Partial Laryngectomy for pT4a Laryngeal Cancer: Outcomes and Limits in Selected Cases.

A large multi-institutional case series of laryngeal cancer (LC) T4a was carried out, including 134 cases treated with open partial horizontal laryngectomies (OPHL) +/- post-operative radiation therapy (PORT). The goal was to understand better whether OPHL can be included among the viable options in selected pT4a LC patients who refuse a standard approach, represented by total laryngectomy (TL) + PORT. All 134 patients underwent OPHL type I (supraglottic), II (supracricoid), or III (supratracheal), according to the European Laryngological Society Classification. Comparing clinical and pathological stages showed pT up-staging in 105 cases (78.4%) and pN up-staging in 19 patients (11.4%). Five-year data on overall survival, disease-specific survival, disease-free survival, freedom from laryngectomy, and laryngo-esophageal dysfunction-free survival (rate of patients surviving without a local recurrence or requiring total laryngectomy and without a feeding tube or a tracheostomy) were, respectively, 82.1%, 89.8%, 75.7%, 89.7%, and 78.3%. Overall, complications were observed in 22 cases (16.4%). Sequelae were observed in 28 patients (20.9%). No patients died during the postoperative period. This large series highlights the good onco-functional results of low-volume pT4a laryngeal tumors, with minimal or absent cartilage destruction, treated with OPHLs. The level of standardization of the indication for OPHL should allow consideration of OPHL as a valid therapeutic option in cases where the patient refuses total laryngectomy or non-surgical protocols with concomitant chemo-radiotherapy.

Voice and communication after open partial horizontal laryngectomies: A cross-sectional outcome study.

OBJECTIVE: The present study evaluates voice and communication after open partial horizontal laryngectomies (OPHLs), according to surgery and patient-related variables. METHODS: Fifty-eight patients were included: 18 type I OPHL, 20 type II OPHL and 20 type III OPHL. Acoustic, aerodynamic, endoscopic, perceptual and self-assessment analyses were carried out. Surgery-related variables and patient-related variables were considered for the analysis. RESULTS: Type I OPHL revealed the best phonatory outcomes. Type II and type III OPHL showed similar and poor results, with a highly deteriorated voice quality. A significant difference in MTP was found for patients who had both arytenoids/cricoarytenoid units preserved. Age and time from surgery showed significant correlations with voice quality after OPHLs. CONCLUSIONS: Voice and communication outcomes after OPHLs are heterogeneous and might be influenced by several factors. Knowing variables with a substantial impact on phonatory outcomes may help clinicians in the preoperative decision-making process and the postoperative rehabilitative program.

The glottic-subglottic laryngectomy: Surgical technique, oncological, and functional outcomes.

OBJECTIVES: The aim of this article was to describe the surgical technique and report the oncological and functional outcomes of the partial glottic-subglottic laryngectomy (GSL). METHODS: A retrospective review of the clinical charts of patients who underwent GSL for laryngeal cancer from 1989 to 2020 at the Otolaryngology Unit of the Vittorio Veneto Hospital, a referral center for laryngeal cancer treatment. RESULTS: The present article considered 36 patients who were submitted to GSL for laryngeal cancer. The pathological exam found squamous cell carcinoma (SCC) in 16 cases, adenoid-cystic carcinoma (ACC) in 9 cases, laryngeal chondrosarcoma in 8 cases, 1 giant cell carcinoma, 1 carcinosarcoma, and 1 metastasis of colon adenocarcinoma. Considering the 16 SCC cases we observed a recurrence rate of 31%, the overall survival (OS) and disease-specific survival (DSS) were 75%. The 9 ACC cases had a recurrence rate of 23% and OS/DSS of 88%. In the 8 chondrosarcomas no relapses were reported and the OS/DSS were 100%. Among the patients without recurrence of the disease, a definitive decannulation was achieved in 21 cases (75%). CONCLUSIONS: The GSL represents a valid alternative to total laryngectomy in selected cases of laryngeal cancer involving the glottic and subglottic regions.

Laryngeal adenoid cystic carcinoma: Radical or conservative surgery?

PURPOSE: The present paper describes our experience in surgical treatment of laryngeal ACC, and discuss the effectiveness of conservative surgery. METHODS: We retrospectively reviewed the clinical charts of 17 patients with laryngeal ACC treated surgically at the Otolaryngology Unit of Vittorio Veneto Hospital (Italy) from November 1989 to April 2020. RESULTS: Fourteen patients underwent partial laryngectomy, and three had a total laryngectomy. Five patients (29%) experienced a laryngeal ACC relapse after a disease-free survival of 66.6 ± 50.1 months. The distant metastasis rate was 17%. At latest follow-up, two patients had died of distant metastatic disease after 156 and 243 months. CONCLUSIONS: Radical surgery for laryngeal ACC does not warrant free margins and even cases with positive deep margins rarely experience any relapsing disease. We recommend that surgical treatment for laryngeal ACC be as conservative as possible.

Open partial horizontal laryngectomy and adjuvant (chemo)radiotherapy for laryngeal squamous cell carcinoma: results from a multicenter Italian experience.

PURPOSE: To evaluate the functional and oncologic outcomes of adjuvant (chemo)radiation [(C)RT] after open partial horizontal laryngectomies (OPHLs). METHODS: Multicenter retrospective evaluation of 130 patients (116 males, 14 females) submitted between 1995 and 2017 to OPHL Types II and III for laryngeal cancer and receiving adjuvant (C)RT for one or more of the following risk factors at histopathologic examination of the surgical specimen: pT4a and/or > pN2a categories, close/positive resection margins, or presence of both perineural (PNI) and lympho-vascular invasion (LVI). The primary study endpoints were evaluation of the presence of tracheostomy and/or gastrostomy at last follow-up, and calculation of laryngo-esophageal dysfunction-free survival (LEDFS). RESULTS: Mean age of the study cohort was 60.8 ± 8.9 years (median, 62; interquartile range [IQR], 13). Mean follow-up was 50.7 ± 39.4 months (range 24-188; median, 38; IQR, 51). Adjuvant therapy consisted of CRT in 53 (41%) patients, and RT alone in 77 (59%). Five-year LEDFS was 85%. Overall survival was 71.5%, while 13% of patients remained tracheostomy- and 3% gastrostomy-dependent at the last follow-up. The only significant variable in predicting survival (p = 0.020) was tracheostomy dependence: it was maintained in 7.5% of subjects after OPHL Type II and in 34% of those submitted to OHPL Type III (p < 0.001). CONCLUSIONS: In selected patients affected by advanced laryngeal cancer, OPHLs Type II and III have a relatively good laryngeal safety profile and provide favorable oncologic outcomes even in case of need for adjuvant (C)RT.

Oncological and Functional Outcomes of Primary and Salvage Total Laryngectomy.

OBJECTIVES: To evaluate and compare the oncological and functional outcomes of total laryngectomies (TL) performed as first line treatment or for salvage after failure of conservative approaches for treating advanced laryngeal carcinoma (LSCC). STUDY DESIGN: A retrospective cohort study. METHODS: A cohort of 217 patients who underwent TL was divided according to whether the procedure was for primary treatment of their LSCC (101 patients) or for recurrences after conservative surgery or chemo-radiotherapy (116 patients). RESULTS: The overall survival rate and disease-specific survival rate were significantly higher in the primary TL group than in the salvage TL group (P = .04 and P = .01, respectively). The recurrence rate was significantly higher and the disease-free survival (in months) was shorter for patients who had salvage TL than for those who had primary TL (P = .00 and P = .01, respectively). The salvage TL group also included significantly more cases of postoperative pharyngo-cutaneous fistula needing salivary stent positioning, and experienced significantly longer hospital stays than the primary TL group (P = .04 and P = .03, respectively). CONCLUSION: Oncological and functional outcomes of primary TL were significantly better than after salvage TL. If salvage TL was performed after conservative surgery had failed, the oncological and functional results were better than after the failure of organ-preserving protocols. This could justify a first attempt at conservative surgery for intermediate-advanced LSCC in selected cases, reserving chemo-radiotherapy only for patients unsuitable for surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E569-E575, 2021.

Modular approach in OPHL: are there preoperative predictors?

OBJECTIVE: Open partial horizontal laryngectomies (OPHLs) nowadays represent the first line surgical choice for the conservative treatment of locally intermediate and selected advanced stage laryngeal cancers. Among the peculiarities of OPHLs, there is the possibility of intraoperatively modulating the procedure. It would be useful for the surgeon to recognise preoperative endoscopic and radiological factors that can predict the possibility to modulate the laryngectomy. METHODS: The present study retrospectively reviewed a cohort of 72 patients who underwent OPHL for glottic LSCC, in order to identify preoperative (endoscopic and radiological) parameters that are able to predict modulation surgery. RESULTS: The hypoglottic extension of the glottic tumour was the preoperative finding that was most informative in predicting OPHL modulation. However, it had no significant impact on oncological outcomes. CONCLUSIONS: Patients affected by tumours with hypoglottic extension and eligible for OPHL type II should be preoperatively informed about the possibility of an intraoperative switch towards OPHL type III.

The Penetration-Aspiration Scale: Adaptation to Open Partial Laryngectomy and Reliability Analysis.

A standard for assessing swallowing function after open partial horizontal laryngectomy (OPHL) is still not established. The variability in the measures used to investigate swallowing functional outcomes after OPHL limits the communication among clinicians and the possibility to compare and combine results from different studies. The study aims to adapt the PAS to the altered anatomy after OPHLs using fiberoptic endoscopic evaluation of swallowing (FEES) and to test its reliability. To adapt the PAS, two landmarks were identified: the entry of the laryngeal vestibule and the neoglottis. Ninety patients who underwent an OPHL were recruited (27 type I, 31 type II and 32 type III). FEES was performed and video-recorded. Two speech and language therapists (SLTs) independently rated each FEES using the PAS adapted for OPHL (OPHL-PAS). FEES recordings were rated for a second time by both SLTs at least 15 days from the first video analysis. Inter- and intra-rater agreement was assessed using unweighted Cohen's kappa. Overall, inter-rater agreement of the OPHL-PAS was k = 0.863, while intra-rater agreement was k = 0.854. Concerning different OPHL types, inter- and intra-rater agreement were k = 0.924 and k = 0.914 for type I, k = 0.865 and k = 0.790 for type II, and k = 0.808 and k = 0.858 for type III, respectively. The OPHL-PAS is a reliable scale to assess the invasion of lower airway during swallowing in patients with OPHL using FEES. The study represents the first attempt to define standard tools to assess swallowing functional outcome in this population.

Salvage open partial horizontal laryngectomy after failed radiotherapy: A multicentric study.

OBJECTIVES: The primary aim of the present study was to report our multi-institutional experience in surgical salvage with open partial horizontal laryngectomies (OPHL) after failed radiotherapy (RT) for laryngeal squamous cell carcinoma (LSCC). Secondary aims were to analyze the prognostic meaning of the main clinical and pathological parameters in relation to the oncologic outcome and to compare our results with the available literature. STUDY DESIGN: A retrospective multicenter analysis of surgical oncological outcomes. METHODS: We retrospectively review the clinical charts of 70 recurrent LSCC patients after primary RT failure undergone salvage OPHL. RESULTS: At last follow-up, 46 patients (65%) were disease-free; six (9%) were alive with disease; nine (12%) died because of the disease; and nine (12%) died without evidence of disease. The final local control, overall survival, disease-specific survival, and laryngectomy-free survival were 87%, 75%, 87%, and 91%, respectively. Twelve patients (17%) experienced postoperative complications, whereas 18 patients (25%) experienced late sequelae. In five patients (7%), decannulation was not possible because of postoperative laryngeal stenosis. CONCLUSION: In selected patients, when proper selection criteria for conservation laryngeal surgery are adopted, OPHL can be considered for salvage after RT failure. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:431-436, 2020.

Could the infiltration of the thyroarytenoid muscle define the pT2 glottic carcinoma?

BACKGROUND: The involvement of the thyroarytenoid (TA) muscle by glottic cancer may be related to an impaired vocal cord mobility, which is classified as cT2 disease. The primary endpoint was to evaluate the prognostic significance of TA muscle involvement in early glottic cancer treated with transoral laser microsurgery (TLM). METHODS: A review was conducted on a cohort of 209 patients consecutively treated with TLM for early glottic carcinoma. Univariate analysis was used to examine the prognostic meaning of clinical and pathological parameters. RESULTS: The statistical analysis showed that TA muscle infiltration correlated significantly with a worse prognosis in terms of recurrence rate and disease-free survival, and this was confirmed even in the subcohort with pT1a glottic cancer. CONCLUSIONS: Our preliminary findings suggest that it could be considered as a criterion for upstaging a glottic cancer from pT1 to pT2.

Sclerosis of the arytenoid cartilage and glottic carcinoma: A clinical-pathological study.

BACKGROUND: Given the relevance of any tumor invasion of the arytenoid cartilage or crico-arytenoid unit to the planning open partial horizontal laryngectomy (OPHL) for laryngeal squamous cell carcinoma (LSCC), it is important to have a reliable radiological test to assess impairments of these structures. METHODS: We retrospectively compared the endoscopic, radiological, and pathological findings in patients with glottic LSCC who underwent OPHL. RESULTS: The endoscopic finding of a reduced (impaired or absent) vocal cord motility proved more sensitive, with better positive and negative predictive values, but less specific than the radiological finding of complete arytenoid sclerosis in detecting histologically assessable infiltration of the arytenoid cartilage. CONCLUSIONS: Endoscopy retains a key role in the preoperative workup for glottic LSCC. CT evidence of complete sclerosis of the arytenoid cartilage is related to a dangerous contiguity of the tumor to the cartilage.

Treatment for T3 to T4a laryngeal cancer by open partial horizontal laryngectomies: Prognostic impact of different pathologic tumor subcategories.

BACKGROUND: The purpose of this retrospective study was to identify subcategories in cT3 to cT4a supraglottic/glottic cancers, describing their different spreading patterns, and local and locoregional recurrence modes. METHODS: Four hundred eighty-nine patients who underwent open partial horizontal laryngectomies (OPHLs) were retrospectively classified as: subcategory I (anterior pT3 with normal arytenoid mobility); subcategory II (posterior pT3 with impaired/absent mobility); subcategory III (anterior pT4 with normal mobility); and subcategory IV (posterior pT4 with impaired/absent mobility). RESULTS: Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), locoregional, local control, freedom from laryngectomy, and laryngectomy-free survival were significantly better in anterior tumors (subcategories I and III) when compared with the corresponding posterior ones (subcategories II and IV). CONCLUSION: Anterior cT3 tumors are manageable by OPHL, and this approach could also be proposed in the treatment of early anterior cT4aN0. Despite promising results, OPHLs should be considered under investigation in posterior cT3 tumors due to clinical and biological behavior similar to cT4a tumors.

Bocca's hemipharyngo-total laryngectomy for hypopharyngeal carcinoma to avoid reconstruction with a pedicled flap.

BACKGROUND: Major pharyngeal defects after total pharyngolaryngectomy for hypopharyngeal squamous cell carcinoma (SCC) frequently demand reconstruction strategies that include myocutaneous pedicled flaps, such as the pectoralis major flap. METHODS: We retrospectively reviewed the clinical charts of 24 patients with hypopharyngeal SCC treated with Bocca's hemipharyngo-total laryngectomy (HPTL) at our Institution. RESULTS: Eighteen patients (80%) experienced no disease recurrence after primary surgery and were alive with no evidence of disease after a mean follow-up of 43 months. The 2-year overall survival (OS) and disease-specific survival (DSS) rates in our sample were 69% and 82%, respectively. CONCLUSION: Bocca's HPTL enables an immediate neopharyngeal reconstruction, and is indicated in selected patients with intermediate to advanced hypopharyngeal tumors.

Relationship between swallowing-related quality of life and fiberoptic endoscopic evaluation of swallowing in patients who underwent open partial horizontal laryngectomy.

BACKGROUND: Several studies have previously analyzed the relationship between QOL and signs of dysphagia in patients treated for head and neck cancer and have reported heterogeneous findings. To the best of our knowledge, no study has previously investigated this relationship among patients who underwent open partial horizontal laryngectomy (OPHL). The aim of the study is to determine if patient-reported swallowing-related QOL can discriminate between safe and unsafe swallowing in OPHL patients. METHODS: 92 type I, type II, and type III OPHL patients at least 6 months postoperatively were recruited. Fiberoptic endoscopic evaluation of swallowing (FEES) was conducted using liquids, semisolids, and solids. FEES recordings were assessed through the penetration-aspiration scale, the pooling score and the dysphagia outcome and severity scale. All patients completed the MD Anderson dysphagia inventory (MDADI). Kruskal-Wallis test and post-hoc Mann Whitney U test were performed to compare MDADI scores among different level of airway invasion, post-swallow pharyngeal residue's degree and overall dysphagia severity. ROC curves were generated to determine diagnostic accuracy of the MDADI. RESULTS: Statistically significant differences in MDADI scores were found between level of airway invasion with semisolids and solids, degree of pharyngeal residue with solids, and severity of dysphagia. MDADI showed significant diagnostic accuracy only in the detection of moderate/severe pharyngeal residue and severe dysphagia; however, sensitivity and specificity were low. CONCLUSIONS: Investigating patients' perception of swallowing impairment and swallowing-related QOL is not sufficient to discriminate safe and unsafe swallowing in OPHL patients.

Could laser-assisted dissection of the pre-epiglottic space affect functional outcome after ESL?

OBJECTIVES: To evaluate the effect of preepiglottic space (PES) dissection in the endoscopic supraglottic laryngectomy (ESL). STUDY DESIGN: A retrospective cohort study. METHODS: We retrospectively compared 15 patients who underwent ESL with 15 patients matched for clinical stage who underwent open partial horizontal laryngectomy (OPHL). The functional outcomes were assessed in terms of hospital stay; need for nasal feeding tube (NFT) and tracheostomy, as well as duration of their use; postoperative complications; aspiration pneumonia rates; voice quality; and dysphagia. RESULTS: Among the ESL cases, combined dissection of the epiglottis and PES (type III) had a negative impact on functional outcomes. ESL patients experienced shorter hospital stays, as well as shorter use of NFT and tracheostomy, than patients who had OPHL. CONCLUSION: Combined dissection of the epiglottis and PES (ESL type III) negatively affected functional outcome in patients undergoing ESL, a procedure generally related to significantly better functional outcomes than OPHL type I. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1371-1378, 2018.

Management of paratracheal lymph nodes in laryngeal cancer with subglottic involvement.

BACKGROUND: The purpose of this study was to present our findings on the involvement of paratracheal lymph nodes in laryngeal squamous cell carcinoma (SCC) with subglottis extension, which is controversial. METHODS: We assessed 196 patients with laryngeal SCC involving the subglottis, treated with open laryngeal surgery with or without paratracheal neck dissection (PTND). The relationship of the paratracheal lymph node metastatic pattern with laterocervical nodal status and tumor location within different subglottic subsites was analyzed. The influence of PTND on regional disease control was assessed. RESULTS: Paratracheal lymph nodes were affected in 12.2% of cases. An increased frequency (P = .064) of paratracheal metastasis was noticed in case of anterior subglottis extension with respect to other subsites. A correlation (P < .001) between paratracheal lymph node and laterocervical node involvement was found among subjects with posterior subglottic extension. CONCLUSIONS: Prophylactic PTND is indicated in laryngeal SCC with anterior subglottic extension and/or posterior subglottis involvement with clinically apparent laterocervical node metastases.

Lateral pharyngotomy approach in the treatment of oropharyngeal carcinoma.

Surgery for early-intermediate oropharyngeal squamous cell carcinoma (OPSCC) may involve using transoral endoscopic approaches or open surgical procedures. "Lateral pharyngotomy" (LP) is an open surgical approach that improves exposure of the oropharyngeal region, while avoiding mandibulotomy. The aim of the present study was to retrospectively analyze our experience with the surgical treatment of early-intermediate OPSCC using the LP approach, and to investigate the potentially prognostic clinical and/or pathological factors that might identify patients at higher risk of recurrence after primary surgery. Sixty-four patients with previously untreated early-intermediate (pT1-T2-T3) OPSCC consecutively underwent partial pharyngectomy using a LP approach, performed by the same surgical team at a tertiary head and neck oncology center (Otolaryngology Unit, Vittorio Veneto Hospital, Italy). The 2-year disease-specific survival rates were 86% for stage I-II and 77% for stage III-IV disease. All patients who experienced locoregional or distant metastases died of their disease, while no patients died of any complications of the treatment. Postoperative complications occurred in 25 patients (39%), the most common being pharyngocutaneous fistula. All but one of the patients experienced a complete recovery of oral food intake. In conclusion, the LP approach to oropharyngeal cancer could be a valid open surgical alternative to oropharyngectomy with mandibulotomy for: (a) patients with early-intermediate OPSCC in whom oropharyngeal exposure proves difficult, and/or who are not eligible for transoral endoscopic surgery; (b) HPV-negative OPSCCs; and

Supratracheal partial laryngectomy: indications, oncologic and functional results.

PURPOSE OF REVIEW: To describe current evidence about supratracheal laryngectomies, focusing on indications, contraindications, oncologic results, functional outcomes and side-effects of this 'extreme' function-sparing surgical approach to laryngeal cancer. RECENT FINDINGS: In the latest years, some studies have analyzed oncologic and functional results of open partial supratracheal laryngectomy, a surgical approach whose modern technique was recently described. In selected patients, supratracheal partial laryngectomies show promising long-term oncologic and functional outcomes, similar to those of supracricoid partial laryngectomies. SUMMARY: The application of supratracheal laryngectomy in the context of a surgical modular approach can be considered a valid and effective therapeutic choice for selected patients with glottic or transglottic laryngeal cancer with subglottic extension, not only in terms of oncologic results, but also in regard of functional outcomes.

Two-stage CO2-laser-assisted bilateral cordectomy for cT1b glottic carcinoma.

PURPOSE: The aim of the present paper was to investigate the oncological safety of two-stage bilateral cordectomy for the treatment of cT1b glottic SCC, and to compare its oncological outcome and synechia development rate with those of single-stage procedures. MATERIALS AND METHODS: A retrospective cohort study was performed at the Otolaryngology Unit of Vittorio Veneto Laryngeal Cancer Center (Italy). The prognostic significance of clinical, pathological and surgical factors was also investigated, in terms of recurrence rate and disease-free survival, in a univariate statistical setting. RESULTS: Our results indicate that patients treated with primary two-stage bilateral cordectomy achieved local control in 96% of cases, with 95% disease-specific and 88% overall survival rates, and a 95% organ preservation rate, with anterior synechiae developing in 1 case. Involvement of the deep surgical margins correlated with a worse prognosis. Patients developed anterior synechiae less frequently after two-stage bilateral cordectomy, and experienced no higher recurrence rate or shorter disease-free survival than patients treated with a single-stage procedure. CONCLUSIONS: Two-stage bilateral cordectomy is a safe and effective procedure. In selected patients it could be considered the primary approach for the treatment of early glottic cT1b carcinomas.