Radiation fibrosis and necrosis of the larynx

Late laryngeal dysfunction in head and neck cancer survivors

Objectives

Head and neck cancer (HNC) survivorship issues are areas of increasing research interest. Laryngeal dysfunction in HNC patients is particularly important given the importance of the larynx in voice, swallowing, and airway protection. The objective of our study is to characterize late laryngeal dysfunction in a cohort of long-term HNC survivors.

Methods

HNC survivors who were at least 2 years post-treatment were recruited prospectively for standard collection of videolaryngoscopy findings, videofluoroscopic swallowing studies, and assessment of clinical outcomes. Descriptive statistics were performed and clinical presentation and outcomes were compared between survivors >10 years and <10 years post-treatment. Additional factor analysis to correlate clinical outcomes with clinical variables was performed.

Results

Thirty participants were analyzed with a mean age of 66 years. The majority were male (80%) patients treated for oropharyngeal squamous cell carcinoma (67%). Within the cohort, 43% underwent primary chemoradiation therapy and had 13% radiation alone. Common presenting symptoms included swallowing dysfunction (83%), voice change (67%), and chronic cough (17%). Laryngeal findings on video laryngoscopy include vocal fold motion abnormalities (VFMA) in over half of participants (61%) and mucosal changes in 20%. A weak correlation was found between time since treatment and laryngeal dysfunction (r = .182, p = .34), and no correlation was found between age, sex, time since treatment, or primary site and the presence or absence of VFMA, G-tube status, or tracheostomy-tube status.

Conclusion

Late laryngeal dysfunction in HNC survivors contributes to significant morbidity, is difficult to treat, and remains static decades after treatment for their original cancer.

Lay Summary

The voice-box, or the larynx, plays an important role in voice, swallowing and airway protection. It is particularly vulnerable to radiation-related damage and changes. This study demonstrates the sequelae of long-term damage of the larynx in head and cancer survivors.

Level of Evidence

IV.

Carotid arterial blowout after organ preserving chemoradiation therapy in hypopharyngeal cancer

Laryngeal preserving concurrent chemoradiation has been advocated for hypopharyngeal cancers. The use of radiotherapy (RT) in the larynx could lead to increased rates of radionecrosis. In this study, we investigated a rare but disastrous complication, carotid blow-out syndrome (CBS), related with the persistent radionecrosis. Retrospective cohort study. This retrospective study enrolled hypopharyngeal cancer patients with biopsy-proven pharyngeal and laryngeal chondronecrosis (PLCRN), which was rated by the Chandler Grading System. From 2002 to 2018, a total of 346 hypopharygeal cancer patients received upfront radiation therapy, 13 PLCRN patients were identified in a rate of 3.8%. All PLRN patients received RT with a mean radiation dose of 70.81 ± 0.85 Gy. All patients had Chandler Grade IV at the time of presentation, which was a mean of 15.08 months (range: 5-109 months) from the time of cancer diagnosis to PLCRN diagnosis. In 5 of the 13 PLCRN patients developed CBS. Three of the CBS originated from superior thyroid artery, one from lingual artery and one from the carotid artery. Three (60%) of the 5 CBS patients expired due to loss of airway and hemodynamic instability. Two (40%) were rescued by emergent airway secure and emergent angiographic embolization. Persistent PLCRN could lead to disastrous vascular complications. CBSs were demonstrated to be more frequently originated from the branches of carotid artery rather than carotid artery per se. Clinical alert with early airway protection could strive for time to do interventions and prevent mortalities.

Radiation necrosis of the bone, cartilage or cervical soft-tissues following definitive high-precision radio(chemo)therapy for head-neck cancer: uncommon and under-reported phenomenon

Background

The impact of modern high-precision conformal techniques on rare but highly morbid late complications of head and neck radiotherapy, such as necrosis of the bone, cartilage or soft-tissues, is not well described.

Method

Medical records of head and neck cancer patients treated in prospective clinical trials of definitive high-precision radiotherapy were reviewed retrospectively to identify patients with necrosis.

Results

Twelve of 290 patients (4.1 per cent) developed radiotherapy necrosis at a median interval of 4.5 months. There was no significant difference in baseline demographic (age, gender), disease (primary site, stage) and treatment characteristics (radiotherapy technique, total dose, fractionation) of patients developing radiotherapy necrosis versus those without necrosis. Initial management included antibiotics or anti-inflammatory agents, tissue debridement and tracheostomy as appropriate followed by hyperbaric oxygen therapy and resective surgery for persistent symptoms in selected patients.

Conclusion

Multidisciplinary management is essential for the prevention, early diagnosis and successful treatment of radiotherapy necrosis of bone, cartilage or cervical soft tissues.

Imaging of Complications of Chemoradiation

Chemoradiation for head and neck cancer is associated with a variety of early and late complications. Toxicities may affect the aero-digestive tract (mucositis, salivary gland injury), regional osseous and cartilaginous structures (osteoradionecrosis (ORN) and chondronecrosis), vasculature (progressive radiation vasculopathy and carotid blow out syndromes), and neural structures (optic neuritis, myelitis, and brain injury). These may be difficult to distinguish from tumor recurrence on imaging, and may necessitate the use of advanced MRI and molecular imaging techniques to reach the correct diagnosis. Secondary radiation-induced malignancies include thyroid cancer and a variety of sarcomas that may manifest several years after treatment. Checkpoint inhibitors can cause a variety of adverse immune events, including autoimmune hypophysitis and encephalitis.

Chondroradionecrosis of the trachea after definitive radiotherapy for cervical esophageal cancer: A case report

Chondroradionecrosis (CRN) is an infrequent phenomenon after definitive RT. The clinical manifestation is usually difficult to distinguish from that of tumor recurrence; however, clinicians should be aware of the possibility of CRN.

Smoking-induced radiation laryngeal necrosis after definitive radiotherapy alone for T1a glottic squamous cell carcinoma: A case report

Background

We report the case of a patient with smoking‐induced radiation laryngeal necrosis (RLN) after undergoing definitive radiotherapy (RT) alone for T1a glottic squamous cell carcinoma.

Case

The patient was a 63‐year‐old man who had a history of heavy smoking. He quit smoking when he was diagnosed with glottic squamous cell carcinoma. The RT dose was 63 Gy, delivered in 28 fractions with the three‐dimensional conventional RT technique for the larynx. After RT completion, the initial treatment response was complete response. He then underwent follow‐up examinations. At 13 months after RT, the patient resumed smoking. At 2 months after resuming smoking, he had severe sore throat and hoarseness. Laryngoscopy revealed a large tumor in the glottis. Surgical excision was performed, and the patient was histologically diagnosed with RLN, as late toxicity without cancer recurrence. At 3 weeks postoperatively, the patient had dyspnea, and laryngoscopy revealed total laryngeal paralysis. Thus, he underwent an emergent tracheostomy. The administration of steroids affected RLN, and laryngeal paralysis gradually improved.

Conclusions

This case suggests that smoking may have the potential to induce RLN after RT. Moreover, continuing smoking cessation is significantly important for patients with glottic cancer who receive RT. Rather than leaving smoking cessation up to the patient, it would be necessary for clinicians to actively intervene to help patients continue their effort to quit smoking.

Salvage carbon dioxide transoral laser microsurgery for laryngeal cancer after (chemo)radiotherapy: a European Laryngological Society consensus statement

Purpose

To provide expert opinion and consensus on salvage carbon dioxide transoral laser microsurgery (CO₂ TOLMS) for recurrent laryngeal squamous cell carcinoma (LSCC) after (chemo)radiotherapy [(C)RT].

Methods

Expert members of the European Laryngological Society (ELS) Cancer and Dysplasia Committee were selected to create a dedicated panel on salvage CO₂ TOLMS for LSCC. A series of statements regarding the critical aspects of decision-making were drafted, circulated, and modified or excluded in accordance with the Delphi process.

Results

The expert panel reached full consensus on 19 statements through a total of three sequential evaluation rounds. These statements were focused on different aspects of salvage CO₂ TOLMS, with particular attention on preoperative diagnostic work-up, treatment indications, postoperative management, complications, functional outcomes, and follow-up.

Conclusion

Management of recurrent LSCC after (C)RT is challenging and is based on the need to find a balance between oncologic and functional outcomes. Salvage CO₂ TOLMS is a minimally invasive approach that can be applied to selected patients with strict and careful indications. Herein, a series of statements based on an ELS expert consensus aimed at guiding the main aspects of CO₂ TOLMS for LSCC in the salvage setting is presented.

Anaplastic thyroid cancer with long-term survival with lenvatinib therapy and preservation of laryngeal function after one-stage reconstruction: A case report

Laryngotracheal reconstruction is performed to treat locally advanced thyroid carcinoma invading the larynx and/or trachea. The reconstructive technique varies. The present report describes the case of a 71-year-old female patient who underwent surgery for thyroid carcinoma involving the larynx. Reconstructive surgical techniques were employed to maintain laryngeal structure and function. An anterolateral thigh flap with free rib cartilage grafts was used to compensate for laryngeal defects. Although a temporary tracheal stoma was constructed, it closed spontaneously after decannulation. Therefore, one-stage laryngeal reconstruction was accomplished. Post-operative histopathological examination revealed focal anaplastic changes in the lesion, which mainly consisted of papillary components. Post-operative positron emission tomography/computed tomography indicated early recurrence in the left side of the neck. Therefore, lenvatinib was started as adjuvant therapy. Complete response was observed with lenvatinib therapy. The patient was alive and had good laryngeal function 26 months after the operation. One-stage laryngeal reconstruction can reduce burden and improve quality of life in patients with thyroid carcinoma involving the larynx. Lenvatinib may be useful for treating early recurrence of anaplastic thyroid carcinoma after reconstructive surgery with a free flap.

Development of an International, Multicenter, Hyperbaric Oxygen Treatment Registry and Research Consortium: Protocol for Outcome Data Collection and Analysis

BACKGROUND

Hyperbaric oxygen (HBO₂)-oxygen at pressures higher than atmospheric-is approved for 14 indications by the Undersea and Hyperbaric Medical Society. HBO₂'s main effect is to increase oxygen content in plasma and body tissues, which can counteract hypoxia or ischemia. Laboratory studies show that HBO₂ has effects beyond relieving hypoxia (eg, promoting angiogenesis in irradiated tissue, anti-inflammatory effects, radiosensitization of tumors, hypoxia preconditioning, and fungal growth inhibition) and has potential to treat conditions such as inflammatory bowel disease and pyoderma gangrenosum. Lack of consistently collected outcome data on a large cohort of individuals receiving HBO₂ therapy limits its use for both established and new indications. A course of therapy often involves 30-40 visits to a hyperbaric chamber, so the number of patients seen at any given center is constrained by chamber capacity. As a result, published HBO₂ outcome data tend to be from small case series because few patients with a particular condition are treated at a given center. To solve this problem, a registry that collects and pools data systematically from multiple institutions has been established.

OBJECTIVE

The aim of this study is to collect consistent outcome data across multiple hyperbaric centers to assess treatment effectiveness and establish a research consortium.

METHODS

A consortium of hyperbaric centers who have agreed to collect consistent outcome data on all patients seen has been assembled. Data are collected at each participating center using Research Electronic Data Capture (REDCap), a web-based, data collection system used frequently for research. Standard outcome measures have been defined for each condition, which are programmed into the REDCap data collection templates. Governance is through a consortium agreement that defines data security, data sharing, publications, liability, and other issues. Centers obtain Institutional Review Board (IRB) and ethics approval to participate, either from their own institutions or by relying on the IRB at the coordinating center at Dartmouth College. Dissemination will occur through a yearly report and by publications based on the data in the registry.

RESULTS

Early results from some common indications show significant pretreatment to posttreatment changes. Additional indications and outcome measures are being added using the procedures outlined in the consortium agreement.

CONCLUSIONS

The registry collects consistent outcome information for a therapy that needs further study and a stronger evidence base. It also overcomes the challenge of collecting data from an adequate number of patients for both established and emerging indications by combining data collection from multiple centers. The data entry requirements should be within the capabilities of existing staff at any given hyperbaric center. By using REDCap, the registry can be expanded to include detailed information on particular indications and long-term follow-up on selected patients without significantly increasing the basic data entry requirements. Through the registry, a network of enrolled hyperbaric centers has been established that provides the basis for a clinical trial network.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18857.

Chondroradionecrosis of the larynx

PURPOSE OF REVIEW

Purpose of the present review is to revise the literature of the last 18 months, looking for novelties or new trends in diagnosis and therapeutical approaches to a very uncommon complicaton.

RECENT FINDINGS

Some comorbidities as well as prior surgical laryngeal treatment and lifestyle factors are known to increase tissue susceptibility to radiation injury and to complications due to endotracheal intubation.

SUMMARY

Chondroradionecrosis (CRN) of the larynx is a rare and severe complication of radiotherapy and endotracheal intubation which can be fatal if not managed promptly. In recent years, the trend in oncological surgery is organ preservation even in the advanced stage of laryngeal malignancies. However, in certain stages of squamous cell carcinomas, radiotherapy is necessary as a first or second line of treatment. Endotracheal intubation has also been associated with chondronecrosis and it is thought to be secondary to excessive pressure of the endotracheal tube or its cuff on the cartilage itself. Clinical diagnosis of CRN is extremely difficult and should be placed in differential diagnosis with postradiation outcomes and cancer recurrence. PET is useful, but biopsy is still required to confirm the diagnosis. The use of the laryngeal mask airway should prevent this complication and is a reasonable choice through which to administer general anesthesia in selected patients.

Evaluating the Expression of NOX2 and NOX4 Signaling Pathways in Rats' Lung Tissues Following Local Chest Irradiation; Modulatory Effect of Melatonin

Lung injury is one of the major concerns for chest cancer patients that undergo radiotherapy as well as persons exposed to an accidental radiological event. Reduction/oxidation (redox) system plays a key role in lung injury via chronic upregulation of pro-oxidant enzymes. NOX2 and NOX4 are two important reactive oxygen species generating enzymes that are involved in radiation toxicity in some organs such as the bone marrow. In this study, we aimed to evaluate the expression of NOX2 and NOX4 signaling in rat's lung tissues. Upregulation of these genes may be involved in radiation-induced lung injury. Moreover, we evaluated the role of pre-treatment with melatonin on the expression of these genes. Twenty male rats were divided into 4 groups as control; melatonin treated; irradiation; and irradiation with melatonin pre-treatment. Rats were exposed to 15 Gy ⁶⁰Co gamma rays and sacrificed after 10 weeks for evaluation of NF-κB, TGFβR1, SMAD2, NOX2, and NOX4 gene expression by real-time PCR. Results showed the upregulation of all five genes. The expression of NOX2 was more obvious compared to other genes. Administration of melatonin before irradiation could attenuate the expression of all mentioned genes. Results indicate that upregulation of NADPH oxidase genes such as NOX2 and NOX4 may be involved in the late effects of lung exposure to ionizing radiation. Melatonin via downregulation of these pro-oxidant genes is able to attenuate radiation toxicity in the lung.

Hyperbaric oxygen therapy in the treatment of complications of irradiation in laryngeal cancer

One of the standard treatments in laryngeal cancer is radiotherapy (RT). Many short- and long-term complications can occur in the region that has received radiotherapy. Definitive treatment of the emerging complications is still debatable, and treatment is challenging for radiation oncologists and ear nose throat specialists. Recently, hyperbaric oxygen treatment (HBOT) has become a promising alternative for the treatment of these complications. The aim of this report is to discuss the effectiveness of HBOT in the treatment of late-term RT-related potential complications in a patient with laryngeal cancer. We applied HBOT for a 58-year-old male patient with laryngeal cancer for the treatment of laryngeal oedema, and dyspnoea that developed one year after RT. In a decompression chamber at 2.4 atm pressure, the patient was made to breath 100% oxygen with a mask for 90 minutes. At the beginning, HBOT was planned for 30 days; however, it was terminated upon improvement of the symptoms at the 19^th session. The symptoms, which developed one year after RT, were relieved completely with HBOT, and the patient is maintaining his life without any complaint under our control. The HBOT can be an alternative treatment for late-term complications developed after radiotherapy. It can be especially used for laryngeal oedema, and dyspnoea related to the field of radiotherapy.

Laryngeal chondronecrosis after radiation therapy in a dog

A 5-year-old pug presented with a soft tissue swelling on the ventral neck and moderate stridor with associated respiratory effort. This patient received hypofractionated radiotherapy for metastatic upper lip mast cell tumour and to the submandibular lymph nodes 6 months before presentation. Oral examination showed moderate elongation of the soft palate, stage III laryngeal collapse with only the right laryngeal saccule mildly everted and exuberant pale epiglottal and left pharyngeal mucosa. Staphylectomy, resection of the epiglottal mucosa and left arytenoid lateralisation were performed. One day after surgery, temporary tracheostomy was performed after respiratory distress due to the severe laryngeal and pharyngeal oedema. A third oral exam showed pale and redundant caudal pharyngeal mucosa obstructing the rima glottis, soft and collapsible arytenoid cartilage with pale mucosa and bilateral everted laryngeal saccules. Permanent tracheostomy was elected and laryngeal cartilage biopsies were taken. Histologic diagnosis showed cartilage necrosis and abundant tissue oedema. The patient was euthanased 1 week later.

Condroradionecrose de laringe após radioterapia

RESUMO Objetivo: estudar a condroradionecrose de laringe por complicação de radio-quimioterapia para tratamento do câncer de laringe e propor um fluxograma de tratamento com a utilização de câmara hiperbárica. Métodos: estudo retrospectivo de pacientes portadores de carcinoma de laringe admitidos em dois hospitais terciários num período de cinco anos. Resultados: de 131 pacientes portadores de câncer de laringe, 28 foram submetidos à radio e quimioterapia exclusiva e destes, três evoluíram com condroradionecrose. O tratamento destes pacientes foi realizado com câmara hiperbárica e com desbridamento cirúrgico, conforme proposição do fluxograma. Todos os pacientes tiveram a laringe preservada. Conclusão: a incidência de condroradionecrose de laringe por complicação de radioterapia e quimioterapia em nossa casuística foi de 10,7% e o tratamento com oxigenoterapia hiperbárica, com base no nosso fluxograma, foi efetivo no controle desta complicação.

Chondroradionecrosis of the larynx: 24-year University of Wisconsin experience

BACKGROUND

Chondroradionecrosis (CRN) is an uncommon but significant complication of laryngeal radiotherapy that presents a diagnostic challenge to clinicians through its similarity in presentation to cancer recurrence.

METHODS

Two hundred ninety-four patients underwent primary, adjuvant, or salvage radiation for laryngeal cancer from 1991 to 2015 at the University of Wisconsin. Medical records were reviewed to identify and characterize patients with a diagnosis of CRN.

RESULTS

Of the 294 patients, 7 cases (2.4%) of CRN were identified. Development of CRN was associated with the presence of cartilage invasion by tumor (p = .038) and ongoing alcohol use postradiotherapy (p = .036). Additionally, a trend between development of CRN and ongoing smoking postradiotherapy was observed (p = .067).

CONCLUSION

The diagnosis of CRN is challenging, and the likelihood of successful resolution is modest. A high premium should be placed on efforts directed at prevention, such as tobacco and alcohol cessation. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1189-1194, 2017.

Fungal contribution in chondroradionecrosis of the larynx

OBJECTIVE

To assess the prevalence of invasive fungal elements in the specimens of patients who underwent salvage total laryngectomy for chondroradionecrosis (CRN) in the absence of recurrent or persistent malignancy.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic medical center.

METHODS

One hundred fifty-nine patients were identified who underwent salvage total laryngectomy. Pathology reports were reviewed, and all laryngectomy specimens that did not contain residual malignancy were reevaluated for evidence of invasive fungal elements.

RESULTS

Twelve of 159 (7.5%) patients who underwent total laryngectomy after primary radiotherapy or chemoradiotherapy had no evidence of residual malignancy. Each of these specimens contained histopathologic evidence of CRN; invasive fungal elements were identified in 25%. There was no statistical difference in demographic or treatment-related variables between patients who underwent salvage total laryngectomy with evidence of persistent or recurrent malignancy in the laryngectomy specimen versus patients without evidence of tumor on final histopathologic analysis. Patients with evidence of ulceration or necrosis in the laryngectomy specimen had reduced overall survival, irrespective of the presence of persistent malignancy (hazard ratio = 2.923, 95% confidence interval = 1.023-8.352, P = .045).

CONCLUSION

Among salvage total laryngectomy patients, no difference was identified between patients who underwent total laryngectomy for recurrent or persistent malignancy after primary radiotherapy and those who received total laryngectomy without evidence of malignancy in their specimens. Invasive fungal elements were detected in several laryngectomy specimens that did not contain residual malignancy. Empiric antifungal therapy may therefore benefit patients diagnosed with CRN who are at risk for progression to nonfunctional larynx. Patients with evidence of ulceration or necrosis in the salvage laryngectomy specimen had worse overall survival.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:E159-E165, 2017.

Imaging appearance of a post-intubation cricoid chondronecrosis

Chondronecrosis is a known complication of external beam radiation therapy and endotracheal intubation. Radiation therapy is the most common cause of chondronecrosis owing to local cartilage ischaemia following treatment. Prolonged endotracheal intubation can lead to chondronecrosis as it is associated with excessive pressure on the cartilage by the endotracheal tube or its cuff. The cricoid ring is the most commonly affected cartilage. CT imaging is an integral part of the workup, although reports on imaging appearances are scant. We report the imaging and clinical presentation of a case of chondronecrosis secondary to the use of endotracheal tube ventilation. The patient was managed conservatively with good clinical outcome.

Predictors of wound complications after laryngectomy: A study of over 2000 patients

OBJECTIVES: To identify risk factors for and the rate of wound complications after laryngectomy in a large, prospectively collected national dataset, and to generate a predictive model.

STUDY DESIGN: We used the National Surgical Quality Improvement Program (NSQIP) registry created by the Department of Veterans Affairs (VA) to identify patients undergoing total laryngectomy from 1989 to 1999 (n = 2063). We linked these data to inpatient and outpatient VA administrative records to capture data for prior radiation. Over 20 preoperative and intraoperative risk factors were analyzed using bivariate techniques. Those significant at the P < 0.01 level were analyzed with logistic regression and conjunctive consolidation to identify independent predictors of wound complications.

RESULTS: The overall wound complication rate was 10.0%. In adjusted analyses, prolonged operative time (> 10 hours, odds ratio = 2.10, 95% confidence interval: 1.32-3.36), exposure to prior radiation therapy (OR =1.63, 1.07-2.46), presence of diabetes (OR = 1.78, 1.04-3.04), preoperative hypoalbumine-mia (OR =1.90, 1.32-2.74), anemia (OR =1.59, 1.07-2.36), and thrombocytosis (OR =1.48, 1.04-2.10) were independently associated with postoperative wound complications. A prognostic model using three variables—prior radiation therapy, diabetes, and hypoalbuminemia—provided excellent risk stratification into three tiers (6.3%, 13.7%, 21.7%).

CONCLUSIONS: Preoperative radiation, prolonged operative time, low albumin, and diabetes were independently associated with postoperative wound infections. These results will help to identify patients at risk for wound complications, thus allowing for heightened surveillance and preventive measures where possible.

Chondronecrosis of the larynx following use of the laryngeal mask airway

This case describes the development of laryngeal chondronecrosis after use of the laryngeal mask airway (LMA). A 69-year-old male with prior laryngeal irradiation underwent total knee replacement with general anesthesia via LMA. Postoperatively, he developed laryngeal chondronecrosis, bilateral vocal fold immobility, and aspiration, necessitating tracheostomy and gastrostomy placement. He improved with hyperbaric oxygen therapy, intravenous antibiotics, and endoscopic repair of a residual fistula. Vocal fold motion returned and he was decannulated. Chondronecrosis of the larynx may occur with the use of the LMA, and caution should be used in patients with a history of prior laryngeal irradiation.

Chondroradionecrosis of larynx a delayed complication of radiotherapy: management and review of literature

Background/objectives Chondroradionecrosis (CRN) of the larynx is a rare and grave complication of radiotherapy which can be fatal if not managed aggressively. A recent trend towards organ preservation protocols towards even advanced stage laryngeal malignancies and with further advances in terms of technology and safety radiation as external beam and intensity modulated varieties are preferred for certain stages of squamous cell carcinomas. Materials and methods We are reporting a series of 4 cases of CRN of the larynx treated in our hospital with 3 cases of stage III carcinoma glottis and one stage III carcinoma supraglottis with no nodal metastasis. One glottis cancer had 2 sittings of laser microlaryngeal excision earlier. All were in grade 4 CRN and one improved with medical line and HBO and the other 3 progressed and salvage laryngectomy and pectoralis major myocutaneous flap to cover the fistulous skin defect was grafted.

CONCLUSION

Laryngeal CRN being a rare and intensely morbid complication of radiotherapy should be suspected and diagnosed at the earliest by endoscopic and imaging methods. Disease progression and chances of tumor recurrence should be followed up with PET CT and a call on salvage laryngectomy with repair of the anterior neck defects with non irradiated musculocutaneous flaps or vascularised tissue transfer should be promptly taken.

Radiotherapy concurrent with S-1 and radiotherapy alone for T2N0 glottic carcinoma: a retrospective comparative study

OBJECTIVE

We examined the completion rate, safety, and adverse events in patients with T2N0 glottic carcinoma who received chemoradiotherapy with S-1 (tegafur-gimeracil-oteracil potassium).

METHODS

In T2N0 glottic carcinoma patients, we retrospectively compared the local control rate and outpatient therapy completion rate between 20 patients who received radiotherapy plus S-1 (S-1 group) and 20 who received radiotherapy alone (RT group).

RESULTS

Local recurrence was not detected in any of the 20 subjects from the S-1 group, whereas local recurrence was found in 4 of the 20 subjects (20%) from the RT group (p<0.05). Outpatient treatment was completed by 15 of the 20 subjects from the S-1 group and 17 of the 20 subjects from the RT group (p=0.43).

CONCLUSION

We investigated chemoradiotherapy with S-1 in patients who had T2N0 glottic carcinoma and found a higher local control rate when compared with radiotherapy alone as well as comparable safety for outpatient delivery.

Clinical Assessment and Treatment of the Dysfunctional Larynx after Radiation

Objective

To review the pathophysiology of early and late radiation-related tissue changes, methods to differentiate these changes from disease recurrence, and treatment of these changes in the irradiated larynx.

Data Sources

Peer-reviewed publications.

Review Methods

PubMed database search.

Conclusions/Implications for Practice

Early and late radiation-related changes in the larynx manifest variably between individual patients. Severe radiation-related tissue changes in the larynx and recurrent malignancy share many clinical characteristics, and the presence of malignancy must be considered in these patients. Positron emission tomography may help select patients who need operative biopsy to rule out recurrence. In patients with a cancer-free but dysfunctional larynx, both surgical and nonsurgical treatment options, including hyperbaric oxygen, are available for attempted salvage. Further investigation is needed before hyperbaric oxygen can be considered standard-of-care treatment for these patients.

Comprehensive review of hyperbaric oxygen therapy

Hyperbaric oxygen therapy involves inspiration of pure high pressure oxygen. For the past 20 years, administration of 100% high pressure oxygen and its potential benefits in management of diseases have been more clarified. Physiological advantages advocate HBO for the first-line treatment of several conditions. The specialty of craniofacial surgery is broad and deals with a diverse range of complications. The goal of this review is to help surgeons in their treatment planning by categorizing the indications of HBO therapy for oral and maxillofacial surgery. We also assess research data substantiating these indications where we believe basic physiological mechanisms and clinical evidences support further investigation on HBO efficacy to greater understanding of its potential benefit in oral and maxillofacial surgery.

Successful hyperbaric oxygen therapy for laryngeal radionecrosis after chemoradiotherapy for mesopharyngeal cancer: case report and literature review

Laryngeal radionecrosis is one of the most troublesome late complications of radiotherapy, because it is frequently resistant to treatment and laryngectomy is required in the worst case. Here, we report a case of laryngeal radionecrosis, successfully treated by use of hyperbaric oxygen (HBO) therapy, in which laryngectomy was avoided. A 67-year-old male received radical chemoradiotherapy (CRT) for mesopharyngeal cancer, which included radiotherapy with a total dose of 71.4 Gy/38 Fr and chemotherapy with CDDP + S-1. He developed dyspnea and throat pain 9 months after completion of CRT. Laryngoscopy revealed vocal cord impairment because of severe laryngeal edema. He was diagnosed as having laryngeal radionecrosis and initially received conservative therapy combined with antibiotics, steroids, and prostaglandins. Because his dyspnea was persistent despite this treatment, HBO therapy was administered 20 times, and resulted in complete remission of the dyspnea. HBO therapy, therefore, is regarded as an effective conservative therapeutic option for laryngeal radionecrosis.

Laryngeal radiation fibrosis: a case of failed awake flexible fibreoptic intubation

Awake fibreoptic intubation is accepted as the gold standard for intubation of patients with an anticipated difficult airway. Radiation fibrosis may cause difficulties during the intubation procedure. We present an unusual severe case of radiation induced changes to the larynx, with limited clinical symptoms, that caused failure of the fibreoptic intubation technique. A review of the known literature on radiation fibrosis and airway management is presented.

Unusual computed tomography findings of radionecrosis after chemoradiation of stage IV hypopharyngeal cancer: a case report

INTRODUCTION

Radionecrosis (post-radiotherapy laryngeal submucosal inflammation and necrosis) is a complication of (chemo) radiotherapy for hypopharyngeal cancer that is difficult to differentiate from tumor recurrence.

CASE PRESENTATION

A 67-year-old Japanese man presented with a condition extremely difficult to diagnose differentially as radionecrosis or tumor recurrence after radiotherapy for hypopharyngeal cancer. Although tumor recurrence was suspected from clinical conditions and computed tomography findings, pathologic analysis revealed no evidence of tumor recurrence, and successful therapy with steroids and antibiotics reduced the mucosal edema.

CONCLUSION

Our findings emphasize the wide spectrum of radiographic presentation of radionecrosis after chemoradiation of stage IV hypopharyngeal cancer.

Post-treatment imaging appearances in head and neck cancer patients

Surgery and radiotherapy (with or without chemotherapy) for head and neck cancer can create a daunting array of radiological appearances post-treatment. The role of the radiologist lies not only in detecting recurrent neoplastic disease, but also identifying non-neoplastic changes that may account for clinical presentation and symptoms in this patient group. There are a number of non-neoplastic as well as neoplastic changes and disease entities that can present on surveillance imaging, such as primary resection and reconstructive surgical change, surgical neck dissection changes, radionecrosis, post-treatment denervation change, and radiotherapy-related secondary tumours. Some of these require conservative management, while others require more active treatment. Awareness and recognition of the imaging appearances of these post-treatment changes is therefore critical for the radiologist involved in the multidisciplinary care of the head and neck cancer patient.

Chondroradionecrosis of the larynx: diagnostic and therapeutic measures for saving the organ from radiotherapy sequelae

Objectives

Chondroradionecrosis (CRN) of the larynx is a rare but fatal complication of radiotherapy. We determined the optimal diagnostic methodology and management of laryngeal CRN in six patients.

Methods

We retrospectively reviewed the records of six patients with Chandler grade IV laryngeal CRN who had received prior radiotherapy (mean total radiation dose, 66.7±4.5 Gy) at a tertiary care hospital. Two patients underwent transoral laser microresection of their laryngeal carcinoma plus postoperative radiotherapy. All patients underwent endoscopy, computed tomography (CT), positron emission tomography (PET), removal of necrotic tissue, biopsy under suspension laryngoscopy, administration of antibiotics, and hyperbaric oxygen therapy (HBO). Their diagnostic and therapeutic results were assessed.

Results

CT showed CRN of the anterior larynx in three patients and CRN of the posterior larynx in three patients, with one patient having a false-positive result on PET. HBO consisted of a mean of 36±6 dives. After early debridement and HBO, five patients showed CRN improvement, but one had aggravation and subsequently underwent total laryngectomy. None of these patients showed local tumor recurrence on pathologic examination or during a mean follow-up of 24 months.

Conclusion

Although CRN of the larynx may be detected by endoscopic and imaging work-ups, detection may require pathologic examination. Early debridement and HBO may effectively treat CRN, saving the functional larynx.

A dramatic case of genital radionecrosis

BACKGROUND

Epidermoid carcinoma of the penis presents in 1% of malignant tumors in men. Penis cancer treatment has traditionally been total or partial amputation. There are authors who consider radiation to be part of penis cancer treatment in select cases--especially the use of brachytherapy and external radiation.

CLINICAL CASE

The case of a 48-year-old male who in 2004 presented with an ulcerated lesion of the penis that was left unattended to is presented. Two years later, he sought medical attention and physical examination revealed an ulcerated penile lesion with poorly defined edges and limited to the glans.

DIAGNOSIS

The lesion was biopsied and the histopathological study reported Epidermoid Carcinoma. After radiological studies, it was classified as stage T2-N0-M0.

TREATMENT

Total penectomy without lymphadenectomy was performed. The patient received adjuvant treatment of 15 sessions of cobalt radiation treatment at a dose of 3,500 cGy. Six months later, the patient noticed the presence of erythema at the genital and inguinal level which later ulcerated and extended toward the perineum. The disease progressed tragically and the patient died 2 years later.

Laryngeal and hypopharyngeal carcinomas after (chemo)radiotherapy: a diagnostic dilemma

PURPOSE OF REVIEW

During recent years, (chemo)radiotherapy has evolved into a primary treatment modality for both early and advanced laryngeal and hypopharyngeal carcinomas. Head and neck surgeons will be concerned more frequently with patients presenting symptoms and signs suggesting recurrent tumor or complications of (chemo)radiotherapy.

RECENT FINDINGS

Analysis of histologic characteristics and tumor spread of recurrent carcinomas on whole-organ slices of salvage laryngectomy specimens showed that recurrent laryngeal carcinomas are often present with multiple tumor foci dispersed in different regions; furthermore, they may develop beneath an intact mucosa. Only a few articles analyze the reliability of laryngoscopy and biopsy in detecting recurrences after (chemo)radiotherapy: the number of false negative biopsies is relatively high. The differentiation between radionecrosis and tumor recurrence is difficult by computed tomography scan and magnetic resonance imaging in many cases. Positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging are promising diagnostic modalities to detect or exclude persistent or recurrent disease after (chemo)radiotherapy.

SUMMARY

Endoscopy with biopsy, computed tomography scan and conventional magnetic resonance imaging present several deficiencies in diagnosing recurrent disease after (chemo)radiotherapy. New imaging modalities such as positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging show promising results, increasing the diagnostic efficacy.

Laryngektomia jako postępowanie ratujące u chorych z nasilonym odczynem popromiennym po radioterapii raka krtani

INTRODUCTION

Author discusses problems and treatment principles of patients with massive postradiation injury, who had laryngectomy procedure as a result of insufficience of the farmacological treatment.

MATERIAL AND METHODS

There were 12 patients who were performed laryngectomy as a treatment of massive postradiation injury of the larynx in the period 1975-2005. We suspected presence of persistent neoplasm with postradiation changes. Seven laryngectomies were performed after confirmation of the neoplasm in 1-3 biopsies. Three patients were treated operatively without this confirmation in spite of two biopsies which were negatively, and two patients were treated in this way without biopsies.

RESULTS

Two patients had tomour free postlaryngectomy specimens in the histopathological examinations, and among 10 others the reccurence of the tumour after radiotherapy was present during the post-laryngectomy histopathological examinations. In 7 cases this reccurence was proved with massive postradiation injury in endoscopic biopsies before laryngectomy.

DISCUSSION

Author presents his own problems and presents methods of treatment of the patients with massive postradiation injury of the larynx described in literature.

Chondroradionecrosis of larynx following radiotherapy for metastatic neck disease originating from oral carcinoma

Chondroradionecrosis of larynx is a rare but serious complication of radiotherapy. Here is described a case of chondroradionecrosis after 20 years of completion of radiotherapy for oral cancer. The patient underwent excision of necrotic anterior skin of the neck, together with devitalized thyroid cartilage and most of the cricoid cartilage, and reconstruction with pectoralis major muscle transposition. This resulted in preservation of laryngeal function, and avoided further exploration of the irradiated neck and possible further skin loss.

Treatment of laryngeal radionecrosis with hyperbaric oxygen therapy: a case report

An 81-year-old male with early-stage laryngeal carcinoma had been treated with 60 Gy curative radiotherapy. He complained of a sore throat, foul odor in the mouth, progressive dyspnea, and fever 2 months after the completion of radiotherapy. Direct laryngoscopy revealed narrowing of the glottis with diffuse ulcerative necrotic tissue. Biopsies at multiple sites and pathology revealed intense coagulation necrosis with complete denudation of covering epithelium without any malignancy. Since laryngeal radionecrosis was suspected, the patient received hyperbaric oxygen (HBO) therapy 40 times for 1 hour of 100% O2 at 2 atm absolute pressure. His clinical symptoms gradually improved and repeated endolaryngeal biopsies were undertaken near the end of HBO therapy and again 6 months later. The patient's larynx healed completely with diffuse fibrosis and no malignant cells were found on pathology. Radionecrosis must be differentiated from cancer recurrence following curative radiotherapy for early laryngeal cancer. HBO therapy could be a useful treatment adjunct for laryngeal radionecrosis.

Clinical implications of radionecrosis to the head and neck surgeon

Radiation necrosis is one of the most serious complications in the treatment of malignancies of the head and neck. As radiotherapy becomes more frequently used as a primary modality and in combination with chemotherapy and surgery, the head and neck surgeon needs to be able to prevent and recognize the often subtle signs and symptoms of radiation necrosis. The symptoms of necrosis can mimic the recurrence of cancer, which presents a diagnostic dilemma, because aggressive surgical biopsy may worsen necrosis and contribute to the formation of a fistula. This review provides a brief discussion of the diagnostic and treatment options for osteoradionecrosis and chondroradionecrosis in the head and neck.

[Laryngeal chondro-radionecrosis]

Laryngeal chondroradionecrosis is a complication following radiotherapy for laryngeal tumours that may appear many years after the treatment. We present the case of a 78 year old man, that come to the Accident and Emergency department with a prelaryngeal mass and hemoptysis. He had been treated 17 years before with radiotherapy for a vocal cond carcinoma. Posteriorly the lesion did a cutaneous fistula with complete laryngeal exposition and torpid evolution. Post-radiotherapy necrosis in the larynx is a serious complication though not a common one. A tumour recurrence needs to be excluded and even in this case a total laryngectomy is mandatory as it will end in total loss of laryngeal function.

Laryngeal radionecrosis and hyperbaric oxygen therapy: report of 18 cases and review of the literature

Laryngeal radionecrosis is a difficult late complication of radiotherapy. It is associated with hoarseness, edema, pain, weight loss, and upper airway obstruction. The medical treatment options are limited, and in severe cases, the patient may require tracheostomy or laryngectomy. We report clinical results in 18 patients treated with adjunctive hyperbaric oxygen (HBO) therapy for severe radionecrosis of the larynx. Of these 18 patients, 2 had grade 3 and 16 had grade 4 radionecrosis. The patients received a mean number of 41 HBO treatments (range, 6 to 80) at 2 atmospheres absolute for 2 hours, twice a day, 6 days a week. Thirteen patients (72.2%) had a major improvement after HBO therapy, and none of them required total laryngectomy. All patients preserved their voice and deglutition in good or normal condition. Five patients (27.8%) failed to have a good response to HBO and underwent total laryngectomy. One of these patients had local recurrence of his cancer 4 months later, and the other 3 had significant concurrent medical problems. The remaining patient received only 6 HBO treatments because of emergency heart surgery. These encouraging results are comparable to those of smaller previous studies suggesting that HBO has a beneficial effect in the management of advanced laryngeal radionecrosis.

Short- and long-term effects of irradiation on laryngeal mucosa of the rat

Although radiotherapy is often used to treat laryngeal carcinoma, there is little information on the effects of this treatment on laryngeal structures. Rats were irradiated to the head and neck region and the larynges were studied by light- and electron-microscopy and immunohistochemistry. Ten days after irradiation, a change in the ultrastructural appearance of the granules of the subglottic glands was observed. Substance P-, bombesin- and enkephalin-like immunoreactivity was increased in local ganglionic cells and glandular nerve fibres. The mast cells were reduced in number. At examination 4 6 months after irradiation, there were no obvious differences compared with controls concerning mast-cell numbers and neuropeptide expression. The ultrastructural changes seen in the subglottic glands remained to some extent. The results show that structural changes in the subglottic glands occur concomitantly with an increased expression of certain neuropeptides in the innervation of these glands, which implies a relationship between these two parameters. The mast cells respond drastically to irradiation, but in the long run, regeneration of these cells occurs.

Delayed radionecrosis of the larynx

Radiation has been used to treat carcinoma of the larynx for more than 70 years. Radionecrosis is a well-known complication of this modality when treating head and neck neoplasms. It has been described in the temporal bone, midface, mandible, and larynx. Laryngeal radionecrosis is manifested clinically by dysphagia, odynophagia, respiratory obstruction, hoarseness, and recurrent aspiration. The vast majority of patients who develop laryngeal radionecrosis present with these symptoms within 1 year of treatment; however, delayed presentations have been reported up to 25 years after radiotherapy. We present, in a retrospective case analysis, an unusual case of laryngeal radionecrosis in a patient who presented more than 50 years after treatment with radiotherapy for carcinoma of the larynx. The cases of delayed laryngeal necrosis in the literature are presented. This represents the longest interval between treatment and presentation in the literature. The details of the presentation, clinical course, and diagnostic imaging are discussed. The pathogenesis, clinical features, and treatment options for this rare complication are reviewed. Early stage (Chandler I and II) laryngeal radionecrosis may be treated conservatively and often observed. Late stage (Chandler III and IV) cases are medical emergencies, occasionally resulting in significant morbidity or mortality. Aggressive diagnostic and treatment measures must be implemented in these cases to improve outcome. This case represents the longest interval between initial treatment and presentation of osteoradionecrosis in the literature. A structured diagnostic and therapeutic approach is essential in managing this difficult problem.

Hyperbaric oxygen for the management of radionecrosis of bone and cartilage

OBJECTIVES

To review the use of hyperbaric oxygen in the management of radionecrosis of the head and neck.

STUDY DESIGN

A retrospective analysis of patients utilizing chart review and telephone interviews. All patients diagnosed with osteoradionecrosis and chondroradionecrosis of the head and neck and treated with hyperbaric oxygen at the University of Virginia are included.

METHODS

Demographics, pretreatment data, and precipitating events were recorded. Outcomes were evaluated using a grading scale of symptomatology and physical examination as determined by the patient and physician.

RESULTS

Sixteen patients with osteoradionecrosis and five with chondroradionecrosis were reviewed. All patients showed clinical improvement with decreased pain following HBO therapy. None of the patients with chondroradionecrosis required laryngectomies, and two of the four who were tracheotomy dependent were successfully decannulated. The patient and physician grading scores demonstrated moderate to significant improvement in both groups following therapy.

CONCLUSION

The successful use of hyperbaric oxygen for the management of radionecrosis of the head and neck is supported. The unusual prevalence of chondroradionecrosis may be an early reflection of changes in treatment protocols for patients with head and neck cancer.

Laryngeal radionecrosis versus recurrent cancer: a clinical approach

A group of 38 patients was studied by positron emission tomography utilizing fluorine18-labeled deoxyglucose (FDG-PET) scanning to examine the ability to differentiate postirradiation laryngeal recurrent cancer from radionecrosis. The resulting 79% correct diagnosis showed the technique to be far superior to conventional computed tomography scanning (61%) and clinical examination (43%). An algorithmic approach to evaluating and treating patients with radionecrosis and/or recurrent cancer by utilizing FDG-PET scanning is presented.

Tumour recurrence or treatment sequelae following radiotherapy for larynx cancer

Differentiating between recurrent carcinoma and significant sequelae of radiotherapy after treatment of laryngeal carcinoma is an uncommon but difficult clinical problem. Head and neck surgeons can be faced with deciding on the necessity for salvage laryngectomy without prior histological confirmation of recurrence. This paper reviews the literature pertaining to this topic to provide a better overall estimate of the risk of recurrence in these cases. Approximately 50% of patients with severe oedema or necrosis following radiotherapy for larynx cancer will have recurrence. Less than 10% of all larynges removed will be histologically negative when persistent or recurrent tumour is suspected clinically or indicated by biopsy following radiotherapy.

Invasive candidiasis of a late presentation laryngeal chondroradionecrosis

Laryngeal chondroradionecrosis is an unusual condition which may present many years after the initial radiotherapy. We present a case of late onset chondroradionecrosis which was complicated by invasive candidiasis of the arytenoid cartilages which had themselves been extruded through the laryngeal mucosa.