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Near-Total Laryngectomy for Laryngeal Carcinomas With Subglottic Extension
Ismet Aslan, MD;
Nermin Baserer, MD;
Engin Yazicioglu, MD;
Cagatay Oysu, MD;
Mehmet Tinaz, MD;
Erkan Kiyak, MD;
Necdet Biliciler, MD
Arch Otolaryngol Head Neck Surg. 2002;128:177-180.
ABSTRACT
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Objective To investigate whether Pearson classic near-total laryngectomy is a
sensible surgical treatment modality for laryngeal carcinomas with subglottic
extension.
Design Retrospective analysis of patients treated by near-total laryngectomy
in a university hospital that is an academic tertiary health care center.
Participants and Intervention Medical and computer records of 135 patients who were treated by near-total
laryngectomy for laryngeal and hypopharyngeal carcinomas between April 1,
1989, and June 30, 2000, were searched thoroughly, and the final outcomes
were confirmed by telephone contact.
Main Outcome Measures Survival rates of the patients with laryngeal carcinomas with subglottic
extension treated by near-total laryngectomy were compared with those of the
patients with malignancies of other laryngeal regions given the same treatment.
Results Of the 135 patients in the study, 74 were available for determination
of 5-year survival. The rate was 65.8% (27/41) for transglottic tumors, 53.8%
(7/13) for supraglottic tumors, and 20.0% (4/20) for tumors with subglottic
extension. Only 3 of 16 patients with laryngeal carcinomas with supraglottic
or transglottic localization died of local recurrence; the rest of the deaths
were from regional recurrence or distant metastasis. However, 6 of 13 patients
with subglottic extension died of local recurrence, 5 of peristomal recurrence,
and only 2 of distant metastasis.
Conclusions Success was directly related to adherence to precise indications in
cancer surgery. While near-total laryngectomy is an effective and reliable
treatment modality in laryngeal cancer surgery, its effectiveness in laryngeal
cancers with subglottic extension is debatable. These subglottic lesions should
be treated by total laryngectomy, which is a more radical surgery.
INTRODUCTION
NEAR-TOTAL laryngectomy was described by Pearson1
as an alternative treatment for patients with T3 and T4 laryngeal carcinomas.
With this treatment, these patients would be spared a life without speech,
which is the main consequence of total laryngectomy. Initially described as
"extended vertical hemilaryngectomy" or "subtotal laryngectomy," this technique
was developed over time; "near-total laryngectomy with partial pharyngectomy"
was developed to include the base of the tongue and the hypopharynx, and "near-total
laryngopharyngectomy" was developed to take advantage of pedicled flap reconstruction.2-4
The aphonic condition that the patient has to face after total laryngectomy
has deep psychological and debilitating effects on the human psyche. For this
reason, extensive work has been carried out on alaryngeal voice production
since the beginning of the century.5-8
Complications of adynamic tracheoesophageal shunt methods have been described
mainly as aspiration, stenosis, and difficulty with hygiene.7
Near-total laryngectomy is a surgical treatment modality that was specially
designed to overcome these serious complications of adynamic tracheoesophageal
shunt methods.
Near-total laryngectomy has not gained widespread approval, and few
series have been published in the English-language literature.9-14
The perception of the operative technique as complicated by many surgeons
and the widespread and convenient application of tracheoesophageal puncture
procedure are among possible causes for this reluctance to perform near-total
laryngectomy.
The subglottis is defined as the laryngeal subdivision bounded superiorly
by the junction of squamous and respiratory epithelium on the undersurface
of the true vocal cords, which has been arbitrarily assigned to the point
5 mm below the free edge of the true vocal cords.15
Inferiorly, it extends down to the inferior border of cricoid cartilage.
Primary tumors originating from the subglottic region are rare. Tumors
located in the subglottic region are usually extensions from the glottic or
even supraglottic region by paraglottic space involvement.16
In their study to investigate the means of tumor spread, Strome et al17 determined that the fibroelastic barriers located
in the subglottic region are predisposed to cancerous invasion. According
to the results of this study, even the cartilaginous structures escape tumor
invasion until the advanced stages, whereas the ability of cancer to invade
these fibroelastic barriers leads to insidious spread of the disease. Tumor
progression occurs mainly in the paraglottic region, and the potential for
mucosal spread is limited. A normal endoscopic appearance can be observed
in such a patient because of the absence of mucosal spread as the disease
progresses to advanced stages.
Laryngeal carcinomas extending to the subglottic region or even to several
rings of the upper trachea were also covered by the classic indications for
the operation when described by Pearson.1, 18
Near-total laryngectomy has been commonly performed in our clinic for 11 years.
Despite support in the literature, resection of subglottically extending laryngeal
carcinomas by near-total laryngectomy is questionable because of the embryologic
development and, hence, lymphatic drainage of this region. For this reason,
we decided to examine the indications for the technique by determining the
success rates in our series of 135 cases.
PATIENTS AND METHODS
Between April 1, 1989, and June 30, 2000, 135 near-total laryngectomies
were performed in the Department of Otorhinolaryngology of the Istanbul University
Faculty of Medicine, Istanbul, Turkey, according to the technique of Pearson.1, 18 Cases were evaluated according to
tumor location and the operative technique used.
In this study, survival rates of patients undergoing near-total laryngectomy
with different locations of cancer were compared according to preoperative
variables of T and N stages. In cases of treatment failure, reasons were evaluated
according to location of the primary tumor.
Patients were divided into 3 groups according to the surgery performed.
Classic near-total laryngectomy (104 patients [77.0%]) is the technique described
by Pearson. Near-total laryngectomy with partial pharyngectomy (28 patients
[20.7%]) was performed for advanced laryngeal carcinomas with pharyngeal and
tongue base involvement being prepared to be reconstructed primarily. Near-total
laryngopharyngectomy (3 patients [2.2%]) was performed for advanced laryngeal
tumors that could not be reconstructed primarily but with the aid of pedicled
flap reconstruction (pectoralis major). The operations were performed in accordance
with the original technique described by Pearson.1, 18
The cases were classified into 6 groups according to the location of
the tumors (Table 1). Within this
classification, the term advanced refers to pharyngeal
or tongue base extension for transglottic and supraglottic tumors. The main
indications for near-total laryngectomy for supraglottic carcinoma were advanced
age and poor cardiopulmonary status of patients for whom a classic supraglottic
laryngectomy could cause significant postoperative problems. The patients
in the subglottic extension group were those with tumors extending to the
subglottis to an extent that precluded the use of any partial laryngectomy
technique. This is accepted as subglottic extension more than 10 mm anteriorly
and 5 mm posteriorly. The majority of cases were within the range of 10 to
20 mm of subglottic extension.
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Table 1. Classification of Cases According to Original Location of
the Tumor*
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Six of the 135 patients who underwent near-total laryngectomy were unavailable
for follow-up. Two additional patients died of postoperative complications:
1 patient of a pulmonary embolus and 1 patient of a presurgical chemotherapy
complication. (Chemotherapy was not routinely used in this cohort of patients
treated surgically by near-total laryngectomy. The 1 patient who died of a
preoperative chemotherapy complication was the only one who belonged to a
distinct study group subjected to a neoadjuvant chemotherapy protocol consisting
of methotrexate and fluorouracil.) In 3 cases, near-total laryngectomy was
performed not for oncologic reasons but for functional indications of other
surgical approaches that were complicated by aspiration (2 cases of three-quarters
horizontal-vertical partial laryngectomy, 1 case of commando resection for
a retromolar trigone carcinoma). After exclusion of all cases unavailable
for follow-up, the statistical calculations were performed on 124 cases.
Statistical calculations were performed with the SPSS 10.0 for Windows
software program (SPSS Inc, Chicago, Ill). Survival evaluation between different
surgical groups was performed by Kaplan-Meier life table method, and monthly
survival values were accepted. Local and regional recurrences according to
tumor location were evaluated by the nonparametric Kruskal-Wallis test. Preoperative
variables were age, sex, preoperative characteristics of the tumor (tumor
stage, neck stage, histologic findings, and location), and reason for operation
(functional, primary curative, or salvage). The only operative variable was
the type of procedure performed. Postoperative variables were reasons for
death and use of radiotherapy.
RESULTS
The median age of the 135 patients in the study was 56.2 years (range,
33-80 years). Table 2 summarizes
the main reasons for each type of operation.
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Table 2. Main Reasons for Which Near-Total Laryngectomy Was Performed
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Seventy-two patients did not receive postoperative radiotherapy, in
2 patients radiotherapy had failed, and, omitting the 2 patients who died
during the perioperative period, the remaining 59 patients (43.7%) received
postoperative radiotherapy. All patients with advanced laryngeal carcinoma
with pharyngeal and/or tongue base involvement and all patients with glottic
tumors with subglottic extension were subjected to postoperative radiotherapy.
The postoperative radiotherapy protocol consisted of conventional fractionated
radiotherapy (5000 rad [50 Gy], 25 fractions) for 6 weeks, with the coverage
of stoma and upper mediastinum in all patients with subglottic extension.
Indications for postoperative radiotherapy were cervical metastatic disease
in more than 1 lymph node, periganglionic soft tissue invasion, perineural
and perivascular infiltration, high tumor grade, and advanced T4 stage, with
the exception of limited cartilage invasion.
Existence of tumor cells in the surgical margins was not accepted as
an indication for postoperative radiotherapy. Our policy for positive margins
has been to reoperate with a more radical technique, which is usually total
laryngectomy or watchful waiting. The efficacy of radiotherapy for positive
margins is a matter of debate, since it has been shown that tissue alterations
induced by surgical trauma significantly reduce the efficacy of radiotherapy.19
Three patients who underwent near-total laryngectomy for functional
reasons, 2 who died during the perioperative period, and 6 who were unavailable
for follow-up were excluded from the series of 135 cases. Twenty-eight patients
with disease that extended out of the endolarynx were also excluded from the
series; therefore, the survival evaluation was performed on 54 cases of transglottic,
18 cases of supraglottic, and 24 cases of subglottic tumors that were limited
to the endolaryngeal region. Of 54 patients with transglottic laryngeal carcinomas,
41 completed the 5 years of follow-up, and 27 (65.8%) had no evidence of disease.
Thirteen of 18 patients with laryngeal carcinomas with supraglottic location
completed the 5 years of follow-up, and 7 (53.8%) were free of disease. Of
24 patients with laryngeal carcinomas with subglottic extension, 20 completed
the 5 years of follow-up, and only 4 (20.0%) were free of disease. Tumors
that were located solely in the subglottic region were treated by total laryngectomy
in our clinic.
Kaplan-Meier life table analysis showed the cumulative survival of patients
with transglottic tumors to be 119.1 months; that for supraglottic tumors,
99.5 months; and that for laryngeal cancers extending to subglottic region,
63.6 months. A statistically significant decrease in survival was observed
by Kaplan-Meier life table analysis for laryngeal carcinomas extending to
subglottic region when treated by near-total laryngectomy (Figure 1).
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A statistically significant difference of survival was observed between
the surgical groups of different laryngeal regions treated by near-total laryngectomy.
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Significant differences were observed between the causes of death when
the cases were compared according to the location of the primary tumor. While
regional recurrences and distant metastasis were the main causes of death
of the patients with laryngeal carcinomas of glottic and supraglottic regions,
only 3 patients died of local recurrence. On the other hand, local recurrences
predominated as the primary cause of death for tumors extending down to the
subglottic region; of 13 patients with laryngeal carcinomas with subglottic
extension who died, 6 died of local recurrence and 5 of peristomal recurrence.
Nonparametric Kruskal-Wallis testing demonstrated the statistical significance
of local recurrence as the main cause of death for tumors extending to the
subglottis (local recurrence:  25 = 21.72, P = .001; regional recurrence: 25 = 3.92, P = .56).
COMMENT
Careful determination of tumor dimensions and its spread is the key
determinant of success in conservative laryngeal cancer surgery. Despite the
high success rates of conservative partial surgery performed for more limited
lesions, near-total laryngectomy is usually performed for more extensive laryngeal
or hypopharyngeal cancers. As the tumor mass grows and its stage increases,
deep submucosal invasion, rather than mucosal borders, becomes the main determinant
of real tumor boundaries.20 This critical submucosal
border cannot always be determined definitively in the preoperative period
and during the operation, even with frozen-section analysis.11, 17
The lymphatic drainage of the larynx is usually separate for the 2 sides
and seldom crosses. However, the existence of lymphatic channels crossing
the midline has been shown in the supraglottic and infraglottic regions.15 The probability of spontaneous appearance of contralateral
lymphatic drainage is higher in the region below the glottis, and, therefore,
prediction of metastatic patterns of tumors originating in the subglottis
is much more difficult.15 An even more important
issue is the invasion of the upper tracheal rings, since circular lymphatic
drainage of this region precludes the determination of any tumor spread.21
The largest series of near-total laryngectomy for laryngeal cancers
is that of Pearson et al,22 and in that study
no local recurrences were encountered in cases with subglottic extension.
The outcomes of patients with subglottic extension of their tumors in Pearson
and coworkers' series contradict ours. In our series, 20 of 24 patients undergoing
near-total laryngectomy who had laryngeal tumors extending to the subglottis
completed the 5-year survival evaluation period, and only 4 of the 20 completed
this period without any evidence of disease. We saw 6 cases of local recurrence
in this laryngeal region, whereas Pearson et al observed no local recurrences
in their series. The local recurrences were usually located at the inferior
extent of the speaking shunt. Furthermore, 5 patients died of peristomal recurrence.
The other studies of near-total laryngectomy do not contain an adequate number
of cases for a reliable evaluation of results for tumors extending to the
subglottic region.11-12,23
In addition to providing an oncologic success rate similar to that of total
laryngectomy in glottic and supraglottic laryngeal tumors, near-total laryngectomy
also prevents a major problem by providing phonation. On the other hand, success
of near-total laryngetomy for tumors extending to the subglottis is limited.
In light of this study, the surgical treatment of subglottic laryngeal
tumors should not use the same surgical technique with millimetrical resection
margins as is performed for other laryngeal-region tumors. The aggressiveness
or intrinsic insidiousness of tumors located in the subglottic region or the
difficulty of determining the true surgical margins despite the safe appearance
of the mucosa precludes such an approach in this region. It may not be logical
to relate the surgical treatment failure of laryngeal tumors extending to
the subglottic region only to the surgical technique used, since many other
factors exist (eg, degree of cellular differentiation and biological factors
bound to the tumor-host relationship) that are influential in tumor spread.24 However, surgical treatment as aggressive as possible
is the approach that many investigators agree on for laryngeal carcinomas
extending to the subglottis.15, 25
Wide-field laryngectomy instead of simple total laryngectomy, lower-than-usual
tracheostomy instead of normal tracheostomy, and more extensive thyroidectomy
instead of hemithyroidectomy are the surgical strategies that should be applied.26 Use of near-total laryngectomy in such a critical
region puts the patient at risk of treatment failure.
CONCLUSIONS
According to the results of this study, near-total laryngectomy is an
alternative surgical modality that also carries significant risk of failure
for laryngeal tumors extending to the subglottic region. Near-total laryngectomy
should not be undertaken for patients with subglottic extension; instead,
these patients should be treated with total laryngectomy, since the local
recurrence rate is higher with the former technique. The results of this study
are informative for anyone who is interested in laryngeal cancer surgery and
are cautionary, given the lack of other literature that evaluates the success
of near-total laryngectomy for laryngeal tumors extending to the subglottic
region.
AUTHOR INFORMATION
Accepted for publication September 5, 2001.
We gratefully thank Brian Burkey, MD, Department of Otolaryngology,
Vanderbilt University Medical Center, Nashville, Tenn, for his editorial contribution.
Corresponding author and reprints: Ismet Aslan, MD, Kardelen 4-5
D: 3, 81120 Atasehir Istanbul, Turkey (e-mail: ismetaslan{at}istanbul.edu.tr).
From the Departments of Otorhinolaryngology, Faculty of Medicine, Istanbul
University (Drs Aslan, Baserer, Yazicioglu, Tinaz, Kiyak, and Biliciler),
and Taksim State Hospital for Research and Education (Dr Oysu), Istanbul,
Turkey.
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