The advent of combined chemotherapy and radiation protocols in the treatment of laryngeal cancer has given rise to the term “organ preservation.” Open organ preservation surgical procedures for laryngeal cancer and their indications for use are reviewed. Principles involved in organ preservation laryngeal surgery and how they relate to evaluating and confidently selecting surgical candidates are discussed. Because total laryngectomy and medical organ preservation protocols may not be acceptable to the patient from a quality of life standpoint, the authors emphasize that it is incumbent upon the head and neck surgeon to have a thorough understanding of all options available for treatment in the organ preservation paradigm for laryngeal cancer to provide the best oncologic and functional outcome.
The advent of combined chemotherapy and radiation protocols in the treatment of larynx cancer has given rise to the term organ preservation . It is easy to think of medical strategies such as chemoradiation or radiation alone as organ preserving. They do not intimately alter the anatomy of the larynx and hence, the physiologic function of the larynx theoretically should not be altered. Physicians who treat larynx cancer should also be aware of the wide array of organ preservation surgeries for larynx cancer. There has been a renaissance in the area of surgical management of laryngeal cancer. New technology and instrumentation have helped facilitate minimally invasive strategies for early laryngeal cancer. There also has been a renewed interest in open organ preservation surgeries. Any surgical procedure that maintains physiologic speech and swallowing functions without the need for a permanent tracheostoma should be considered as an organ preservation laryngeal surgery. A thorough understanding of these surgical options and their indications is essential to provide the most comprehensive care in the treatment of the laryngeal cancer patient. The goal of this presentation is to review the open organ preservation surgical procedures for laryngeal cancer and their indications for use. Before this can be done, one must understand the principles involved in organ preservation laryngeal surgery and how it relates to evaluating and confidently selecting surgical candidates.
Principles of organ preservation surgery
Organ preservation surgery for laryngeal cancer is an art. The art is in determining which patients are eligible for an organ preservation surgical procedure. One must delicately balance the need for maximizing local control versus a good functional outcome. All patients with laryngeal cancer should be evaluated for organ preservation surgery from their initial visit. It is the head and neck surgeon’s role to find a reason why the patient would not be eligible for an organ preservation surgical approach. Certain key principles must be systematically adhered to in determining patient eligibility .
The most important principle is that of local control. Survival from the index cancer is compromised if there is a local failure following radiation therapy or surgery to the glottis and supraglottis . Early detection of the primary site recurrence may be difficult. Medical and surgical organ preservation modalities alter the topography of the larynx and make definitive evaluation of recurrent cancer difficult. Symptoms may be attributed to the treatment intervention or recurrent tumor, although, increasing pain, ear pain, and dysphagia are ominous signs. Repeat endoscopy and biopsy of the original primary cite is certainly warranted. CT, MR, and positron emission tomography (PET) imaging may also be helpful in elucidating recurrent or persistent cancer. Organ preservation surgical procedures should only be employed when resection of the tumor can be accomplished comfortably with local control rates approximating those of total laryngectomy.
The second principle of organ preservation surgery is to be able to confidently predict the extent of the tumor. A thorough head and neck evaluation is essential. A dynamic interpretation of laryngeal function must be made. This may be performed with a mirror or fiber-optic laryngoscope. Arytenoid mobility must be carefully assessed. Maneuvers such as having the patient cough lightly will elucidate arytenoid mobility or lack thereof. It is imperative to distinguish between a fixed true vocal fold secondary to paraglottic space invasion versus crioarytenoid joint involvement with tumor. Arytenoid immobility secondary to cricoarytenoid joint involvement with tumor is a contraindication to all organ preservation surgery. CT and MRI are useful to assess nodal disease and the extent of preepiglottic and extralaryngeal spread in large tumors . CT, MRI, and PET have all been advocated to some degree in helping to identify cartilaginous invasion . Pretreatment endoscopy is recommended in all patients, regardless of the treatment modality employed. Diligent endoscopy under anesthesia uses microscopic and endoscopic techniques to evaluate the extent of tumor spread. Subglottic extension is carefully assessed via apneic technique with a 0- and 30-degree laryngeal rigid endoscope. The tumor should be mapped out on a standardized image of the larynx.
The third principle is that the cricoarytenoid unit is the basic functional unit of the larynx. The cricoarytenoid unit consists of an arytenoid cartilage, the cricoid cartilage, the associated musculature, and the superior and recurrent laryngeal nerves for that unit. This is a foreign concept to most surgeons who perform vertical partial laryngectomy and supraglottic laryngectomy. The surgeons, along with the T system for staging laryngeal cancer, focus on the vocal fold rather than the cricoarytenoid unit. The paradigm shift from the vocal fold to the cricoarytenoid unit is essential for the head and neck surgeon to be able to use the full spectrum of organ preservation surgeries. It is the cricoarytenoid unit, not the vocal folds, that allow for physiologic speech and swallowing without the need for a permanent tracheostoma after organ preservation surgeries such as the supracricoid laryngectomy. As long as one cricoarytenoid unit can be preserved, the patient is a candidate for organ preservation laryngeal surgery.
It is not enough for the organ preservation surgeon to describe the extent of the larynx cancer via the T staging system. The eligibility of the patient for organ preservation surgery will be based on the extent of tumor, not the T stage. For example, one can have a T2 tumor of the glottis that involves the subglottis to the level of the cricoid. This would preclude the surgeon from entertaining thoughts of organ preservation surgery because of the high likelihood of cricoid resection in obtaining a margin. On the contrary, a T4 glottic lesion with inner table cartilage invasion at the anterior commissure is a candidate for supracricoid resection, which includes resection of the entire thyroid cartilage. The T3 lesion describes a fixed vocal fold. Again, this may be secondary to paraglottic space invasion or cricoarytenoid joint involvement. The former would be a candidate for organ preservation surgery (supracricoid laryngectomy) versus the latter, where the cricoid cartilage is involved with tumor. The T staging system is important for comparing outcomes with regard to treatment modalities but certainly does not dictate the treatment modality to be employed.
The fourth principle is one that may seem counterintuitive to many. The resection of normal tissue in organ preservation surgery is necessary to achieve consistent functional outcomes in terms of speech and swallowing. Extended vertical partial laryngectomy and extended supraglottic laryngectomy typically render a defect that each time may be new and novel to reconstruct. The defect and the reconstruction are defined each time by the margins that are necessary to achieve tumor removal. This may be responsible for the variable outcomes reported in the literature for these procedures with regard to speech and swallowing . A reliable reconstruction for each surgery that is proven with regard to speech and swallowing outcome may put the surgeon at ease with regard to the choice of organ preservation surgery versus nonsurgical organ preservation alternatives.
Evaluation
As with any head and neck neoplasm, a thorough head and neck examination is essential. Particularly important in the evaluation of a patient for organ preservation surgery is the ability to accurately predict the surface and three-dimensional extent of the lesion (second principle). A dynamic evaluation of the larynx is necessary to determine whether the patient is a candidate for organ preservation surgery. Indirect mirror examination or flexible fiber-optic laryngoscopy help to examine the mobility of the true vocal folds and the arytenoid cartilages. Numerous authors have stated that evaluating true vocal fold mobility and arytenoid mobility were key points for the preparation of organ preservation surgery . Glottic, supraglottic, and transglottic tumors that exhibit true vocal fold fixation and arytenoid fixation should be considered a major contraindication to organ preservation surgery. Arytenoid fixation implies malignant infiltration of the cricoarytenoid joint, cricoarytenoid musculature, or both. True vocal fold fixation without arytenoid fixation is not a contraindication to organ preservation surgery. Carefully evaluating the patient to vocalize a sustained /e/, to breathe gently, to cough lightly, and to vocalize at a higher pitch, help to elucidate the status of arytenoid mobility. One must also attempt to make the distinction between apparent vocal fold fixation secondary to weight impact of supraglottic tumors versus actual transglottic spread . There is a statistically significant relationship between the presence of abnormal cord mobility and involvement at the glottic level. This scenario could provide an unwelcome surprise for the surgeon expecting to perform a supraglottic laryngectomy if not appreciated preoperatively.
Direct laryngoscopy under general anesthesia should be employed to help with the precise mapping of the extent of tumor. Systematic use of laryngoscopes allowing for complete examination of the laryngeal structures is essential. The subglottis can be inspected with rigid 0- and 30-degree endoscopes. Bimanual palpation should be used to assess the tongue base and thyrohyoid membrane to appreciate submucosal extent of disease and possible preepiglottic space involvement. Maintaining the hyoid bone as a means for impaction on to the remaining thyroid cartilage (supraglottic laryngectomy) or cricoid cartilage (supracricoid laryngectomy) is oncologically sound in supraglottic cancer unless tumor involves the tongue base, vallecula mucosa, or hyoid bone itself . The hyoid bone is essential in the reconstruction following supracricoid laryngectomy. Palpation and manipulation of the arytenoid cartilages with endoscopic instruments help to ascertain mobility. Although careful evaluation often helps to confidently define the extent of gross disease, one may not fully be able to appreciate the submucosal extent of tumor until the intended organ preservation surgery is being attempted. It is for this reason that all patients must consent to the possibility of total laryngectomy, if intraoperatively the tumor extent precludes the use of organ preservation surgery.
If the tumor is bulky and partially obstructing the airway, debulking can be accomplished with a laser or powered instrumentation (debrider) to avoid a tracheostomy. This is particularly important in supracricoid laryngectomy where placement of the tracheotomy is important. Simultaneous second primary tumors of the head and neck should be searched for at this time. One may or may not elect to place a percutaneous endoscopic gastrostomy tube at this time if severe dysphagia is expected to last for more than 1 month.
CT and MRI are helpful in evaluating the primary lesion with regard to the status of the preepiglottic and paraglottic spaces, the subglottic extent of tumor, and cartilaginous invasion . The studies are supplemental and should not supplant the clinical examination. CT is especially helpful to assess for nodal metastasis .
The general medical evaluation cannot be overly emphasized in selecting patients for organ preservation surgery. The ability of the patient to tolerate general anesthesia along with factors that may complicate wound healing must be evaluated. Particularly important is the patient’s cardiopulmonary status. Aging and chronic obstructive pulmonary disease greatly increase the risk of postoperative atelectasis and pneumonia . The risk of postoperative aspiration increases with procedures that most disturb the sphincteric function of the larynx. A chronic and inefficient cough, purulent sputum, and, most importantly, the inability to walk up two flights of stairs without shortness of breath, bode poorly for the patient’s ability to tolerate an organ preservation procedure.
The patient’s sex, occupational use of voice, social status, and nutritional status, as well as alcohol intake should be strongly considered. Patient motivation for speech and swallowing therapy should be assessed and the patient should be counseled by a speech pathologist familiar with organ preservation approaches preoperatively. The need for a temporary feeding tube and tracheostomy must also be emphasized. Overall, organ preservation surgery is not recommended if the general medical status of the patient suggests potential significant complications.
Following the approach outlined above will rarely result in the need for completion total laryngectomy (for oncologic or aspiration purposes) or permanent gastrostomy.
Evaluation
As with any head and neck neoplasm, a thorough head and neck examination is essential. Particularly important in the evaluation of a patient for organ preservation surgery is the ability to accurately predict the surface and three-dimensional extent of the lesion (second principle). A dynamic evaluation of the larynx is necessary to determine whether the patient is a candidate for organ preservation surgery. Indirect mirror examination or flexible fiber-optic laryngoscopy help to examine the mobility of the true vocal folds and the arytenoid cartilages. Numerous authors have stated that evaluating true vocal fold mobility and arytenoid mobility were key points for the preparation of organ preservation surgery . Glottic, supraglottic, and transglottic tumors that exhibit true vocal fold fixation and arytenoid fixation should be considered a major contraindication to organ preservation surgery. Arytenoid fixation implies malignant infiltration of the cricoarytenoid joint, cricoarytenoid musculature, or both. True vocal fold fixation without arytenoid fixation is not a contraindication to organ preservation surgery. Carefully evaluating the patient to vocalize a sustained /e/, to breathe gently, to cough lightly, and to vocalize at a higher pitch, help to elucidate the status of arytenoid mobility. One must also attempt to make the distinction between apparent vocal fold fixation secondary to weight impact of supraglottic tumors versus actual transglottic spread . There is a statistically significant relationship between the presence of abnormal cord mobility and involvement at the glottic level. This scenario could provide an unwelcome surprise for the surgeon expecting to perform a supraglottic laryngectomy if not appreciated preoperatively.
Direct laryngoscopy under general anesthesia should be employed to help with the precise mapping of the extent of tumor. Systematic use of laryngoscopes allowing for complete examination of the laryngeal structures is essential. The subglottis can be inspected with rigid 0- and 30-degree endoscopes. Bimanual palpation should be used to assess the tongue base and thyrohyoid membrane to appreciate submucosal extent of disease and possible preepiglottic space involvement. Maintaining the hyoid bone as a means for impaction on to the remaining thyroid cartilage (supraglottic laryngectomy) or cricoid cartilage (supracricoid laryngectomy) is oncologically sound in supraglottic cancer unless tumor involves the tongue base, vallecula mucosa, or hyoid bone itself . The hyoid bone is essential in the reconstruction following supracricoid laryngectomy. Palpation and manipulation of the arytenoid cartilages with endoscopic instruments help to ascertain mobility. Although careful evaluation often helps to confidently define the extent of gross disease, one may not fully be able to appreciate the submucosal extent of tumor until the intended organ preservation surgery is being attempted. It is for this reason that all patients must consent to the possibility of total laryngectomy, if intraoperatively the tumor extent precludes the use of organ preservation surgery.
If the tumor is bulky and partially obstructing the airway, debulking can be accomplished with a laser or powered instrumentation (debrider) to avoid a tracheostomy. This is particularly important in supracricoid laryngectomy where placement of the tracheotomy is important. Simultaneous second primary tumors of the head and neck should be searched for at this time. One may or may not elect to place a percutaneous endoscopic gastrostomy tube at this time if severe dysphagia is expected to last for more than 1 month.
CT and MRI are helpful in evaluating the primary lesion with regard to the status of the preepiglottic and paraglottic spaces, the subglottic extent of tumor, and cartilaginous invasion . The studies are supplemental and should not supplant the clinical examination. CT is especially helpful to assess for nodal metastasis .
The general medical evaluation cannot be overly emphasized in selecting patients for organ preservation surgery. The ability of the patient to tolerate general anesthesia along with factors that may complicate wound healing must be evaluated. Particularly important is the patient’s cardiopulmonary status. Aging and chronic obstructive pulmonary disease greatly increase the risk of postoperative atelectasis and pneumonia . The risk of postoperative aspiration increases with procedures that most disturb the sphincteric function of the larynx. A chronic and inefficient cough, purulent sputum, and, most importantly, the inability to walk up two flights of stairs without shortness of breath, bode poorly for the patient’s ability to tolerate an organ preservation procedure.
The patient’s sex, occupational use of voice, social status, and nutritional status, as well as alcohol intake should be strongly considered. Patient motivation for speech and swallowing therapy should be assessed and the patient should be counseled by a speech pathologist familiar with organ preservation approaches preoperatively. The need for a temporary feeding tube and tracheostomy must also be emphasized. Overall, organ preservation surgery is not recommended if the general medical status of the patient suggests potential significant complications.
Following the approach outlined above will rarely result in the need for completion total laryngectomy (for oncologic or aspiration purposes) or permanent gastrostomy.
Open organ preservation surgical approaches for larynx cancer
The discussion of open organ preservation surgical approaches for larynx cancer will focus on vertical partial laryngectomy (VPL), supraglottic laryngectomy (SGL), and supracricoid laryngectomy (SCL). Indications, contraindications, and key technical principles will be emphasized. The goal of this section is to familiarize the physician with these open surgical options while understanding that this is but one part of the organ preservation paradigm that also includes radiation and chemoradiation protocols.
Vertical partial laryngectomy
The vertical partial laryngectomy (VPL) and its many derivations is probably the most familiar organ preservation surgery to all surgeons. Classically, the vertical partial laryngectomy involves a vertical transection at some point in the thyroid cartilage. The goal is to resect a portion of the thyroid cartilage along with tumor at the glottic level. An in-depth discussion of all modifications is best left for the surgical atlases. Most patients are left with some degree of permanent hoarseness, which obviously varies with the reconstructive technique employed. Chronic dysphagia is not common. Patients typically resume a normal diet within 1 month .
The oncological results are variable across T stage of lesions and from institution to institution. This may be secondary to the wide array of modifications for both resection and reconstruction. In general, the literature demonstrates good 5-year local control rates for T1a lesions. The local failure rate ranges from 0% to 11% . Local control becomes more difficult when the tumor involves the anterior commissure. One reason may be that the vertical thyrotomy is often made “blindly” and the extent of tumor at the anterior commissure may not have been fully appreciated preoperatively. Kirchner’s series demonstrated that the most common site of recurrence for lesions involving the anterior commissure was the subglottis . Whole organ series have demonstrated the propensity for subglottic involvement with anterior commissure tumors . It is often difficult to clear the subglottic level bilaterally in vertical partial laryngectomy.
The local control rates for T2 lesions have to be carefully evaluated. Although some reports suggest good local control for T2 lesions, these lesions typically are without cord mobility impairment and without significant subglottic or supraglottic extension. Local control rates have been typically worse for T2 lesions with cord mobility impairment or significant subglottic or supraglottic extension. Most series report local failure rates greater than 14% and two series report greater than 20% . The local control rates for VPL in the treatment of T3 lesions are widely variable with some series demonstrating a greater than 30% local failure rate . T3 lesions are designated such because of cord fixation secondary to either paraglottic space invasion or cricoarytenoid joint involvement. Most versions of VPL do not fully address the paraglottic space and certainly do not address the cricoarytenoid joint.
In light of the above discussion, VPL can be used successfully to achieve local control for T1 lesions without anterior commissure involvement. Caution should be exercised with regard to implementing its use for anterior commissure lesions and extensive T2 lesions. The supracricoid laryngectomy provides a better oncologic option for T3 lesions without cricoarytenoid joint involvement .
Supraglottic laryngectomy
Supraglottic laryngectomy (SGL), like VPL, has a number of extensions that complicate assessing local control rates. We discuss the typical supraglottic laryngectomy that preserves both true vocal folds, both arytenoids, the tongue base, and the hyoid bone. The main oncologic contraindications to standard supraglottic laryngectomy are:
- (1)
Involvement at the glottic level (three-quarter SGL has been used)
- (2)
Invasion of the cricoid or thyroid cartilage
- (3)
Involvement of the tongue base to within 1 cm of the circumvallate papillae
- (4)
Involvement of deep muscles of base of tongue
Supraglottic squamous cell cancer is a different disease process than glottic squamous cell carcinoma in many ways. Supraglottic carcinoma has a higher incidence of occult nodal metastasis and frank nodal disease at presentation. Nineteen percent of surviviors experienced a second respiratory tract primary within 5 years after the diagnosis of supraglottic carcinoma . These reasons alone tend to favor a surgical treatment of supraglottic cancer. Reserving radiation for the future, if possible, may be advantageous.
Local control rates for supraglottic laryngectomy range from 0% to 15% for T1 and T2 lesions of the supraglottis . There is greater variability when SGL is used for T3 and T4 lesions . These series did not elucidate the factors that were responsible for recurrence in these lesions. It is possible that unrecognized glottic level involvement for T3 lesions was a factor.
Key surgical resection steps to supraglottic laryngectomy include:
- (1)
Expose the upper half of the thyroid cartilage
- (2)
Release the pyriforms to the level of the ventricle and not to the midline
- (3)
Anterior commissure is localized at the anterior midpoint of the thyroid cartilage
- (4)
Perform an oblique cut 1 mm above anterior commissure toward superior cornua of the thyroid cartilage
- (5)
If the preepiglottic space is involved to the thyrohyoid membrane, leave straps over it and resect hyoid bone. If not, it is oncologically sound to leave the hyoid bone
- (6)
If possible, perform a transvallecula pharyngotomy below the hyoid bone
- (7)
Grasp the free edge of the epiglottis and transect the aryepiglottic fold just anterior to the arytenoid on the noninvolved side
- (8)
At the ventricle, proceed anteriorly and split the thyroid cartilage along its anterior spine to visualize the extent of tumor and proceed with the cut on the involved side.
- (9)
Preserve the main trunks of the superior laryngeal nerves
It is possible to extend the resection to transect a portion or all of one arytenoid cartilage for tumor extending to the glottic level. This typically results in a challenging and often creative reconstruction to achieve glottic competency . While these authors have had success with these complex reconstructions, the supracricoid laryngectomy with cricohyoidopexy provides a more established functional outcome with less variability with regard to glottic competency because the reconstruction is always the same.
The reconstruction for SGL typically varies among surgeons. One common closure technique is to drill numerous holes into the remaining thyroid cartilage at its superior edge. The tongue base is then sutured to thyroid cartilage making a shelf of tissue over the glottis . A simpler approach is to use a closure similar to that used in reconstructing the supracricoid laryngectomy ( Fig. 1 ) . The goal of closure is to impact the tongue base with or without the hyoid bone onto the remaining thyroid cartilage. Three symmetric, submucosal, interrupted sutures (Vicryl 1 on a 65-mm needle) are looped around the remaining thyroid cartilage and inserted into no less than 1 cm of the base of tongue. This helps to bunch up the central portion of the tongue over the glottis and assists with diverting the food bolus into the pyriform sinus. The functional outcome is maximized when patients are selected appropriately for SGL and technical errors are avoided. The need for a speech and language pathologist familiar with SGL in the rehabilitation process cannot be overemphasized.
