Post-laryngectomy stomal recurrence: tumour implantation or paratracheal lymphatic metastasis?

Abstract

In the treatment of obstructing laryngeal cancer, an association has often been noted between emergency tracheotomy for airway relief and subsequent post-laryngectomy stomal recurrence. It is however unclear whether this is due to tumour implantation in the tracheotomy track, or paratracheal lymph node metastasis. To investigate the pathophysiology of stomal recurrence, the recurrence rate and clinical outcome of 26 cases of T3N0M0 glottic cancer treated with emergency tracheotomy and subsequent laryngectomy were analysed, and compared with 65 stage-matched cases treated with laryngectomy alone. Analysis shows the 'emergency tracheotomy' group to have a very poor prognosis with a higher incidence of recurrence at the stoma, and also in the regional lymph nodes. These findings suggest that paratracheal lymph node metastasis is an important mechanism in the development of stomal recurrence and thus has considerable implications for the prevention of such a recurrence following laryngectomy in the patient presenting with malignant airway obstruction.

Histopathological factors influencing results of combined treatment in patients with laryngeal cancer

“…Prognostic significance of this factor is controversial, as it is most frequently related to higher tumour stage as well as poorer overall performance status of patients and thus may not be an independent prognostic factor. It should be noted that the procedure alone may result in tumour cell implantation and, consequently, the development of recurrence [32,46,47,49]. The performed analysis and the above-cited literature reports indicate that individual prognostic factors, when considered alone, may sometimes lack prognostic significance.…”

“…Meredith et al [22] suggest irradiation of the pre-existing tracheostomy region. In the literature reports, the recurrence rates in patients who have undergone emergency tracheostomy range between 27% and 71% [7,43,46,47,48]. Prognostic significance of this factor is controversial, as it is most frequently related to higher tumour stage as well as poorer overall performance status of patients and thus may not be an independent prognostic factor.…”

Recorrência na área do traqueostoma após laringectomia total

“…Although the lack of prospective studies is responsible for us not having enough information about the ideal surgical approach in the NO neck, elective neck dissection is always advocated when the risk of microscopic lymphnode disease in the neck exceeds 20% 16 . In larynx tumors, especially those that affect the infraglottic region, the lymphnode group at risk would be the paratracheal and pre-tracheal lymphnode chain, and it is possible if these are not properly investigated and treated, that they would be involved in the recurrence we see in the tracheostoma area 10,24,25 . These lymphnodes are rarely palpable and are not routinely included in neck dissections.…”

“…The different treatment modalities for these recurrences, that include surgery, radio and chemotherapy, have not been satisfactory to control the disease, and therefore, a special attention has been given to the prevention of such pathology 2,[8][9][10] . 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 .…”

“…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] . The goal of the present study is to investigate the cases of patients in our institution who suffered laryngectomy between the years of 1995 and 2004, and analyze the cases in which there was tumor recurrence in the tracheostoma area by means of the clinical findings in these patients, trying to identify some risk factors in the causation of such pathology and what could prevent it.…”