Salvage Total Laryngopharyngectomy For Carcinoma Larynx After Chemo Radiation
Two decades earlier for locally advanced laryngeal cancer total laryngectomy and postoperative radiotherapy was standard of care. Now Radiotherapy with concurrent chemotherapy is considered standard care for patients desiring laryngeal preservation, and total laryngectomy is reserved for recurrent or residual disease as salvage therapy. The advantage of chemo radiation is larynx is preserved in 60-70% patients with better locoregional control. The drawback of primary chemo radiation, if there is recurrent or residual tumor then conservative laryngeal surgery cannot be performed as spread of tumor is very unpredictable and post operative complications are very high so ultimately patient end up undergoing total laryngectomy and losing natural voice.
A 62 year old patient diagnosed as squamous cell carcinoma larynx (supraglottic) cT3N1M0 (i.e. malignant lesion in the supraglottic larynx with fixation of ipsilateral vocal cord with ipsilateral enlarged level II lymph node [upper jugular]).The metastatic workup was within normal limits. The case was discussed in the tumor board and planned for concurrent chemo-radiation .The patient tolerated the treatment well but symptoms still persisted. After a month of this treatment patient was evaluated by CT scan neck which showed lesion in the supraglottis with post radiotherapy changes, flexible laryngopharyngoscopy revealed lesion in the left supraglottis with post RT changes. Biopsy was taken, reported as squamous epithelium with post RT changes. PET CT scan revealed FDG avid lesion in the larynx and hypopharynx. Rigid Direct laryngoscopy was done under GA which revealed lesion in the left sided supraglottis with extension to left hypopharynx .Biopsy report was a moderately differentiated squamous cell carcinoma.
Patient was planned for salvage surgery and underwent Total laryngopharyngectomy with patch pectoralis major pharyngoplasty with Left RND and right Lateral neck dissection with deltopectoral flap reconstruction for skin defect and Provox I voice prosthesis insertion .The patient's postoperative recovery was uneventful. After 4weeks deltopectoral flap final insetting was done. The final histopathology report was moderately differentiated squamous 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. Patient is on regular follow up doing fine and is able to communicate well using Provox voice prosthesis. The course of disease in this patient would support that:
- after concurrent radio-chemotherapy 20-30% patient will fail within 2 years of 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 is not done then survival of these patients is poor.
- salvage laryngopharyngectomy has high (2-3 times) post operative complication rates and pharngocutaneous fistula, secondary hemorrhage, aspiration pneumonia etc. are recognized problems.
- the surgically suture line should be reinforced with a vascularised flap like pectoralis major muscle, myocutaneous flap or free flap because healing in post radiated 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 carry out their work independently and communication is easy.
In summary larynx preservation, and a chemo-radiation regimen should be prescribed to patients who has good performance status, who is eager to be in this regimen and is ready for regular intensive follow up .The salvage laryngectomy is part of the protocol because if this is not done then 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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