Functional Outcomes and Complications After Salvage Total Laryngectomy for Residual, Recurrent, and Second Primary Squamous Cell Carcinoma of the Larynx and Hypopharynx: A Multicenter Retrospective Cohort Study

Abstract

Background/Purpose: We analyzed complications and functional outcomes and aimed at identifying prognostic factors for functional outcomes and complications in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx after initial (chemo)radiation. Methods: Retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018. Prognostic factors for functional outcomes and complications were identified with uni- and multivariable analysis. Results: A total of 405 patients were included in the final analysis. STL was performed for residual tumor (40.2%), local recurrence (40.5%), or second primary laryngeal or hypopharyngeal SCC (19.4%). Early postoperative complications were experienced by 34.2% of patients: postoperative hemorrhage occurred in 5.4%, wound infection in 16.2%, and clinical pharyngocutaneous fistula (PCF) in 25.5% of patients. Early readmission proved necessary in 15.1% of cases, most often due to late PCF development (72.2%). Patients achieved total peroral intake in 94.2% of cases. However, subjective dysphagia was reported by 31.3% of patients during follow-up. Functional speech, defined as functional communication by speech without additional aids, was reported in 86.7% of cases and was most often achieved by tracheo-esophageal puncture (TEP) (94.1%). In a multivariable model, lower preoperative hemoglobin (<12.5 g/dl) was identified as an independent prognostic factor for higher overall complication rate. No risk factors were found significant for clinical fistula formation. Vascularized tissue augmentation did not significantly prevent clinical PCF. Patients with positive section margins, patients initially treated with surgery combined with adjuvant RT (vs. radiotherapy alone), and those developing PCF after STL were less likely to achieve total peroral intake. Postoperative dysphagia proved more likely in patients who developed a PCF postoperatively, and less likely in patients who underwent STL without partial pharyngectomy and in patients with myocutaneous pectoralis major (PM) flap reconstruction, compared to muscle onlay PM flap. Achieving postoperative functional speech proved most likely in patients with smaller tumors (lower pT classification) and free section margins. Conclusion: Substantial complication rates and favorable functional outcomes are reported after STL.

A New Classification System to Predict Functional Outcome after Laryngectomy and Laryngopharyngectomy

“…Although, several studies already reported on functional endpoints after primary or salvage laryngectomy, laryngopharyngectomy, and on the usage of different flaps, we believe that our study has significant strengths providing new data that adds to the current literature [ 18 , 20 , 21 ]. First, we have shown long-term functional outcomes of patients with a mean follow-up time of 5 years.…”

“…Rehabilitation of speech is a major goal after laryngectomy [ 18 ]. Indeed, rates for voice rehabilitation range from approximately 80% in patients with laryngectomies to less than half in patients undergoing pharyngectomy with a need for free flap reconstruction [ 14 , 19 , 20 ]. In our cohort, voice rehabilitation was achieved in more than two-thirds with valved voice prosthesis insertion and sufficiently acquired esophageal speech.…”

Recurrent/Metastatic Squamous Cell Carcinoma of the Head and Neck: A Big and Intriguing Challenge Which May Be Resolved by Integrated Treatments Combining Locoregional and Systemic Therapies

“…In these patients, salvage treatments may also allow to a fairly good outcome. Nevertheless, both surgery and re-irradiation are burdened by not insignificant toxicities, and importantly, by a high rate of second and third recurrences [ 77 , 78 ]. Therefore, research on the possible means of enhancing the anti-PD-1 effect, and overall, the systemic therapy effect, is much needed.…”

Preventing Biofilm Formation and Development on Ear, Nose and Throat Medical Devices

“…The rehabilitation rate is influenced by the type of intervention utilized. Some studies show percentages for patient voice recovery in the range of 80% for patients who have undergone laryngectomies and under 50% for pharyngectomy, which requires a free flap rebuilding [93]. Multiple studies are focusing on the endpoints for laryngectomy or laryngopharyngectomy, approaching variations of flap types [94].…”