Wei Zhong Ernest Fu*, Ming Yann Lim, Jeevendra Kanagalingam and Christopher GL Hobbs
Department of Otolaryngology, Tan Tock Seng Hospital, Singapore
Received: 06 June, 2016; Accepted: 14 July, 2016; Published: 15 July, 2016
Dr, Ernest Fu, Department of Otolaryngology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, E-mail:
Ernest Fu WZ, Lim MY, Kanagalingam J, Hobbs CGL (2016) Outcomes following total Laryngectomy for Squamous Cell Carcinoma at a Singapore Tertiary Referral Centre. Arch Otolaryngol Rhinol 2(1): 038-043. DOI: 10.17352/2455-1759.000021
© 2015 Ernest Fu WZ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Laryngectomy; Larynx; Hypopharynx; Survival; Tracheostomy
Objectives: To evaluate the clinical outcomes and complications following total laryngectomy in a South-East Asian Population.
Design: 10-year retrospective review of cases of total laryngectomy or laryngo-pharygectomy.
Main outcome measures: 5-year overall survival (OS) and disease-free survival (DFS).
Results: 61 patients of which 55 (90%) had laryngeal SCC while 6 (10%) had hypopharyngeal SCC. Overall median survival was 85 months. 5-year OS and DFS for laryngeal SCC were 65% and 47% respectively while 5-year OS and DFS for hypopharyngeal SCC were both 33%. Most common cause of death was due to advanced cancer secondary to disease recurrence.
Conclusion: Although there is increasing tendency towards laryngeal preservation, surgery remains a safe treatment option for selected patients with laryngeal and hypopharyngeal SCC. In our local population, patients often present late with advanced cancer, as demonstrated by the high rate of emergency preoperative tracheostomy. However, there is no evidence that this affects survival.
Squamous cell carcinomas (SCC) of the larynx is the one of the most common cancers of the head and neck region, accounting for 2.4% of new malignancies and 0.7% of all cancer deaths worldwide every year . Hypopharyngeal SCCs, although less common, carry a poor overall prognosis. Worldwide estimation of 5-year overall survival (OS) of laryngeal and hypopharyngeal cancers ranges from 32 to 70% and 7 to 35% respectively [2,3].
In Singapore, there has been an overall decline in incidence rates among males from 6.8 per 100,000 in 1968-1972 to 3.7 per 100,000 in 2003-2007. Laryngeal cancer constituted only 1.2% of all male cancer deaths in 2003-2007. As consistent with the global pattern, laryngeal cancer exhibits a marked male predominance. In 2003-2007, the male: female ratio was 10.7:1. The rates are significantly lower in Malay and Indian males compared to those with Chinese ethnicity .
Despite advances in chemoradiation, surgery continues to play an important role in the management of laryngeal and hypopharyngeal cancers. Laryngeal preservation techniques such as transoral resection with or without laser have been gaining in popularity but total laryngectomy (TL) remains the gold standard for advanced disease in selected patients.
In this context, the aims of our study was to evaluate our local patient population and report our clinical outcomes and complications following TL in a head and neck cancer unit of a tertiary hospital in Singapore.
The Department of Otolaryngology, Head and Neck Surgery at Tan Tock Seng Hospital is part of the National Healthcare Group, a regional health system for the central part of Singapore, serving a population of 1.5 million. A retrospective review of the departmental electronic database and clinical notes was undertaken between January 2000 and December 2010. The cases were reviewed for epidemiological data, tumour stage, and extent of surgery, complications and survival outcomes.
Patients who underwent TL for squamous cell carcinoma (SCC) of the larynx and hypopharynx were included, as well as those who had salvage TL for recurrence following primary radiotherapy (RT), chemoradiation (CRT) or transoral resection. Recurrence was defined as histological evidence of malignancy at least 12 months after completion of the primary treatment. Patients who had TL as part of tumour resection for cancers of other sites in the head and neck region such as thyroid, tongue base were excluded. The departmental database and patient clinical case notes were reviewed for epidemiological data, tumour stage, extent of surgery, complications and survival outcomes.
All patients were staged according to the American Joint Commission on Cancer (AJCC) staging system. If patients presented with acute airway distress, either preoperative tracheostomy or endoscopic tumour debulking would be performed. Preoperative staging of tumour was performed by endoscopy and radiological imaging (CT neck and chest). The management of all patients were discussed at the weekly head and neck multi-disciplinary team (MDT) meeting. Patients were counselled regarding possible treatment options including methods of voice restoration and informed consent for surgery was obtained. Therapeutic and selective neck dissections were performed at the time of laryngectomy in patients with or without cervical node involvement respectively. Adjuvant RT or CRT were given to the primary site and neck based on clinicopathological risk factors including status of resection margins, perineural invasion, lymph node involvement and the presence of extra capsular nodal spread.
Patients were regularly followed up in the head and neck cancer clinics. The standard follow-up regime in our institution is monthly review in the 1st year, 2-monthly in the 2nd year, 4-monthly in the 3rd year, 6-monthly in the 4th year and yearly onwards from the 5th year onwards.
NHG Domain Specific Review Board (DSRB) approval was granted for this retrospective review.
Statistical analysis of the data was performed with Stata. All survival probabilities were estimated by using the Kaplan-Meier method from the day of surgery. Log-rank tests (Cox Mantel) were performed to compare differences between the estimates. Results were regarded as statistically significant if P ≤0.05.
The 2 main survival end-points considered in our analysis were the cumulative 5-year overall survival (OS) and disease-free survival (DFS). Time was calculated from the date of diagnosis to the event of interest, which was death (due to any cause) or date last known alive for OS, and first treatment failure, defined as either disease or death, for DFS. Mean survival period, together with standard error (SE) and 95% confidence interval (95% CI) were also calculated.
The review period spanned 10 years. 61 patients (60 males, 1 female) fulfilled the inclusion criteria for this study. The median age of the patients was 66 years (range 37-88 years). Eighty-seven percent of the patients were Chinese, followed by Malays at 7%, Indians 5% and Eurasians 1%. Seventy-seven percent of the patients had a positive history of smoking while 18% had a positive history of alcohol consumption. Twenty-five patients (41%) had a preoperative tracheostomy before definitive surgery while only 1 patient had endoscopic tumour debulking, thus avoiding tracheostomy.
The median post-operative follow-up period was 25 months (range 1-132). Patients stayed in hospital for a median of 19 days (range 9-120 days).
Fifty-five (90%) patients were diagnosed with laryngeal SCC, out of which 23 (42%) had glottic tumours, followed by 21 (38%) supraglottic tumours, 3 (5%) subglottic tumours and 8 (15%) transglottic tumours. Only 6 patients (10%) had hypopharyngeal SCC.
Table 1 represents the stage of disease at presentation. Overall, 52 patients (85%) presented with either T3 or T4 SCC. The remaining 9 patients (15%) had T2 tumours at presentation, of which 7 out of 9 patients had previously undergone RT, CRT or transoral resection.
Of the 42 patients (69%) who had surgery as the primary treatment modality, 38 had TL including 1 patient who had a total glossectomy while 4 had total laryngo-pharyngectomy. Thirty-two patients subsequently had adjuvant RT while 4 had adjuvant CRT.
The remaining 19 patients (31%) had salvage surgery of which 8 had previously been treated with CRT and 11 with RT which also include 2 patients with prior transoral resection. Of these, 16 had TL, 2 had horizontal partial laryngectomies (1 supracricoid laryngectomy, 1 supraglottic laryngectomy) with completion laryngectomies at a later date, and 1 had total laryngo-pharyngectomy.
Out of the cohort, 5 patients had flap reconstruction (3 pectoralis major flaps, 1 anterolateral thigh flap, and 1 deltopectoral flap and jejunal free flap). 59 patients (97%) had neck dissections at the time of laryngeal resection.
Overall, there were low rates of post-operative complications amongst the cohort.
Pharyngocutaneous fistula (PCF) was the most common post-operative complication, occurring in 8 patients (13%). Five cases were from the salvage surgery group who all did not have prior flap mucosal reconstruction, and 3 cases from the primary surgery group of which only 1 had a prior flap mucosal reconstruction. Table 2 shows the fistula rates for primary versus salvage surgery groups while Table 3 shows the fistula rates for primary mucosal closures and flap mucosal closures.
Four patients subsequently required flap repair for closure which included 1 patient who had 3 flap procedures due to recurrent wound breakdown. The other 4 cases resolved with conservative management.
The details of the rest of the post-operative complications are shown in Table 4.
Twenty-eight (46%) patients opted for the Tracheoesophageal Voice Prosthesis (TEP) whereby the puncture was performed secondarily in all but 1 case. Four patients (7%) had the electrolarynx while 29 patients (47%) did not have any final voice rehabilitation.
Overall survival outcomes
The overall median survival period following TL was 85 months.
The 5-year OS and DFS for laryngeal SCC were 65% and 47% respectively while the 5-year OS and DFS for hypopharyngeal SCC were both 33%. (Figures 1,2)