Residual value total Laryngopharyngectomy to the larynx Carcinoma after Chemo radiation

Published: Manish Kumar Sinha (6) on Wed 16th Mar 2011 | Word Count: 602 | Comments (0)

Two decades earlier to locally advanced laryngeal cancer was total laryngectomy and postoperative radiotherapy standard care. Now Radiotherapy with concurrent chemotherapy is considered standard of care for patients want laryngeal preservation, and total laryngectomy is reserved for recurrent or residual disease as salvage therapy. The advantage of chemo radiation is the larynx are preserved in the 60-70% patients with better locoregional control. Reimbursement of primary radiation, chemo if there are recurrent or residual tumor conservative laryngeal surgery cannot be performed because the spread of the tumor is very unpredictable and post operative complications is very high so in the end the patient undergoing total laryngectomy and ends up losing the natural voice.

62-year-old patient diagnosed as squamøs cell carcinoma larynx (supraglottic) cT3N1M0 (i.e. malignant lesion of supraglottic larynx with fixation of ipsilateral vocal cords with ipsilateral lymph node enlarged level II [upper vena]).Metastatic workup was within normal limits. The matter was discussed in the tumor Board of Directors and scheduled for simultaneous chemo-radiation.The patient tolerated the treatment well, but the symptoms still persisted. After a month after this treatment the patient was evaluated by CT scan, which showed the neck lesion in the supraglottis with post radiotherapy changes revealed flexible laryngopharyngoscopy lesion of the left supraglottis with record RT changes. Biopsy was taken, reported as squamøs epithelium with record RT changes. FDG PET CT scan showed avid lesion of larynx and hypopharynx. Rigid direct laryngoscopy was done under GA, which revealed the lesion in the left-sided extension to the left with the supraglottis hypopharynx.Biopsy report was a moderately differentiated squamøs cell carcinoma.

Patient was scheduled to salvage surgery and underwent total laryngopharyngectomy with patch pectoralis major pharyngoplasty with left and right Lateral RND neck dissection with deltopectoral flap reconstruction for the skin defect and Provox I voice prosthesis insertion.The patient's postoperative recovery was uneventful. After 4weeks deltopectoral flap final insetting was carried out. Report final histopathology was moderately differentiated squamøs cell carcinoma with minimal thyroid cartilage invasion, all margins were negative, and a single lymph node was positive. No evidence of a leak was found after gastrograffin swallow after 15 days. The patient is on the regular follow-up makes fine and communicate well using the Provox voice prosthesis. The course of the disease in this patient would support

After concurrent radio-chemotherapy 20-30% of patients fail within 2 years after therapy. Regular intensive follow-up of the patient is therefore a must. Recurrent or residual disease after this treatment is difficult and so PET CT has an important role. if salvage surgery does not happen so that the survival of these patients have poor. salvage laryngopharyngectomy high (2-3 times) post operative complication rates and pharngocutaneous Fistula, secondary hemorrhage, aspiration pneumonia, etc are recognized problems. the surgical necessary line should be expanded with a vascularised flap like pectoralis major myocutaneous flap muscles, or free flap because healing in Post radiated the patient is very poor and this reduces the likely chance of wound breakdown. patient should be rehabilitated with a voice prosthesis so that they can perform their work independently and communication is easy.

In summary the larynx preservation and a chemo-radiation should recipe prescribed for patients who have good performance status, which is eager to be in this recipe and is ready for the regular intensive follow-up.Residual value laryngectomy is part of the Protocol, because if this does not happen overall survival is poorer than primary laryngectomy followed by radiotherapy. This can only be done by an experienced trained person in a comprehensive cancer care institution where all this expertise is available under one roof and coordination and planning can be done.

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