The classification and the most appropriate treatment of the precancerous lesions of the larynx continue to be controversial. It is an established fact that the dysplastic lesions of the larynx have the potential to evolve into malignant lesion. It is also well-known that the capacity of this transformation significantly correlates to the grade of dysplasia of the epithelium. The diagnosis, treatment, and prognosis of these lesions depend almost entirely on their histological abnormalities.
Imaging plays an important role in the diagnostic evaluation of laryngeal cancers. This article discusses important technical issues related to cross-sectional imaging modalities, imaging anatomy, patterns of tumor spread and the contribution of imaging in pretreatment staging and post-treatment surveillance.
Cancer of the larynx has numerous implications—respiration, swallowing and speech, besides disability, vocational, recreational, etc. There are numerous treatment options which have been proven to be effective with randomized controlled trials and meta-analysis’. Often, the choice of modality offered to the patient is tailored to the patient's requirements as regard to his/her domestic, vocational and recreational environment. Although we may have a plethora of options for patients belonging to each stage of the disease, there are certain guidelines which must be adhered to in order to prevent any compromise of oncological safety. This article focuses on the planning of the treatment options based on various assessment modalities.
The airway is not only shared but operated upon during laryngeal cancer surgery. Patients with laryngeal cancer may require general anesthesia for diagnostic endoscopic procedures, for endolaryngeal laser surgery or for major cancer resectional surgery. This review outlines the importance of careful assessment of the airway and medical comorbidities and discusses the options for anesthetic and ventilatory management whilst ensuring a safe airway, adequate oxygenation and the best possible view of the surgical field. Laryngeal cancer surgery may improve the airway or create new problems and the need for meticulous planning, multidisciplinary input, good communication and close cooperation between all members of the team is emphasized.
A spectrum of treatment plans and surgical procedures are available for management of laryngeal cancer. Transoral laser resection has proved an effective, minimally invasive and functionally satisfactory procedure for management of suitable T1 and T2 glottic cancers, and stage I-III supraglottic cancers. Introduction of chemoradiotherapy has also made great impact on the laryngeal preservation. The treatment of laryngeal cancer should be individualized according to the size and extent of the tumor, the age and physical condition of the patient, and the skill and experience of the surgeon with various treatment modalities and surgical procedures.
Laryngeal cancer can associated with significant long-term morbidities. Photodynamic (PDT), a minimally invasive treatment that uses light of a specific wavelength to activate a photosensitizing agent in the tumor and its microenvironment, offers a viable alternative treatment for this patient population without permanent treatment related sequelae.
Our focus in this review is to discuss the existing evidence for the utilization PDT in treating laryngeal cancers and to summarize the advantages and limitations of this novel therapy.
Early cancer of the larynx can be addressed by single modality treatment (surgery or radiotherapy) while advanced cancer larynx is addressed with multimodality treatment—surgery (total laryngectomy) + postoperative RT or concurrent chemotherapy + radiotherapy. But there is a subset of population with carcinoma larynx in whom single modality treatment with radiotherapy or conventional partial laryngectomy may not be sufficient while total laryngectomy with postoperative radiotherapy may be overkill. In this subset of population supracricoid partial laryngectomy is the perfect answer which bridges the gap between partial laryngectomy and total laryngectomy. In addition to utilizing this procedure in the post-RT residual disease scenario the upfront performance of SCPL can also avoid adjuvant RT in many instances. Supracricoid partial laryngectomy is an organ preservation procedure in the true sense that it can achieve an oncological safe margin and also provide a high quality of life.
Total laryngectomy since it was first performed more than a century ago has undergone numerous modifications with increasing attention to voice restoration. Function preservation has also been achieved by voice sparing surgical procedures, and organ preservation strategies with chemoradiotherapy for laryngeal carcinoma. However, total laryngectomy remains the standard of care for very advanced laryngeal cancers with cartilage destruction, and as a salvage procedure for failures to organ preservation therapies. In this article, we review the indications, complications and outcomes of total laryngectomy in the era of chemoradiotherapy.
Tapan K Saikia
The management of locally advanced squamous cell carcinoma of the larynx is complex. Data from recent clinical trials have refined the use of existing therapies, such as radiation therapy and chemotherapy, and providing new treatment options, such as cetuximab. Selecting the most appropriate treatment for an individual patient requires a multidisciplinary approach and careful assessment of the relative advantages and disadvantages of each treatment approach. Chemoradiation is more effective than conventional radiation therapy, but also more toxic. Cetuximab plus radiation therapy is more effective than radiation alone and does not substantially increase radiation-related toxicity. Multimodality approach for laryngeal cancer has shown better organ preservation rates and survival. Ideally, multidisciplinary teams should weigh all these factors when making individual treatment decisions. Data from current trials will help further optimize multimodality treatment for Laryngeal Cancer.
Comprehensive rehabilitation after total laryngectomy is more than just restoration of the voice alone. Due to central position in the upper aerodigestive tract, its removal requires rehabilitation of all three ‘systems’ depending on respiratory airflow, i.e. Voice, Pulmonary and Olfactory functions. Rehabilitation of speech takes preference, but pulmonary and olfactory rehabilitation require multidisciplinary team effort in order to achieve optimal results and good quality of life.
Improvements in voice rehabilitation over the past century have paralleled the surgical success of laryngectomy. The establishment of the tracheoesophageal puncture marked a turning point in the development of successful and dependable voice rehabilitation. Surgical options include both primary and secondary placement of a tracheoesophageal puncture. Though complications, such as pharyngoesophageal spasm or prosthesis leakage may occur, patients should expect functional voice restoration after laryngectomy.
The principles of treatment of laryngeal carcinoma have undergone changes over the last few years and can be very complex with early (I-II) and advanced (III-IV) stage diseases to be differentiated. Recent emphasis is on organ preservation and laryngeal function. Transoral CO2 laser surgery has become a standard surgical procedure not only in early stage I and II laryngeal carcinomas but also in advanced stage III cases in combination with postoperative adjuvante radiochemotherapy. This retrospective study reflects the role of transoral laser surgery as a single or multimodality treatment regime with neck dissection and postoperative radiochemotherapy in laryngeal carcinomas.
From January 1997 to February 2007, 239 patients (215 men and 24 women; mean age 61 years) were examined with laryngeal squamous cell carcinoma (stage I-IV). 220 out of these 239 patients underwent transoral laser surgery, depending on their tumor stage either as a single or as a multimodality treatment regimen in combination with bilateral neck dissection and postoperative radio-chemotherapy. Thirteen patients underwent a transcervical tumor resection, 5 patients underwent radiochemotherapy alone and one patient refused a treatment of his tumor disease. Median follow-up time was 60 months.
The 5-year overall survival rate of the 220 patients who were treated with laser surgery was 86%. The 5-year recurrence-free survival rate was 69.5%. After laser surgical interventions, postoperative complications occurred in 16%.
The oncological outcome of transoral laser surgery as a single mode in early laryngeal carcinomas or in combination with bilateral neck dissection and postoperative adjuvant radiochemotherapy in advanced tumor stages is satisfying if clean surgical tumor margins (R0) can be reached. If tumor-free margins cannot be achieved (R1 and R2 resection) and transoral revision is not possible, transcervical procedures (total or partial laryngectomy) must be considered.
Arsheed Hussain Hakeem,
Sultan A Pradhan
Recent years have seen paradigm shift in the treatment of early laryngeal tumors towards microscopic CO2 laser resection because of excellent oncologic and functional results. The coupling of the carbon dioxide (CO2) laser to the operating microscope has greatly simplified, even revolutionized, microlaryngoscopic surgery. Focus is now not just on oncological outcome but also on preservation of vocal function. This results in a continuous conflict between the need to remove tissue for oncological stability and the need to preserve tissue for optimal vocal function.
Dr. Bruce Pearson described near-total laryngectomy (NTL) in 19811 a procedure which creates a biological shunt between the airway and the neopharynx to restore speech. Unlike other biological shunts, this is a dynamic myomucosal shunt which has universal applicability as seen by various series published from around the world.2-11 We feel that the NTL procedure is oncologically safe and can provide a serviceable, prosthesis free voice and should be considered as a sound treatment option in advanced but lateralized cancers of the laryngopharynx. NTL has been described extensively in literature but we would like to highlight in this technical note a few modifications which we have found to be suitable and easily applicable by surgeons who regularly perform a total laryngectomy. We feel strongly that each and every surgeon who intends to treat laryngopharyngeal cancer should be well versed in this technique. A NTL shunt performed in a suitable patient gives the ability to phonate at will and makes the patient independent of a medical professional since the shunt is permanent and maintenance free.
Pectoralis major myocutaneous flap,laryngectomy,pharyngocutaneous fistula
DOI: 10.5005/jp-journals-10003-1045 |
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Souza CD, Chaturvedi P, Kale S. Liberal Use of Pectoralis Major Muscle Flap Reduces Incidence of Pharyngocutaneous Fistula Following Salvage Laryngectomy. Int J Otorhinolaryngol Clin 2010; 2 (3):253-255.
Patients undergoing salvage laryngectomy following chemoradiotherapy are more vulnerable to develop pharyngocutaneous fistula. This is due to fibrosis and reduced vascularity that results in poor postoperative healing. We are presenting a simple technique that can reduce this distressing complication. In patients where primary closure cannot be achieved, myocutaneous flap to reconstruct the pharynx reduces the incidence of postoperative complications. Similarly, buttressing of the suture line with the pectoralis major myofacial flap has been shown to reduce the fistula rates. Needless to say that pectoralis major muscle flap is a robust flap with acceptable complication rates.
Juvenile laryngeal papillomatosis,Malignant transformation,Squamous cell cancer
DOI: 10.5005/jp-journals-10003-1047 |
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Tubachi J, Hakeem AH, Kumar RR, Pawar S. Malignant Transformation of Nonirradiated Recurrent Juvenile Laryngeal Papillomatosis. Int J Otorhinolaryngol Clin 2010; 2 (3):259-261.
Very few cases of spontaneous malignant transformation of nonirradiated recurrent juvenile laryngeal papillomatosis (JLP) have been reported in literature. We document a case of invasive laryngeal carcinoma arising in pre-existing juvenile laryngeal papillomatosis. After multiple CO2 Laser resections, a 29-year-old female, non-smoker, who had never received radiation therapy, developed a florid exophytic transglottic squamous cell carcinoma. Therefore, regular extensive biopsies and careful histopathological examination are required in cases of JLP. We also emphasize the need to maintain a high index of suspicion for malignant transformation in long standing cases.