www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Supratracheal
laryngectomy:
a
multi-institutional
study
Ariana
M.
Garcia
a,∗,
Fernando
L.
Dias
a,
Antônio
J.
Gonc
¸alves
b,
Claudio
R.
Cernea
c,
Emilson
Q.
Freitas
a,
Marcelo
B.
Menezes
b,
Marco
Aurélio
V.
Kulcsar
caInstitutoNacionaldeCâncer(INCA),Servic¸odeCirurgiadeCabec¸aePescoc¸o,RiodeJaneiro,RJ,Brazil
bIrmandadeSantaCasadeMisericórdiadeSãoPaulo(ISCMSP),DepartamentodeCirurgiadeCabec¸aePescoc¸o,SãoPaulo,SP,
Brazil
cUniversidadedeSãoPaulo(USP),HospitaldasClínicas(HC),DepartamentodeCirurgiadeCabec¸aePescoc¸o,SãoPaulo,SP,Brazil Received29September2018;accepted7April2019
Availableonline23May2019
KEYWORDS Supratracheal laryngectomy; Tracheohyoido-epiglottopexy; Tracheohyoidopexy Abstract
Introduction:Supratracheallaryngectomyhasbeendescribedasasurgicalprocedureforglottic orsupraglotticcancerextendingtothesubglotticregionand/orinvolvingthecricoarytenoid joint,aimingtopreservelaryngeal function(breathing,phonationandswallowing), without diminishinglocoregionalcancercontrol.Thechoiceofsupracricoidlaryngectomyinthesecases couldresultinahighriskofcompromisedresectionmargins.
Objective: Todeterminethesafety,viability,adequacyofsurgicalmarginsandthe supratra-cheallaryngectomyresultsforintermediateandadvancedlaryngealcancerbyreviewingthe resultsatthreedifferentinstitutionsinBrazil.
Methods:This is a retrospective study that analyzed the charts of 29 patients submitted to supratracheallaryngectomy fromOctober 1997toJune 2017. The typeof laryngectomy performed wasclassified accordingtotheEuropean LaryngologicalSocietyclassification for horizontallaryngectomies.Earlyandlateresultswereevaluated.Survivalrates(overall, spe-cific,disease-freeandtotallaryngectomy-freesurvival)werecalculated.Themeanfollow-up timewas44months.
Results:Ofthe29patientssubmittedtosupratracheallaryngectomy,25hadnoprevious treat-ment. One patient(3.4%) hadcompromisedmargins.Four patients (13.8%)hadrecurrence. Ofthese,threehadlocalrecurrenceandonehadregionalrecurrence.Five patients(17.2%) required atotallaryngectomy,twoduetorupturedpexyandthreeduetolocalrecurrence.
夽 Pleasecitethisarticleas:GarciaAM,DiasFL,Gonc¸alvesAJ,CerneaCR,FreitasEQ,MenezesMB,etal.Supratracheallaryngectomy:a
multi-institutionalstudy.BrazJOtorhinolaryngol.2020;86:609---16.
∗Correspondingauthor.
E-mail:ariana.mgarcia@hotmail.com(A.M.Garcia).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2019.04.004
1808-8694/©2019Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Fourofthesepatients(80%)achievedasuccessfultotalprocedure.Fourpatients(13.8%)died, twoduetopostoperativecomplicationsandtwoduetorecurrence.Overall,specific, disease-freeandtotallaryngectomy-freesurvivalat5yearswere,respectively,82.1%;88.2%;83.0% and80.2%.
Conclusion:Selectedpatientswithintermediateandadvancedlaryngeal cancermay benefit fromsupratracheallaryngectomy,thatresultedintotallaryngectomy-freesurvivalandspecific survivalof80.2%and88.2%,respectively.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Laringectomia supratraqueal; Traqueohioidoepiglo-topexia; Traqueohioidopexia
Laringectomiasupratraqueal:umestudomulti-institucional
Resumo
Introduc¸ão:A laringectomia supratraqueal tem sidodescrita como um procedimento cirúr-gicocomobjetivodepreservarafunc¸ãodalaringe (respirac¸ão,fonac¸ãoedeglutic¸ão),sem prejuízonocontroleoncológicolocorregional,paracâncerglóticoousupraglóticocom exten-sãoàsubglotee/ouenvolvimentodaarticulac¸ãocricoaritenóidea.Aopc¸ãopelalaringectomia supracricoidenessescasospoderiaresultaremgranderiscoparamargensderessecc¸ão com-prometidas.
Objetivo:Determinaraseguranc¸a,viabilidade,adequac¸ãodasmargenscirúrgicaseos resulta-dosdalaringectomiasupratraquealparaocâncerdelaringeintermediárioeavanc¸adoatravés darevisãodosresultadosdetrêsinstituic¸õesdistintasnoBrasil.
Método: Estudo retrospectivo, com análise dos prontuários de 29 pacientes submetidos à laringectomia supratraqueal,de outubrode1997ajunho de2017. Otipode laringectomia realizadafoi classificadodeacordocomaclassificac¸ãodaSociedadeLaringológicaEuropeia paralaringectomiashorizontais.Foramavaliadososresultadosprecocesetardios.Astaxasde sobrevida(global,específica,livrededoenc¸aelivredelaringectomiatotal)foramcalculadas. Otempomédiodeseguimentofoi44meses.
Resultados: Dos29pacientessubmetidosàlaringectomiasupratraqueal,25nãotinham trata-mento prévio. Um paciente (3,4%) teve margenscomprometidas. Quatro pacientes(13,8%) recidivaram. Desses, três tiveram recidiva local e um apresentou recidiva regional. Cinco pacientes(17,2%)necessitaram detotalizac¸ãoda laringectomia,duaspor rupturadapexia etrêsporrecidivalocal.Quatrodessespacientes(80%)obtiveramsucessonatotalizac¸ão. Qua-tropacientes(13,8%)foramaóbito,doisporcomplicac¸õespós-cirúrgicasedoisporrecidiva.As sobrevidasglobal,específica,livrededoenc¸aelivredelaringectomiatotalem5anosforam, respectivamente,82,1%;88,2%;83,0%e80,2%.
Conclusão:Pacientesselecionadoscomcâncerintermediárioeavanc¸adodelaringepodemser beneficiadoscomlaringectomiasupratraqueal,queofereceusobrevidalivredelaringectomia totalesobrevidaespecíficade80,2%e88,2%,respectivamente.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Advanced laryngeal cancer treatment remains challeng-ing for control of disease and preservation of organ function. The conventional surgical therapy for these cases is total laryngectomy, with or without adjuvant radiotherapy.1,2 Since total laryngectomy results in loss
of function and a high degree of morbidity, organ preservationprotocolswithchemoradiotherapyhave been proposed, with the intent of preserving laryngeal func-tion and achieving a global survival rate of around 60%.3---5
Anothertherapeuticoptionforselectedcaseswithstages III and IV laryngeal tumors is Supracricoid Laryngectomy (SCL);however,asignificantnumberofpatientscannotbe safely treated bythis technique,when thereissubglottic extension >1cm or when the lesion affects the posterior portionofthecricoarytenoidjoint.6
Supratracheallaryngectomy(STL)hasbeendescribedas asurgicalprocedureaimedatpreservinglaryngealfunction (breathing, phonation and swallowing), without affecting locoregionalcancercontrol,forglotticorsupraglottic can-cerextendingtothesubglotticareaand/orcricoarytenoid jointinvolvement.
The clinical feature most often characterising these tumorsisunilateralvocal cordandarytenoid fixationwith cricoarytenoid joint and cricothyroid space involvement, combined with arytenoid and/or cricoid sclerosis. The choiceofaSCLinthesecaseswouldresultingreaterriskof positivemargins.6,7
Indications for STL include glottic tumors with ante-rior and/or lateral subglottic extension and cricoid ring involvement (T2---T3); glottic and/or supraglottic tumors withparaglottic space invasion and involvement of up to onecricoarytenoidunit,characterizedbyarytenoidfixation (T3);andlocally advanced laryngeal tumorswithanterior extensionthroughthethyroidcartilageandminimal extrala-ryngealextravasation(T4a).Localcontraindicationsinclude tumors involving the two arytenoids, the interarytenoid space,thebaseofthetongue,thehypopharynxand/orthe trachea, lesions with gross invasion of the pre-epiglottic spaceandinvolvementofthehyoidbone,aswellaslesions withlargeextralaryngealextravasation.6,8---10
In2014,theEuropeanLaryngologicalSocietyproposeda systematic classificationfor open partial horizontal laryn-gectomies, identifying three types of surgical procedures based on the lower limit of resection: Type I, supraglot-tic laryngectomy; Type II, supracricoid laryngectomy and Type III, supratracheal laryngectomy. ForTypes II and III, the suffix ‘‘a’’ means that the suprahyoid epiglottis has been preserved and a cricohyoidoepiglottopexy (Type IIa) or tracheohyoidoepiglottopexy(Type IIIa) wasperformed, whilethesuffix‘‘b’’indicatesthatthesuprahyoidepiglottis has been removed, with the construction of a cricohy-oidopexy (Type IIb) or a tracheohyoidopexy (Type IIIb). Additionally, each typeof laryngectomy maybeextended toadjacentstructures.Thus,thesurgicalresection exten-sionisindicated bythefollowing abbreviations:+ARY, the whenresectioninvolvesanarytenoid;+BOT,whenthereis involvementofthebaseofthetongue;+PIR,forresection ofapyriformsinus;+CAU,intheinvolvementofa cricoary-tenoidunit,consistingofthearytenoid,cricoarytenoidjoint andcorrespondinghalfoftheposteriorcricoidlamina.11
The aimofthisstudywastodeterminethesafety, via-bility,adequacyofsurgicalmarginsandtheSTLresultsfor intermediateandadvanced laryngealcancer,byreviewing theresultsofthreedifferentinstitutionsinBrazil.
Methods
Inthepresent retrospective study,29 patientsundergoing STLwerestudied,ofwhom14werefrom‘‘ISCMSP’’,10from ‘‘INCA’’and5from‘‘HCFMUSP’’,fromOctober1997toJune 2017. The follow-up period ranged from2 to 232 months (meanof44months).
Amongthem,26(89.7%)weremalesand3(10.3%)were females.Age rangedfrom35to82years(meanageof 59 years).
Fourpatients(13.8%)hadundergoneprevioustreatment, withtwoofthemhavingbeensubmittedtolasersurgery,one toradiotherapyandonetocordectomy(Table1).
Regarding tumor location, 27 (93.1%) were in located in the glottic and 2 (6.9%) in the supraglottic area. All caseswere reclassifiedaccording totheTNM Union Inter-nationale Contre le Cancer Classification of Malignant
Table 1 Characteristics ofthe 29 patients submitted to STL. n/N % Characteristic Gender Male 26/29 89.7 Female 3/29 10.3 Age Mean(years) 59 ---Range(years) 35---82 ---Previoustreatment Lasersurgery 2/29 6.9 Radiotherapy 1/29 3.4 Cordectomy 1/29 3.4 STL=Supratracheallaryngectomy Table2 2016UICCTNM. TNM pT0 pT1 pT2 pT3 pT4a cT3 0 0 2 12 8 cT4a 0 0 1 0 2 rT2 0 0 1 0 0 rT3 1 0 0 2 0
UICCTNM=TNMUnionInternationaleContreleCancer Classifi-cationofMalignantTumors
Table3 Typeofsurgeryaccordingtotumorlocation. Glotticregion n(%) Supraglotticregion n(%) IIIa 4(13.8) 0 IIIa+CAU 17(58.6) 0 IIIb 3(10.3) 2(6.9) IIIb+CAU 3(10.3) 0
CAU=cricoarytenoidunit
Tumors (UICC-2016). According to the clinical staging, 22
patients (75.9%) were classified as cT3 and 3 (10.3%) as
cT4a.Ofthepatientswithprevioustreatment anddisease
recurrence, one patient (3.4%) was rT2 (laser surgery)
and three (10.3%) were rT3 (radiotherapy, laser surgery
and cordectomy). However, pathologically, one patient
(3.4%)hadnoneoplasia,four(13.8%)werepT2,14(48.3%)
were pT3, and 10 (34.5%) were pT4a. Thus, 4 patients
presentedadowngradeand8presentedanupgradeinthe
pathologicalstagingwhencomparedtotheclinicalstaging.
Onepatient(3.4%)hadcN2bneckmetastasisattheclinical
examination; however, the pathological analysis showed
4 patients (13.8%) withneck metastasis, 2 (6.9%) pN1, 1
(3.4%)pN2aand1(3.4%)pN2b.Onlyonepatient(3.4%)was
notsubmittedtoneckdissection(Table2).
The typeof surgeryperformed, according tothe Euro-pean Laryngological Society classification11 was IIIa in 4
(13.8%), IIIa+CAU in 17 (58.6%), IIIb in 5 (17.2%) and IIIb+CAUin3patients(10.3%)(Table3).
One patient (3.4%) showed compromised resection margins. Regarding adjuvant therapy, 7 patients (24.1%)
100 Ov er all sur viv al (%) Disease-free sur viv al (%) T o tal lar yngectom y-free sur viv al (%) Specific sur viv al (%) 100 100 100 80 80 80 80 60 60 60 60 40 40 40 40 20 20 20 20 0 0 0 0 -1 -1 -1 -1 2 2 2 2 4 4 4 4 6 6 6 6 8 8 8 10 8 Time (years) Time (years) Time (years) Time (years) 10 10 10 12 12 12 12 14 14 14 14 16 16 16 16 18 18 18 18 20 20 20 20
Figure1 Overall,specific,disease-freeandtotallaryngectomy-freesurvivalat5years.
were submitted to radiotherapy alone and 5 (17.2%) to chemotherapycombinedwithradiotherapy.
Overall, specific, disease-free and total laryngectomy-freesurvivalwasestimatedbytheKaplan---Meiermethod.
Results
In5years,theoverallsurvivalratewas82.1%;thespecific survivalwas88.2%;thedisease-freesurvivalwas83.0%,and 4patientshadrecurrenceinthefirst18months;thetotal laryngectomy-freesurvivalwas80.2%,andthe5caseswere submittedtototallaryngectomyinthefirst12monthsafter STL(Fig.1).
Onepatient(3.4%)showedabsenceof neoplasiainthe STL histopathological report. This patient had mucosal melanomawithcT3N0M0staging,hadbeenpreviously sub-mitted to two laser microsurgeries, with compromised margins,buthadnoresidualdiseaseinthesalvageSTL.
Eight patients (27.6%) had acute postoperative complications, three with neck bleeding, two with ruptured pexy, one with aspiration pneumonia, one with neckcellulitisandonewithstroke.
Ninepatients (31%) hadlatecomplications after treat-ment,whichincludedtwowithchronicaspiration,fivewith laryngealremnantstenosis,onewithaspirationpneumonia andonewithdyspneaduetoredundantlaryngealmucosa. Patientswith chronic aspiration were undergoing speech-languagetherapy.Thosewhodevelopedlaryngeal stenosis maintainedtheuseofthetracheotomycannula.Thepatient with aspiration pneumonia was treated only with antibi-otictherapy,sincehewasalreadyinpalliativecaredueto recurrentandunresectableneckdisease.Thepatientwith
Table4 Acuteandlatepostoperativecomplications.
n/N % Acutecomplications Neckbleeding 3/29 10.3 Rupturedpexy 2/29 6.9 Aspirationpneumonia 1/29 3.4 Neckcellulitis 1/29 3.4 Stroke 1/29 3.4 Total 8/29 27.6 Latecomplications Chronicaspiration 2/29 6.9 Neolarynxstenosis 5/29 17.2 Aspirationpneumonia 1/29 3.4 Dyspnea 1/29 3.4 Total 9/29 31
redundantlaryngeal mucosawassuccessfullytreatedwith
endoscopiclaserresection(Table4).
Fourpatients(13.8%)haddiseaserecurrence.Ofthese, threehadlocalrecurrence(onepT3N0M0patientwhowas submittedtoadjuvantradiotherapyhadrecurrenceafter9 months;onepT3N0M0patientwhohadthemargins compro-misedinSTL,underwentadjuvantchemoradiotherapyand had recurrenceafter4 months;a pT3N0M0patient previ-ouslytreatedwithradiotherapy,submittedtosalvageSTL, showed recurrence after 7 months)and one had regional recurrence(pT3pN2b, submittedto adjuvant chemoradio-therapy,hadanunresectableneckrecurrenceanddiedafter 15months).
Five patients (17.2%) required total laryngectomy, 2 (6.9%) due to ruptured pexy and 3 (10.3%) due to local
Table5 Analysisbyinstitution. ‘‘ISCMSP’’ n(%) ‘‘INCA’’ n(%) ‘‘HCFMUSP’’ n(%) N 14(48.3) 10(34.5) 5(17.2) pT pT0 0 1(3.4) 0 pT1 0 0 0 pT2 0 1(3.4) 3(10.3) pT3 7(24.1) 7(24.1) 0 pT4a 7(24.1) 1(3.4) 2(6.9) Acutecomplications Neckbleeding 2(6.9) 1(3.4) 0 Rupturedpexy 1(3.4) 0 1(3.4) Aspirationpneumonia 0 1(3.4) 0 Neckcellulitis 0 1(3.4) 0 Stroke 1(3.4) 0 0 Latecomplications Chronicaspiration 2(6.9) 0 0 Neolarynxstenosis 5(17.2) 0 0 Aspirationpneumonia 0 1(3.4) 0 Dyspnea 0 1(3.4) 0 Totallaryngectomy Rupturedpexy 1(3.4) 0 1(3.4) Localrecurrence 2(6.9) 1(3.4) 0 Causesofdeath Neckbleeding 1(3.4) 0 0 Stroke 1(3.4) 0 0 Diseaserecurrence 1(3.4) 1(3.4) 0 Enteralfeeding Withdrew 11/12(91.7) 9/10(90) 5/5(100)
Rangeoftimeofuse(days) 30---330 23/397 30---203
Tracheotomy
Decannulated 3/9(33.3) 9/9(100) 4/4(100)
Rangeoftimeofuse(days) 47---257 11---90 60---230
diseaserecurrence.Fourofthesepatients(80%)hada
suc-cessfulsalvagetotallaryngectomy.
Fourpatients(13.8%)died,amongthemtwodueto
post-operative complications(onedue toneckbleedingonthe
5thpostoperativedayandoneduetoastrokeonthe11th
postoperativeday)andtwoduetoregionalunresectable
dis-easerecurrence(onedied15monthsaftertheSTLandone
hadlocalrecurrence9monthsaftertheSTL,wassubmitted
tototallaryngectomy,developedneckmetastasisanddied
after30months).
Twenty-five of 27 patients (92.6% --- excluding the two
whodieddue toacutecomplications inthe postoperative
period)wereabletoreceive anoraldiet,andthetimeof
withdrawalofthefeedingtuberangedfrom23to397days
(medianof45days);onepatient(3.7%)whowasoperated
9monthsago, wasstilldependant onenteralfeedingdue
tochronicaspirationbythetimethisworkwaswrittenand
onepatient(3.7%)whohadanunresectablecervical
recur-rence,hadtoreceivedietthroughagastrostomytubeuntil
death.
Regarding the tracheotomy, 16 of 22 patients (72.7%
- excluding the two who died due to postoperative
complications and five submitted to total laryngectomy)
weredecannulated,andthetimeofdecannulationranged
from 11 to 257 days (median of 50 days). Five patients
(22.7%)remainedwithtracheotomyduetostenosis ofthe
laryngealremnantand1(4.6%)duetochronicaspiration.
The rate of laryngeal function preservation, regarding
the ability to feed without a feeding tube,
comprehen-sible speech and breathing without a tracheotomy, was
68.2%. Of the 22 patients (excluding the two who died
duetocomplications in thepostoperative periodandfive
whounderwenttotallaryngectomy),fivepatientswerestill
tracheotomy-dependant, 1 patient mantained the use of
enteralfeeding,and1patienthadtracheotomyplusenteral
feeding.
Table5showstheanalysisofpathologicalstaging,acute andlatecomplications,totallaryngectomy,deathsand eval-uationof patientswhowithdrewenteralfeedingand who weredecannulatedperinstitution.
In thelast follow-up,of the 25 patientswhosurvived, none had locoregionaldisease recurrence and 1 (4%) was followedduetoanisolatedpulmonarynodulewithno diag-nosticdefinitionsofar.
Discussion
The first STL with tracheohyoidoepiglottopexy was per-formed by Serafini in 1972. This procedure involved the preservationofthesuprahyoidepiglottisandpexybetween the hyoid bone, the remaining epiglottis and the first trachealring;however,thistechniqueremovedthetwo ary-tenoids, with a poor functional result. Therefore, it was abandonedintheearly1980s.12
In1990,Laccourreyeetal.publishedtheoncologicaland functionalresultsofSCLwithcricohyoidoepiglottopexyfor glotticcancer,performedin36patients.In34cases,both arytenoids were preserved; however, in one patient, the cricoarytenoidjointwasdisarticulatedwithresectionofone arytenoid, and in another, resection of the anterolateral portion of the cricoid cartilage with trachecricohyoido-epiglottopexy was performed. No complications occurred in these two patients, and both were decannulated at 7 and 3 days, respectively. The 3-year survival rate was 86.5% and local and regional recurrence rates were 5.6% and8.4%,respectively.Inthisstudy,allthepatientswere decannulated(meantime7days,3---57days),recoveredthe swallowing and withdrew enteral tube (mean time of 15 days,9---30days)andhadvocalqualitythatallowedsocial interaction.13
In another publication, the same authors describe the oncological and functional results of SCL with cricohy-oidopexyforsupraglottic/transglottictumors,performedin 68 patients. In this study,a 3-year survival rate of 71.4% wasobserved,withnolocalrecurrence,butwitharegional recurrence rate of 5.8% and a distant metastasis rate of 8.8%.Allpatientsweredecannulated(meantimeof7days, 3---51 days); 74.6% acquired normal swallowing and with-drewtheenteraltube(meantimeof15days,13---70days) andallhadphonationthatallowedsocialinteraction. One patientdiedonthe3rdpostoperativedayduetoruptureof anabdominalaorticaneurysmandanotherinthe5thmonth duetorecurrentaspirationpneumonia.14
In104patientssubmittedtoSCLwith cricohyoidoepiglot-topexy between 1972 and 1985, Piquet and Chevalier achievedan overall survival rateat 5 yearsof 75%, with-drawaloftheenteraltubewithin45dayspostoperativelyin 100%ofcasesanddecannulationinupto28daysof81.5% ofthepatients.15
In1996, Laccourreyeetal.describeda modificationin theconventional SCL technique,in which the cricoidring wasremoved incases ofglottictumorswithanterior sub-glotticextension.Inthisseriesof21patients,survivalrates, localcontrol,neckrecurrence,anddistantmetastasisat5 yearswere, respectively, 74.7%; 88.9%; 11.1% and 22.4%, withalaryngealpreservationrateof90.5%.16
In1997, anotherstudy publishedbyLaccourreyeetal. described the cases of rupturedpexy afterSCL. Duringa periodof22years(1974---1996),theincidenceofthis compli-cationwas0.8%(3/371).Inthesesituations,onemaychoose toperformatotallaryngectomyortoreviewthepexy,with
resection of the anterior cricoid arch and reconstruction withtrachecricohyoido-epiglottopexy.17Inourseries,the2
cases of ruptured pexy were treated withtotal laryngec-tomy.
Inthe studyby Limaetal., whichevaluatedthe func-tionalandoncologicresultsof43patientswithT3/T4glottic cancertreatedwithSCLwithcricohyoidoepiglottopexy, spe-cificsurvivalanddisease-freesurvivalof78%and83%were observed at 5 years, respectively. The rate of laryngeal preservation was83.7%.1 In a previous study bythe same
authors,2of27 patientssubmittedtoSCL with cricohyoi-doepiglottopexyduetoT2/T3glotticcancerrequiredtotal laryngectomy (onedue torecurrentaspiration pneumonia andoneduetorupturedpexy).18
In2006, Rizzottoet al. proposeda change in the pre-viously described extended SCL technique that allowed preservation of function andthe possibility of postopera-tiverehabilitation.Thistechniqueisbasedontheresection oftheentireglottisandpartofthesubglottis,inaddition to the thyroid cartilage, preserving both or at least one functioningcricoarytenoidunit,consistingofthearytenoid, cricoarytenoidjointandcorrespondinghalfoftheposterior cricoidlamina. Inferiorly,theresectionlimit encompasses theentirecricoidringandhalfoftheposteriorlamina, pre-servingthefirsttrachealring.Thetypeofreconstruction, tracheohyoidoepiglottopexy or tracheohyoidopexy, differs accordingtothesupraglotticresectionextent.8,9
Subsequently, these authors evaluated the oncological and functional results of 115 patients submitted to STL between 2002 and 2011. The overall, disease-free sur-vivalandlocoregionalcontrolin3yearswere,respectively, 84.6%;72.3%and73.3%;and,in5years,78.9%;68.5%and 69.6%.Thenasoenteraltubeorgastrostomywaswithdrawal in 97.4%of thepatients,withan averagetimeof 21days (12---161 days).The meantracheotomyocclusiontimewas 86days(29---489days).19
Inourseries,onepatientunderwentSCLthatextended totheposterolateralportionofthecricoidcartilage,with theresectionofacricoarytenoidunitin1997,whenSTLhad notyet beendescribed. Thiscase wasreclassifiedastype IIIa+CAUlaryngectomyandincludedinthestudy.Allother caseswereperformedafterthetechniquedescription.
Succoetal.publishedtheresultsofthelargestseriesin theinternationalliterature,with142patientssubmittedto STLinamulti-institutionalstudycarriedoutinItaly.Inthis, 21.1%ofthecaseshaddiseaserecurrence,being70%local recurrenceand30%regionalrecurrence.Theoverall, spe-cific,disease-freeandtotallaryngectomy-freesurvivalat5 yearswere,respectively,78.7%;90.4%;69.1%and85.4%.6
Theoncologicalresultsofthepresentstudyare compara-bletothosepublishedintheinternationalliteraturetodate, withoverall,specific,disease-freeandtotal laryngectomy-freesurvivalat 5yearsof82.1%,88.2%,83.0% and80.2%, respectively.
Astudy by Rizzotto etal. evaluated 469 patients sub-mitted to SCL (399) and STL(70) during a periodof over 10 yearsand compared oncologicaland functional results between them. The overall and disease-freesurvival at 5 yearsandpreservationoflaryngealfunctionafter2yearsof surgerywere,respectively,95.6%;90.9%and95.7%forSCL and80%;72.9%and80%forSTL.Thetotallaryngectomyrate amongallpatientsinthisserieswas4.4%.Withdrawalofthe
nasoenteraltube or gastrostomy occurredin 99.4% of the patients(meantimeof16days,4---161days)and decannu-lationoccurredin98.3%ofthecases(meantimeof73days, 16---852 days). Both types of laryngectomies showed high survivalratesthanthoseobtainedthroughorgan preserva-tionprotocols,basedonchemoradiotherapy.20Inourseries,
thefunctional resultwasslightly lower,with92.6%of the patientswithdrewtheenteralfeeding(medianof45days, 23---397days)and72.7%weredecannulated(median50days, 11---257days).
Regarding the acute and late postoperative complications, we observed neck bleeding, neck cel-lulitis,laryngealremnantstenosis, dyspneaandaspiration pneumoniain10.3%; 3.4%;17.2%;3.4%and6.9%of cases, respectively. In the study by Rizzotto et al., these rates were 1.7%; 0.9%; 17.4%; 0.9% and 9.6%; andin the study by Succo et al., they were 0.7%; 1.4%; 17.6%; 2.1% and 9.9%.6,19
The long-term functional results after STL have been describedintheinternationalliterature.Astudypublished in 2015 evaluatedswallowing,voiceand qualityof lifein agroup of22 patientssubmittedtothis procedure. Swal-lowingrecoverywasachievedin20cases,withtwopatients showingseveredysphagiaforsolidfoods. Thevoiceinthe postoperative period was highly dysphonic and the maxi-mumphonationtimewassignificantly reduced,butitwas enoughtoallownormalspontaneousspeech.Despitethat, patientsreportedonlyasmallimpactontheirqualityoflife. Milddysphagiaandaspirationpneumoniarepresentthemost common,althoughinfrequent,earlycomplicationsafterthis procedure and areusually well tolerated. Laryngeal rem-nant stenosis is the most commonlate complication.The functionalresultsofSTLaresimilartothoseobservedwith SCL.9,21---23
The expansionoftheSTLlowerlimitincreasedtheSCL indications,breakingsomeparadigms. Casesinvolving one cricoarytenoidunit and/or withsubglotticextension were considered contraindications for SCL, and total laryngec-tomy was indicated. With the advent of this technique, theseselectedcasesweretreated withsubtotal laryngec-tomy,withlaryngealfunctionpreservation andnoharmto locoregionaldiseasecontrol.
Conclusion
Selectedpatientswithintermediateandadvancedlaryngeal cancermaybenefitfromSTL,whichinthisstudyresultedin totallaryngectomy-free andspecificsurvival of80.2% and 88.2%,respectively.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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