Diagnosis and treatment of recurrent laryngeal cancer following initial nonsurgical therapy

Surgery is the preferred modality for curative treatment of recurrent laryngeal cancer after failure of nonsurgical treatments. Patients with initial early-stage cancer experiencing recurrence following radiotherapy often have more advanced-stage tumors by the time the recurrence is recognized. About one third of such recurrent cancers are suitable for conservation surgery. Endoscopic resection with the CO(2) laser or open partial laryngectomy (partial vertical, supracricoid, or supraglottic laryngectomies) have been used. The outcomes of conservation surgery appear better than those after total laryngectomy, because of selection bias. Transoral laser surgery is currently used more frequently than open partial laryngectomy for treatment of early-stage recurrence, with outcomes equivalent to open surgery but with less associated morbidity. Laser surgery has also been employed for selective cases of advanced recurrent disease, but patient selection and expertise are required for application of this modality to rT3 tumors. In general, conservation laryngeal surgery is a safe and effective treatment for localized recurrences after radiotherapy for early-stage glottic cancer. Recurrent advanced-stage cancers should generally be treated by total laryngectomy.

Radionecrosis or tumor recurrence after radiation of laryngeal and hypopharyngeal carcinomas

OBJECTIVE: To analyze the incidence and diagnostic difficulties of radionecrosis vs tumor recurrence of laryngeal and hypopharyngeal carcinomas. STUDY DESIGN AND SETTING: Retrospective study on 341 patients treated by radiation alone or radiochemotherapy. The clinicopathologic findings, work-up, treatment, and follow-up of 20 patients with symptoms suggestive but negative for tumor recurrence on initial imaging studies and endoscopy were analyzed. RESULTS: The incidence of chondroradionecrosis in 341 irradiated patients was 5%. Ten of 20 patients initially negative for tumor recurrence were treated by total laryngectomy; in all laryngectomy specimens, chondroradionecrosis was present, in six specimens associated with tumor recurrence. Ten patients were treated by tracheotomy and tumor recurrence was detected in one patient during follow-up. CONCLUSION: Chondroradionecrosis is a relatively rare treatment complication. Typical imaging findings suggestive of radionecrosis are often missing. Tumor recurrence may be present beneath an intact mucosa and missed by endoscopy.

Endoscopic resection of laryngeal and tracheal lesions using the microdebrider

CONCLUSION: Endoscopic resection of laryngeal and tracheal lesions using the microdebrider is a safe, accurate and reliable method. OBJECTIVE: The microdebrider is an important tool for endoscopic nasal and sinus surgery and over the last few years a powered blade with a long shaft has been developed for endoscopic laryngeal and tracheal surgery. The aim of this non-randomized prospective study was to determine the advantages and disadvantages of the microdebrider for treating patients with different laryngeal and tracheal pathologies. MATERIAL AND METHODS: The laryngeal microdebrider was used under endoscopic control in 37 patients. In 29 cases a benign laryngeal lesion was removed endoscopically. In four patients debulking of a malignant obstructive endolaryngeal tumor was performed in order to avoid a tracheotomy. In four cases a bulky obstructing endotracheal lesion was removed. RESULTS: All laryngotracheal lesions could be removed, and this was facilitated by the use of angled rigid telescopes and the laryngeal blade. No traumatic lesions to normal laryngeal tissue occurred as a result of use of the microdebrider and no postoperative endolaryngeal bleeding was observed. The histological diagnosis of the biopsies taken with the microdebrider was accurate in every case. In three of the four cases with obstructive laryngeal malignancies, a tracheotomy was avoided until definitive therapy was undertaken. Normal breathing was restored in all patients with endotracheal lesions.

Pretherapeutic staging of recurrent laryngeal carcinoma: clinical findings and imaging studies compared with histopathology

OBJECTIVE: To assess the accuracy of preoperative imaging studies and clinical and endoscopic examinations for recurrent laryngeal carcinoma evaluation. STUDY DESIGN AND SETTING: A retrospective comparative study was performed at a university department on 42 recurrent laryngeal carcinomas. Surgical specimens were cut into whole-organ slices. Histologic findings were compared with the findings of the different preoperative diagnostic modalities. RESULTS: The craniocaudal tumor spread was correctly evaluated by endoscopy and imaging studies in 52% and 24%, respectively, and the contralateral tumor spread in 50% and 52%, respectively. The sensitivity, specificity, and accuracy for detection of tumor infiltration of the thyroid was 48%, 88%, and 64% and of the cricoid 47%, 80%, and 67%. The accuracy of recurrent tumor classification (crT) was 50%; most tumors were underclassified. CONCLUSION: The inadequately evaluated tumor spread and the inadequately classified recurrent tumors were underestimated and underclassified in most cases, respectively.

Laryngeal and hypopharyngeal carcinomas after (chemo)radiotherapy: a diagnostic dilemma

PURPOSE OF REVIEW: During recent years, (chemo)radiotherapy has evolved into a primary treatment modality for both early and advanced laryngeal and hypopharyngeal carcinomas. Head and neck surgeons will be concerned more frequently with patients presenting symptoms and signs suggesting recurrent tumor or complications of (chemo)radiotherapy. RECENT FINDINGS: Analysis of histologic characteristics and tumor spread of recurrent carcinomas on whole-organ slices of salvage laryngectomy specimens showed that recurrent laryngeal carcinomas are often present with multiple tumor foci dispersed in different regions; furthermore, they may develop beneath an intact mucosa. Only a few articles analyze the reliability of laryngoscopy and biopsy in detecting recurrences after (chemo)radiotherapy: the number of false negative biopsies is relatively high. The differentiation between radionecrosis and tumor recurrence is difficult by computed tomography scan and magnetic resonance imaging in many cases. Positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging are promising diagnostic modalities to detect or exclude persistent or recurrent disease after (chemo)radiotherapy. SUMMARY: Endoscopy with biopsy, computed tomography scan and conventional magnetic resonance imaging present several deficiencies in diagnosing recurrent disease after (chemo)radiotherapy. New imaging modalities such as positron emission tomography-computed tomography and diffusion-weighted magnetic resonance imaging show promising results, increasing the diagnostic efficacy.

Neoplastic invasion of laryngeal cartilage: reassessment of criteria for diagnosis at MR imaging

PURPOSE: To evaluate whether proposed diagnostic criteria applied to magnetic resonance (MR) images of patients with laryngeal and hypopharyngeal carcinoma may be used to distinguish neoplastic from inflammatory involvement of the laryngeal cartilages. MATERIALS AND METHODS: The radiologic and histopathologic data in 121 consecutive patients with primary squamous cell carcinoma of the larynx (n = 63) or hypopharynx (n = 58) who underwent MR imaging before laryngectomy formed the basis of this retrospective study. Patient consent for retrospective chart review was waived by the institutional review board. All laryngectomy specimens were processed with a dedicated histopathologic whole-organ slice technique. MR images were evaluated by two readers according to established ("old") and proposed ("new") diagnostic criteria on the basis of the signal intensity behavior of cartilage on T2-weighted images and contrast material-enhanced T1-weighted images compared with that of the adjacent tumor. Specifically, with the new criteria, T2-weighted or postcontrast T1-weighted cartilage signal intensity greater than that of the adjacent tumor was considered to indicate inflammation, and signal intensity similar to that of the adjacent tumor was considered to indicate neoplastic invasion. The results of the MR image interpretation were compared with the histologic reference standard. RESULTS: The area under the receiver operating characteristic curve for the new criteria (0.94) was nominally but significantly larger than that for the old criteria (0.92) (P = .01). Overall specificity was significantly improved (82% for new vs 74% for old criteria, P < .001) and was greatest for the thyroid cartilage (75% for new vs 54% for old criteria, P < .001) with the new criteria. The sensitivities of the established and the proposed criteria were identical. CONCLUSION: The proposed MR imaging criteria enable improved differentiation of neoplastic cartilage invasion from peritumoral inflammation.

Crossover comparison of the laryngeal mask supreme and the i-gel in simulated difficult airway scenario in anesthetized patients

BACKGROUND: The single-use supraglottic airway devices LMA-Supreme (LMA-S; Laryngeal Mask Company, Henley-on-Thames, United Kingdom) and i-gel (Intersurgical Ltd, Wokingham, Berkshire, United Kingdom) have a second tube for gastric tube insertion. Only the LMA-S has an inflatable cuff. They have the same clinical indications and might be useful for difficult airway management. This prospective, crossover, randomized controlled trial was performed in a simulated difficult airway scenario using an extrication collar limiting mouth opening and neck movement. METHODS: Sixty patients were included. Both devices were placed in random order in each patient. Primary outcome was overall success rate. Other measurements were time to successful ventilation, airway leak pressure, fiberoptic glottic view, and adverse events. RESULTS: Success rate for the LMA-S was 95% versus 93% for the i-gel (P = 1.000). LMA-S needed shorter insertion time (34 +/- 12 s vs. 42 +/- 23 s, P = 0.024). Tidal volumes and airway leak pressure were similar (LMA-S 26 +/- 8 cm H20; i-gel 27 +/- 9 cm H20; P = 0.441). Fiberoptic view through the i-gel showed less epiglottic downfolding. Overall agreement in insertion outcome was 54 (successes) and 1 (failure) or 55 (92%) of 60 patients. The difference in success rate was 1.7% (95% CI -11.3% to 7.6%). CONCLUSIONS: Both airway devices had similar insertion success and clinical performance in the simulated difficult airway situation. The authors found less epiglottic downfolding and better fiberoptic view but longer insertion time with the i-gel. Our study shows that both devices are feasible for emergency airway management in patients with reduced neck movement and limited mouth opening.

Virtopsy: postmortem imaging of laryngeal foreign bodies

CONTEXT: Death from corpora aliena in the larynx is a well-known entity in forensic pathology. The correct diagnosis of this cause of death is difficult without an autopsy, and misdiagnoses by external examination alone are common. OBJECTIVE: To determine the postmortem usefulness of modern imaging techniques in the diagnosis of foreign bodies in the larynx, multislice computed tomography, magnetic resonance imaging, and postmortem full-body computed tomography-angiography were performed. DESIGN: Three decedents with a suspected foreign body in the larynx underwent the 3 different imaging techniques before medicolegal autopsy. RESULTS: Multislice computed tomography has a high diagnostic value in the noninvasive localization of a foreign body and abnormalities in the larynx. The differentiation between neoplasm or soft foreign bodies (eg, food) is possible, but difficult, by unenhanced multislice computed tomography. By magnetic resonance imaging, the discrimination of the soft tissue structures and soft foreign bodies is much easier. In addition to the postmortem multislice computed tomography, the combination with postmortem angiography will increase the diagnostic value. CONCLUSIONS: Postmortem, cross-sectional imaging methods are highly valuable procedures for the noninvasive detection of corpora aliena in the larynx.

The use of bougie-guided insertion of a laryngeal mask airway device in neonatal piglets after unexpected complications

After marked airway obstruction with laryngeal mask (LM) placement in neonate piglets, anatomical observations in cadavers revealed a large epiglottis advancing markedly over the soft palate. CT imaging in vivo confirmed that the LM pushes the epiglottis caudally thereby obstructing the larynx. As a new approach, in 20 piglets a flexible PVC bougie placed under laryngoscopy was used to guide the LM to the correct position at the larynx. Placement of the bougie was easy and the LM was positioned successfully in all piglets at first attempt. In 14 piglets, the epiglottis was positioned dorsal to the soft palate before LM insertion and had to be pushed downwards to advance the bougie. In case of failure of LM placement with potential airway obstruction, the use of a bougie to guide the LM over the epiglottis was simple, rapid, and improved the success rate without complication.

Definitive intensity modulated radiotherapy in locally advanced hypopharygeal and laryngeal squamous cell carcinoma: mature treatment results and patterns of locoregional failure.

PurposeTo assess clinical outcomes and patterns of loco-regional failure (LRF) in relation to clinical target volumes (CTV) in patients with locally advanced hypopharyngeal and laryngeal squamous cell carcinoma (HL-SCC) treated with definitive intensity modulated radiotherapy (IMRT) and concurrent systemic therapy.MethodsData from HL-SCC patients treated from 2007 to 2010 were retrospectively evaluated. Primary endpoint was loco-regional control (LRC). Secondary endpoints included local (LC) and regional (RC) controls, distant metastasis free survival (DMFS), laryngectomy free survival (LFS), overall survival (OS), and acute and late toxicities. Time-to-event endpoints were estimated using Kaplan-Meier method, and univariate and multivariate analyses were performed using Cox proportional hazards models. Recurrent gross tumor volume (RTV) on post-treatment diagnostic imaging was analyzed in relation to corresponding CTV (in-volume, > 95% of RTV inside CTV; marginal, 20¿95% inside CTV; out-volume, < 20% inside CTV).ResultsFifty patients (stage III: 14, IVa: 33, IVb: 3) completed treatment and were included in the analysis (median follow-up of 4.2 years). Three-year LRC, DMFS and overall survival (OS) were 77%, 96% and 63%, respectively. Grade 2 and 3 acute toxicity were 38% and 62%, respectively; grade 2 and 3 late toxicity were 23% and 15%, respectively. We identified 10 patients with LRF (8 local, 1 regional, 1 local¿+¿regional). Six out of 10 RTVs were fully included in both elective and high-dose CTVs, and 4 RTVs were marginal to the high-dose CTVs.ConclusionThe treatment of locally advanced HL-SCC with definitive IMRT and concurrent systemic therapy provides good LRC rates with acceptable toxicity profile. Nevertheless, the analysis of LRFs in relation to CTVs showed in-volume relapses to be the major mode of recurrence indicating that novel strategies to overcome radioresistance are required.

MeV ion beam lithography of biocompatible halogenated Parylenes using aperture masks

Parylenes are poly(p-xylylene) polymers that are widely used as moisture barriers and in biomedicine because of their good biocompatibility. We have investigated MeV ion beam lithography using 16O+ ions for writing defined patterns in Parylene-C, which is evaluated as a coating material for the Cochlear Implant (CI) electrode array, a neuroprosthesis to treat some forms of deafness. Parylene-C and -F on silicon and glass substrates as well as 50 μm thick PTFE were irradiated to different fluences (1×1013-1×10161×1013-1×1016 1 MeV 16O+ ions cm−2) through aperture masks under high vacuum and a low pressure (<10−3 mbar) oxygen atmosphere. Biocompatibility of the irradiated and unirradiated surfaces was tested by cell-counting to determine the proliferation of murine spiral ganglion cells. The results reveal that an oxygen ion beam can be used to pattern Parylene-C and -F without using a liquid solvent developer in a similar manner to PTFE but with a ∼25× smaller removal rate. Biocompatibility tests showed no difference in cell adhesion between irradiated and unirradiated areas or ion fluence dependence. Coating the Parylene surface with an adhesion-promoting protein mixture had a much greater effect on cell proliferation.