Total Laryngopharyngectomy
Fausto Chiesa
INTRODUCTION
Treatment of cancer of the larynx is particularly challenging due to the need to combine cure with preservation of laryngeal function, the loss of which has a major impact on people’s communicative and functional skills in society. For this reason, major research efforts have, in recent decades, been dedicated to the introduction of treatment modalities that allow preservation of the larynx. In fact total laryngopharyngectomy (TLP) nowadays seems to play a restricted role in the management of untreated laryngohypopharyngeal cancer because of the progressive increase of nonsurgical “organ preservation” protocols and conservative surgical approaches, even though Hoffman in 2006 reported a decreasing survival rate among patients with laryngeal cancer during the last two decades in the United States. These unexpected results might be explained by the increasing use of such nonsurgical conservation treatment modalities.
Nevertheless, TLP remains, today, the main treatment modality employed in laryngohypopharyngeal diseases such as advanced squamous cell carcinoma (SCC) or other nonepithelial rare tumors of the larynx with massive invasion of the cartilage framework, in recurrences after failure of chemoradiotherapy or after conservation partial laryngectomy, in an emergency procedure in airway obstructive tumors, or in rare complications of previous treatments (e.g., chondroradionecrosis) or, finally, for advanced T3-T4 subglottic cancers.
The first total laryngectomy (TL) was performed by Billroth in Vienna on a 36-year-old man with a subglottic tumor who originally underwent a hemilaryngectomy on November 27, 1873, and a successive TL on December 31, 1873. He was discharged on March 1874 but expired 7 months after surgery from metastatic cancer. In 1875, Bottini performed the first primary surgical treatment by TL, in Italy (Turin): the patient, with a diagnosis of laryngeal sarcoma, survived for 15 years after surgery. In the early 1900s, the complete separation of the airway from the digestive tract, suturing the trachea directly to the cervical skin to create a stoma and a primarily closed pharynx, was performed by Gluck in Europe and Solis-Cohen in the United States.
In 1909, Finzi reported good results with the use of external beam radiation therapy for cancer of the larynx. At the Curie Foundation in Paris, during the 1920s, Coutard treated patients with cancer of the tonsil, larynx, and hypopharynx with radiotherapy. Between 1920 and 1950, radiotherapy became the treatment of choice for cancer of the larynx. After 1950s the modern “wide field” TL combined with neck dissection became the treatment of choice for advanced or recurrent cancer of the larynx.
The evolution of clinical tools and techniques from Garcia’s indirect mirror laryngoscopy to the modern videolaryngoscopy and dedicated imaging with computed tomography (CT) or magnetic resonance imaging (MRI) have improved current clinical evaluation and treatment planning. All of these have formed the basis of today’s progressive increase in conservation partial laryngectomy approaches (e.g., endoscopic, supracricoid, or supraglottic laryngectomy) and nonsurgical “organ preservation” protocols, such as neoadjuvant chemotherapy followed by radiotherapy or concomitant chemoradiation, and have thereby limited the role of TL in the management of cancer of the larynx and hypopharynx.
The current recommendations for the management of advanced cancer of the larynx are described in the National Comprehensive Cancer Network practice guidelines.
HISTORY
Before proposing laryngeal surgery, the patient’s history should be carefully collected. The presenting symptoms, such as dysphonia or dysphagia, should be investigated. Concomitant lung, mediastinal, or esophageal cancer must be excluded. The patient’s habits should also be collected: the relationship between laryngopharyngeal cancer and smoking, alcohol, and diet has been known for many years. A previous history of cancer of the head and neck or other malignant tumors is mandatory to know, since previous radiation treatment can compromise the wound healing of the neck region after laryngopharyngectomy. The history of heart disease, hypertension, chronic obstructive pulmonary disease, diabetes, or other comorbidities has to be investigated, because they can influence the perioperative period.
PHYSICAL EXAMINATION
Accurate clinical staging of cancer of the larynx/pharynx is the key to success in its management. This includes inspection of the larynx, palpation of the neck, flexible video-fiberoptic pharyngolaryngoscopy. In some cases, direct microlaryngoscopy under general anesthesia may be useful. One notes any hoarseness or roughness suggesting involvement of the vocal cords or a toad-like voice suggesting supraglottic involvement. Any airway obstruction is noted, and plans should be made to alleviate the obstruction.
Palpation of the neck may reveal the presence of metastatic lymph nodes. Note should be made of any lack of mobility of the larynx with respect to deep structures. The second step of clinical evaluation is videoassisted fibrolaryngoscopy. This is mandatory for a thorough evaluation of the local extension of the lesion; it is important to determine the mobility of the arytenoids, the respiratory space, and subglottis extension of disease. The pharynx and hypopharynx are examined for extent of tumor involvement.
INDICATIONS
TLP remains, today, the main treatment of cancer of the laryngohypopharyngeal complex in the following cases:
In advanced resectable SCC of the larynx and hypopharynx, rare epithelial tumors (e.g., adenocarcinomas, tumors of salivary gland origin), or other nonepithelial malignancies (melanomas, fibrosarcomas, chondromas, chondrosarcomas, and paragangliomas) of the larynx with massive invasion of the cartilage framework
In advanced resectable hypopharyngeal cancers with massive laryngeal invasion or spread across the postcricoid region
In recurrence/persistence of cancer following chemoradiotherapy
As completion surgery for failed conservation partial pharyngolaryngectomy
In an emergency procedure in tumors causing airway obstruction or in rare complications of previous treatments (e.g., chondroradionecrosis)
For advanced subglottic cancers with or without infiltration of the cricoid cartilage
CONTRAINDICATIONS
The major contraindications to TLP are tumor-related and patient-related factors. Cancer-related factors include laryngopharyngeal cancer with invasion of the prevertebral fascia, massive tracheoesophageal invasion, continuity between primary cancer and neck metastases, fixed metastatic lymph node, fixation of the larynx, involvement of the common or internal carotid artery, and presence of distant metastasis or incurable synchronous cancer. The patient-related factors include patient desire, age, and severe comorbidity that contraindicates major surgery. In these cases, it is preferable to carry out a tracheostomy, with percutaneous gastrostomy and palliative/supportive care.
PREOPERATIVE PLANNING
Clinical staging of the patient must be completed by imaging evaluation that includes CT, MRI, and positron emission tomography-computed tomography (PET-CT) scan. MRI is especially useful in detecting any involvement of the preepiglottic and paraglottic spaces, infiltration into cartilage structures, as well as submucosal spread of disease. Finally, the PET-CT scan may reveal distant metastases or other possible synchronous cancers, which severely impact patient survival.
Direct Microlaryngoscopy
Direct microlaryngoscopy under general anesthesia is another clinical staging procedure that is used for determining the histology by biopsy, evaluation of cancer extension, and “mapping” of the lesion. This procedure, used widely in the past, is losing its mission due to improvement of diagnostic tools such as flexible video laryngoscopy, high resolution of diagnostic imaging, MRI, and CT scan that make the most accurate evaluation of not only the superficial extension but also the deep extension of the cancer. Ultrasound-guided transcutaneous Tru-Cut biopsy under topical anesthesia in the outpatient office makes for a reliable histologic diagnosis of the suspect lesion, especially in those patients who have previously been treated by radiotherapy or chemoradiotherapy. In those patients, there are usually some problems regarding intubation and laryngeal exposure due to the side effects of chemoradiation, which require a preliminary tracheostomy.
In the case of dysphagia or when the lesion clinically involves the hypopharynx, or the retrocricoid area or pyriform sinus, an esophagoscopy is recommended. This will provide information as to when the cancer of the pyriform sinus infiltrates inferiorly into the cervical esophagus.
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