Functional outcomes of supraglottic squamous cell carcinoma treated by transoral laser microsurgery compared with horizontal supraglottic laryngectomy in patients younger and older than 65 years

Abstract

Il trattamento dei carcinomi sopraglottici rappresenta al momento una problematica controversa. Al momento sono disponibili 5 differenti opzioni di trattamento: la tradizionale laringectomia orizzontale sopraglottica (HSL), la laringectomia sopraglottica con laser CO2 (TLM), l’approccio mediante chirurgia robotica, la radioterapia e la radioterapia in combinazione con la radiochemioterapia. Alcuni studi hanno evidenziato come il rate di complicanze della chirurgia del distretto testa collo aumenti significativamente nei soggetti al di sopra dei 65 anni. Abbiamo pertanto voluto effettuare uno studio retrospettivo che confrontasse i risultati funzionali e il rate di complicanze nei pazienti al di sotto e al di sopra dei 65 anni, affetti da carcinomi squamocellulari sopraglottici T1-T3, sottoposti a laringectomia orizzontale sopraglottica tradizionale (HSL) o a TLM presso un Polo ospedaliero Universitario di terzo livello. Il gruppo di pazienti al di sopra dei 65 anni sottoposto a TLM ha mostrato differenze statisticamente significative per quanto riguarda il rate di polmonite ab ingestis (p = 0.026), tempo medio necessario al decannulamento (p = 0.001) e tempo medio di ricovero ospedaliero (p = 0.007) tutti risultati più lunghi rispetto a quelli osservati nei pazienti al di sotto dei 65 anni. Per quanto riguarda la chirurgia open, abbiamo rilevato una differenza statisticamente significativa solo per il tempo medio necessario per il decannulamento (p = 0.001) risultato essere più lungo nel gruppo di pazienti più giovani di 65 anni. In accordo coi nostri risultati sia la TLM che l’approccio open rappresentano opzioni sicure nei pazienti al di sopra dei 65 anni, ma in cosiderazione dell’aumentato rischio di polmonite ab ingestis è mandatoria un adeguata valutazione della funzionalità polmonare preoperatoria, in particolare nei pazienti trattati con TLM. Nei pazienti al di sopra dei 65 anni inoltre la TLM rispetto all’approccio open riduce il rate di tracheostomie postoperatorie, il tempo medio necessario al decannulamento e il tempo medio di ricovero. Tuttavia non è stata rilevata alcuna differenza significativa in termini di rate di polmonite ab ingestis, disfagia o tempo medio di utilizzo del sondino naso gastrico.

Prognostic Features in Intermediate‐Size Supraglottic Tumors Treated With Open Supraglottic Laryngectomy

“…23 In elderly patients over 65 years old specifically, Chiesa Estomba et al reported postoperative rates of aspiration pneumonia of 20% after open surgery and of 41.2% after TLM in supraglottic carcinoma, albeit difference was not statistically significant and the rates of dysphagia were similar, 30% versus 29.4%, respectively. 9 Together with our results, these findings argue for considering a transoral procedure rather than an open procedure for a tumor smaller than thirty millimeters when local exposition is favorable and no local extension associated with a risk of decreased local control after a transoral is suspected. Oncological results in group III with tumors of the lateral epilarynx where PES invasion is less frequent indicate that either open or transoral partial laryngectomy is a good option for selected patients, although non-surgical alternatives may be considered with tumors larger than approximately 30 mm where the risk of unfavorable pathological features is high such as lymphovascular invasion, perineural invasion, or positive margins due to pharyngeal involvement.…”

“…Regarding functional outcomes, Bertolin et al, found worse results in patients undergoing endoscopic epiglottis and PES resection compared to patients undergoing the same resection by open approach reported to the increase in the sphincter capacity potentially obtained by a compensatory effect of the laryngopexy performed in open surgery, advocating for the authors for open surgery in every case requiring resection of the epiglottis and the PES 23 . In elderly patients over 65 years old specifically, Chiesa Estomba et al reported postoperative rates of aspiration pneumonia of 20% after open surgery and of 41.2% after TLM in supraglottic carcinoma, albeit difference was not statistically significant and the rates of dysphagia were similar, 30% versus 29.4%, respectively 9 . Together with our results, these findings argue for considering a transoral procedure rather than an open procedure for a tumor smaller than thirty millimeters when local exposition is favorable and no local extension associated with a risk of decreased local control after a transoral is suspected.…”

“…[3][4][5][6] Comparative studies between supraglottic open versus transoral surgery have revealed similar oncological results, but improved postoperative outcomes after transoral procedures such as a shorter hospital stay, a lower rate of tracheotomy, and a shorter time before oral feeding. [7][8][9] Consequently, a number of teams have replaced open partial procedures with transoral approaches when deemed feasible. 4,10 However, the available evidence is limited to retrospective series based on previous experience from open surgery and there is still a need to understand the appropriate and the inappropriate indications for each procedure, particularly according to the local extensions.…”

“…Among surgical therapeutic strategies that aim to improve functional laryngeal preservation, transoral approaches by transoral laser microsurgery or more recently by transoral robotic surgery have gained acceptance as treatment modalities for limited supraglottic carcinomas, based on published evidence of feasibility 3‐6 . Comparative studies between supraglottic open versus transoral surgery have revealed similar oncological results, but improved postoperative outcomes after transoral procedures such as a shorter hospital stay, a lower rate of tracheotomy, and a shorter time before oral feeding 7‐9 . Consequently, a number of teams have replaced open partial procedures with transoral approaches when deemed feasible 4,10 .…”

Preoperative prognostic factors for functional and clinical outcomes after open partial horizontal laryngectomies

“…Many authors analyzed OPHL functional outcomes, suggesting that overall functional recovery is generally satisfactory concerning the main neo‐larynx functions (voice, breathing, and swallowing) even if a great variability can be observed 14,15 . Voice quality is usually well preserved after Type I OPHLs, since vocal folds are spared, while is highly and similarly deteriorated after Type II and Type III OPHLs 6,15–17 . Nevertheless, a satisfactory level of oral communication is generally achieved through a substitution voice 18,19 .…”