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Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report
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Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report Yukinori Asada a,1,*, Koreyuki Kurosawa b,1, Ko Matsumoto c, Takahiro Goto b, Kengo Katoh d, Takayuki Imai a, Shigeru Saijo a, Kazuto Matsuura a a
Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan Department of Plastic and Reconstructive Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan c Department of Diagnostic Radiology, Miyagi Cancer Center, Natori, Miyagi, Japan d Department of Otorhinolaryngology, Head and Neck Surgery, Tohoku University School of Medicine, Miyagi Japan b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 December 2016 Received in revised form 18 January 2017 Accepted 10 March 2017 Available online xxx
For locally advanced laryngeal cancers, the standard treatment of choice is chemoradiotherapy if organ function needs to be conserved. Surgical treatment with larynx preservation is conducted only for limited cases. For locally advanced laryngeal cancers such as those with vocal cord fixation and/ or cricoid cartilage destruction, there is no apparent standardized organ-preserving surgery keeping the essential laryngeal functions, viz. the airway, deglutition and articulation, uncompromized. Recently, our surgical team saw a patient with T4a advanced laryngeal cancer with vocal cord fixation who aspired to maintain his laryngeal function. Driven by his eagerness, we contrived novel techniques for laryngeal function preservation and performed a two-staged operation. In the first stage, extended vertical partial laryngectomy was conducted including resection of the affected thyroid, arytenoid, and cricoid cartilages, followed by local closure of the hypopharynx. Additionally, laryngeal suspension surgery and cricopharyngeal myotomy were performed in addition to suturing the epiglottis with the intact arytenoid cartilage to enhance swallowing function. In the second stage, airway reconstruction was performed using a local skin flap. As of 10 months after operation, there has been no tumor recurrence, and the reconstructed larynx has been working satisfactorily. In this report we describe an innovative operation that was especially contrived for laryngeal function preservation. © 2017 Elsevier B.V. All rights reserved.
Keywords: Laryngeal cancer Surgery Laryngeal function preservation Partial laryngectomy
1. Background In the U.S., laryngeal cancer accounts for 3600 deaths out of 12,000 annual new cases [1]. Conversely, in Japan, according to the National Cancer Center, the annual incidence is reported to be 5325 for the year 2012 [2]. The Report of Head and Neck
* Corresponding author at: Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi 981-1293, Japan. Fax: +81 22 381 1168. E-mail address: [email protected] (Y. Asada). 1 Contributed equally.
Cancer Registry of Japan Clinical Statistics of Registered Patients 2003 shows locally advanced T3 and T4 cases constitute about 23% of all laryngeal cancers [3]. The primary purpose of treatment of locally advanced laryngeal cancers is to save patients’ lives, and, to preferably, conserve laryngeal function. To attain these results when treating laryngeal cancers of T3 and T4, chemoradiotherapy (CRT) is considered to be the current standard of treatment [4–6]. Only a very limited number of T3 and T4 patients may undergo organ-preservation surgery because the operation becomes progressively difficult with the advancement of the
http://dx.doi.org/10.1016/j.anl.2017.03.012 0385-8146/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
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local tumor. However, in far-advanced T4 cases such as those with thyroid cartilage invasion, little evidence exists of successful management by CRT to conserve laryngeal functions, which renders CRT not indicated for that purpose [7]. For locally advanced cancers without vocal cord fixation, some such definitive operations as “supracricoid partial laryngectomy with cricohyoidopexy (CHP)” and “supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP)” occasionally work well to preserve laryngeal function. But for those with vocal cord fixation, standardized surgical treatment has never existed [8,9,10]. Therefore, T3 patients with vocal cord fixation and most T4 patients are not viable candidates for larynx-preservation operation. Recently, we experienced a case of advanced laryngeal cancer with vocal cord fixation. For this patient, we contrived a new operation comprising: (1) radical tumorectomy with generous margins, (2) specially devised method of suturing the residual larynx, and (3) adding laryngeal suspension and cricopharyngeal myotomy. The operation was successful and went according to plan, and the postoperative larynx continues to function sufficiently. This new operational technique was approved by our institute’s institutional review board. 2. Case report A 67-year-old man was referred to our hospital for treatment of a glottic-type laryngeal squamous cell carcinoma. At the initial endoscopy, the tumor was located at the right vocal cord with its fixation. Computed tomography (CT) revealed an ipsilateral lymphadenopathy and no other metastatic lesions including the lung. From these findings, the disease was diagnosed as T3N1M0 (stage III). The patient requested laryngeal conservation, thus, we assumed CRT. However, during his waiting period at home, the patient developed difficulty in breathing and was hospitalized. At the 27th day since his first visit, a tracheotomy was performed. CT for radiation planning revealed thyroid cartilage destruction, which upstaged the disease to T4aN1 (Fig. 1). Because local control by CRT was considered impossible, we recommended the patient undergo total laryngectomy. However, the patient’s desire to keep his laryngeal function was so intense that he took up our offer of our new surgical treatment. After obtaining fullyinformed consent, we performed the operation. 3. Operation 3.1. First-stage operation (Figs. 2 and 3) A T-shaped skin incision was made at the level of the hyoid bone. First, we conducted conservative neck dissection, then marked cut lines on the anterior cervical muscles (strap muscles) by referring to the CT images. The muscles and part of the thyroid cartilage were resected along the cut lines. We reached inside the larynx from above the thyroid cartilage. After reaching the larynx, we resected en bloc the tumor with more
Fig. 1. Preoperative images. (a) Enhanced CT. The laryngeal cancer (arrow) with slight enhancement has already penetrated and destructed the lamina of the thyroid cartilage. (b) Endoscopic image of the laryngeal cancer (arrow) is seen on the right vocal cord.
than a few mm margins together with part of the arytenoid cartilage and cricoid lamina under direct observation . The next procedures included our original method to preserve laryngeal function, viz. innovative partial laryngohypopharyngeal closure together with the conventional deglutition improvement method. First, laryngeal suspension was done by suturing the residual thyroid cartilage to the hyoid bone and also the hyoid bone to the mandible. Then cricopharyngeal myotomy was performed. Care was taken to raise the affected side higher than the healthy side by adjusting the degree of suspension of the hyoid bone to the mandible — the distance between the hyoid bone and mandible being 15 mm on the right side and that on the left being 25 mm. After confirming the hypopharynx/esophagus transitional portion, cricopharyngeal myotomy was performed. This consisted of resection of a 10 mm 20 mm strip of the
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
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Fig. 2. Operational cut lines and pathological specimens (sliced). (a) Anterior view of a human model (strap muscles removed) indicating cut lines (white lines). Note the medial line is placed 5 mm beyond the midline on the healthy side, while the lateral line is 12 mm lateral to the lateral tumor margin. Both the strap muscles and thyroid cartilage were resected en bloc. The arytenoid cartilage on the affected side was also resected. (b) Posterior view of the larynx (model). The cut lines (white lines) included both the arytenoid and cricoid cartilages on the affected side (arrow). (c) Sagittal view of the unaffected side of the larynx. Half of the vocal cord on the unaffected side was resected together with the thyroid cartilage (black lines). (d) Sagittal view of the affected side of the larynx. The arytenoid portion including cricoid lamina together with thyroid cartilage and vocal cord was resected (black lines). (e) Resected specimen. Numbers indicate the slices of the en bloc specimen in (f). (f) Transaxial slices of the surgical specimen (formalin-fixed, numbers indicating the slices in (e)). The regions encircled by red lines indicate cancerous tissue. #1 and #12 denote the cranial and caudal ends of the resected specimen, respectively.
cricopharyngeus muscle, which was well expanded at the esophageal entrance using a Foley catheter. A sufficiently high ridge (watershed) was then created to maintain laryngeal function and anatomical structure (Fig. 3). To prevent laryngeal penetration on swallowing and inflow of food retained in the hypopharynx into the larynx, laryngoplasty was done by suturing the intact arytenoid cartilage and the superomedial portion of the epiglottic cut surface. The more caudal pharyngeal mucosae, namely the pyriform sinus and postocricoid membranes, were sutured. Next, the laryngeal mucosa was sutured to the cervical skin incision to create a laryngocutaneous fistula. Pathological examination showed that the operated specimen was free from cancer-positive margins (Fig. 2e and f).
3.2. Second-stage operation (Fig. 4a–c) The laryngocutaneous fistula was closed using a local skin flap. After reconstruction of the inner side of the larynx with a hinge flap, the cutaneous defect was closed with a transposition flap raised from the skin around the clavicle. 3.3. Third-stage operation The tracheostomy was closed under local anesthesia. 3.3.1. Postoperative course We conducted videofluoroscopic examination of swallowing (VF) on the 21st postoperative day. Thick foods such as
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
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Fig. 3. Our original method of reconstructive suturing of the surgical defect at the larynx: before and after the operation. (a) Posterior view of the human laryngeal model showing the epiglottis and arytenoid region. The slightly craniomedial region of the cut site of the epiglottis was sutured to the arytenoid portion (tuberculum corniculatum) on the unaffected side (indicated by “X-arrowed line-X”). Then, mucosas of the hypopharynx (indicated by white arrowed lines) were sutured. The laryngeal side of the defect was reconstructed by placing a cutaneous flap, and by making a muco-cutaneo fistula suturing the posterior laryngeal mucosa to the skin. (b)–(e) Schematic representation of the reconstruction surgery (c, d: pre- and e, f: post-operative states). (b) Scheme showing the surgical defect (white region) viewed from above. (c) Scheme showing the surgical defect (white region) viewed posteriorly. (d) Schematic representation of post-reconstruction state viewed from above. The arytenoid portion on the healthy side works as the posterior wall of the larynx. (e) Schematic figure showing the post-reconstruction state of the larynx viewed posteriorly.
jelly were not aspirated, but when the viscosity decreased, liquid was aspirated. Our overall assessment of laryngeal function was in favor of starting per os food intake. On the 29th postoperative day, the patient was able to consume all food per os, which was estimated at level 6 (total oral diet with multiple consistencies without special preparation, but with specific food limitations) on the Functional Oral Intake Scale [11]. Swallowing rehabilitation made ordinary meal intake possible, but non-viscous food caused aspiration. The patient was discharged on the 41st postoperative day. As of the 10th postoperative month, the patient was able to ingest per os anything to the level of eating out, with some restriction on water. Videofluoroscopy of the patient’s swallowing condition can be viewed via Supplementary Videos 1 and 2. Vocation to the degree of loud whispering was possible using half of the vocal cord. Pronunciation was clear because the glossopharyngeal portion was intact (Supplementary Video 3). The laryngocutaneous fistula rapidly healed and could be operatively closed. However, the operation was postponed at the patient’s request and due to social problems. The secondstage operation was conducted 7 months after the first operation
and the third-stage operation was conducted 1 month after the second operation. 4. Discussion The standard operation for locally advanced laryngeal cancers is total laryngectomy, which entails loss of laryngeal function. If patients select a larynx-conserving treatment, CRT is the treatment of choice [6]. Some patients may undergo larynx-preservation surgeries, but those with vocal cord paralysis have no such option. Furthermore, if CRT is not indicated due to the patients’ physical conditions, the final treatment should be total laryngectomy. At present, two methods of larynx-preservation operation, CHEP and CHP, are generally accepted [6,7,8]. These operations are called subtotal laryngectomy and require long-term postoperative rehabilitation. Prognosis and postoperative laryngeal functioning are favorable in patients who undergo CHEP or CHP, with more than 80% of these patients enjoying their meals within 1 year. However, these surgical interventions suffer longterm rehabilitation period postoperatively [10,12]. Cases with invasion to the cricoarytenoid joint, which is equal to vocal cord
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
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Fig. 4. The second-stage operation and the final state. (a) The skin around the laryngo-cutaneous fistula was incised (indicated by black lines, measuring 4.5 cm 5.0 cm). (b) The fistula was closed using a hinge flap. (c) After making a transposition flap over the right clavicle, it was placed on the region of the hinge flap (surgical closure of the skin). (d) Final state of the operation site (anterior view).
fixation, and/or those requiring combined resection of the cricoid cartilage are not indicated for CHEP or CHP. To date, there have been sporadic case reports regarding larynx preservation operation for vocal cord fixation cases, [13,14] but those operations should not be considered standardized. In the present case, we performed an operation that maintains the anatomical structure and function of the larynx. We did this by suturing the residual arytenoid cartilage, which is considered to work as a conduit or pathway to the superomedial portion of the epiglottis. We were successful in maintaining favorable deglutition by combining an operation to improve swallowing. The patient was able to take food per os meals within 3 weeks after the operation, and unlike CHEP and CHP, he was able to eat normal meals within a very short period. The operation we conducted can be called “super-extended frontolateral hemilaryngectomy.” Pathological examination of the resected material showed no marginal cancer. The patient remains under observation. We believe that the results of frontolateral vertical laryngectomy for T1 laryngeal cancers are favorable. However, a large-scale prognostic study conducted in France reports that the recurrence rates of frontolateral vertical laryngectomy without tracheotomy for T2 and T3 cases are high [10,15]. This
is because the operation margins at the anterior commissure are insufficient. Conversely, our operation included sufficient margins at the commissure, hence the negative pathology at the cut surfaces of the resected material.
5. Conclusion We, a combined team of head and neck surgeons and plastic surgeons, performed an innovative operation on a patient with advanced laryngeal cancer who aspired to maintain his laryngeal function. Our method comprised radical tumor resection and a well-devised suturing method combined with conventional deglutition improvement operation. The patient’s laryngeal function has remained favorable after operation. We believe our new surgical treatment, with further refinement, should be a strongly recommended option for patients with advanced-stage laryngeal cancer and vocal cord fixation who wish to have their laryngeal function conserved.
Conflict of interest The authors declare no conflict of interest.
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
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Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.anl. 2017.03.012. References [1] American Cancer Society. Cancer facts and figures 2014. Atlanta, Ga: American Cancer Society; 2014, Available online. [Last accessed May 21 2014]. [2] http://ganjoho.jp/reg_stat/statistics/dl/index.html#incidence. Cancer registry and statistics. Cancer Information Service, National Cancer Center, Japan. [3] http://www.jshnc.umin.ne.jp/pdf/2003syourei_houkoku.pdf. Report of head and neck cancer registry of Japan Clinical Statistics of registered patients, 2003. [4] Forastiere AA, Zhang Q, Weber RS, Maor MH, Goepfert H, Pajak TF, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol 2013;31(7):845–52. [5] Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349(November (22)):2091–8. [6] Shah J, Petel S, Singh B. Jatin Shah’s head and neck Surgery and oncology. 4th ed. Elsevier; 2012. p. 366–7. [7] Rosenthal DI, Mohamed AS, Weber RS, Garden AS, Sevak PR, Kies MS, et al. Long-term outcomes after surgical or nonsurgical initial
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
therapy for patients with T4 squamous cell carcinoma of the larynx: a 3-decade survey. Cancer 2015;121(May (10)):1608–19. Laccourreye O, Brasnu D, Me´rite Drancy A, Cauchois R, Chabardes E, Me´nard M, et al. Cricohyoidopexy in selected infrahyoid epiglottic carcinomas presenting with pathological preepiglottic space invasion. Arch Otolaryngol Head Neck Surg 1993;119:881–6. Brasnu DF. Supracricoid partial laryngectomy with cricohyoidopexy in the management of laryngeal carcinoma. World J Surg 2003;27(July (7)):817–23. Rodrigo JP, Coca-Pelaz A, Sua´rez A. The current role of partial surgery as a strategy for functional preservation in laryngeal carcinoma. Acta Otorrinolaringol Esp 2011;62(3):231–8. Crary MA, Carnaby-Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil 2005;86:1516–20. Naudo P, Laccourreye O, Weinstein GS, Hans S, Laccourreye H, Brasnu D. Functional outcome and pronostic factors after supracricoid partial laryngectomy with cricohyoidopexy. Ann Otol Rhinol Laryngol 1997;106:291–6. Biller HF, Som ML. Vertical partial laryngectomy for glottic carcinoma with posterior subglottic extension. Ann Otol Rhinol Laryngol 1977;86:715–8. Yoshimoto S, Asai M. Case of subtotal laryngectomy and reconstruction by using forearmfree flap for supraglottic T3 cancer with cordal fixation. Koutou 2014;26:52–6. Japanese. Brumund KT, Gutierrez-Fonseca R, Garcia D, Babin E, Hans S, Laccourreye O. Frontolateral vertical partial laryngectomy without tracheotomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience. Ann Otol Rhinol Laryngol 2005;114: 314–22.
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
ANL-2264; No. of Pages 6 Auris Nasus Larynx xxx (2017) xxx–xxx Contents lists available at ScienceDirect
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Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report Yukinori Asada a,1,*, Koreyuki Kurosawa b,1, Ko Matsumoto c, Takahiro Goto b, Kengo Katoh d, Takayuki Imai a, Shigeru Saijo a, Kazuto Matsuura a a
Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan Department of Plastic and Reconstructive Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan c Department of Diagnostic Radiology, Miyagi Cancer Center, Natori, Miyagi, Japan d Department of Otorhinolaryngology, Head and Neck Surgery, Tohoku University School of Medicine, Miyagi Japan b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 10 December 2016 Received in revised form 18 January 2017 Accepted 10 March 2017 Available online xxx
For locally advanced laryngeal cancers, the standard treatment of choice is chemoradiotherapy if organ function needs to be conserved. Surgical treatment with larynx preservation is conducted only for limited cases. For locally advanced laryngeal cancers such as those with vocal cord fixation and/ or cricoid cartilage destruction, there is no apparent standardized organ-preserving surgery keeping the essential laryngeal functions, viz. the airway, deglutition and articulation, uncompromized. Recently, our surgical team saw a patient with T4a advanced laryngeal cancer with vocal cord fixation who aspired to maintain his laryngeal function. Driven by his eagerness, we contrived novel techniques for laryngeal function preservation and performed a two-staged operation. In the first stage, extended vertical partial laryngectomy was conducted including resection of the affected thyroid, arytenoid, and cricoid cartilages, followed by local closure of the hypopharynx. Additionally, laryngeal suspension surgery and cricopharyngeal myotomy were performed in addition to suturing the epiglottis with the intact arytenoid cartilage to enhance swallowing function. In the second stage, airway reconstruction was performed using a local skin flap. As of 10 months after operation, there has been no tumor recurrence, and the reconstructed larynx has been working satisfactorily. In this report we describe an innovative operation that was especially contrived for laryngeal function preservation. © 2017 Elsevier B.V. All rights reserved.
Keywords: Laryngeal cancer Surgery Laryngeal function preservation Partial laryngectomy
1. Background In the U.S., laryngeal cancer accounts for 3600 deaths out of 12,000 annual new cases [1]. Conversely, in Japan, according to the National Cancer Center, the annual incidence is reported to be 5325 for the year 2012 [2]. The Report of Head and Neck
* Corresponding author at: Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi 981-1293, Japan. Fax: +81 22 381 1168. E-mail address: [email protected] (Y. Asada). 1 Contributed equally.
Cancer Registry of Japan Clinical Statistics of Registered Patients 2003 shows locally advanced T3 and T4 cases constitute about 23% of all laryngeal cancers [3]. The primary purpose of treatment of locally advanced laryngeal cancers is to save patients’ lives, and, to preferably, conserve laryngeal function. To attain these results when treating laryngeal cancers of T3 and T4, chemoradiotherapy (CRT) is considered to be the current standard of treatment [4–6]. Only a very limited number of T3 and T4 patients may undergo organ-preservation surgery because the operation becomes progressively difficult with the advancement of the
http://dx.doi.org/10.1016/j.anl.2017.03.012 0385-8146/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
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local tumor. However, in far-advanced T4 cases such as those with thyroid cartilage invasion, little evidence exists of successful management by CRT to conserve laryngeal functions, which renders CRT not indicated for that purpose [7]. For locally advanced cancers without vocal cord fixation, some such definitive operations as “supracricoid partial laryngectomy with cricohyoidopexy (CHP)” and “supracricoid partial laryngectomy with cricohyoidoepiglottopexy (CHEP)” occasionally work well to preserve laryngeal function. But for those with vocal cord fixation, standardized surgical treatment has never existed [8,9,10]. Therefore, T3 patients with vocal cord fixation and most T4 patients are not viable candidates for larynx-preservation operation. Recently, we experienced a case of advanced laryngeal cancer with vocal cord fixation. For this patient, we contrived a new operation comprising: (1) radical tumorectomy with generous margins, (2) specially devised method of suturing the residual larynx, and (3) adding laryngeal suspension and cricopharyngeal myotomy. The operation was successful and went according to plan, and the postoperative larynx continues to function sufficiently. This new operational technique was approved by our institute’s institutional review board. 2. Case report A 67-year-old man was referred to our hospital for treatment of a glottic-type laryngeal squamous cell carcinoma. At the initial endoscopy, the tumor was located at the right vocal cord with its fixation. Computed tomography (CT) revealed an ipsilateral lymphadenopathy and no other metastatic lesions including the lung. From these findings, the disease was diagnosed as T3N1M0 (stage III). The patient requested laryngeal conservation, thus, we assumed CRT. However, during his waiting period at home, the patient developed difficulty in breathing and was hospitalized. At the 27th day since his first visit, a tracheotomy was performed. CT for radiation planning revealed thyroid cartilage destruction, which upstaged the disease to T4aN1 (Fig. 1). Because local control by CRT was considered impossible, we recommended the patient undergo total laryngectomy. However, the patient’s desire to keep his laryngeal function was so intense that he took up our offer of our new surgical treatment. After obtaining fullyinformed consent, we performed the operation. 3. Operation 3.1. First-stage operation (Figs. 2 and 3) A T-shaped skin incision was made at the level of the hyoid bone. First, we conducted conservative neck dissection, then marked cut lines on the anterior cervical muscles (strap muscles) by referring to the CT images. The muscles and part of the thyroid cartilage were resected along the cut lines. We reached inside the larynx from above the thyroid cartilage. After reaching the larynx, we resected en bloc the tumor with more
Fig. 1. Preoperative images. (a) Enhanced CT. The laryngeal cancer (arrow) with slight enhancement has already penetrated and destructed the lamina of the thyroid cartilage. (b) Endoscopic image of the laryngeal cancer (arrow) is seen on the right vocal cord.
than a few mm margins together with part of the arytenoid cartilage and cricoid lamina under direct observation . The next procedures included our original method to preserve laryngeal function, viz. innovative partial laryngohypopharyngeal closure together with the conventional deglutition improvement method. First, laryngeal suspension was done by suturing the residual thyroid cartilage to the hyoid bone and also the hyoid bone to the mandible. Then cricopharyngeal myotomy was performed. Care was taken to raise the affected side higher than the healthy side by adjusting the degree of suspension of the hyoid bone to the mandible — the distance between the hyoid bone and mandible being 15 mm on the right side and that on the left being 25 mm. After confirming the hypopharynx/esophagus transitional portion, cricopharyngeal myotomy was performed. This consisted of resection of a 10 mm 20 mm strip of the
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
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Fig. 2. Operational cut lines and pathological specimens (sliced). (a) Anterior view of a human model (strap muscles removed) indicating cut lines (white lines). Note the medial line is placed 5 mm beyond the midline on the healthy side, while the lateral line is 12 mm lateral to the lateral tumor margin. Both the strap muscles and thyroid cartilage were resected en bloc. The arytenoid cartilage on the affected side was also resected. (b) Posterior view of the larynx (model). The cut lines (white lines) included both the arytenoid and cricoid cartilages on the affected side (arrow). (c) Sagittal view of the unaffected side of the larynx. Half of the vocal cord on the unaffected side was resected together with the thyroid cartilage (black lines). (d) Sagittal view of the affected side of the larynx. The arytenoid portion including cricoid lamina together with thyroid cartilage and vocal cord was resected (black lines). (e) Resected specimen. Numbers indicate the slices of the en bloc specimen in (f). (f) Transaxial slices of the surgical specimen (formalin-fixed, numbers indicating the slices in (e)). The regions encircled by red lines indicate cancerous tissue. #1 and #12 denote the cranial and caudal ends of the resected specimen, respectively.
cricopharyngeus muscle, which was well expanded at the esophageal entrance using a Foley catheter. A sufficiently high ridge (watershed) was then created to maintain laryngeal function and anatomical structure (Fig. 3). To prevent laryngeal penetration on swallowing and inflow of food retained in the hypopharynx into the larynx, laryngoplasty was done by suturing the intact arytenoid cartilage and the superomedial portion of the epiglottic cut surface. The more caudal pharyngeal mucosae, namely the pyriform sinus and postocricoid membranes, were sutured. Next, the laryngeal mucosa was sutured to the cervical skin incision to create a laryngocutaneous fistula. Pathological examination showed that the operated specimen was free from cancer-positive margins (Fig. 2e and f).
3.2. Second-stage operation (Fig. 4a–c) The laryngocutaneous fistula was closed using a local skin flap. After reconstruction of the inner side of the larynx with a hinge flap, the cutaneous defect was closed with a transposition flap raised from the skin around the clavicle. 3.3. Third-stage operation The tracheostomy was closed under local anesthesia. 3.3.1. Postoperative course We conducted videofluoroscopic examination of swallowing (VF) on the 21st postoperative day. Thick foods such as
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
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Fig. 3. Our original method of reconstructive suturing of the surgical defect at the larynx: before and after the operation. (a) Posterior view of the human laryngeal model showing the epiglottis and arytenoid region. The slightly craniomedial region of the cut site of the epiglottis was sutured to the arytenoid portion (tuberculum corniculatum) on the unaffected side (indicated by “X-arrowed line-X”). Then, mucosas of the hypopharynx (indicated by white arrowed lines) were sutured. The laryngeal side of the defect was reconstructed by placing a cutaneous flap, and by making a muco-cutaneo fistula suturing the posterior laryngeal mucosa to the skin. (b)–(e) Schematic representation of the reconstruction surgery (c, d: pre- and e, f: post-operative states). (b) Scheme showing the surgical defect (white region) viewed from above. (c) Scheme showing the surgical defect (white region) viewed posteriorly. (d) Schematic representation of post-reconstruction state viewed from above. The arytenoid portion on the healthy side works as the posterior wall of the larynx. (e) Schematic figure showing the post-reconstruction state of the larynx viewed posteriorly.
jelly were not aspirated, but when the viscosity decreased, liquid was aspirated. Our overall assessment of laryngeal function was in favor of starting per os food intake. On the 29th postoperative day, the patient was able to consume all food per os, which was estimated at level 6 (total oral diet with multiple consistencies without special preparation, but with specific food limitations) on the Functional Oral Intake Scale [11]. Swallowing rehabilitation made ordinary meal intake possible, but non-viscous food caused aspiration. The patient was discharged on the 41st postoperative day. As of the 10th postoperative month, the patient was able to ingest per os anything to the level of eating out, with some restriction on water. Videofluoroscopy of the patient’s swallowing condition can be viewed via Supplementary Videos 1 and 2. Vocation to the degree of loud whispering was possible using half of the vocal cord. Pronunciation was clear because the glossopharyngeal portion was intact (Supplementary Video 3). The laryngocutaneous fistula rapidly healed and could be operatively closed. However, the operation was postponed at the patient’s request and due to social problems. The secondstage operation was conducted 7 months after the first operation
and the third-stage operation was conducted 1 month after the second operation. 4. Discussion The standard operation for locally advanced laryngeal cancers is total laryngectomy, which entails loss of laryngeal function. If patients select a larynx-conserving treatment, CRT is the treatment of choice [6]. Some patients may undergo larynx-preservation surgeries, but those with vocal cord paralysis have no such option. Furthermore, if CRT is not indicated due to the patients’ physical conditions, the final treatment should be total laryngectomy. At present, two methods of larynx-preservation operation, CHEP and CHP, are generally accepted [6,7,8]. These operations are called subtotal laryngectomy and require long-term postoperative rehabilitation. Prognosis and postoperative laryngeal functioning are favorable in patients who undergo CHEP or CHP, with more than 80% of these patients enjoying their meals within 1 year. However, these surgical interventions suffer longterm rehabilitation period postoperatively [10,12]. Cases with invasion to the cricoarytenoid joint, which is equal to vocal cord
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012
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Fig. 4. The second-stage operation and the final state. (a) The skin around the laryngo-cutaneous fistula was incised (indicated by black lines, measuring 4.5 cm 5.0 cm). (b) The fistula was closed using a hinge flap. (c) After making a transposition flap over the right clavicle, it was placed on the region of the hinge flap (surgical closure of the skin). (d) Final state of the operation site (anterior view).
fixation, and/or those requiring combined resection of the cricoid cartilage are not indicated for CHEP or CHP. To date, there have been sporadic case reports regarding larynx preservation operation for vocal cord fixation cases, [13,14] but those operations should not be considered standardized. In the present case, we performed an operation that maintains the anatomical structure and function of the larynx. We did this by suturing the residual arytenoid cartilage, which is considered to work as a conduit or pathway to the superomedial portion of the epiglottis. We were successful in maintaining favorable deglutition by combining an operation to improve swallowing. The patient was able to take food per os meals within 3 weeks after the operation, and unlike CHEP and CHP, he was able to eat normal meals within a very short period. The operation we conducted can be called “super-extended frontolateral hemilaryngectomy.” Pathological examination of the resected material showed no marginal cancer. The patient remains under observation. We believe that the results of frontolateral vertical laryngectomy for T1 laryngeal cancers are favorable. However, a large-scale prognostic study conducted in France reports that the recurrence rates of frontolateral vertical laryngectomy without tracheotomy for T2 and T3 cases are high [10,15]. This
is because the operation margins at the anterior commissure are insufficient. Conversely, our operation included sufficient margins at the commissure, hence the negative pathology at the cut surfaces of the resected material.
5. Conclusion We, a combined team of head and neck surgeons and plastic surgeons, performed an innovative operation on a patient with advanced laryngeal cancer who aspired to maintain his laryngeal function. Our method comprised radical tumor resection and a well-devised suturing method combined with conventional deglutition improvement operation. The patient’s laryngeal function has remained favorable after operation. We believe our new surgical treatment, with further refinement, should be a strongly recommended option for patients with advanced-stage laryngeal cancer and vocal cord fixation who wish to have their laryngeal function conserved.
Conflict of interest The authors declare no conflict of interest.
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Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.anl. 2017.03.012. References [1] American Cancer Society. Cancer facts and figures 2014. Atlanta, Ga: American Cancer Society; 2014, Available online. [Last accessed May 21 2014]. [2] http://ganjoho.jp/reg_stat/statistics/dl/index.html#incidence. Cancer registry and statistics. Cancer Information Service, National Cancer Center, Japan. [3] http://www.jshnc.umin.ne.jp/pdf/2003syourei_houkoku.pdf. Report of head and neck cancer registry of Japan Clinical Statistics of registered patients, 2003. [4] Forastiere AA, Zhang Q, Weber RS, Maor MH, Goepfert H, Pajak TF, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol 2013;31(7):845–52. [5] Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349(November (22)):2091–8. [6] Shah J, Petel S, Singh B. Jatin Shah’s head and neck Surgery and oncology. 4th ed. Elsevier; 2012. p. 366–7. [7] Rosenthal DI, Mohamed AS, Weber RS, Garden AS, Sevak PR, Kies MS, et al. Long-term outcomes after surgical or nonsurgical initial
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
therapy for patients with T4 squamous cell carcinoma of the larynx: a 3-decade survey. Cancer 2015;121(May (10)):1608–19. Laccourreye O, Brasnu D, Me´rite Drancy A, Cauchois R, Chabardes E, Me´nard M, et al. Cricohyoidopexy in selected infrahyoid epiglottic carcinomas presenting with pathological preepiglottic space invasion. Arch Otolaryngol Head Neck Surg 1993;119:881–6. Brasnu DF. Supracricoid partial laryngectomy with cricohyoidopexy in the management of laryngeal carcinoma. World J Surg 2003;27(July (7)):817–23. Rodrigo JP, Coca-Pelaz A, Sua´rez A. The current role of partial surgery as a strategy for functional preservation in laryngeal carcinoma. Acta Otorrinolaringol Esp 2011;62(3):231–8. Crary MA, Carnaby-Mann GD, Groher ME. Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Arch Phys Med Rehabil 2005;86:1516–20. Naudo P, Laccourreye O, Weinstein GS, Hans S, Laccourreye H, Brasnu D. Functional outcome and pronostic factors after supracricoid partial laryngectomy with cricohyoidopexy. Ann Otol Rhinol Laryngol 1997;106:291–6. Biller HF, Som ML. Vertical partial laryngectomy for glottic carcinoma with posterior subglottic extension. Ann Otol Rhinol Laryngol 1977;86:715–8. Yoshimoto S, Asai M. Case of subtotal laryngectomy and reconstruction by using forearmfree flap for supraglottic T3 cancer with cordal fixation. Koutou 2014;26:52–6. Japanese. Brumund KT, Gutierrez-Fonseca R, Garcia D, Babin E, Hans S, Laccourreye O. Frontolateral vertical partial laryngectomy without tracheotomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience. Ann Otol Rhinol Laryngol 2005;114: 314–22.
Please cite this article in press as: Asada Y, et al. Laryngeal function-preserving operation for T4a laryngeal cancer with vocal cord paralysis — A case report. Auris Nasus Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.03.012