Novel Larynx Organ Preservation Surgery

(Philadelphia, PA)- Researchers at the University of Pennsylvania Cancer Center have completed a study assessing both the oncologic outcome and quality life implications following a novel surgical technique to partially remove the larynx (“voice box”) of patients with cancer of the larynx, as opposed to a total removal of the larynx (TL). This organ preservation surgical procedure is known as the supracricoid partial laryngectomy (SCPL). The study which will be published in the February issue of Laryngoscope, demonstrates that the SPCL procedure provides excellent local control of the cancer, significantly improves a patient’s quality of life vis-a-vis the TL procedure, and suggests that many patients who underwent total voice box removal in the past could have been reasonable candidates for this partial removal procedure to save their voice box.

The treatment of larynx cancer, the most common form of head and neck cancer, can have a major impact on many aspects of the quality of life of patients, including their ability to swallow and speak, as well as their ability to breathe normally. Depending on the size and extent of the cancer, several surgical and non-surgical procedures are available as treatment options. Historically, a total removal of the larynx has been the most common treatment method in cases where the cancer was very extensive and when non-surgical interventions such as chemotherapy and/or radiation have failed, resulting in a recurrence of the cancer. The main problem encountered after total removal of the voice box is that the patient no longer breathes through their nose and mouth, and must breathe through a “stoma”, or breathing hole in the neck.

Total laryngectomy impacts on quality of life in numerous ways including: one’s self-image because of the cosmetic impact of a breathing hole in the neck, by causing swallowing dysfunction, and other problems such as a marked decrease in smell and taste because of lack of breathing through the nose. This still remains the case today in most such situations. However, the SCPL, now provides a new option for both intermediate as well as advanced size cancers, resulting in improved breathing and swallowing without the need for a permanent breathing hole in the neck, which significantly improves quality of life in these patients.

While the SPCL procedure first originated in Europe in 1959 and has been performed extensively there for years, it was not initially available to patients in the United States and was not first performed here until 1989, 30 years after it’s European introduction. Gregory S. Weinstein, MD, Associate Director of the Center for Head and Neck Cancer at Penn’s Cancer Center, the first surgeon to perform this procedure in the United States, serves as the primary instructor of this procedure in the nation “ Informing the public of this option is crucial” said Weinstein. In many situations, this procedure, can provide much less hardship to the patient, lessen the negative impact on the patient's quality of life, with just as much oncologic success and excellent local control. A patient with larynx cancer should no longer be unaware of the availability and clinical effectiveness of this procedure which has been shown to be less drastic and less debilitating” notes Weinstein.

The primary indications for the SCPL are selected cancers with intermediate to advanced stage larynx cancers in which the only other surgical option is total removal of the voice box. A second important indication of the SCPL is as an alternative to non-surgical approaches such as radiation or chemotherapy and radiation when the risk for treatment failure may be high. The final indication is for patients who already underwent radiation therapy for very early cancers of the voice box and then had the cancer recur. Unfortunately, if a patient undergoes radiation or chemotherapy and radiation for an intermediate or advanced cancer and then has a recurrence in the voice box, they are almost never a candidate for a SCPL at that point. The cure rate in the voice box following SCPL, however, is consistently in the 90% range.

Quality of post-operative life is a key concern for surgeons and patients alike. All medical treatments have some degree of acute and chronic side effects. The expected outcome after SCPL is temporary difficulty swallowing, a temporary breathing tube in the windpipe (“tracheostomy”) and some degree of permanent hoarseness. In addition, post-surgical voice box swelling occurs. Although this swelling is temporary, a temporary tracheostomy tube is put into the windpipe, but typically removed after two weeks.

Speech after total removal of the voice box is frequently facilitated by either an implanted or hand-held prosthetic device. The SPCL patient, who will have some degree of permanent hoarseness, is able to speak without the need for a permanent breathing hole in the neck and without the need for using prosthetic tone/voice generators. Evidence suggests that the absence of such prosthetic devices has a significant positive effect on the patient's physical functioning, general health, vitality and emotional state. Generally, three months after the SPCL procedure, treatment and rehabilitation have ended, the patients’ quality of life issues such as eating, breathing, speaking and other activities of life far exceed his or her initial expectations. What the SPCL procedure now allows for is the local control of cancer, while preserving enough of the larynx to allow for speech and swallowing without the need for a permanent tracheostomy, concludes Weinstein.

Also contributing to this study performed at the University of Pennsylvania and to this article were Mohamed Mahmoud El-Sawy, MD and Mostafa Mohamed El-Sayed, MD of the Al-Ashar University, Cairo, Egypt, Cesar Ruiz, MA, Patricia Dooley, MA, and Ara Chalian, MD, University of Pennsylvania and Andrew Goldberg, MD, University of San Francisco.