Search

Carcinomas of the larynx and hypopharynx tend to present as local-regional disease that often requires multidisciplinary management. Preservation of function, as well as anatomy, can be paramount in the decision-making process. This tends to favor radiation therapy in the selection process. Treatment can, and should, be tailored to match the virulence of individual tumors and the impact of such therapy on individual patients.

It is generally accepted that tumors with vocal fold fixation are unsuitable for conservation surgery because the lower resection margin of a partial laryngectomy is confined to the upper part of the cricoid cartilage. Preservation of the cricoid is essential to allow for postoperative decannulation, whereas a rational ablation of a T2 (extending subglottically) and T3 glottic cancer necessitates the resection of the paraglottic space and its contiguous structures, including the thyroid and cricoid cartilages. Currently, the surgical treatment of advanced, unilateral glottic cancer consists of a total or a near-total laryngectomy, with a resulting permanent tracheostomy. Advanced, unilateral glottic cancers may fall within the scope of partial laryngectomy, if a laryngeal remnant consisting of one thyroid ala with the corresponding true vocal cord and one half of the cricoid, with one mobile arytenoid, can be reconstructed. The desired repair tissue for this difficult defect may be found inside the trachea.

Concerns have been expressed about the weakness of the T classification for laryngeal cancer, and for cancers at other head and neck sites, as the cure rates reported in the literature vary and prognosis is not sufficiently related to the T values (BAILEY 1991; HARRISON 1988; PICCIRILLO 1995). Modern radiologic imaging methods assist in pretreatment planning by defining the extension of infiltrating head and neck tumors better, and, moreover, quantitative evaluation of tumor volume is feasible. In this chapter the use of pretherapeutic imaging in coming to a more refined estimation of the local outcome of laryngeal cancer after radiation treatment is discussed.

In this paper we describe the current state of our surgical planning environment for a conservation method for unilateral glottic cancer with significant subglottic extension. The latter consists of a hemicricolaryngectomy and subsequent reconstruction of the laryngeal defect with a transferable patch of revascularized cervical trachea.

Of the 182 patients with early squamous cell cancer of the true vocal cord treated from 1962 to 1974 at the Mayo Clinic, 47 (26%) had complications during the operation, during the postoperative hospitalization, or later (Table 1) (Neel et al. 1980).

The operative care extends from the preparation of the patient for sugery, until his discharge from the hospital.

Early subglottic spread and high tendency to penetrate through the framework were described as typical behaviour of carcinomas at the anterior commissure of the cords (Broyles 1943; Ogura 1955; Leroux-Robert 1957; Kirchner 1970; Olofsson et al. 1972; Tucker 1973; Bridger 1974). From 1966 to 1972 more than five hundred glottic carcinomas were treated and histologically investigated in the Department of Otorhinolaryngology of the University of Frankfurt.

The histological T-classification (pT) of laryngeal carcinomas correlates well with the prognosis (Norris et al. 1970; Meyer-Breiting 1981). But the clinical T-classification often fails because the examination was limited to superficial findings and indirect signs. 1977 Mancuso and coworkers produced a first report about the use of computerized tomography (CT) for the investigation of laryngeal cancer. Since 1980 we have tested the availability of the computerized tomography for the investigation of laryngeal cancer in cooperation with various radiological institutes of the Frankfurt region. The radiological findings have been compared with our histological observations in serial whole organ sections of the completely or partially resected larynx. During this procedure we were interested in clarifying the following points: 1. of what value is the CT scan deciding on conservative surgery? 2. Which anatomical structures can help to reveal the extent of the tumor? 3. Where are the limits of CT for laryngeal tumors, and what are its consequences for conservative surgery of the larynx.

Dealing with the indications for surgery or radiotherapy for laryngeal cancer, two propositions can be formulated with regard to oncological and functional results: 1. Post-operative radiotherapy is not indicated after a partial vertical laryngectomy, because the surgical resection must be extensive enough to cure the carcinoma. 2. If the tumor is too large to allow a partial vertical laryngectomy, pre-operative radiotherapy does not change the surgical indication.