of patients with LSCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1184-1190, 2023.

Oncological Outcomes of Primary vs. Salvage OPHL Type II: A Systematic Review

Background: Open partial horizontal laryngectomy type II (OPHL type II) has two main aims: oncological radicality and laryngeal preservation. The aim of this review is to define and emphasize the oncological efficacy of OPHL type II, both as primary and salvage surgery, by analyzing the latest literature. Methods: The research was carried out on Pubmed, Scopus and Web of Science databases, by using strict keywords. Oncological outcomes were evaluated by the following parameters: overall survival, disease-specific survival, disease-free survival, local control, laryngeal preservation, local recurrence. Results: The review included 19 articles divided into three groups: (1) primary OPHL type II, (2) salvage OPHL type II, (3) adjuvant radiotherapy after primary OPHL type II. The articles showed excellent results as far as oncological radicality and organ preservation. Conclusions: This review demonstrated that OPHL type II is useful to obtain oncological radicality both as primary surgery and salvage surgery. Nevertheless, the only criterion that determined the positive outcome and efficacy of this technique is the strict selection of patient and tumor.