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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1417-1422

Outcome of supracricoid laryngectomy in moderately advanced cancer larynx


Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission09-Jul-2018
Date of Decision30-Jul-2018
Date of Acceptance31-Jul-2018
Date of Web Publication31-Dec-2019

Correspondence Address:
Anwar Abd El-Atty Ibrahim
Department of Otorhinolaryngology, Faculty of Medicine, Shebin El-Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_210_18

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  Abstract 


Objective
To assess the oncological outcomes of supracricoid laryngectomy in moderately advanced laryngeal cancer.
Background
Recently supracricoid partial laryngectomy (SCPL) with cricohyoidopexy (CHP) or cricohyoidoepiglottopexy (CHEP) and other surgical laryngeal preservation protocols have undergone major advancement to treat early and moderately advanced laryngeal tumors. SCPL with CHEP and CHP preserves the airway and laryngeal sphincter function with considerable decrease in the amount of risk of aspiration.
Patients and methods
A total of 10 patients with moderately advanced laryngeal squamous cell carcinoma (T2b toT4a) who were fit for surgery were recruited from two different specialized care centers in Egypt and India from January 2017 to January 2018. Patients with interarytenoid area involvement, cricoarytenoid joint involvement, pre-epiglottic space invasion, or subglottic extension were excluded.
Results
Patients were mainly T3 (four patients). They underwent SCPL with CHP in four cases and with CHEP in six cases. Preservation of one arytenoid was done in nine patients. The local control rate was 100%. Aspiration occurred in two cases. Both pexy rupture and salivary fistula occurred in one case. Removing of nasogastric tube and decannulation of tracheostomy were done in seven and six cases, respectively, before 1 month.
Conclusion
SCPL with CHEP and CHP was an effective treatment option with excellent oncological outcomes for T2b–T4a laryngeal cancer. Specific efficacy was revealed in cases with anterior commissure or paraglottic space involvement. Low rate of complications was reported in our study.

Keywords: cricohyoidoepiglottopexy, cricohyoidopexy, moderately advanced laryngeal carcinoma, partial laryngectomy, supracricoid laryngectomy


How to cite this article:
El-Rasheedy ALI, Khlail YA, Abd El-Shafy IA, Husien HA, Ibrahim AE. Outcome of supracricoid laryngectomy in moderately advanced cancer larynx. Menoufia Med J 2019;32:1417-22

How to cite this URL:
El-Rasheedy ALI, Khlail YA, Abd El-Shafy IA, Husien HA, Ibrahim AE. Outcome of supracricoid laryngectomy in moderately advanced cancer larynx. Menoufia Med J [serial online] 2019 [cited 2020 Jan 20];32:1417-22. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1417/274236




  Introduction Top


According to American statistics in 2017, laryngeal cancer accounts for 0.8% of all cases of cancers diagnosed in the United States, affecting men more than women (5.4 to 1.1%), predominantly starting in the fifth decade of life [1]. The main modalities of treatment are surgery (total laryngectomy and partial laryngectomy) and radiation therapy [2]. Partial laryngectomy shows cure rates comparable to total laryngectomy. Different horizontal partial laryngectomy procedures (supracricoid laryngectomy or supraglottic laryngectomy) and reconstruction techniques are used depending on tumor extension [3].

Supracricoid laryngectomy, which is a form of subtotal laryngectomy [supracricoid partial laryngectomy (SCPL)], was initially described by Majer and Rieder [4] and thereafter by Labayle and Bismuth [5]. This procedure was developed to avoid total laryngectomy in patients with tumor in whom traditional partial procedures would not be indicated, thus avoiding definitive tracheostomy and the irreversible loss of laryngeal voice [6].

SCPL can be used for a wide range of supraglottic and glottic carcinomas (T2b–T4). This procedure avoids the creation of a tracheostoma via preservation of the hyoid bone, cricoid cartilage, and at least one functional arytenoid unit to preserve the airway and laryngeal sphincter function. The epiglottis may or may not be resected depending on the extent of the tumor. Reconstruction is then performed using either cricohyoidoepiglottopexy (CHEP) or cricohyoidopexy (CHP). This neoglottis functions via close approximation of the remaining arytenoid mucosa against the epiglottis or base of the tongue; this allows for voice generation via vibration of mucosa between these surfaces [7].

SCPL seems to be safe in most clinical T2 lesions, as bilateral extensive glottic involvement, impairment of the vocal fold mobility, and subglottic extension not reaching the cricoid cartilage are all considered as indications for this surgery. SCPL can be also used in T3–T4 lesions with some precautions [2]. The functional aspects of these surgical procedures have not been widely described in medical literature (swallowing and phonation) [6]. The approach of supracricoid laryngectomy is not performed at a wide scale in Egypt, with only a small number of Egyptian publications in this field, which raises the need to evaluate this approach in dealing with Egyptian patients with their specific socioeconomic status. The aim of this study was to assess the oncological outcomes of supracricoid laryngectomy in moderately advanced cancer larynx.


  Patients and Methods Top


This study was a descriptive case series study conducted in two tertiary care centers (LeLe Hospital for Advanced Head and Neck Cancer and Laser in Nashik, Mumbai, India, by Professor Pushkar Lele, and Kasr El-Ainy School of Medicine, Cairo University, by Professor Mohammad Mosleh) from January 2017 to January 2018. This allowed us to compare different schools regarding this procedure to standardize our approach. Approval of the ethical committee of the hospital was taken, with a written consent taken from every patient. Inclusion criteria were as follows: (a) glottic squamous cell carcinoma (T2b–T4) with impaired mobility or even fixity of vocal cord/cords but with mobile arytenoid, or supraglottic tumor reaching the anterior commissure; (b) no prior induction chemotherapy; and (c) patients fit for surgery with adequate pulmonary function tests. Patients with subglottic extension more than 10 mm anteriorly and 5 mm posteriorly, glottic carcinoma with cord fixation, or supraglottic carcinoma with invasion of base of tongue were excluded. Moreover, tumors reaching the pre-epiglottic space or postcricoid region were also excluded. All patients underwent the following: (a) full history taking and detailed office examination including routine otolaryngology examination with rigid or fibro-optic laryngoscopy for a better evaluation of vocal cord movements along with that of arytenoids; (b) direct laryngoscopy with panendoscopy using 0° and 30° rigid endoscopes to specify the exact extension at the anterior commissure, the subglottic region, and the ventricle; (c) neck imaging using computed tomography (CT) and MRI in specific cases to evaluate tumor extensions inside the larynx; (d) metastatic workup to exclude the distant metastases and pulmonary function tests to exclude respiratory insufficiency. All patients were treated by SCPL-CHEP according to Majer and Rieder [4] and Piquet et al. [8] techniques. All patients underwent tracheostomy during surgery. Ten patients were operated: six cases with CHEP and four cases with CHP, having one case with preservation of both arytenoids for each surgical approach [Figure 1] and [Figure 2]. Statistical analysis was performed using statistical package for the social sciences, 24.0 for Windows (SPSS, Chicago, Illinois, USA). Quantitative data were expressed as mean and SD whereas qualitative data were expressed as number and frequency.
Figure 1: Incision for supracricoid laryngectomy.

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Figure 2: Three vicryl stitches for complete fixation of the cricoid cartilage to the hyoid bone.

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  Results Top


Regarding patients' characteristics, this study included 10 patients, comprising eight males and two females, with a sex ratio of 8:1. The patients' age ranged between 45 and 75 years, with a mean age of 50.9 ± 9.2 years and coefficient of variation of 1.5% [Table 1]. The glottis was the most common site of origin of the lesions, as seen in nine (90%) patients, whereas one (10%) patient had a purely supraglottic carcinoma [Table 1].
Table 1: Clinical characteristics of the studied group

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This study focused on T2b–T4a, which is a moderately advanced laryngeal carcinoma. Most patients were T3NOMO (four patients). Others were T2N0M0 (two patients), T2N2A M0 (two patients), T2N2b M0 (one patients), and T4aN0M0 (one patients) [Table 1].

SCPL-CHEP was the main surgery in the study patients (60%). One arytenoid was resected routinely in all patients, except one patient who had both arytenoids preserved. Neck dissection was performed on the tumor side in 60%, and on the contralateral side in 40% of patients. The types of neck dissection are mentioned in [Table 2]. Postoperative radiotherapy was delivered in two (20%) of the primary operations. The indications of postoperative radiotherapy were high T category, extranodal disease, and positive or close margins.
Table 2: Operative characteristics of the studied group

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Regarding the outcomes, the adjusted primary local control and overall control results at the time of the analysis were 100%. There was a deficit in follow-up owing to the short period of the study. The median duration of hospital stay was 30 days, with maximum of 90 days. Tracheotomy was done during the surgery for all patients and was kept in place for 1 week at least. Six cases were decannulated before 1 month, and four cases after 1 month, with two of them decannulated after 3 months owing to severe aspiration. All the patients had nasogastric feeding tube during the operation, and it was kept for more than 30 days in three patients owing to aspiration [Table 3]. The complications of SCPL were aspiration pneumonia, salivary fistula [Figure 3], pexy rupture, and arytenoid paralysis [Table 3]. Detailed description of the study patients are revealed in [Table 4], [Table 5], [Table 6].
Table 3: Postoperative recovery of the studied group

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Figure 3: Salivary fistula with rupture of pexy.

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Table 4: Detailed description of demographic and clinical data of the study patients

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Table 5: Detailed description of the tumor characteristics of the study patients

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Table 6: Detailed description of operative and postoperative details of the study patients

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  Discussion Top


SCPL had been introduced as an alternative to total laryngectomy since 50 years ago, but the standardization and development of these procedures had been limited to several French surgeons during the 1970s and 1980s of the last century [9]. Up to July 2009, 186 publications addressed SCPL directly as revealed by a systematic review. However, even nowadays the large series tier is still confined to some European centers [10]. In this study, all patients were assessed using CT neck, with 3-mm cuts in the neck and 1–2 mm cuts in the area of the larynx, to allow better visualization and reconstruction with endoscopic examination under general anesthesia to obtain a precise mapping of the lesion. Some authors stated that the MRI has the advantage of delivering slightly better results than modem CT regarding tongue base infiltration and pre-epiglottic space invasion [11]. In the present study, there were no cases of T1, but six cases with T2 glottic carcinoma. Early glottic carcinoma is a highly curable disease by several modalities, including radiotherapy, transoral surgery, and open conservation surgery with high and comparable survival results with SCPL [12]. On the contrary, there were three cases of T3 and one case of T4. SCPL was preferred in T3–T4 lesions for the following reasons. It is easy to have negative resection margins with SCPL when compared with the CO2 laser. As neck treatment is mandatory in T3–T4 lesions, neck opening is unavoidable. Anterior commissure involvement represents one of the most important problems in the management of cancer larynx [13]. In the present study, eight (80%) patients had involvement of the anterior commissure clinically. The safety of SCPL-CHEP in resecting glottic carcinomas reaching the anterior commissure was also found by Laccourreye et al. [14] and Chevalier et al. [15]. In the few reports that examined the pathological efficacy of SCPL regarding anatomical laryngeal subsites, a nonsignificant effect of the pathological anterior commissure involvement was constant, matching the results of the present study. Regarding anterior commissure extension in cancer larynx, it was concluded that SCPL is the best conservation modality regarding the oncologic outcome [13]. In this study, there was one case with subglottic extension with anterior extension less than 10 mm. SCPL is efficient for this extension with excellent local control results, provided that the subglottic extension does not reach the upper border of the cricoid cartilage. The lower resection can be extended minimally to resect the cricoid cartilage, but the overextended technique (tracheohyoidoepiglottopexy) should be approached carefully in highly selected patients [12]. In the present study, there were seven patients with impaired vocal cord mobility, and three patients with fixed vocal fold. Several authors reported excellent local control and specific survival for impaired (clinically T2) and fixed vocal fold (clinically T3). The local control rate was usually around 90% at 5 years [16]. Among these studies, the report of Chevalier et al. [15] was unique as it included 112 patients with impaired or fixed cord; all the patients were treated with SCPL, and the 5-year local control and laryngeal preservation rates were ∼95%. This strongly supported the efficacy of SCPL in this extension. In this study, paraglottic space invasion was found in four cases. Traditionally, SCPL was introduced as an ideal method that could remove the paraglottic spaces bilaterally and completely, and this still remains one of its main oncologic principles [17]. In the present study, there were no cases with SPCL used as salvage. However, many authors reported other conservation modalities as salvage, but the real problem in these studies is that the indication was usually linked to the experience of the surgeon, and it was usually done in super-selected cases as no pathological validation for partial surgery as a salvage procedure had been performed [18]. In this study, the two arytenoids were preserved in one case only and one arytenoid was preserved in nine cases. Basaran et al. studied the effect of arytenoid resection in patients who had undergone SCPL by comparing functional and oncologic results between patients with both arytenoids preserved and those with one arytenoid resected. There was no statistically significant difference in the early and late functional outcomes, and the oncologic outcomes were also similar [19]. In the present study, there was no mortality related to the surgery. There were two cases of aspiration that prolonged time of decannulation and spontaneously improved after 3 months. In addition, there was one case of delayed rupture of pexy and salivary fistula that underwent completion laryngectomy. The period of hospitalization in the present study was 1 month on average until the patient could swallow adequately. Longer hospitalization periods were adopted for some patients who developed major complications such as aspiration. Most studies on SCPL reported similar hospitalization durations, usually 3–4 weeks [20],[21],[22], whereas short hospitalization periods were reported in few reports [14]. In the present study, all patients were decannulated at 3 months with 30 days of mean tracheotomy period; these results are again comparable to most of the reports on SCPL except in one article where the authors usually preferred to do early decannulation [14]. Similar or slightly shorter tracheotomy durations were reported with supraglottic laryngectomy and vertical hemilaryngectomy [23]. In the present study, three patients had their nasogastric tube removed after 3 months owing to aspiration. All other patients had the tube removed within 1 month. Ozturk et al. [20] found that median nasogastric tube removal time was 16.5 and 14 days in CHP and CHEP patients, respectively, with median decannulation time of 30 and 19 days in CHP and CHEP patients, respectively. Resection of one arytenoid significantly increased nasogastric tube removal time. Wang et al. [22] found that decannulation was achieved in nearly all patients, with the average time to decannulation being 20 ± 11.52 days in CHEP patients and 28 ± 8.92 days in CHP patients. The nasogastric tubes were removed at an average of 18 ± 7.39 days in CHEP patients and 25 ± 13.87 days in CHP patients. The limitations of this study included the relatively small number of study patients. But this can be attributed to the rarity of the procedure among different modalities for partial laryngectomy. Another limitation is the short follow-up period with unavailability of some functional outcome assessment. This can be attributed to the short time available in India for 3 months.


  Conclusion Top


SCPL with CHEP and CHP was an effective treatment option with excellent oncological outcomes for T2b–T4a laryngeal cancer. Specific efficacy was revealed in cases with anterior commissure or paraglottic space involvement. Low rate of complications was reported in our study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

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    Tables

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