Functional organ preservation in laryngeal and hypopharyngeal cancer

Abstract

The principles of open versus laser microsurgical approaches for partial resections of the larynx are described, oncologic as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.

Keywords: chemoradiation; hypopharyngeal cancer; laryngeal cancer; organ preservation; partial laryngectomy; transoral laser microsurgery; treatment.

Table 1. Results of transoral laser microsurgery for T1 vocal cord carcinoma

Table 2. Results of transoral laser microsurgery for T2 vocal cord carcinoma

Table 3. Results of radiotherapy for T1 vocal cord carcinoma

Table 4. Results of radiotherapy for T2 vocal cord carcinomas

Figure 1. Left: Histologic coronal section of an adult larynx. Specimen: P. Steven. Photograph: B. Tillmann. Stain: Orcein-Pikroindigokarmin. From B. Tillmann, 2010 [262]. Right: Histologic coronal section through the vocal fold of an adult.

Specimen: B. Tillmann. Stain: Elastica. From B. Tillmann, 2010 [262].

Figure 2. Bony and fibroelastic structures of the larynx. Axial view. Specimen of the scientific collection of the Inst. of Anatomy of CAU Kiel, Photograph: B. Tillmann. From B. Tillmann, 1997 [263]. The dotted lines show the resection in a case of advanced vocal cord carcinoma with resection of the vocal fold, the false cord and the arytenoid cartilage.

Figure 3. Left superior: Histologic horizontal section through an adult larynx. Stain: Goldner. Specimen: B. Tillmann.

Left inferior: Histologic horizontal section through an adult larynx at the plane of the anterior commissure. Stain: Goldner. Specimen: B. Tillmann. Right: Laryngeal skeleton with blood vessels. Corrosion specimen of the scientific collection of the Inst. of Anatomy of CAU Kiel, Klaws fecit. Photograph: B. Tillmann.

Figure 4. Histologic horizontal section through an adult larynx at the insertion of the vocal ligaments at the anterior commissure. Stain: Gomori. Specimen: F. Paulsen and B. Tillmann. From Paulsen F, Tillmann B, 1996 [30].

Figure 5. Anatomic specimen, non-fixed. The dotted lines show the resection in case of a supraglottic carcinoma.

Figure 6. Right adult hemilarynx. Specimen of the scientific collection of the Inst. of Anatomy of CAU Kiel. Photograph: B. Tillmann. The dotted lines show the resection in a case of a supraglottic carcinoma with complete resection of the epiglottis, the preepiglottic fat and the false cord.

Figure 7. Anatomic specimen, non-fixed. The dotted lines show the resection in a case of an advanced supraglottic carcinoma with the resection extended to the aryepiglottic fold and the arytenoid cartilage.

Figure 8. a: Diagram showing arteries and nerves of the larynx. From B. Tillmann, 2010 [262]. b: Corrosion specimen of the arteries of the neck. Four-colour injection of methacrylat with preservation of the laryngeal skeleton. Specimen of the scientific collection of the Inst. of Anatomy of CAU Kiel. Klaws fecit, Photograph: B. Tillmann.

Figure 9. Anatomic specimen, non-fixed. The dotted lines show the resection in a case of a carcinoma of the piriform sinus.