Risk factors involved in stomal recurrence following laryngectomy

Abstract

Stomal recurrence after surgery for laryngeal tumours is an extremely serious complication, with a dismal prognosis despite aggressive surgical therapy or high-dose irradiation. Data from 209 patients who underwent total laryngectomy for cancers of the larynx and hypopharynx were retrieved from the registry of the Department of Otorhinolaryngology at the Hospital ‘Virgen de las Nieves’ of Granada. Stomal recurrence developed in 8.1 per cent of them (17 cases). We analysed several parameters from each case: first, those parameters significantly associated with stomal recurrence were detected, and secondly, a logistic regression analysis was done. Three factors were found independently related to stomal recurrence: T-staging, site of the primary tumour and prior tracheostomy. Together with a review of the literature, we discuss our findings and a proposal for management of the high risk patient.

Recorrência na área do traqueostoma após laringectomia total

“…Many of these tumors that cause upper ai- rway obstruction also extend towards the subglottis. Prior tracheostomy in these patients, necessary to establish a new airway has been identified as an important risk factor for recurrences in the tracheostoma area 1,7,19 . This is due to the fact that prior tracheostomy may allow the implantation of viable neoplastic cells from tumor shedding that have an intense inflammatory process and repair granulation tissue -the bed may be prone to cell adhesion.2 In the literature such risk is reported as varying between 8 and 41% 1,6 .…”

“…Another significant factor that may cause difficulties in analyzing recurrence incidence in the tracheostoma area is the number of synonyms used to describe such pathology, such as: tracheal metastasis, peritracheal recurrence, tracheal recurrence, paratracheostomal tumor, tracheostomal metastasis, second primary tumor in the trachea 3 . Most relapses in the tracheostoma area are diagnosed in the first year after total laryngectomy and its pathogeny is still not clearly defined 1,[4][5][6][7] . Tumor site and disease staging, infraglottic invasion, previous tracheostomy, insufficient surgical margins after total laryngectomy, thyroid invasion by the laryngeal tumor, tumoral implants during surgery and paratracheal lymphnode metastasis are the most mentioned correlated factors in the literature .…”

“…Many methods have been proposed to prevent recurrence in the tracheostoma area, such as: lower trachea section allowing for a broader surgical margin, dissection of lymphnodes located in the paratracheal chains, emergency laryngectomies in patients that required tracheostomy prior to their laryngectomy, postoperative radiotherapy including the tracheostoma and the upper mediastinum 1,3,7,11 . Historically, recurrences in the tracheostoma area are considered very difficult to treat and are associated to little likelihood of survival 10,[12][13][14][15] .…”

Pre-operative tracheostomy does not impact on stomal recurrence and overall survival in patients undergoing primary laryngectomy

“…Indeed in this paper we have not attempted to distinguish between these particular types and classify all stomal/peri-stomal recurrences as LR. Patients presenting with local recurrence have a dismal outcome with approximately 50 % presenting in the first year after completion of treatment [3,4] and 80 % dying in the first 2 years after completion of treatment [19].…”

“…The latter technique has largely been abandoned [1] and there has been a move away from pre-operative tracheostomy (POT) towards TOL in recent years. This move has been driven by studies which showed that POT was associated with a higher risk of stomal/peristomal recurrence [2][3][4][5], and that TOL could reliably secure the airway [6].…”