Oncological and surgical outcome of total laryngectomy in combination with neck dissection in the elderly

Oncological features and outcomes of laryngeal cancer surgery: a multicentric study

BACKGROUND

Laryngeal cancer (LC) is among of the most frequent head and neck cancers, associated to a high social impact and mortality. Unfortunately, the current treatment outcomes of LC are often scant, with different factors affecting patient's prognosis (i.e., advanced age, advanced disease stage, lymph node involvement, tumor pathological features, type of intervention). The aims of the present study were: 1) to evaluate the epidemiological and clinical features of patients affected by LC; and 2) to focus on tumor risk factors affecting patient's overall survival (OS) and recurrences.

METHODS

A retrospective analysis of all patients affected by LC and surgically treated at two different hospital settings has been performed.

RESULTS

Two hundred twenty-five patients were enrolled in the present study; of these 189 were males (84%) and 36 (16%) were females. The most frequently performed surgery was total laryngectomy. Thirty-two (14.2%) patients experienced local recurrence, while 15 patients (6.6%) had regional recurrence and 15 distant metastases. Multivariate analysis showed that locoregional recurrence was associated to the occurrence of distant metastases (P=0.002, HR=25,35). Analyzing OS, the only statistically significant factor that correlated with an increased risk of mortality (P<0.015, HR=2,45) was locoregional recurrence.

CONCLUSIONS

The present study confirms the literature data about age and sex distribution of LC, about tumors localization, lymph nodes metastasis and distant metastasis incidence and OS rate, based on T and N stage. Interestingly, within this series, the presence of locoregional recurrence or distant metastasis is related to a worst prognosis and a lower overall survival rate.

Classifying and Predicting Surgical Complications After Laryngectomy: A Novel Approach to Diagnosing and Treating Patients

OBJECTIVES

The total laryngectomy is one of the most standardized major surgical procedures in otolaryngology. Several studies have proposed the Clavien-Dindo classification (CDC) as a solution to classifying postoperative complications into 5 grades from less severe to severe. Yet more data on classifying larger patient populations undergoing major otolaryngologic surgery according to the CDC are needed. Predicting postoperative complications in clinical practice is often subject to generalized clinical scoring systems with uncertain predictive abilities for otolaryngologic surgery. Machine learning offers methods to predict postoperative complications based on data obtained prior to surgery.

METHODS

We included all patients (N = 148) who underwent a total laryngectomy after diagnosis of squamous cell carcinoma at our institution. A univariate and multivariate logistic regression analysis of multiple complex risk factors was performed, and patients were grouped into severe postoperative complications (CDC ≥ 4) and less severe complications. Four different commonly used machine learning algorithms were trained on the dataset. The best model was selected to predict postoperative complications on the complete dataset.

RESULTS

Univariate analysis showed that the most significant predictors for postoperative complications were the Charlson Comorbidity Index (CCI) and whether reconstruction was performed intraoperatively. A multivariate analysis showed that the CCI and reconstruction remained significant. The commonly used AdaBoost algorithm achieved the highest area under the curve with 0.77 with high positive and negative predictive values in subsequent analysis.

CONCLUSIONS

This study shows that postoperative complications can be classified according to the CDC with the CCI being a useful screening tool to predict patients at risk for postoperative complications. We provide evidence that could help identify single patients at risk for complications and customize treatment accordingly which could finally lead to a custom approach for every patient. We also suggest that there is no increase in complications with patients of higher age.

Laryngectomy in Elderly Patients: A Case Series and Review of the Literature

Background and objective Patients over the age of 75 years make up 20% of the head and neck cancer population, which is a relatively under-represented patient cohort in clinical literature. To our knowledge, there are no studies evaluating the outcomes of laryngectomy in patients aged over 75 years, which prompted us to present this unique series. Methods We reviewed departmental records at the University College Hospital, London over a 10-year period, and identified a total of 18 patients over the age of 75 years who underwent total laryngectomy for squamous cell carcinoma. We evaluated the demographic, clinical, and histopathologic features and outcomes for each patient. Results The age of the cohort ranged from 75 to 90 years, with a mean age of 79.8 years. All patients had a Charlson Comorbidity Index (CCI) score of 3 or more (due to age), with a mean of 4.7, and a maximum score of 8 for two patients. Length of inpatient stay varied significantly, ranging from 20 to 149 days, with a mean of 46 days. We identified 14 patients who underwent laryngectomy prior to September 2017, in whom the five-year survival was 21.4%. The three-year survival rate for all patients was 22.2%. In bivariate analysis, advanced age at surgery positively correlated with increased length of hospital admission and increased incidence of complications, although these results were not statistically significant (p<0.05). Conclusions Our study highlights the significance of the impact of age and comorbidities on postoperative outcomes and sheds light on the unique challenges faced by an ageing population. Careful consideration must be made in terms of appropriate patient selection, and clinicians must offer a robust and tailored approach to elderly care.

Perioperative Factors Aggravating Pharyngocutaneous Fistula After Total Laryngectomy: A Single-Center Retrospective Analysis Using the Clavien-Dindo Classification

BACKGROUND

Pharyngocutaneous fistula formation represents a major postoperative complication following total laryngectomy. We aimed to investigate the risk factors for pharyngocutaneous fistula development after total laryngectomy and to identify factors that lead to severe cases of pharyngocutaneous fistula.

METHODS

Patients who underwent total laryngectomy between January 2013 and February 2021 were included in the study and were divided into 2 groups: Those with and without pharyngocutaneous fistula. The severity of pharyngocutaneous fistula was graded using the Clavien-Dindo classification.

RESULTS

Patients with pharyngocutaneous fistula experienced longer operative time, greater intraoperative blood loss, greater decrease in perioperative hemoglobin level, and longer postoperative hospitalization. Unlike in lower-severity cases, patients with grade IIIb pharyngocutaneous fistula underwent preoperative radiotherapy or chemoradiotherapy; preoperative treatment was thus a risk factor for higher severity of pharyngocutaneous fistula (odds ratio, 35; P = 0.004).

CONCLUSION

Salvage laryngectomy was found to be a predictor of severe pharyngocutaneous fistula development. Prolonged operative time, increased intraoperative blood loss, and decreased postoperative hemoglobin level were found to be predictors of postlaryngectomy pharyngocutaneous fistula formation.

Proposal for an algorithm to avoid neck dissection during salvage total laryngectomy. A GETTEC multicentric study

OBJECTIVES

To identify the factors related to the presence of occult metastases before salvage total laryngectomy (STL) in rcN0 patients and to propose an algorithm to identify patients who do not require neck dissection (ND).

PATIENTS AND METHODS

This multicentric retrospective study included five centers with recruitment from 2008 to 2018. Inclusion criteria were: i) having been treated for laryngeal squamous cell carcinoma in first intention by radiotherapy (either alone or potentiated or preceded by induction chemotherapy), ii) having received STL with or without ND, iii) having an rcN0 neck at the time of STL.

RESULTS

120 patients met the inclusion criteria. The overall rate of occult metastases was 9.1 %. The rate was significantly higher in patients with an initial positive cN+ lymph node status (p < 0.005) and in advanced stages with rcT3-T4 lesions at recurrence (p < 0.005). Patients with occult metastases recurred earlier than those without (p = 0.002). The overall survival of patients was the same with or without ND (p = 0.16). There were significantly more healing complications requiring revision surgery in the group with ND than in the group without (p = 0.048).

CONCLUSION

ND does not confer a net survival benefit and is associated with significant complications. Patients without initial lymph node metastases who are rcT1-T2 at recurrence or rcT3-T4 with a recurrence period of more than 12 months could benefit from STL without ND. This decisional algorithm, which needs to be validated, would help avoid 58 % of ND procedures and their proven morbidity.

DISCIPLINE

Head and neck surgery.

Lymph Nodes Dissection in Elderly Patients with T3-T4 Laryngeal Cancer

Objective

To explore the survival value of lymph node dissection (LND) in elderly patients with T3-T4 laryngeal cancer, analyze the risk factors of lymph node metastasis, and construct a preoperative prediction model.

Materials and Methods

The study included 996 patients aged ≥65 years with laryngectomy confirmed T3-T4 laryngeal cancer queried from Surveillance, Epidemiology and End Results (SEER) database between 2010 and 2017. Propensity score matching (PSM) was applied to balance the effects of confounding factors. Kaplan–Meier (K–M) analysis and competitive risk model were used to compare the overall survival (OS) and cancer-specific survival (CSS) between LND and no-LND (N-LND) group. Combined with risk factors of multivariate logistic regression, a nomogram was built to predict lymph node metastasis preoperatively. The performance was assessed in the training set and the validation set, and internal validation was assessed.

Results

Among the cohort, 822 patients underwent LND and 410 patients had positive lymph nodes. The OS and CSS of patients who underwent LND were not better than that of N-LND patients (P>0.05). The prognosis of patients with lymph node metastases was significantly worse than that of negative patients (P<0.05). On multivariate logistic regression, supraglottis cancer, tumor size >5cm and grade 3–4 classification were associated with significantly greater odds of lymph node metastasis. The nomogram showed favorable predictive efficacy and good calibration (in the training cohort C-index=0.700; in the validation cohort C-index=0.721).

Conclusion

For elderly patients with T3-T4 laryngeal cancer, LND did not bring significant survival values. Supraglottis cancer, tumor size >5cm and grade 3–4 classification were independent risk factors of lymph node metastasis, which means poor prognosis. The nomogram developed was an easy-to-use tool for lymph node prediction.

Does age influence disease-specific survival in patients with squamous cell carcinomas of the head and neck?

BACKGROUND AND OBJECTIVES

The number of patients diagnosed with head and neck squamous cell carcinoma (HNSCC) at an advanced age has increased. The aim of this study is to evaluate the age at which disease-specific survival (DSS) significantly decreases in HNSCC.

METHODS

We performed a retrospective study of 5469 patients with HNSCC treated at our center (1985-2016). External validation with 2082 oral squamous cell carcinomas from a collaborative institution from another continent was performed.

RESULTS

We observed an orderly decrease in overall survival as age at diagnosis increased. There were no differences in DSS based on age for patients <80 years old (P = .623), while older patients had a significant decrease in DSS. These results were validated in the independent dataset. In a multivariable analysis performed in the test set, compared to patients <80 years old, patients between 80 to 85 had a 1.50 times higher risk of disease-specific death (95% confidence interval [CI]: 1.19-1.89; P = .001), and patients >85 had a 2.19 times higher risk (95% CI: 1.68-2.87; P < .001).

CONCLUSIONS

DSS started to significantly decrease in HNSCC at 80 years old. These findings, validated in an independent cohort, indicate that chronological age on its own should not withhold curative treatment in the majority of patients with HNSCC.

Lymph Node Ratio Predicts Recurrence and Survival for Patients with Resectable Stage 4 Hypopharyngeal Cancer

BACKGROUND

This study aimed to investigate the clinicopathologic prognostic predictors of stage 4 hypopharyngeal cancer and to extend the traditional tumor-node-metastasis classification system to advance its predictive ability.

METHODS

The study enrolled 120 patients with pathologically stage 4 hypopharyngeal cancer treated with pharyngolaryngectomy and neck dissection between 2001 and 2007.

RESULTS

The study showed a 5-year overall survival (OS) of 44.6%, a disease-specific survival (DSS) of 51.6%, and a disease-free survival (DFS) of 48% for all the patients. In the multivariate analysis, a lymph node (LN) ratio of 0.113 or higher was a significant poor prognostic factor for OS (hazard ratio [HR] 1.89; 95% confidence interval [CI] 1.17-3.05; p = 0.009), DSS (HR 2.17; 95% CI 1.29-3.64; p = 0.003), and DFS (HR, 2.24; 95% CI 1.12-4.52; p = 0.024) in stage 4 hypopharyngeal cancer. In addition, pretreatment neutrophil-lymphocyte ratio, lymphovascular invasion, and margin status also were predictors of survival outcomes. Furthermore, the study found that disease recurrence differed significantly between the patients with a LN ratio of 0.113 or higher (68.2%) and those with a LN ratio lower than 0.113 (39.5%) (p = 0.002).

CONCLUSIONS

A LN ratio of 0.113 or higher is a strong predictor of disease recurrence and survival for patients with stage 4 hypopharyngeal cancer.