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Salvage Resection After Previous Laryngeal Surgery
Total Laryngectomy With En Bloc Resection of the Overlying Cervical Skin
Andrea Gallo, MD, PhD;
Rossana Moi, MD;
Marilia Simonelli, MD;
Domenico Vitolo, MD;
Maria Luisa Fiorella, MD;
Vincenzo Marvaso, MD;
Valentina Manciocco, MD;
Marco de Vincentiis, MD
Arch Otolaryngol Head Neck Surg. 2001;127:786-789.
ABSTRACT
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Objective To evaluate the effectiveness of extended total laryngectomy for the
treatment of recurrences of laryngeal cancer.
Design We conducted a retrospective clinical study of patients who had undergone
extended total laryngectomy and were seen over a 15-year period. The follow-up
period ranged from 3 to 15 years.
Setting Academic tertiary referral medical center.
Patients We observed 15 patients who were affected by a recurrence of laryngeal
cancer that extended to the overlying soft tissue. All patients were male.
The mean age was 61.5 years. Thirteen patients had previously undergone partial
laryngeal surgery, and 2 patients had undergone radiation therapy, without
success.
Intervention All patients underwent total laryngectomy extending to the soft tissue,
including the overlying skin.
Results Five of the 15 patients died of local recurrence, and 1 patient died
of massive postoperative hemorrhaging. An actuarial survival rate of 60% was
observed at 5 years.
Conclusion Total laryngectomy extending to the soft tissues seems to be an effective
procedure for treating local recurrences of laryngeal cancer after partial
laryngectomy or failure of radiation therapy.
INTRODUCTION
ALTHOUGH PARTIAL laryngectomies1-2
and the combination of chemotherapy and radiation therapy3
have considerably reduced the number of total laryngectomies that have been
performed in the past 40 years, this procedure still remains the most appropriate
for specific conditions. A review of the literature reveals significant differences
in the treatment of T1, T2, and T3 laryngeal tumors,4-9
whereas T4 laryngeal tumors are usually treated with total laryngectomy.10-11
Although the thyroid cartilage and the perichondrium represent a natural
obstacle against the spreading of the tumor outside the larynx, laryngeal
tumors that grow toward the front of the larynx sometimes cross the cartilage,
thus infiltrating prelaryngeal soft tissues.12-15
In such cases, radiation therapy has not proved to be effective16
owing to the spreading of the tumor to the cartilage. When total laryngectomy
is performed, however, the procedure should be extended to the strap muscles
or even to the overlying skin.17
This type of surgery, ie, the removal of the larynx in addition to prelaryngeal
soft tissues, including the skin, is known as laringectomie
carré in France18 and as square total laryngectomy in the rest of Europe17 because it is characterized by the removal of a square
skin area overlying the larynx and strap muscles. In US literature,19-20 however, this procedure is not categorized
separately but is classified as enlarged or extended total laryngectomy (ETL)
or as wide-field total laryngectomy. These case studies include tumors that
spread in various directions, either to the front (as in our study) or to
the back, toward the hypopharynx and cervical esophagus. Few series of cases
treated exclusively with this type of surgery have been previously reported.17
In addition to cases in which the tumor has spread in a forward direction
across the cartilage, total laryngectomy is the most suitable approach when
the cartilage no longer represents a natural barrier against neoplastic infiltrations,
eg, in cases of recurrence in patients who have previously undergone partial
laryngectomies.17 Also, in such cases, the
recurrence of laryngeal tumor can spread easily to the prelaryngeal soft tissues
because the surgical opening of the thyroid cartilage has resulted in a less-resistant
pathway.
The aim of the present study was to verify the effectiveness of ETL
with en bloc resection of the overlying cervical skin as salvage surgery in
neoplastic recurrences with diffusion in a forward direction.
PATIENTS AND METHODS
From 1981 to 1996, we performed more than 500 partial, total, and subtotal
surgical procedures for laryngeal cancer at the Otorhinolaryngology Clinic,
"La Sapienza" University–Rome, Rome, Italy.5-6
Out of this series, 15 patients underwent ETL. All patients were male, and
their ages ranged from 45 to 77 years (average age, 61.5 years). All patients
underwent ETL as salvage surgery because of recurrences of squamous cell carcinoma
after partial or subtotal laryngectomies or after failure of radiation therapy
(Table 1). Follow-up lasted from
3 years to 15 years 4 months.
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Patients Treated With Extended Total Laryngectomy*
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After careful presurgical examination of the tumor extension using endoscopic
techniques and imaging, the skin area that is to be removed and that will
represent surgical access during the laryngectomy as well as during the neck
dissection, when necessary, is outlined. Immediately after the incision of
the skin that is to be removed, frozen sections are obtained to determine
whether the skin resection margins have been infiltrated. In fact, a subcutaneous
neoplastic lymphangitis may be one of the complications involved in tumors
that extend to the soft tissues of the neck.
The incision is continued at full thickness without detachment of the
underlying cutaneous, subcutaneous, and muscle layers. The upper resection
boundaries may include the hyoid bone and the preepiglottic space, whereas
the lower margins may include, when necessary, the entire thyroid gland and
2 or more tracheal rings, depending on the subglottic extension of the tumor.
Laterally, the dissection is similar to that of a normal total laryngectomy,
with the possibility of a level II to IV neck dissection without any additional
skin incisions.
Tissue defects of the hypopharynx due to ETL is closed as in a normal
total laryngectomy, whereas the remaining integument defect of the neck requires
reconstructive surgery. A pectoralis major myocutaneous flap is used to fill
the cutaneous, subcutaneous, and muscle defects. The low margin of the myocutaneous
flap is sutured to the first remaining tracheal ring to obtain a firm, wide
tracheotomy, allowing the tracheal cannula to be prompty removed.
RESULTS
Of the 15 patients who were included in this study, 6 (40%) have died
(Figure 1): 5 (33%) had local laryngeal
tumor recurrence, and 1 (7%) died of massive hemorrhaging after surgery. Nine
patients (60%) are alive with no evidence of disease. Of the 6 patients who
died, 1 had undergone a frontolateral laryngectomy, 3 had undergone a supracricoid
laryngectomy with cricohyoidopexy, and 2 had undergone radiation therapy,
without success.
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Actuarial survival rates at 5 years.
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None of the patients had a recurrence in the lymph nodes, including
those who underwent a neck dissection at the time of salvage surgery (Table 1). In all patients who had undergone
external surgery and in 1 who had been treated with radiation therapy, a total
thyroidectomy was combined with the laryngectomy.
During surgery, the histological examination of the entire perimeter
of the removed skin allowed us to obtain ample margins of normal skin, whereas
diffuse infiltration was found in the thyroid gland in 3 patients who died
of recurrence after cricohyoidopexy. All patients underwent radiation therapy
after surgery, with the exception of 2 patients who had previously undergone
a full cycle of radiation therapy as initial treatment.
COMMENT
Treatment of T4 laryngeal carcinoma with extensive cartilage infiltration
has always been considered a difficult problem. In fact, it is well known14-16 that the perichondrium
and the cartilage itself represent an important natural barrier against tumor
spreading toward the outside of the larynx. Because of this characteristic,
the larynx can be considered a closed box whose removal helps increase survival
rates when compared with many other human tumors. However, according to the
literature,21-22 these survival
rates decrease to 65% at 5 years after surgery when there is infiltration
of the thyroid cartilage without penetration of the soft tissues and to 32%
at 5 years in cases of clear penetration and subsequent invasion of the soft
tissues of the neck.
However, in cases in which infiltration extends to the skin, the survival
rates decrease to 12% to 15% at 5 years after surgery.23
It should be stressed that although radiation therapy is not effective in
treating T4 laryngeal tumors with evident infiltration of the thyroid cartilage,
it plays a significant role as a complementary treatment. In fact, local tumor
control percentages increase by 15% when surgery is combined with radiation
therapy, compared with surgery alone.21
Treatment of recurrences of laryngeal carcinoma in patients who have
previously undergone external surgery is even more difficult. Surgical interruption
of the cartilage during partial or subtotal laryngectomies creates a preferential
pathological pathway, allowing the tumor to spread to the soft tissues of
the neck. In such cases, the concept of removing the "box" along with the
tumor is no longer feasible with a total laryngectomy alone. To reconstruct
the concept of a box that can be removed along with the tumor, it is necessary
to outline new anatomical boundaries whereby the removal of wide margins of
normal tissue compensates for the defensive role that is naturally played
even by thin tissues, such as the perichondrium. The problem remains as to
how to establish anatomical boundaries that would be capable of containing
tumor progression in a forward and outward direction in relation to the larynx.
Strap muscles, when not removed during previous surgery, adhere to thyroid
cartilage alae and thus represent an obstacle against lateral diffusion of
the neoplasm and is strongly aided in this by the lateral thyroid gland lobes.
The thyroid gland, in fact, can be invaded by an extralaryngeal diffusion
tumor as well as by a paraglottic space tumor across the cricothyroid membrane.24 Therefore, complete removal of the thyroid gland
guarantees a resection margin extension for a tumor that is spreading beyond
the larynx both laterally (lateral lobes) and downward (thyroid isthmus).
The upper boundary of this extended laryngeal box is represented by the hyoid
bone, the preepiglottic space, and the elastic laminae that circumscribe it.
Toward the front, however, the en bloc box removal of the larynx, including
the strap muscles, the subcutaneous tissue, and a wide area of skin above
the tumor, ensures the highest level of tumor control possible. In fact, the
attempt to search for a subcutaneous cleavage plane, to maintain the skin's
integrity, may result in loss of tumor control. In our opinion, the only way
to stop the neoplastic progression of a tumor growing beyond the natural laryngeal
borders is to re-create an "extended" box that can be removed with all its
neoplastic contents.
Although some authors17 claim that removal
of the thyroid gland in patients with locally advanced laryngeal tumors does
not greatly increase survival rates, we believe that partial or total thyroidectomies
are absolutely necessary in cases involving tumors with evident extralaryngeal
diffusion. Also, removal of prelaryngeal skin, which represents a safety margin
in tumors spreading to the soft tissues of the neck, should not be considered
an overtreatment. In fact, an underestimation of subcutaneous tumor infiltration
can have disastrous effects, whereas the covering of even a large area of
skin removed at surgery can be easily carried out with several reconstructive
techniques.
Among the numerous pedunculate and free flaps currently available for
reconstruction, the pectoralis major myocutaneous flap still represents, in
our opinion, the best alternative owing to its reliability, its speedy execution,
and, above all, its thickness, which is suitable for covering the cutaneous,
subcutaneous, and muscle defects caused by the surgery.
CONCLUSIONS
Treatment of laryngeal tumors with extensive cartilage invasion, as
well as of neoplastic laryngeal recurrences spreading beyond the larynx, remains
a problem that is yet to be solved. The ETL with en bloc resection of the
overlying cervical skin, which yields a 60% survival rate at 5 years after
surgery, represents a valid therapeutic possibility. Although imaging can
provide evidence of soft tissue involvement, we advocate routine sacrificing
of the skin in all patients (who have undergone previous laryngeal surgery)
who have a recurrence of tumor spreading toward the front of the larynx.
Owing to the limited number of cases in this study, no definitive conclusion
can be made regarding whether sacrificing of the skin is always necessary
and whether the pectoralis major flap (a standard approach to this problem)
is the best reconstructive option. On the other hand, our surgical experience
does provide specific data on salvage surgery after modern, more extensive,
partial laryngeal resections, thus contributing to the limited knowledge available
on this topic.
AUTHOR INFORMATION
Accepted for publication April 5, 2001.
Presented at the annual meeting of the American Head and Neck Society,
Fifth International Conference on Head and Neck Cancer, San Francisco, Calif,
July 30, 2000.
We thank Maria Grazia Saladino for her help in the manuscript preparation.
Corresponding author: Andrea Gallo, MD, PhD, Via Adolfo Venturi,
19, 00162 Rome, Italy, (e-mail: andrea.gallo{at}uniroma1.it).
From the Departments of Otolaryngology (Drs Gallo, Moi, Marvaso, Manciocco,
and de Vincentiis) and Experimental Medicine and Pathology (Dr Vitolo), "La
Sapienza" University–Rome, and the Speech and Swallowing Rehabilitation
Service, Santa Lucia Hospital (Dr Simonelli), Rome, Italy.
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