Salvage laryngectomy: Oncological and functional outcome

Primary fit tracheoesophageal puncture in primary versus salvage laryngectomy: Short-term and long-term complications and functional outcomes

BACKGROUND

Primary fit tracheoesophageal puncture (TEP) is widely preferred for individuals who have not undergone prior radiation. However, there is no consensus on the relative utility of primary-fit TEP in the setting of salvage laryngectomy.

METHODS

A retrospective, single-center review was conducted of individuals undergoing laryngectomy with primary fit TEP between 2012 and 2018. Multivariable analysis was conducted to compare short-term and long-term complications, as well as speech and swallowing outcomes, of those who underwent primary versus salvage laryngectomy.

RESULTS

In this study, 134 patients underwent total laryngectomy with primary fit TEP. Aside from a higher rate of peristomal dehiscence (13.1% vs. 1.4%) found in the salvage group, there was no difference in incidence of all other complications, including pharyngocutaneous fistula formation. The groups had comparable speech and swallow outcomes.

CONCLUSION

Primary fit TEP is a safe and effective surgical choice for individuals undergoing salvage laryngectomy who desire a voice prosthesis.

Development of a nomogram for predicting pharyngocutaneous fistula based on skeletal muscle mass and systemic inflammation indices

BACKGROUND

Laryngeal and hypopharyngeal cancers often require surgical treatment, which can lead to the development of pharyngocutaneous fistula (PCF). Our research aimed to assess the predictive value of skeletal muscle mass (SMM) and systemic inflammation indices for PCF and construct a clinically effective nomogram.

METHODS

A nested case-control study of 244 patients matched from 1171 patients with laryngeal or hypopharyngeal cancer was conducted. SMM was measured at the third cervical level based on CT scans. A PCF nomogram was developed based on the univariate and multivariate analyses.

RESULTS

Glucose, white blood cell count, platelet-to-lymphocyte ratio, and skeletal muscle index were independent risk factors for PCF. The area under the curve for the PCF nomogram was 0.841 (95% CI 0.786-0.897). The calibration and decision curves indicated that the nomogram was well-calibrated with good clinical utility.

CONCLUSIONS

The nomogram we constructed may help clinicians predict PCF risk early in the postoperative period, pending external validation.

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.

Predictors of multiple dilations and functional outcomes after total laryngectomy and laryngopharyngectomy

BACKGROUND

Following total laryngectomy (TL) or laryngopharyngectomy (TLP), patients may develop strictures that require multiple dilations to treat. However, the risk factors associated with dysphagia refractory to a single dilation are unknown.

METHODS

Single-institution retrospective review of patients who underwent at least one stricture dilation after TL/TLP between March 2013 and March 2022.

RESULTS

A total of 49 patients underwent stricture dilation after TL/TLP. Thirty-five (71%) underwent multiple dilations. Pharyngocutaneous fistula, primary chemoradiation therapy, and a shorter time interval from TL/TLP to first dilation were independently associated with dysphagia requiring multiple dilations. Patients in the multiple dilations group had a higher rate of limited diet and G-tube dependence compared to patients in the single dilation group.

CONCLUSIONS

Shorter time interval to stricture formation is a prognostic indicator of the need for multiple dilations following TL/TLP. Patients requiring multiple dilations are at increased risk of persistent dysphagia long-term.

A nationwide analysis of salvage surgery for laryngeal cancer in the elderly

BACKGROUND

We aim to describe outcomes of elderly patients undergoing salvage surgery for laryngeal cancer and to characterize the interplay of age with various other factors in this growing population.

METHODS

Using the National Cancer Database, we identified cases of salvage laryngectomy in patients who failed chemoradiation. An age cutoff of 70 years was used to separate subjects into two groups. Various factors were compared.

RESULTS

Of the 825 patients included, 166 (20.1%) were elderly. Elderly patients had worse overall survival (p = 0.001), higher 30-day and 90-day mortality (p = 0.006, p < 0.001), and a longer length of stay (LOS) (p = 0.015). LOS over 1 week was associated with worse survival (p = 0.032).

CONCLUSION

Elderly patients had worse overall perioperative survival than their younger counterparts. LOS and 30-day readmissions were associated with higher risk of mortality in this group. We provide a contemporary set of relevant information for head and neck cancer providers to consider in this growing population.

Functional and quality-of-life outcomes following salvage surgery for recurrent squamous cell carcinoma of the head and neck: a systematic review and meta-analysis

BACKGROUND

Recurrent head and neck squamous cell carcinomas (HNSCC) are frequently managed with salvage surgery, but the impact these operations have on function and quality-of-life (QoL) is understudied. This review aimed to provide a quantitative and qualitative assessment of the functional and QoL effects of salvage surgical procedures.

METHODS

Systematic review and meta-analysis were conducted of studies reporting QoL and function following salvage HNSCC resections.

RESULTS

The search identified 415 articles and 34 were selected for inclusion. Pooled random effects analysis revealed long-term feeding and tracheostomy tube rates of 18% and 7%. Pooled long-term feeding tube rates in open oral and oropharyngeal, transoral robotic, total and partial laryngectomy surgeries were 41%, 25%, 11% and 4%. Eight studies used validated QoL questionnaires.

CONCLUSIONS

Functional and QoL outcomes from salvage surgery are acceptable, but appear to be worse following open procedures. Prospective studies measuring changes over time are needed to assess these procedures impact on patient well-being.

Salvage transoral laser microsurgery for early local recurrence of glottic squamous cell cancer

BACKGROUND

For recurrent laryngeal cancer, the feasibility of salvage transoral laser microsurgery (TLM) remains controversial. This study compared the efficacy of TLM and open partial laryngectomy (OPL) for treatment of early local recurrence of glottic squamous cell cancer (GSCC) and confirm the effectiveness of salvage TLM as a treatment option.

METHODS

This retrospective study involved 55 patients with early local recurrent GSCC treated with TLM, and the oncologic outcomes, functional outcomes, hospitalization time and complications were compared with a group of 40 recurrent GSCC patients matched for clinical variables of TLM group, treated by OPL by the same team of surgeons.

RESULTS

The 5-year overall survival and disease-specific survival rates were 65.8% and 91.5%, respectively, for 55 patients with rT_is-rT₂ stage treated by TLM and 77.1% and 94.7%, respectively, for 40 patients with rT_is-rT₂ stage treated by OPL (OPL group). In the TLM and OPL groups, the local control rates after 5 years were 77.5% and 79.3%, respectively, and the laryngeal preservation rates were 94.4% and 83.6%, respectively (p > 0.05). Compared with the OPL group, the complication rate (1.82%) and hospitalization duration (5.42 ± 2.26 days) were significantly lower in the TLM group (p < 0.05). Compared with the OPL group, postsurgical health-related quality of life and quality of voice were significantly better in the TLM group (p < 0.001).

CONCLUSION

Salvage TLM can be used as an effective treatment option for suitable patients after a full, comprehensive, and careful assessment of the characteristics of early locally recurrent glottic carcinoma.

Salvage Surgery

The Department of Veterans Affairs Laryngeal Cancer Study propelled the combination of chemotherapy and radiation therapy to the forefront of strategies used for the management of locally advanced laryngeal cancer. The organ preservation rate was 84%. However, over the past 30 years that these approaches have been in place, there have been concerns regarding long-term survival and high failure rates requiring salvage. Furthermore, salvage laryngectomy, if feasible when considering increased morbidity after CRT, is fraught with a higher risk of wound complications including fistula, longer hospitalization, and reduced quality of life.

Salvage vs. Primary Total Laryngectomy in Patients with Locally Advanced Laryngeal or Hypopharyngeal Carcinoma: Oncologic Outcomes and Their Predictive Factors

BACKGROUND

The aims of this study were to compare the survival outcomes of salvage vs. primary total laryngectomy (TL) in patients with locally advanced laryngeal or hypopharyngeal carcinoma and to determine their predictive factors.

METHODS

Overall (OS), cause-specific (CSS) and recurrence-free survival (RFS) of primary vs. salvage TL were compared in univariate and multivariate analysis taking into account other potential predictive factors (tumor site, tumor stage, comorbidity level etc.).

RESULTS

A total of 234 patients were included in this study. Five-year OS was 53% and 25% for the primary and salvage TL groups, respectively. Multivariate analysis confirmed the independent negative impact of salvage TL on OS (p = 0.0008), CSS (p < 0.0001) and RFS (p < 0.0001). Hypopharyngeal tumor site, ASA score ≥ 3, N-stage ≥ 2a and positive surgical margins were the main other predictors of oncologic outcomes.

CONCLUSIONS

Salvage TL is associated with significantly worse survival rates than primary TL highlighting the need for careful selection of patients who are candidates for larynx preservation. The predictive factors of survival outcomes identified here should be considered in the therapeutic decision-making, especially in the setting of salvage TL, given the poor prognosis of these patients.

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.

Response-Adapted Treatment Following Radiotherapy in Patients With Resectable Locally Advanced Hypopharyngeal Carcinoma

IMPORTANCE

Laryngeal preservation strategies for resectable locally advanced hypopharyngeal carcinoma (LAHPC) have been explored. However, the optimal strategy remains unclear.

OBJECTIVE

To evaluate a response-adapted strategy based on an early response to radiotherapy (RT) in patients with resectable LAHPC.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted from May 2009 to October 2019 with a median (IQR) follow-up period of 66.5 (44.7-97.0) months. The study was conducted at a tertiary academic medical center and included 423 patients pathologically confirmed stage III and IVB LAHPC. A total of 250 patients with previous cancer history, synchronous primary cancer, stage I or II, or with unresectable hypopharyngeal carcinoma were excluded.

EXPOSURES

Patients who reached 80% or greater tumor regression when evaluated endoscopically and by imaging methods at 50 Gy received definitive RT or concurrent chemoradiotherapy, and those with less than 80% regression underwent surgery 4 to 6 weeks after RT.

MAIN OUTCOMES AND MEASURES

Five-year overall survival and survival with a functional larynx.

RESULTS

Overall, 423 patients were included in the study (median [IQR] age, 55 [50-63] years; 408 [96.5%] men and 15 [3.5%] women). The response-adapted and primary surgery groups had significantly better survival than the primary RT group (52.7% and 54.4% vs 27.7%, respectively; P < .001). The response-adapted and primary surgery groups had similar 5-year overall survival of 52.7% vs 54.4%, respectively (hazard ratio [HR], 1.02; 95% CI, 0.75 to 1.39; P = .89). The response-adapted group had better 5-year survival with functional larynx than the primary surgery group (40.6% vs 33.9%; HR, 0.64; 95% CI, 0.49 to 0.84, P = .001). Surgery complications did not significantly differ between the 2 groups. Among patients in the response-adapted group who required total laryngectomy (n = 186) as indicated by pretreatment evaluation, the 5-year cumulative Kaplan-Meier survival with functional larynx was 39.8%.

CONCLUSIONS AND RELEVANCE

In this cohort study, the response-adapted strategy based on an early RT response facilitated better treatment tailoring, maximum tumor control, and higher laryngeal preservation compared with primary surgery and primary RT strategies. This approach could provide a feasible laryngeal preservation strategy in patients with LAHPC.

Arterial calcification on preoperative computed tomography imaging as a risk factor for pharyngocutaneous fistula formation after total laryngectomy

BACKGROUND

Research in esophageal surgery showed that computed tomography (CT) assessed arterial calcification (AC) is associated with postoperative complications. We investigated the association between AC and pharyngocutaneous fistula (PCF) formation after laryngectomy.

METHODS

This was a retrospective cohort study of patients undergoing laryngectomy. AC was scored at 10 different anatomical locations on CT imaging, blinded for PCF occurrence. Association with PCF was investigated using logistic regression.

RESULTS

The 224 patients were included; 62 (27.7%) developed a PCF. Moderate to severe AC was widespread in patients undergoing TL; 7.1% of patients had at most mild AC, of whom 1 experienced a PCF (p = 0.05). A higher cumulative calcification score was associated with PCF in univariable (OR 1.11, p = 0.04) and multivariable analysis (OR 1.14, p = 0.05).

CONCLUSION

AC is widespread in patients undergoing laryngectomy and its burden is associated with PCF. Extensive AC on preoperative imaging may be considered a risk factor for PCF.

Role of Pectoralis Major Myocutaneous Flap in Laryngectomy Surgery: Single Surgeon Experience

Objective

To analyze the effectiveness of the pectoralis major myocutaneous (PMMC) flap in preventing pharyngocutaneous fistula (PCF) formation for salvage total laryngectomy patients.

Study design

Retrospective chart review of all post-surgical laryngectomy patients for a single surgeon.

Methods

Inclusion criteria were adult patients 18 years and older who were diagnosed with laryngeal cancer and treated with a salvage total laryngectomy. Exclusion criteria were any laryngectomy patient treated without the PMMC flap or those with incomplete medical records.

Results

A total of 31 patient charts were identified, and 16 remained after exclusion criteria. The patient age range was 42-71 years (mean = 58.19; SD = 8.093). Greater than 85% of patients had T3 and T4 laryngeal cancers. Without PCF group were 13 patients and with PCF group were only three patients. The mean hospital days in without PCF group were 9.54 and in with PCF group were 16.33.

Conclusion

In this single surgeon’s experience, PCF was prevented by using the PMMC flap in salvage total laryngectomy patients.

Tracheoesophageal fistula and pharyngoesophageal stenosis repair by double skin paddle radial forearm flap

Tracheoesophageal fistula (TEF) constitutes a rare, but serious complication in laryngectomized patients, usually occurring after radiotherapy. TEF may occur spontaneously or may be due to enlargement of the TEF created for placement of a voice prosthesis. Surgical treatment of TEF can be complex, especially in the presence of a concomitant pharyngoesophageal stenosis (PES), and is associated with a high failure rate. In this article, we describe the surgical reconstruction technique for TEF associated with PES using a double skin paddle fasciocutaneous radial forearm free flap. The key points of this technique consist of correct positioning of the 2 skin paddles in order to reconstruct the anterior pharyngoesophageal wall and posterior tracheal wall, as well as de-epidermization of the intermediate part of the flap, which is then placed in the tracheoesophageal space.

Salvage surgery for residual or recurrent laryngeal squamous cell carcinoma after (Chemo)radiotherapy: Oncological outcomes and prognostic factors

Nonsurgical primary treatment of early and advanced laryngeal squamous cell carcinoma, employing radiotherapy with or without chemotherapy, is considered a standard of care in many centers throughout the world. When patients have persistent or recurrent disease after non-surgical treatment, salvage surgery is frequently the only remaining potentially curative treatment. Depending on the extent of the residual/recurrent disease, different surgical salvage options are at the surgeon's disposal. In selected cases with limited local disease, salvage transoral laser microsurgery, transoral robotic surgery and open partial laryngectomies can be employed to achieve cure while preserving laryngeal function. For more advanced cases total laryngectomy is necessary. Identifying situations with unacceptable results from surgical salvage may guide future therapies.

Salvage laryngectomy after primary radio- and radiochemotherapy : A retrospective study

Background

Recurrent and residual laryngeal cancer after organ-preserving radio- or radiochemotherapy is associated with a poor prognosis. Salvage surgery is the most important therapeutic option in these cases.

Objective

The study assessed rates of recurrence and residual tumor as well as survival and complication rates after salvage laryngectomy at the authors’ academic cancer center.

Materials and methods

A retrospective examination of all patients receiving laryngectomy between 2001 and 2019 due to tumor residuals or recurrence after primary radio- and radiochemotherapy was conducted.

Results

A total of 33 salvage procedures were performed. Defect reconstruction was performed by free flap surgery in 30.3% (n = 10) and regional flap surgery in 15.2% (n = 5) . One patient received regional flap surgery and free flap surgery simultaneously. Overall survival after 1, 2, and 5 years was 68.7, 47.9, and 24.2%, and disease-free survival was 81.6, 47.8, and 24.2%, respectively, with 48.5% (n = 16) postoperative tumor recurrences overall. Disease-free survival was significantly shorter for tumor extension into or onto the hypopharynx (p = 0.041). Postoperatively, 72.7% of patients developed a pharyngocutaneous fistula, of which 24.2% required surgical treatment. The hospital stay was 28.0 ± 16.1 days.

Conclusion

Salvage laryngectomy is associated with a high rate of treatable complications and high morbidity. Nevertheless, considering the advanced tumor stages treated, it allows for respectable oncological results.

Supplementary Information

The online version of this article (10.1007/s00106-021-01030-3) includes the patient cohort. Article and supplementary material are available at www.springermedizin.de. Please enter the title of the article in the search field, the supplementary material can be found under “Ergänzende Inhalte”.

[Salvage laryngectomy after primary radio- and radiochemotherapy : A retrospective study. German version]

Hintergrund

Das rezidivierende und residuelle Larynxkarzinom nach organerhaltender Radio- bzw. Radiochemotherapie ist mit einer schlechten Prognose verbunden. Die Salvage-Operation stellt in diesen Fällen die wichtigste therapeutische Option dar.

Ziel der Arbeit

Erfasst wurden die Rate an Rezidiv- und Residualtumoren sowie die Überlebensraten und die Komplikationsrate nach Salvage-Chirurgie des Kehlkopfs an dem akademischen Tumorzentrum der Autor(inn)en.

Material und Methoden

Retrospektiv wurden alle Patienten untersucht, bei denen zwischen 2001 und 2019 eine Salvage-Operation aufgrund eines Tumorresiduums oder Rezidivs nach primärer nichtchirurgischer Therapie erfolgt war.

Ergebnisse

Es wurden 33 Salvage-Operationen durchgeführt. Die Defektrekonstruktion erfolgte in 30,3 % der Fälle (n = 10) mittels freier und in 15,2 % (n = 5) mittels regionaler Lappenplastik. Ein Patient hat sowohl eine freie als auch gleichzeitig eine gestielte Lappenplastik erhalten. Das Gesamtüberleben nach einem, 2 und 5 Jahren betrug 68,7 %; 47,9 % bzw. 24,2 %, das krankheitsfreie Überleben 81,6 %; 47,8 % bzw. 24,2 % bei insgesamt 48,5 % (n = 16) postoperativen Tumorrezidiven. Das krankheitsfreie Überleben war signifikant kürzer bei Tumorausdehnung im bzw. auf den Hypopharynx (p = 0,041). Postoperativ entwickelten 72,7 % der Patienten eine pharyngokutane Fistel unabhängig von einer simultanen Defektrekonstruktion. Nur 24 % der der aufgetretenen Fisteln mussten operativ therapiert werden. Der Krankenhausaufenthalt betrug 28,0 ± 16,1 Tage.

Schlussfolgerung

Die Salvage-Laryngektomie ist mit vielen, aber beherrschbaren Komplikationen und einer hohen Morbidität verbunden. In Anbetracht der behandelten fortgeschrittenen Tumorkategorien und der Gesamtsituation des Patienten sind respektable onkologische Ergebnisse zu erreichen.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00106-021-01029-w) enthält eine Übersicht über die Patientenkohorte. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Survival Outcomes and Predictors for Patients who Failed Chemoradiotherapy/Radiotherapy and Underwent Salvage Total Laryngectomy

Background: To assess the presence of adverse pathological features at the time of salvage total laryngectomy (TL) associated with oncologic outcome. Methods: Ninety patients with persistent/locally recurrent disease and who subsequently underwent salvage TL after definitive treatment by radiation alone (RTO) or concurrent chemo-radiation (CCRT) from 2009 to 2018 were retrospectively enrolled. Kaplan–Meier methods were used to estimate overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Results: Lymphovascular invasion (LVI), perineural invasion, positive margin, and stage IV disease were associated with worse survival in the univariate analysis. In the multivariate analysis, the presence of LVI and positive margin were both independent negative predictors in OS (LVI: adjusted hazard ratio (aHR) = 2.537, 95% CI: 1.163–5.532, p = 0.019; positive margin: aHR = 5.68, 95% CI: 1.996–16.166, p = 0.001), DSS (LVI: aHR = 2.975, 95% CI: 1.228–7.206, p = 0.016); positive margin: aHR = 11.338, 95% CI: 2.438–52.733, p = 0.002), and DFS (LVI: aHR 2.705, 95% CI: 1.257–5.821, p = 0.011; positive margin (aHR = 6.632, 95% CI: 2.047–21.487, p = 0.002). Conclusions: The presence of LVI and positive margin were both associated with poor OS, DSS, and DFS among patients who underwent salvage TL after failure of RTO/CCRT. The role of adjuvant therapy for high-risk patients after salvage TL to improve the chance of survival requires more investigation in the future.

Predictors of Stricture and Swallowing Function Following Salvage Laryngectomy

BACKGROUND

Long-term functional outcomes are poorly characterized for salvage laryngectomy. We identified predictors of esophageal stricture and swallowing function after salvage laryngectomy in a large cohort.

METHODS

A retrospective study of 233 patients who underwent salvage total laryngectomy for recurrent/persistent squamous cell carcinoma of the larynx or hypopharynx after radiation (XRT) or chemoradiation (CRT) was performed. Primary outcomes were esophageal dilation within 1 year, time to dilation, and gastrostomy tube dependence. Multivariate logistic and Cox regressions were used for statistical analysis.

RESULTS

Dilation was performed in 29.9% of patients. Dilation was twice as likely in patients with post-operative fistula compared to those without (Hazard Ratio (HR) 2.10, 95% Confidence Interval (CI) 1.06-4.13, P = .03). Every year between XRT/CRT and salvage was associated with 10% increase in dilation (HR 1.09, 95% CI 1.03-1.17, P = .01). No factors were associated with dilation by 1 year. About 10% of patients were at least partially gastrostomy tube-dependent 1 year post-operatively. At last follow-up (median 29 months), this rate was 13%. Patients with supraglottic recurrence had an increased risk of gastrostomy tube dependence at 1 year compared to glottic (OR 16.7, 95% CI 1.73-160, P = .02). For every 10 pack years pre-salvage, the OR of requiring tube feeds at last follow-up was 1.24 (95% CI 1.04-1.48, P = .02).

CONCLUSIONS

Fistula and pre-salvage smoking were associated with stricture post-salvage laryngectomy. No factors were associated with dilation by 1 year. Supraglottic recurrence and smoking were associated with gastrostomy tube dependence. These findings are important for pre-operative counseling prior to salvage laryngectomy.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 131:1229-1234, 2021.

Prognostic Significance of Oxidation Pathway Mutations in Recurrent Laryngeal Squamous Cell Carcinoma

Simple Summary

Organ preservation protocols have become first line therapy for the majority of advanced laryngeal cancers. Unfortunately, up to one third of patients will develop recurrent disease requiring salvage surgery. These tumors tend to display aggressive features when compared to primary disease. The aim of this study is to identify genomic alterations associated with poor prognosis in the recurrent setting to guide precision therapy and identify potential targetable pathways. Here we show that mutations in the oxidation pathway, specifically the KEAP1-NFR2 pathway, predict survival in a cohort of patients undergoing salvage laryngectomy.

Abstract

Organ preservation protocols are commonly used as first line therapy for advanced laryngeal cancer. Recurrence thereafter is associated with poor survival. The aim of this study is to identify genetic alterations associated with survival among patients with recurrent laryngeal cancer undergoing salvage laryngectomy. Sixty-two patients were sequenced using a targeted panel, of which twenty-two also underwent transcriptome sequencing. Alterations were grouped based on biologic pathways and survival outcomes were assessed using Kaplan-Meier analysis and multivariate cox regression. Select pathways were evaluated against The Cancer Genome Atlas (TCGA) data. Patients with mutations in the Oxidation pathway had significantly worse five-year disease specific survival (1% vs. 76%, p = 0.02), while mutations in the HN-Immunity pathway were associated with improved five-year disease specific survival (100% vs. 62%, p = 0.02). Multivariate analysis showed mutations in the Oxidation pathway remained an independent predictor of disease specific survival (HR 3.2, 95% CI 1.1–9.2, p = 0.03). Transcriptome analysis of recurrent tumors demonstrated that alterations in the Oxidation pathway were associated a positive Ragnum hypoxia signature score, consistent with enhanced pathway activity. Further, TCGA analyses demonstrated the prognostic value of oxidation pathway alterations in previously untreated disease. Alterations in the Oxidation pathway are associated with survival among patients with recurrent laryngeal cancer. These prognostic genetic biomarkers may inform precision medicine protocols and identify putatively targetable pathways to improve survival in this cohort.

Impact of Lymph Node Yield in Patients Undergoing Total Laryngectomy and Neck Dissection

OBJECTIVES

To determine the impact of lymph node yield (LNY) in patients undergoing neck dissection at the time of total laryngectomy (TL). To determine the impact of radiation therapy (RT) on LNY.

METHODS

Retrospective review of LNY and clinical outcomes in 232 patients undergoing primary or salvage total laryngectomy (TL) with ND.

RESULTS

Preoperative RT significantly decreased mean LNY from 31.7 to 23.9 nodes (P < .001). In primary TL patients, age (P < .001) and positive margins (P = .044) were associated with decreased OS. In salvage TL patients, only positive margins was associated with poorer OS (P = .009). No LNY cutoff provided significant OS or DFS benefit.

CONCLUSIONS

Radiotherapy significantly reduces LNY in patients undergoing TL and ND. Within a single institution cohort, positive margins, but not LNY, is associated with survival in both primary and salvage TL patients.Level of Evidence: 4.

Time interval between (chemo)radiotherapy and subsequent laryngectomy is not prognostic for post operative complications and survival

Purpose

Pharyngocutaneous fistula (PCF) formation and swallowing difficulties are common and troublesome complications following total laryngectomy (TL). Prior (chemo)radiotherapy ((C)RT) is thought to be a risk factor for these complications, but there is conflicting evidence as to whether the time interval between (C)RT and TL is important. The impact of time interval on these complications and also its impact on overall survival are investigated.

Methods

This is a retrospective case note review of all patients undergoing TL at the University Medical Center, Utrecht, The Netherlands over the 10-year period from January 2008 to December 2017. The cohort was split into those who underwent TL within a year of finishing (C)RT and those longer than 1 year.

Results

One hundred and twenty-six patients (108 males, 18 females), with a mean age of 66 underwent total laryngectomy after prior (C)RT in the study period. Overall 5-year survival was 35% with a median follow-up of 30 months. Fifty-four patients underwent laryngectomy within a year of their (C)RT versus 72 patients who had a time interval of more than one year. No differences in PCF rate, risk of dilatation or overall survival could be found between the two groups.

Conclusions

In this modern cohort, time interval between (C)RT and surgery did not impact PCF rate, risk of dilatation or overall survival.

Association between postoperative complications and long-term oncologic outcomes following total laryngectomy: 10-year experience at MD Anderson Cancer Center

BACKGROUND

Postoperative complications are an independent predictor of poor survival across several tumors. However, there is limited literature on the association between postoperative morbidity and long-term survival following total laryngectomy (TL) for cancer.

METHODS

We conducted a retrospective review of all TL patients at a single institution from 2008 to 2013. Demographic and clinical data were collected and analyzed, including postsurgical outcomes, which were classified using the Clavien-Dindo system. Multivariable Cox regression analyses were performed to identify factors associated with overall survival (OS) and disease-free survival (DFS).

RESULTS

A total of 362 patients were identified. The mean age was 64 years, and the majority of patients were male (81%). The median follow-up interval was 21 months. Fifty-seven percent of patients had received preoperative radiation, and 40% had received preoperative chemotherapy. Fifty-seven percent of patients underwent salvage TL, and 60% underwent advanced reconstruction (45% free flap and 15% pedicled flap). A total of 136 patients (37.6%) developed postoperative complications, 92 (25.4%) of which were major. Multivariable modeling demonstrated that postoperative complications independently predicted shorter OS (hazard ratio [HR], 1.50; 95% CI, 1.16-1.96; P = .002) and DFS (HR, 1.36; 95% CI, 1.05-1.76; P = .021). Other independent negative predictors of OS and DFS included positive lymph node status, preoperative chemotherapy, comorbidity grade, and delayed adjuvant therapy. Severity of complication and reason for TL (salvage vs primary) were not shown to be predictive of OS or DFS.

CONCLUSION

Postoperative complications are associated with worse long-term OS and DFS relative to uncomplicated cases. Patient optimization and timely management of postoperative complications may play a critical role in long-term survival.

Functional Outcomes and Complications After Salvage Total Laryngectomy for Residual, Recurrent, and Second Primary Squamous Cell Carcinoma of the Larynx and Hypopharynx: A Multicenter Retrospective Cohort Study

Background/Purpose: We analyzed complications and functional outcomes and aimed at identifying prognostic factors for functional outcomes and complications in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx after initial (chemo)radiation.

Methods: Retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018. Prognostic factors for functional outcomes and complications were identified with uni- and multivariable analysis.

Results: A total of 405 patients were included in the final analysis. STL was performed for residual tumor (40.2%), local recurrence (40.5%), or second primary laryngeal or hypopharyngeal SCC (19.4%). Early postoperative complications were experienced by 34.2% of patients: postoperative hemorrhage occurred in 5.4%, wound infection in 16.2%, and clinical pharyngocutaneous fistula (PCF) in 25.5% of patients. Early readmission proved necessary in 15.1% of cases, most often due to late PCF development (72.2%). Patients achieved total peroral intake in 94.2% of cases. However, subjective dysphagia was reported by 31.3% of patients during follow-up. Functional speech, defined as functional communication by speech without additional aids, was reported in 86.7% of cases and was most often achieved by tracheo-esophageal puncture (TEP) (94.1%). In a multivariable model, lower preoperative hemoglobin (<12.5 g/dl) was identified as an independent prognostic factor for higher overall complication rate. No risk factors were found significant for clinical fistula formation. Vascularized tissue augmentation did not significantly prevent clinical PCF. Patients with positive section margins, patients initially treated with surgery combined with adjuvant RT (vs. radiotherapy alone), and those developing PCF after STL were less likely to achieve total peroral intake. Postoperative dysphagia proved more likely in patients who developed a PCF postoperatively, and less likely in patients who underwent STL without partial pharyngectomy and in patients with myocutaneous pectoralis major (PM) flap reconstruction, compared to muscle onlay PM flap. Achieving postoperative functional speech proved most likely in patients with smaller tumors (lower pT classification) and free section margins.

Conclusion: Substantial complication rates and favorable functional outcomes are reported after STL.

Oncologic Outcomes After Salvage Laryngectomy for Squamous Cell Carcinoma of the Larynx and Hypopharynx: A Multicenter Retrospective Cohort Study

OBJECTIVE

We aimed to analyze oncologic outcomes and identify patterns of failure and negative prognostic factors in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx.

METHODS

This was a retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018 for residual/recurrent/second primary SCC in the larynx or hypopharynx after initial (chemo)radiation. Prognostic factors for oncologic outcomes were identified using univariable and multivariable analysis.

RESULTS

A total of 405 patients were included in the final analysis. Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and locoregional relapse-free survival (LRFS) estimates were 47.7% (95% confidence interval [CI] 42.0-53.2%), 68.7% (95% CI 63.7-73.7%), 42.1% (95% CI 36.7-47.4%), and 44.3% (95% CI 38.8-49.7%), respectively. In a multivariable model, increasing clinical tumor stage of the residual/recurrent/second primary tumor, increasing number of metastatic cervical lymph nodes retrieved during neck dissection, hypopharyngeal and supraglottic tumor location, positive section margin status and perineural invasion were independent negative prognostic variables for OS, DSS, DFS, and LRFS. The type of second tumor was identified as an additional independent prognosticator for DSS, with local recurrences and second primary tumors having a better prognosis than residual tumor.

CONCLUSIONS AND RELEVANCE

Favorable oncologic outcomes are reported after STL. Increasing clinical tumor stage, increasing number of metastatic cervical lymph nodes, hypopharyngeal and supraglottic tumor location, positive section margins, and perineural invasion are identified as independent negative prognosticators for all oncologic outcome measures.

Free Flap Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function

OBJECTIVE

To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature.

METHODS

Retrospective review.

RESULTS

Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety-six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)-tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G-tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09).

CONCLUSION

Despite MVFTT reconstruction after STL, G-tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E875-E881, 2021.

Which risk factors are associated with stomal recurrence after total laryngectomy for laryngeal cancer? A meta-analysis of the last 30 years

Introduction

Stomal recurrence is a troublesome complication after total laryngectomy. Despite a large number of studies having been performed, there is still controversy about which risk factors are most significant for the development of stomal recurrence.

Objective

The objective of the present meta-analysis was to analyze the potential factors leading to stomal recurrence after total laryngectomy.

Methods

PubMed, Web of Science, Cochrane Library, and Ovid databases were systematically searched using multiple search terms. Eighteen studies with 6462 patients were identified. The quality of evidence was assessed by The National Institute for Health and Clinical Excellence.

Results

The results showed that, tumor subsite (supraglottic vs. subglottic, RR = 0.292, 95% CI 0.142–0.600, p = 0.001; glottic vs. subglottic, RR = 0.344, 95% CI 0.175–0.676, p = 0.002), T stage (RR = 0.461, 95% CI 0.286–0.742, p = 0.001), preoperative tracheotomy (RR = 1.959, 95% CI 1.500–2.558, p < 0.001) were the high-risk factors associated with the development of stomal recurrence.

Conclusion

From the results of our study, tumor subsite, T stage and preoperative tracheotomy were the significant risk factors for stomal recurrence. Methodologically high-quality comparative investigations are needed for further evaluation.

Management of the irradiated N0-neck during salvage pharyngo-laryngeal surgery

BACKGROUND

Salvage surgeries are challenging procedures, with an associated poor prognosis. Management of the N0 neck in those situations remains controversial. We aim to compare oncologic outcomes regarding neck management after surgery for N0 pharyngo-laryngeal carcinoma occurring after loco-regional radiotherapy.

METHODS

We conducted a multicentric retrospective study, including all patients undergoing surgery for persistent, recurrent or new primary N0 carcinoma of the oropharynx, hypopharynx or larynx between 2005 and 2015, following loco-regional radiotherapy.

RESULTS

A total of 239 patients were included, concerning respectively 44%, 34% and 22% oropharyngeal, laryngeal and hypopharyngeal tumors operated. A neck dissection was performed in 143 patients (60%), with an occult nodal metastasis rate of 9%. This rate was higher for hypopharyngeal carcinomas (18%, p = 0.16) and tumors with initial nodal involvement (16%, p = 0.05). With a median follow-up of 60 months, the median overall survival (OS) and progression-free survival rates (PFS) were 34 months and 25 months. We identified negative margin excision status, age at the time of surgery (under 60) and delay between RT and surgery over 2 years as the only variables associated with better OS (p < 0.0001 and p = 0.004) and PFS (p < 0.0001 and p = 0.010) in multivariable analysis, with no difference regarding neck management. Regional progression (alone or with distant metastasis) was noted in 10 cases: 4 in the neck observation group (4%) versus 6 in the neck dissection group (4%).

CONCLUSION

Elective lymph node dissection of irradiated neck should not be routinely performed in patients undergoing surgery for persistent, recurrent or new primary pharyngo-laryngeal carcinomas.

Association of Positive Initial Margins With Survival Among Patients With Squamous Cell Carcinoma Treated With Total Laryngectomy

Importance

Frozen-section analysis of margin status is routinely performed during total laryngectomy for squamous cell carcinoma; in the case of positive initial frozen margins, re-resection to negative margins can often be accomplished. Some evidence suggests that positive initial margins may be associated with worse survival among patients with head and neck cancer even when final margins are negative, but the significance of positive initial frozen margins in total laryngectomy is poorly understood.

Objective

To determine the association between disease-free survival and positive initial margins among patients treated with total laryngectomy for squamous cell carcinoma.

Design, Setting, and Participants

In this retrospective cohort study conducted at a tertiary care center, records of 237 consecutive patients treated with total laryngectomy for squamous cell carcinoma from February 2008 to July 2016 were reviewed for demographic characteristics, disease staging, pathologic markers, and outcomes. Margins were considered to be positive if they contained invasive carcinoma, carcinoma in situ, or severe dysplasia. Data analysis was performed from March to June 2018.

Interventions

All patients had undergone total laryngectomy for squamous cell carcinoma.

Main Outcomes and Measures

Variables associated with disease-free survival were analyzed using a univariable and multivariable Cox proportional hazards model.

Results

Among all 225 patients (184 [92%] male; mean age, 63.9 years; range, 30-92 years) who underwent total laryngectomy and had negative final margins, 127 patients underwent primary total laryngectomy and 98 underwent salvage total laryngectomy, with mean (SEM) follow-up of 29.3 (1.8) months. Initial frozen margins were positive in 40 of 225 patients (18%); positive initial margins occurred in 21 of 127 patients who underwent primary total laryngectomy (17%) and in 19 of 98 patients who underwent salvage total laryngectomy (19%). On multivariable analysis, only salvage laryngectomy was associated with significantly worse disease-free survival (hazard ratio [HR], 3.35; 95% CI, 1.76-6.36). Among 98 patients who underwent salvage total laryngectomy, positive lymph nodes, lymphovascular invasion, extracapsular nodal extension, and adjuvant therapy were associated with worse disease-free survival on univariable analysis, but no factors remained significant on multivariable analysis. Among 127 patients who underwent primary total laryngectomy, positive nodes, lymphovascular invasion, extracapsular nodal extension, and positive initial margins were associated with worse disease-free survival; however, only positive initial margins were associated with significantly worse disease-free survival on multivariable analysis (HR, 5.01; 95% CI, 1.55-16.2).

Conclusions and Relevance

In this study, positive initial margins were associated with worse disease-free survival among patients who underwent primary total laryngectomy despite negative margins on final pathologic examination. This finding may indicate aggressive tumor behavior in the context of primary laryngeal squamous cell carcinoma.

Salvage surgery for recurrent larynx cancer

BACKGROUND

Despite advances in treatment, the recurrence rates for laryngeal cancer range from 16% to 40%.

METHODS

Patients with recurrent laryngeal cancer treated at Memorial Sloan Kettering (MSK) from 1999 to 2016 were reviewed. Survival outcomes were analyzed.

RESULTS

Of 241 patients, 88% were male; the median age was 67 years; 71% had primary glottic tumors. At initial treatment, 72% of patients were seen with early stage disease; primary treatment was radiation (68%), chemoradiation (29%), and surgery (3%). The most common salvage surgery was total laryngectomy (74%). Forty-seven percentage were upstaged at salvage surgery. The 2- and 5-year disease-specific survival (DSS) was 74% and 57%, respectively. Patients with cT4 disease treated with nonsurgical primary management had a 0% 5-year DSS. Independent predictors of DSS were tumor location, perineural invasion, margin, and stage.

CONCLUSIONS

Salvage surgery results in acceptable oncologic outcomes. Stage, disease site, perineural invasion, and margins are associated with inferior DSS.

Analysis of tumor-infiltrating CD103 resident memory T-cell content in recurrent laryngeal squamous cell carcinoma

BACKGROUND

Recurrent laryngeal squamous cell carcinomas (LSCCs) are associated with poor outcomes, without reliable biomarkers to identify patients who may benefit from adjuvant therapies. Given the emergence of tumor-infiltrating lymphocytes (TIL) as a biomarker in head and neck squamous cell carcinoma, we generated predictive models to understand the utility of CD4+, CD8+ and/or CD103+ TIL status in patients with advanced LSCC.

METHODS

Tissue microarrays were constructed from salvage laryngectomy specimens of 183 patients with recurrent/persistent LSCC and independently stained for CD4+, CD8+, and CD103+ TIL content. Cox proportional hazards regression analysis was employed to assess combinations of CD4+, CD8+, and CD103+ TIL levels for prediction of overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) in patients with recurrent/persistent LSCC.

RESULTS

High tumor CD103+ TIL content was associated with significantly improved OS, DSS, and DFS and was a stronger predictor of survival in recurrent/persistent LSCC than either high CD8+ or CD4+ TIL content. On multivariate analysis, an "immune-rich" phenotype, in which tumors were enriched for both CD103+ and CD4+ TILs, conferred a survival benefit (OS hazard ratio: 0.28, p = 0.0014; DSS hazard ratio: 0.09, p = 0.0015; DFS hazard ratio: 0.18, p = 0.0018) in recurrent/persistent LSCC.

CONCLUSIONS

An immune profile driven by CD103+ TIL content, alone and in combination with CD4+ TIL content, is a prognostic biomarker of survival in patients with recurrent/persistent LSCC. Predictive models described herein may thus prove valuable in prognostic stratification and lead to personalized treatment paradigms for this patient population.

Salvage surgery for advanced stage head and neck squamous cell carcinoma following radiotherapy or chemoradiation

PURPOSE

Salvage surgery for recurrent advanced stage head and neck squamous cell carcinoma (HNSCC) is known to result in poor prognosis. As there are only small and heterogeneous studies available with wide variety in outcome measures, our purpose was to select and pool literature according to specific criteria.

METHODS

Systematic review and meta-analysis of clinical outcome after salvage surgery for recurrent advanced stage HNSCC following primary radiotherapy or chemoradiation.

RESULTS

16 of 3956 screened studies were included for analysis (729 patients). Pooled 5-year OS was 37% (95% CI 30-45%, 12 studies, 17 outcome measurements, 540 patients). Outcome was presented for larynx (6 studies, 397 patients), hypopharynx (2 studies, 47 patients), larynx and hypopharynx combined (3 studies, 69 patients) or separately (1 study, 134 patients), oral cavity (1 study, 11 patients), oropharynx (1 study, 34 patients) and multiple subsites combined (2 studies, 37 patients). There was no significant difference in survival outcome between subsites (p_{heterogeneity} = 0.8116). The pooled tumor-positive resection margin rate was 32% and pooled re-operation rate 17%. Complication rates from the pooled data were: fistulas 33%, wound infections 24% and flap failure 3%. Treatment-related mortality rate was 1% and mean hospital stay was 23 days.

CONCLUSIONS

Salvage surgery for recurrent advanced stage head and neck squamous cell carcinoma after primary (chemo)radiotherapy is a good last resort curative treatment option, resulting in 37% overall survival at 5 years. As data from advanced stage non-laryngeal tumors were sparse, no solid conclusions can be drawn with regard to outcome differences between tumor subsites.

Preoperative low skeletal muscle mass as a risk factor for pharyngocutaneous fistula and decreased overall survival in patients undergoing total laryngectomy

Background

Low skeletal muscle mass (SMM) is associated with postoperative complications, prolonged hospital stay, and short overall survival (OS) in surgical oncology. We aimed to investigate this association in patients undergoing total laryngectomy (TL).

Methods

A retrospective study was performed of patients undergoing TL. SMM was measured using CT or MRI scans at the level of the third cervical vertebra (C3).

Results

In all, 235 patients were included. Low SMM was observed in 109 patients (46.4%). Patients with low SMM had more pharyngocutaneous fistulas (PCFs) than patients with normal SMM (34.9% vs 20.6%; P = .02) and prolonged hospital stay (median, 17 vs 14 days; P < .001). In multivariate analysis, low SMM (hazards ratio, 1.849; 95% confidence interval, 1.202‐2.843) and high N stage were significant prognosticators of decreased OS.

Conclusion

Low SMM is associated with PCF and prolonged hospital stay in patients undergoing TL. Low SMM is an independent prognostic factor for shorter OS.

Salvage Surgery for Recurrence after Radiotherapy for Squamous Cell Carcinoma of the Head and Neck

OBJECTIVE

Most studies that report on salvage surgery after primary radiotherapy for head and neck squamous cell carcinoma (HNSCC) are small and heterogeneous. Subsequently, some relevant questions remain unanswered. We specifically focused on (1) difference in prognosis per tumor subsite, corrected for disease stage, and (2) differences in prognosis after salvage surgery for local, regional, and locoregional recurrences.

STUDY DESIGN

Retrospective analysis.

SETTING

Single-center study (2000-2016).

SUBJECTS AND METHODS

Patients treated with salvage surgery for HNSCC recurrence after (chemo)radiotherapy.

RESULTS

In total, 189 patients were included. Five-year overall survival (OS) was 33%, and median OS was 18 (95% confidence interval [CI], 11-26) months. Treatment-related mortality was 2%. Larynx carcinoma was associated with more favorable local (adjusted hazard ratio [HR] = 4.02; 95% CI, 1.46-11.10; P = .007) and locoregional control (adjusted HR = 5.34; 95% CI, 1.83-15.61; P = .002) than pharyngeal carcinoma. American Society of Anesthesiologists (ASA) score (≥3 vs 1-2: adjusted HR = 3.04; 95% CI, 1.17-7.91; P = .023), pT stage (3-4 vs 1-2: adjusted HR = 4.41; 95% CI, 1.65-11.82; P = .003), and salvage surgery for locoregional recurrences (locoregional vs local: adjusted HR = 3.81; 95% CI, 1.13-11.82; P = .021) were independent predictors for disease-free survival (DFS).

CONCLUSION

Salvage surgery for larynx carcinoma, regardless of disease stage and other prognostic factors, results in more favorable loco(regional) control but not favorable DFS than pharyngeal carcinoma. The observed difference in DFS between salvage surgery for local and regional recurrences was not significant after correction for confounders. However, survival following salvage surgery for locoregional disease is significantly worse. For this subgroup, we propose to consider T status and comorbidity for clinical decision making, as high pT stage and ASA score are independent predictors for worse DFS.

Airway Management During Anesthetic Induction of Secondary Laryngectomy for Recurrent Laryngeal Cancer: Three Cases of Report and Analysis

Surgery for laryngeal cancer and the following recurrent tumor growth may further change the anatomy of the airway. Airway management during anesthesia induction is challenging for the patients undergoing secondary surgery due to recurrence of laryngeal cancer or its postoperative complication, but it has never been reported. In this report, we described three cases of anesthetic induction which had different process of airway events. The first case was given intravenous general anesthetic for induction and experienced failed intubation, difficult mask ventilation and emergent tracheostomy, eventually were rescued successfully. The second case presented a fixed metastatic mass about 6 cm diameter upon the primary surgical scar of incision and preoperative apnea, underwent fibroscopy-guided conscious intubation and the process was uneventful. The third case had erythema and swelling under the mandible with erupted ulcer as well as neck immobility due to recurrent tumor. The anesthesiologist attempted fibroscopy-guided intubation via nasal passage with a tracheal tube in 2.8 mm diameter but it was failed. Subsequently, tracheostomy was performed under bilateral superficial cervical plexus block and the dissected larynx by operation verified distorted structure of glottis with S-shaped stenosis. This report concludes that, during the anesthetic induction for this special type of surgery, a detailed and comprehensive evaluation of the airway, and a routine fibroscopic examination are especially important.

An Overview of Laryngeal Cancer Treatment at a Tertiary Care Oncological Center in a Developing Country

Introduction Development of laryngeal cancer is multifactorial, and management is surrounded with controversies. Recent reports suggest a decline in the survival of these patients. We conducted a study to analyze the clinicopathological parameters and compute the outcomes in terms of survival in patients with laryngeal cancer treated at our institution. Methods Electronic charts of 515 patients with Laryngeal cancer treated at our Hospital and Research Center from 2004 to 2014 were retrospectively reviewed. Results Median age was 62 years. Male: female ratio 91%: 9%. Sixty-two percent were smokers. Histologically, all were squamous cell carcinoma. Most common subsite was glottis (88%). Treatment was non-surgical in 92% and surgical in 8%. The five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and locoregional control (LRC) were 67%, 74%, 59% and 70%, respectively. OS, DSS, DFS and LRC for early stage (I-II) and advance stage (III-IV) were 81 and 54%, 86 and 63%, 75 and 45%, and 83 and 57%, respectively. Twenty-two percent recurred locally. Of these failures, 19% were inoperable, 36% were surgically salvaged and 34% refused laryngectomy. Conclusions Our survival rates are comparable with published data. The high refusal rate for salvage total laryngectomy is concerning and needs further study to evaluate the reasons.

Salvage total laryngectomy after conservation laryngeal surgery for recurrent laryngeal squamous cell carcinoma

The aim of the present study was to evaluate the oncological efficacy of salvage total laryngectomy in patients who had previously undergone supracricoid partial laryngectomy or transoral laser microsurgery for treatment of laryngeal squamous cell carcinoma. We retrospectively reviewed the medical, surgical and pathological records of 35 patients who underwent salvage total laryngectomy after recurrence of laryngeal cancer (following supracricoid partial laryngectomy or transoral laser microsurgery). Kaplan-Meier survival curves as well as univariate and multivariate analyses of prognostic factors were performed. No statistically significant differences were seen comparing the supracricoid partial laryngectomy group with the transoral laser microsurgery group for overall survival and disease-specific survival at 3 years (OS = 38% vs. 52%, p = 0.16; DSS = 40% vs. 61%, p = 0.057) or locoregional control at 2 years (LRC = 40% vs. 54%, p = 0.056). A trend indicating worse survival and locoregional control for supracricoid partial laryngectomy patients emerged. Preservation of the osteocartilaginous frame in transoral laser microsurgery could hypothetically result in better salvageability of anterior recurrences with extralaryngeal spread.

Salvage Transoral Laser Microsurgery for Radiorecurrent Laryngeal Cancer: Indications, Limits, and Outcomes

Purpose of Review

The aim of this report is to identify relevant literature reports on salvage transoral laser microsurgery (TLM); to consider its oncologic and functional outcomes, as well as reported complications; and to address indications and limitations of salvage TLM.

Findings

The weighted average of local control after first salvage TLM was 57%. Repeated TLM procedures for second or third recurrences were required in up to 41% of cases, resulting in a weighted average of local control with TLM alone of 67%. The rate of definite laryngeal preservation was 73%. The ultimate local control rate, including cases that required total laryngectomy, was 90%. The overall complication rate after salvage TLM was 14%.

Summary

Salvage TLM of radiorecurrent laryngeal cancer yields excellent oncologic outcomes. Serious complications are scarce, hospitalization times are short, and functional outcomes in terms of voice and swallowing are favorable when compared to open conservation laryngeal surgery. The key to success is an optimal patient selection.