Survival and function following pharyngo-laryngo-oesophagectomy in Wales: a twelve-year case series.

OBJECTIVE: Treatment of locally advanced hypopharyngeal cancer can cause significant morbidity and late toxicity. Pharyngo-laryngo-oesophagectomy can achieve adequate surgical margins, but data on survival and functional outcome are limited, especially in Wales. This study aimed to describe mortality, morbidity and functional outcome following pharyngo-laryngo-oesophagectomy in a Welsh population. METHOD: This study was a retrospective case note review of pharyngo-laryngo-oesophagectomy cases in Wales over 12 years. RESULTS: Fifteen patients underwent pharyngo-laryngo-oesophagectomy; all but one underwent gastric pull-up. Median survival and disease-free survival were 17 months (range, 2-53 months) and 14 months. Censored 3-month, 1-year and 3-year survival was 93, 71 and 50 per cent, respectively. Common Terminology Criteria for Adverse Events grading of long-term dysphagia was 1 in 58 per cent, 2 in 33 per cent and 3 in 8 per cent, and 87.5 per cent achieved a 'moderate' or 'good' voice rehabilitation. CONCLUSION: These results demonstrate favourable survival and reasonable functional outcome following pharyngo-laryngo-oesophagectomy, suggesting pharyngo-laryngo-oesophagectomy should be considered in all appropriate surgical candidates.

Prognostic implications of Fibroblast growth factor receptor 1 (FGFR1) gene amplification and protein overexpression in hypopharyngeal and laryngeal squamous cell carcinoma.

BACKGROUND: The gene encoding fibroblast growth factor receptor 1 (FGFR1) is emerging as a therapeutic and prognostic biomarker in various cancer types, including head and neck squamous cell carcinoma (SCC). Here, we investigated the clinicopathologic implication of FGFR1 gene amplification and protein overexpression in hypopharyngeal and laryngeal SCC. METHODS: Fluorescence in situ hybridization and immunohistochemistry were performed to determine FGFR1 gene amplification and protein overexpression in 209 surgically resected cases. RESULTS: FGFR1 amplification observed in 8 (8/66, 12.1%; 6 hypopharynx and 2 larynx) patients and high FGFR1 expression in 21 (21/199, 10.6%) patients significantly correlated with lymph node metastasis and advanced pathological stages. FGFR1 amplification was also associated with worse disease-free survival in multivariate analysis (hazard ratio = 4.527, P = 0.032). High FGFR1 expression was more frequently observed, consistent with the worsening of the degree of histologic differentiation. CONCLUSIONS: FGFR1 amplification may serve as an independent prognostic factor for disease-free survival in hypopharyngeal and laryngeal SCC. Aberrant FGFR signaling caused by FGFR1 gene amplification or protein overexpression may play a crucial role in the malignant evolution and progression of hypopharyngeal and laryngeal SCC, and offer novel therapeutic opportunities in patients with hypopharyngeal and laryngeal SCC that usually lack specific therapeutic targets.

[Potential risk factors predicting perioperative mortality in patients with gastric pull-up reconstruction].

Objective: To investigate the potential risk factors for the death of patients underwent gastric pull-up reconstruction following total pharyngoesophagectomy during perioperative periods. Methods: A total of 71 patients, including 64 males and 7 females, aged from 35 to 72 years old, with hypopharyngeal or cervical esophageal carcinoma, who underwent gastric pull-up reconstruction after pharyngoesophagectomy between October 2008 and October 2017, were reviewed retrospectively. Seventeen factors which may have potential influence on the mortality of patients during perioperative periods were evaluated by single factor Logistic regression analysis, and then those factors with obvious difference in statistics were further analyzed by multi-factor Logistic regression. Results: The rate of perioperative mortality was 9.9% (7/71). Single factor Logistic regression analysis indicated that the age of patients, abnormal electrocardiogram, TNM stages, alanine aminotransferase and D-Dimer changes, postoperative bleeding were risk factors for the death of patients(P values were 0.023, 0.004, 0.026, 0.021, 0.015 and 0.002, respectively). Multi-factor Logistic regression showed that postoperative bleeding and D-Dimer changes were 2 independent risk factors for perioperative death(P=0.021 and 0.047, respectively). Conclusions: Many potential factors may affect the perioperative mortality of patients underwent gastric pull-up reconstruction following total pharyngoesophagectomy. Postoperative bleeding and significantly elevated D-Dimer level were independent risk factors for the death of patients, indicating poor prognosis.

Total laryngopharyngectomy with circumferential reconstruction: Helsinki institutional study.

PURPOSE: Surgical complications after total laryngopharyngectomy (TLP) are common, reconstruction is challenging, and patients often lose their ability to swallow and speak. To evaluate these aspects, we analysed outcome after TLP. METHODS: We reviewed all patients who underwent TLP and subsequent circumferential pharyngeal reconstruction through 2004-2017 at the Helsinki University Hospital. RESULTS: For the 26 eligible patients, TLP was the primary treatment for 11 and salvage surgery for 15, followed by reconstruction with free flaps in 22 patients and pedicled flaps in 4. An early (≤ 30 days) pharyngocutaneous fistula developed in seven patients (27%; median time 13 days; range 6-26), and a late (> 30 days) fistula in five patients (19%; median time 370 days; range 46-785). In addition, ten patients (39%) developed an oesophageal stricture. Four patients (15%) resumed full oral feeding. A speech prosthesis was inserted for 15 patients (58%) and most of them could produce intelligible speech. We found acceptable survival figures for patients undergoing TLP both as a primary treatment and as salvage procedure: the overall survival at 1 year was 82% and 67%, and at 5 years 33% and 27%, respectively. Disease-specific survival at 1 year was 90% and 70%, and that at 5 years was 45% and 43%, respectively. CONCLUSIONS: Despite fair survival, TLP carries a high risk for postoperative complications with limited functional outcome, thus necessitating cautious patient selection and surgical experience.

Free Flap Versus Pedicled Flap Reconstruction of Laryngopharyngeal Defects: A 10-Year National Surgical Quality Improvement Program Analysis.

OBJECTIVES/HYPOTHESIS: Large defects after total laryngectomy (TL) and total laryngopharyngectomy (TLP) often benefit from free flap (FF) or pedicled flap (PF) reconstruction to maintain continuity of the aerodigestive tract, protect great vessels, or reinforce pharyngeal closure. Although both techniques are commonly used, no consensus exists as to which results in fewer complications. The goal of this study was to determine if 30-day morbidity/mortality outcomes differ between PF and FF reconstruction in patients undergoing TL/TLP. STUDY DESIGN: Retrospective cohort study. METHODS: Patients were analyzed who underwent TL/TLP with reconstruction using records from the American College of Surgeons National Surgical Quality Improvement Program database (2005-2015). RESULTS: A total of 347 patients were included; 204 received FF reconstruction, whereas 143 received PF reconstruction. FF reconstruction was more commonly used with TLP defects (P = .001). The total operative time in the FF (590 ± 140 minutes) was longer than the PF (441 ± 125 minutes) group (P < .0001). There was a higher rate of postoperative transfusions in those undergoing FF reconstruction (P = .022). There was no significant difference in complication rates among TLP patients. Among TL patients only, FF reconstruction had a higher association with wound infections than PFs (P = .040). On multivariate analysis, low hematocrit was associated with complications (P = .031). Age (P = .031) and congestive heart failure exacerbation (P < .001) were associated with increased hospital stay. Overall, there were no differences in readmissions, reoperations, or deaths between the groups. CONCLUSIONS: Reported complication rates after TL/TLP remain high, despite widespread usage of vascularized flaps in reconstruction. This comparison reveals no significant difference in postoperative complications between patients who received PF and FF laryngopharyngeal reconstruction. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:105-112, 2019.

Total pharyngolaryngectomy in the elderly: The impact of age on postoperative complications and oncologic and functional outcomes.

OBJECTIVES: To evaluate the clinical outcomes of total pharyngolaryngectomy (TPL) in the elderly and to analyze the impact of age on postoperative complications and oncologic and functional outcomes. METHODS: We conducted a retrospective review of the medical records of all patients who underwent TPL for a laryngeal or hypopharyngeal squamous cell carcinoma, between 2000 and 2015. The impact of advanced age (>70 years) on clinical outcomes was assessed in univariate and multivariate analyses. RESULTS: A total of 245 patients (mean age = 66.4 years) were enrolled in this study including 91 (37%) patients aged over 70 years. In patients aged over 70 years, local and general complication rates were 36% and 10%, respectively. Five-year overall, cause-specific and recurrence-free survival rates were 36%, 52% and 31%, respectively. Satisfactory swallowing (swallowing score ≥ 1; i.e. no enteral feeding) and speech (speech score ≥ 1; i.e. intelligible speech) functions were recovered by 94% and 70% of elderly patients. In multivariate analysis, older age had no significant impact on postoperative complications, oncologic outcomes and swallowing function. Compared to younger patients, elderly patients achieved significantly lower speech scores (p = 0.05). CONCLUSION: TPL is associated with favorable clinical outcomes in patients aged over 70 years and can therefore be considered a reliable therapeutic option. However, compared to younger patients, a lower level of recovery regarding speech function is expected in the elderly, and particular attention should be paid to the postoperative speech rehabilitation program in this population of patients.

Management of advanced hypopharyngeal carcinoma: systematic review of survival following surgical and non-surgical treatments.

BACKGROUND: Advanced hypopharyngeal carcinoma has a dismal prognosis. The optimal treatment for these patients remains under debate. This systematic review aimed to compare survival following surgical and non-surgical treatments. METHODS: A systematic review was conducted of randomised studies, with a descriptive analysis of retrospective observational studies. RESULTS: Two randomised trials and 11 observational studies were included in the review. A meta-analysis of randomised trials reported a hazard ratio of 0.89 for overall survival in favour of surgical treatment (p = 0.44). Neither treatment was favoured in terms of overall survival. Observational studies did not report a survival advantage with either treatment. The five-year larynx preservation rates for non-surgically treated patients were between 38 and 58 percent. CONCLUSION: Chemoradiotherapy offers similar survivorship compared to surgery in advanced disease, while also making larynx preservation feasible. It can be used as a treatment in all patients as an alternative to surgery.

The impact of surgical margin status on the outcomes of locally advanced hypopharyngeal squamous cell carcinoma treated by primary surgery.

BACKGROUND: The extent of surgical safety margin remained unclear in hypopharyngeal carcinoma surgery. AIM: The purpose of this study was to evaluate the influence of surgical margin status on the outcomes of patients with advanced hypopharyngeal carcinoma. MATERIAL AND METHODS: A retrospective analysis of clinical data was performed in 205 patients with stage III/IV hypopharyngeal carcinoma treated by primary surgery between January 2005 and December 2014. There were 129 patients with clear surgical margins (≥5 mm) and 76 with close surgical margins (<5 mm). The clinical characteristics and treatment outcomes were compared between the two groups. RESULTS: Close surgical margin (cSM) was found to be a significant risk factor for local recurrence, overall survival (OS) and disease-specific survival (DSS). Analysis by stratification according to pT classification showed that the OS and DSS rates of T1/T2 tumors with clear surgical margins (nSM) were significantly higher than those with cSM (p < .05), while there was no significant difference in the OS and DSS rates between T3/T4 tumors with cSM and nSM (p > .05). CONCLUSIONS AND SIGNIFICANCE: The tailored extent of surgical resection margin was recommended for locally advanced hypopharyngeal carcinomas according to primary tumor stage.

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

BACKGROUND: This study aimed to investigate the clinicopathologic prognostic predictors of stage 4 hypopharyngeal cancer and to extend the traditional tumor-node-metastasis classification system to advance its predictive ability. METHODS: The study enrolled 120 patients with pathologically stage 4 hypopharyngeal cancer treated with pharyngolaryngectomy and neck dissection between 2001 and 2007. RESULTS: The study showed a 5-year overall survival (OS) of 44.6%, a disease-specific survival (DSS) of 51.6%, and a disease-free survival (DFS) of 48% for all the patients. In the multivariate analysis, a lymph node (LN) ratio of 0.113 or higher was a significant poor prognostic factor for OS (hazard ratio [HR] 1.89; 95% confidence interval [CI] 1.17-3.05; p = 0.009), DSS (HR 2.17; 95% CI 1.29-3.64; p = 0.003), and DFS (HR, 2.24; 95% CI 1.12-4.52; p = 0.024) in stage 4 hypopharyngeal cancer. In addition, pretreatment neutrophil-lymphocyte ratio, lymphovascular invasion, and margin status also were predictors of survival outcomes. Furthermore, the study found that disease recurrence differed significantly between the patients with a LN ratio of 0.113 or higher (68.2%) and those with a LN ratio lower than 0.113 (39.5%) (p = 0.002). CONCLUSIONS: A LN ratio of 0.113 or higher is a strong predictor of disease recurrence and survival for patients with stage 4 hypopharyngeal cancer.

Chemoselection combined with alternating chemoradiotherapy or surgery for hypopharyngeal cancer.

OBJECTIVES/HYPOTHESIS: In order to make possible organ preservation, since 2007 our hospital has performed induction chemotherapy (ICT) with cisplatin and 5-fluorouracil (PF) for hypopharyngeal cancer as chemoselection, followed by alternating chemoradiotherapy (ACRT) with docetaxel, cisplatin, and 5-fluorouracil in (TPF) good responders and curative surgery was used in poor responders. METHODS: Twenty-six patients with stage III to stage IVB hypopharyngeal cancer received ICT. Eleven of the patients were classified as poor responders and received curative surgery. The remaining 15 patients were classified as good responders. Three of these patients underwent curative surgery, and the remaining 12 underwent ACRT. RESULTS: The primary lesions in the 12 ACRT patients responded completely to treatment without severe late toxicities. The estimated 3-year laryngectomy-free rate for all 26 patients was 23%. The estimated 3-year overall survival rates for all 26 patients, 12 patients treated with ACRT, and 14 patients who underwent curative surgery, were 79%, 75%, and 84%, respectively. CONCLUSION: The patients who underwent ACRT showed no significant difference in overall survival compared with the patients who underwent curative surgery. All the patients were able to proceed with this series of therapy, indicating that ICT with PF could be a feasible tool for choosing good responders. Because ACRT with TPF had a high response rate and fewer severe toxicities, this treatment could be safe and have enough impact to control hypopharyngeal cancer in good responders. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1349-1353, 2016.

A Contemporary Analysis of Surgical Trends in the Treatment of Squamous Cell Carcinoma of the Oropharynx from 1998 to 2012: A Report from the National Cancer Database.

BACKGROUND: This study examined surgical trends for oropharynx squamous cell carcinoma (OPC) from 1998 to 2012, with a post-2009 focus coinciding with the Food and Drug Administration (FDA) approval of transoral robotic surgery (TORS). METHODS: Using the National Cancer Data Base, the study analyzed 84,449 patients with stage I-IVB OPC. χ (2) tests and logistic regression models were used to examine surgical trends. RESULTS: The use of surgery decreased from 41.4 % in 1998 to 30.4 % in 2009 (p < 0.001). The surgical trends reversed and in 2012 increased to 34.8 % (p < 0.001). There was much variation in surgery in 2012 between American Joint Committee on Cancer stages, with 80.2 % of stage I patients receiving surgery compared with 54.0 % of stage II patients, 36.8 % of stage III patients, and 28.5 % of stage IV patients (p < 0.001). Black patients with high socioeconomic status (SES) showed lower use of surgery (25.3 %) compared to low SES white (32.3 %) and low SES Hispanic patients (27.3 %) (p < 0.001). The highest surgical rates were noted in the West North Central region and lowest rates were observed in the New England and South Atlantic regions. Between 2009 and 2012, independent predictors of surgical treatment included young age, female gender, white or Hispanic race, high SES, private insurance, academic hospitals, hospitals in the West North Central region, residence more than 75 miles from the hospital, increasing comorbidities, stage I disease, and tonsil origin (all p < 0.05). CONCLUSION: Since FDA approval of TORS in 2009, surgical rates have increased with multiple socioeconomic and regional factors affecting patient selection. This study provides a basis for further investigation into factors involved in decision making for OPC patients.

Detailed Analysis of Clinicopathologic Factors Demonstrate Distinct Difference in Outcome and Prognostic Factors Between Surgically Treated HPV-Positive and Negative Oropharyngeal Cancer.

BACKGROUND: Oropharyngeal cancers (OPC) secondary to human papillomavirus (HPV) infections likely represent a completely different disease compared with conventional head and neck cancers. Our objective was to analyze a surgically treated cohort to determine predictors of outcome in HPV-positive versus HPV-negative patients. METHODS: HPV positivity was inferred based on p16-immunohistochemistry. Data was available for 201 patients with OPC treated with surgical resection with/without adjuvant radiotherapy between 1985 and 2005. Subsite distribution was: 66 (33 %) tonsil, 46 (23 %) soft palate, and 89 (44 %) tongue base. Patients were classified into low-, intermediate-, and high-risk groups based on p16 status and smoking history. Outcomes stratified by p16 status and risk groups were determined by the Kaplan-Meier method. Factors predictive of outcome were determined by univariate and multivariate analyses. RESULTS: In this cohort, 30 % had locally advanced disease (pT3/T4) and 71 % had nodal metastasis. The 5-year overall (OS), disease-specific, and recurrence-free survival rates were 60, 76, and 66 %, respectively. There were 22 % low-, 34 % intermediate-, and 44 % high-risk patients. Patients who were p16-positive had better survival compared with p16-negative (OS, 74 vs. 44 %; p < .001). Similarly, low-risk group patients had a better survival compared with intermediate- and high-risk groups (OS, 76, 68, 45 %, respectively, p < .001). Independent predictors of survival in p16-negative patients included margin status, lymphovascular invasion, pN status, and extracapsular spread. In contrast, none of these were predictive in p16-positive patients. CONCLUSIONS: Surgically treated patients with p16-positive OPC have superior survival compared with p16-negative patients. Outcomes in p16-positive and p16-negative OPC are determined by different prognostic factors supporting the notion that these are very different diseases. These should be incorporated into future clinical trials design.

Analysis of the NSQIP database in 676 patients undergoing laryngopharyngectomy: the impact of flap reconstruction.

OBJECTIVE: Assess impact of reconstructive procedures on patients undergoing laryngopharyngectomy and to determine whether 30-day postoperative morbidity and mortality varied between patients who underwent flap reconstruction and those who did not. STUDY DESIGN: Retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. SETTING: Tertiary medical center. SUBJECTS AND METHODS: We reviewed the 2005-2011 ACS-NSQIP database to identify patients undergoing laryngectomy and/or pharyngectomy. Bivariate analysis was done to compare preoperative variables and postoperative outcomes between the flap reconstruction group and non-reconstruction group. Chi-square tests were used for categorical variables and t-tests for continuous variables. Logistic regression analysis was performed to calculate odds ratio to account for potential confounders. To create a valid logistic analysis model, F-test was used to determine whether certain variables should be included in the model. RESULTS: Six hundred seventy-six patients were included in our study; 213 patients received concurrent flap reconstruction whereas 463 did not. After risk adjustment, analyses revealed no statistically significant difference in wound complication, minor morbidity, and mortality between the 2 groups. The flap reconstruction cohort showed significantly longer operative times (8.09 ± 3.36 hours vs 5.63 ± 3.47 hours; P = .001) and higher major morbidity rate (OR = 5.906, 95% CI, 3.131-11.139, P = .001). CONCLUSIONS: This is the first comprehensive analysis of flap reconstruction for laryngopharyngeal defects using the ACS-NSQIP registry. Additional measures involved in flap reconstruction are associated with an increase in major morbidity but not mortality. An understanding of these variables may optimize the decision-making process for patients undergoing laryngectomy and/or pharyngectomy.

Comparison of oncologic and functional outcomes after transoral robotic lateral oropharyngectomy versus conventional surgery for T1 to T3 tonsillar cancer.

BACKGROUND: We performed transoral robotic surgery (TORS) or conventional surgery via a transoral or mandibulotomy approach in patients with tonsillar cancer and prospectively analyzed the oncologic outcomes and functional recovery of the 3 groups. METHODS: Between May 2008 and October 2011, 57 patients were enrolled in this prospective study. RESULTS: Although there was no significant difference in the survival rate of the TORS group (100%) and the conventional surgery group (96.7%), a higher rate of margin negativity was observed in the TORS group, especially in cases in which the tumor extends inferiorly. Patients who received TORS or conventional transoral procedures showed more rapid recovery of swallowing, shorter hospitalization, and shorter operation time than the mandibulotomy group. CONCLUSION: Despite the weakness of this nonrandomized trial and the differences in T classification, TORS seemed to have distinct advantages over conventional transoral surgery and other conventional open surgery, but further studies are needed.

Salvage surgery for recurrent cancers of the oropharynx: comparing TORS with standard open surgical approaches.

IMPORTANCE: Surgical salvage may be the only viable treatment option for recurrent tumors of the oropharynx. To our knowledge, there have been no published reports directly comparing the oncologic and functional outcomes of patients with recurrent oropharyngeal squamous cell carcinoma (SCC) treated with transoral robotic-assisted surgery (TORS) with those treated with traditional open surgical approaches. OBJECTIVE: To compare the oncologic and functional outcomes of patients with recurrent oropharyngeal SCC treated with TORS with those treated with traditional open surgical approaches. DESIGN: Retrospective multi-institutional case-control study; study dates, March 2003 through October 2011. SETTING: Four tertiary care institutions (University of Alabama at Birmingham; M. D. Anderson Cancer Center, Houston, Texas; Mayo Clinic, Rochester, Minnesota; and Henry Ford Hospital, Detroit, Michigan). PARTICIPANTS Sixty-four patients who underwent salvage TORS for recurrent oropharyngeal SCC were matched by TNM stage to 64 patients who underwent open salvage resection. INTERVENTION OR EXPOSURE: Salvage TORS for recurrent SCC of the oropharynx. MAIN OUTCOME AND MEASURES: Patient demographics, operative data, functional, and oncologic outcomes were recorded and compared with a similarly TNM-matched patient group that underwent salvage surgical resection by traditional open surgical approaches. RESULTS Patients treated with TORS were found to have a significantly lower incidence of tracheostomy use (n = 14 vs n = 50; P < .001), feeding tube use (n = 23 vs n = 48; P < .001), shorter overall hospital stays (3.8 days vs 8.0 days; P < .001), decreased operative time (111 minutes vs 350 minutes; P < .001), less blood loss (49 mL vs 331 mL; P < .001), and significantly decreased incidence of positive margins (n = 6 vs n = 19; P = .007). The 2-year recurrence-free survival rate was significantly higher in the TORS group than in the open approach group (74% and 43%, respectively) (P = .01). CONCLUSIONS AND RELEVANCE: This study demonstrates that TORS offers an alternative surgical approach to recurrent tumors of the oropharynx with acceptable oncologic outcomes and better functional outcomes than traditional open surgical approaches. This adds to the growing amount of clinical evidence to support the use of TORS in selected patients with recurrent oropharyngeal SCC as a feasible and oncologically sound method of treatment.

Influence of resection extent on morbidity in surgery for squamous cell cancer at the pharyngoesophageal junction.

PURPOSE: Squamous cell cancer (SCC) of the pharyngoesophageal junction area has a poor prognosis mainly due to late symptom manifestation and diagnosis. Treatment of choice is still pharyngolaryngoesophagectomy, substantially affecting quality of life. Limited surgical procedures have been adopted as well. The aim of this retrospective study was to evaluate whether the extent of resection influences postoperative safety and mortality. METHODS: From 1984 to 2006, 66 patients were operated at a single tertiary referral center. Nineteen patients (28.8 %) had SCC of the hypopharynx and 47 patients (71.2 %) had SCC of the cervical and cervicothoracic esophagus. Thirty-five patients (53.0 %) underwent cervical esophageal resection (CE) and 31 underwent total esophagectomy (TE). In 39 patients (59.1 %), the larynx was preserved. Thirteen patients (19.7 %) underwent multimodal treatment. RESULTS: Overall postoperative morbidity was 69.7 % and reoperation rate reached 28.8 %. TE (P = 0.03) and larynx preservation (P = 0.02) were followed by a higher rate of non-lung infections compared with CE and pharyngolaryngectomy, respectively. Pulmonary complications have been observed more frequently after larynx preservation (P = 0.02). Hospital mortality was 9.1 %. Four patients died after TE (12.9 %) and two patients died after CE (5.7 %). In all of them, the larynx had been preserved (15.4 %). Overall, 53 patients (80.3 %) died until follow-up. One-year and 5-year survival in patients with the major tumor burden at the cervicothoracic site was 35.7 and 0 %. CONCLUSIONS: CE can be recommended as long as R0 resection is warranted. The advantage of larynx preservation is gained by higher morbidity and mortality rates and may not be recommended as standard procedure. Surgery may not be appropriate for advanced SCC in the cervicothoracic region.

Prognostic value of a microRNA signature in nasopharyngeal carcinoma: a microRNA expression analysis.

BACKGROUND: MicroRNAs (miRNAs) can be used as prognostic biomarkers in many types of cancer. We aimed to identify miRNAs that were prognostic in patients with nasopharyngeal carcinoma. METHODS: We retrospectively analysed miRNA expression profiles in 312 paraffin-embedded specimens of nasopharyngeal carcinoma from Sun Yat-sen University Cancer Center (Guangzhou, China) and 18 specimens of non-cancer nasopharyngitis. Using an 873 probe microarray, we assessed associations between miRNA signatures and clinical outcome in a randomly selected 156 samples (training set) and validated findings in the remaining 156 samples (internal validation set). We confirmed the miRNAs signature using quantitative RT-PCR analysis in 156 samples from a second randomisation of the 312 samples, and validated the miRNA signature in 153 samples from the West China Hospital of Sichuan University in Chengdu, China (independent set). We used the Kaplan-Meier method and log-rank tests to estimate correlations of the miRNA signature with disease-free survival (DFS), distant metastasis-free survival (DMFS), and overall survival. FINDINGS: 41 miRNAs were differentially expressed between nasopharyngeal carcinoma and non-cancer nasopharyngitis tissues. A signature of five miRNAs, each significantly associated with DFS, was identified in the training set. We calculated a risk score from the signature and classified patients as high risk or low risk. Compared with patients with low-risk scores, patients with high risk scores in the training set had shorter DFS (hazard ratio [HR] 2·73, 95% CI 1·46-5·11; p=0·0019), DMFS (3·48, 1·57-7·75; p=0·0020), and overall survival (2·48, 1·24-4·96; p=0·010). We noted equivalent findings in the internal validation set for DFS (2·47, 1·32-4·61; p=0·0052), DMFS (2·28, 1·09-4·80; p=0·030), and overall survival (2·87, 1·38-5·96; p=0·0051) and in the independent set for DFS (3·16, 1·65-6·04; p=0·0011), DMFS (2·39, 1·05-5·42; p=0·037), and overall survival (3·07, 1·34-7·01; p=0·0082). The five-miRNA signature was an independent prognostic factor. A combination of this signature and TNM stage had better prognostic value than did TNM stage alone in the training set (area under receiver operating characteristics 0·68 [95% CI 0·60-0·76] vs 0·60 [0·52-0·67]; p=0·013), the internal validation set (0·70 [0·61-0·78] vs 0·61 [0·54-0·68]; p=0·012), and the independent set (0·70 [0·62-0·78] vs 0·63 [0·56-0·69]; p=0·032). INTERPRETATION: Identification of patients with the five-miRNA signature might add prognostic value to the TNM staging system and inform treatment decisions for patients at high risk of progression. FUNDING: Science Foundation of Chinese Ministry of Health, National Natural Science Foundation of China, Pearl River Scholar Funded Scheme, Guangdong Key Scientific and Technological Innovation Program, Guangdong Natural Science Foundation, Fundamental Research Funds for the Central Universities.

Supracricoid hemilaryngopharyngectomy in patients with invasive squamous cell carcinoma of the pyriform sinus. Part I: Technique, complications, and long-term functional outcome.

On the basis of a retrospective review of an inception cohort of 135 patients, with an isolated, previously untreated, moderately differentiated to well-differentiated invasive squamous cell carcinoma of the pyriform sinus and a minimum of 3 years of follow-up, consecutively managed with a supracricoid hemilaryngopharyngectomy (SCHLP) at a single tertiary referral care center and locally controlled, the authors review in detail the surgical technique, highlight the potential technical pitfalls, and document the complications and long-term functional outcome. The overall postoperative mortality rate was 3.7%. The overall mortality rate directly related to the SCHLP was 1.5%. A significant surgical complication directly related to SCHLP completion was noted in 9.6% of cases. The mean lengths of time to removal of the tracheotomy and feeding tubes were 9 and 19 days, respectively. The mean duration of hospitalization was 25 days. Normal swallowing without aspiration by the first postoperative month was noted in 64.6% of patients. Temporary grade 1-2 aspiration and grade 3 aspiration were noted in 26.9% and 8.5% of patients, respectively. Overall, in our series, successful oral alimentation without gastrostomy or completion total laryngectomy was achieved in 91.9% of patients by the first postoperative year, and the incidences of permanent gastrostomy, completion total laryngectomy, and aspiration-related death were 0.7%, 1.5%, and 0.7%, respectively. A significant late complication related to the use of postoperative radiotherapy was noted in 26.5% of cases. From a functional point of view, such results suggest that SCHLP should be integrated among the various conservation treatment options available to patients with selected invasive squamous cell carcinoma of the pyriform sinus.

Complications following gastric transposition after total laryngo-pharyngectomy.

AIMS: To investigate restoration of the pharynx after total laryngo-pharyngectomy (TLP), one of the major problems in head and neck surgery. METHODS: A retrospective analysis of 60 patients undergoing total laryngo-pharyngectomy with gastric transposition was performed between June 1991 and June 1996. The analysis focused on morbidity, mortality and long-term function following gastric transposition. RESULTS: The post-operative mortality was 8.3% and the peri-operative morbidity 31.2%. The average hospital stay was 15 days. Immediate restoration of swallowing was achieved in 83% of patients. CONCLUSIONS: Gastric transposition after total laryngo-pharyngectomy is a safe procedure and can be performed with low mortality, acceptable morbidity and good long-term function.

[Reconstruction by free jejunal transplant after circular pharyngolaryngectomy (functional results and survival)]. / Reconstruction par transplant libre de jéjunum après pharyngolaryngectomie circulaire (résultats fonctionnels et survie).

One hundred and ninety seven patients with cancer of the hypopharynx underwent after circular resection, reconstruction with a free jejunal graft. The quality of free jejunal grafts is controlled by many investigations: clinical examination, radiography, electromyography, fibroscopy with biopsy. These investigations show that technically jejunal grafts must be short and linear to give the best functional results. Average resumption of oral intake was 14 days. Oral feeding was possible in 92% of cases. The free jejunal grafts with microsurgery are one of the more reliable procedures for reconstruction of pharynx and cervical esophagus after resection for cancer. (2 post-operative deaths and 8 grafts necrosis on 197 cases). The cumulative survival rate of 5 years was 35% for free jejunal graft. Survival depends on selection of the patients for local and nodes invasion. The quality of survival has improved. This operation must be reserved for the hypopharyngeal cancers which need a circular resection and do not invade the esophagus. The surgery is performed for a curative aim. The distant follow up of the patients is imperative: consultation every four months and then every six months: clinical examination, endoscopic, E.N.T., bronchial, and esophageal investigation. Chemotherapy and radiotherapy have specific indications.