Challenges in Laryngeal Cancer: Just Like the Text Books

Document Type

Conference Proceeding

Publication Date

7-1-2025

Publication Title

Int J Oral Maxillofac Surg

Keywords

adult, complication, conference abstract, debridement, diagnosis, drug therapy, hematoma, high risk patient, human, island flap, laryngectomy, larynx cancer, latissimus dorsi flap, male, meta analysis, middle aged, neck dissection, neoadjuvant chemotherapy, organ preservation, pharyngectomy, postoperative complication, pyriform sinus, radiotherapy, squamous cell carcinoma, surgery, survival rate, total laryngectomy, total thyroidectomy, tracheostomy

Abstract

Advancements in laryngeal cancer management have emphasized organ preservation following the pivotal results of the Veterans Affairs Laryngeal Cancer Study Group and RTOG 91-11 trials. These studies demonstrated that radiotherapy and chemoradiotherapy offered comparable survival rates to primary total laryngectomy (PTL) in advanced disease. However, progression post-chemoradiotherapy necessitates salvage surgery, which is associated with significant morbidity, including pharyngocutaneous fistula (28.9%), infection (14.1%), and bleeding (5.9%) as reported in Hasan et al.'s meta-analysis. We present the case of a 52-year-old male with T4aN0M0 squamous cell carcinoma of the right piriform sinus, initially managed with neoadjuvant chemotherapy followed by definitive radiation. Disease progression post-salvage chemotherapy led to an awake tracheostomy and definitive surgical management, including total laryngectomy, partial pharyngectomy, bilateral neck dissection (levels II-IV and VI), total thyroidectomy, and reconstruction using a supraclavicular artery island flap and latissimus dorsi flap. Postoperative complications included pharyngocutaneous fistula, neck hematoma, and stenosis, requiring iterative procedures such as esophageal diversion, wound debridement, and Montgomery salivary bypass tube placement. Final pathology revealed keratinizing moderately differentiated SCC (ypT3, ypN0). This case underscores the multifaceted challenges of salvage surgery in irradiated tissue. Vascularized flap reconstruction, as supported by current evidence, played a critical role in mitigating complications and optimizing outcomes and how we managed at our institution. This highlights the importance of a multidisciplinary approach and evidence-based strategies in managing salvage laryngectomy to achieve functional and oncologic success in high-risk patients.

Volume

54

First Page

159

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