A Voice Conserving Option For Advanced Laryngeal Cancer
Laryngeal cancer is the second common Head & Neck cancer in the United States, despite all the measures to curb, we in India also have high incidence because of habit of consumption of tobacco and Alcohol. The ultimate goal of every clinician treating laryngeal cancer is to remove the disease with the preservation of voice and swallowing. Early glottic and supraglottic cancers are treated by surgery or radiation therapy without affecting the phonatory function but this is difficult to achieve in larger transglottic lesions because the preferred surgical treatment for advanced laryngeal tumors remains total laryngectomy (TL), a surgical technique in which laryngeal speech is sacrificed. This is the reason majority of our Indian patients refuse treatment.
The other alternative is Radiation and chemotherapy, part of the so-called organ-sparing protocols, have also resulted in effective outcomes but 30 -40% may require salvage surgery for recurrent disease and post radiotherapy conservative procedures cannot be performed because of poor healing resulting in high fistula rate and assessment of oncological safe margins is not adequate. So these patients land in Total Laryngectomy with high postoperative complications, so primary surgery with voice conservation is preferred modality of treatment. There is a report by Hoffmann et all that for supraglottic cancers survival is poorer with Concurrent chemo radiotherapy as compared to primary surgery followed by radiotherapy.
In 1980, Pearson and colleagues described an alternative to the standard TL in patients with stage T3 glottic cancers. Following pathologic examination of an excised larynx, they noted that in certain pathology specimens, the total larynx was often not involved in the disease process. As such, these researchers discovered that the uninvolved column of endolarynx could be preserved and converted into a sphincteric tube serving as a speech valve.
Studies have shown that near-total laryngectomy (NTL) in select T3 and T4 laryngeal tumors provides a high rate of disease control comparable with that of the total laryngectomy. The NTL spares non tumor involved larynx, which is subsequently used for reconstruction. A patient who undergoes NTL speaks using an internal myomucosal shunt, which is lung powered. It does, however, require a tracheostomy for breathing.
Near-total laryngectomy (NTL) is indicated in patients with advanced (T3, T4) laryngeal cancers when the postcricoid and interarytenoid areas are free of disease and the contra lateral arytenoids is salvageable. The contraindications of this procedure are tumor in the interarytenoid, postcricoid region, and bilateral arytenoids.
A 54 years old male, also a chronic smoker, came to our hospital with the complained of change in voice for last six months and irritation in throat while having food for 3 months. Flexible direct laryngoscopy revealed ulceroproliferative lesion on the Right supraglottic area (Aryepiglottic fold + Epiglottis) with fixity of right vocal cord. Interarytenoid area and postcricoid area was free. Biopsy revealed moderately differentiated Squamous cell carcinoma. CT scan of neck revealed Right supraglottic mass with paraglottic extension with few lymph nodes at right level II, CXR did not have any evidence of disease. . Clinically it was staged as T3N1M0. The patient was discussed in the tumor board and both options of surgery and chemo radiotherapy were given to the patient. Patient chose for surgery provided he can be rehabilitated for voice production. Patient was given option of NTL/TL+ Provox voice prosthesis insertion and taken up for surgery. Intraoperative frozen section was sent from interarytenoid area for involvement which was negative, so we proceeded with NTL and bilateral level II, III, IV neck dissection. Postoperative recovery was uneventful. He was started oral feed after 10 days, he had mild aspiration which settled in few days, his voice rehabilitation was started after 2 weeks. Final Histopathology revealed T3N2M0 Squamous cell carcinoma grade II, all margins were free.
The Ultimate outcome should be oncologically safe resection margins, with good voice production for communication; this depends on in part on the surgeons skill and the extent of resection and subsequent reconstruction.