Supracricoid Partial Laryngectomy Should Be One Treatment of Choice for Intermediate to Advanced Laryngeal Cancer
Supracricoid partial laryngectomy (SCPL) should be considered as an important option for the treatment of selected intermediate to advanced laryngeal cancers because it can preserve functionality of the larynx, according to expert surgeons interviewed for this article. SCPL, developed as an alternative to total laryngectomy for selected glottic and supraglottic carcinomas, typically preserves a patient’s ability to speak and swallow while at the same time assuring a high rate of local control of cancer.
Slow to Catch On
Despite the advantages of SCPL, a confluence of factors has kept this procedure from enjoying more widespread use in the United States.
“SCPL avoids total removal of the voice box and is a particular advance for the surgical management of selected intermediate and advanced as well as some recurrent cancers of the larynx,” stated Gregory S. Weinstein, MD, Professor and Vice Chair of the Department of Otorhinolaryngology–Head and Neck Surgery at the University of Pennsylvania in Philadelphia.
“SCPL avoids total removal of the voice box and is a particular advance for the surgical management of selected intermediate and advanced as well as some recurrent cancers of the larynx.” – Gregory S. Weinstein, MD
Dr. Weinstein helped introduce the technique in the United States and has written widely about his experience with SCPL. He explained that SCPL “passes the test” of saving the voice box and preserving the patient’s ability to speak and eat without a permanent tracheostomy or gastrostomy tube two years after the procedure—the point when no local recurrence is expected. Dr. Weinstein stated that he has colleagues that can perform SCPL who are within driving distance of any patient in the United States.
“SCPL is a remarkable, unprecedented advance as a surgical option for intermediate to advanced laryngeal cancers. Despite the opportunity for using this technique, it is not as widely implemented as it should be,” explained Chris Holsinger, MD, Assistant Professor at M.D. Anderson Cancer Center in Houston, Tex., a surgeon experienced with the technique and author of several articles about SCPL.
Development of SCPL
In 1959, two surgeons working in Vienna proposed the idea of removing most of the larynx and attaching the hyoid bone (tongue base) to the cricoid cartilage, Dr. Holsinger explained. The technique was published in French and was greeted with enthusiasm in Paris. Over the next 20 years, three French surgeons—Laccoureye, Labayle, and Piquet—improved on the technique. These surgeons published papers in the early 1970s that advanced the technique and refined patient selection, Dr. Holsinger continued.
SCPL was categorized by Henry Laccoureye, who provided a nomenclature to describe these approaches: cricohyoidoepiglottopexy (CHEP) for glottic cancer, which preserves the epiglottis, and cricohyoidopexy (CHP) for supraglottic cancer, which includes removal of the epiglottis because the cancer has spread to it, explained Erich Sturgis, MD, Associate Professor at M.D. Anderson Cancer Center in Houston, Tex. Dr. Sturgis noted that CHEP is a less complicated procedure, “from a functional point of view.”
During the period that CHEP and CHP were being described in France, total laryngectomy was the procedure of choice in the United States, and exploratory studies were being done using radiotherapy and chemotherapy to treat laryngeal cancer.
Over the next 20 years, supracricoid CHP and CHEP were widely performed in France.
“Most head and neck surgeons in France were able to perform these procedures. However, only a handful of US surgeons were aware of SCPL, and still only about two dozen surgeons in the US regularly perform SCPL and its variations,” Dr. Holsinger stated.
“Only about two dozen surgeons in the US regularly perform SCPL and its variations.” – Chris Holsinger, MD
Introduction of SCPL in the US
In the summer of 1990, Olivier Laccoureye, a surgical resident from France who was fluent in English, visited the University of Iowa where he met Dr. Weinstein and taught him about SCPL. The two surgeons collaborated on the first articles on SCPL to be published in the English language, and Dr. Weinstein did the illustrations for the articles.
“At the time, SCPL was considered radical and the publications were greeted with skepticism. Over the next five years, Laccoureye and Weinstein published more papers and gave talks around the US and trained other surgeons in the technique, teaching them about the need to preserve the cricoarytenoid joint,” Dr. Holsinger said.
“A comprehensive surgical approach with SPCL became a new surgical option that did not leave patients with a permanent tracheostoma. It was clear that one could remove virtually the entire larynx, saving the arytenoids, and then place strong stitches between the cricoid and hyoid, allowing patients to retain the ability to speak and swallow,” Dr. Holsinger commented.
SCPL is a reasonable option for advanced or intermediate vocal cord cancers where the cricoarytenoid joint is still mobile.
Total laryngectomy creates a stoma in the neck, which has a negative impact on quality of life. Further surgery and a plastic speaking valve are necessary for speech. “They can never again go swimming,” Dr. Holsinger said, “and social functioning is profoundly affected.”
Radiation and Chemotherapy
In the spring of 1991, the New England Journal of Medicine published the VA study, which found no difference in survival between total laryngectomy plus radiotherapy versus chemotherapy plus radiotherapy as treatment of laryngeal cancer (N Engl J Med. 1991;324(24):1685–1690). After the VA study, chemotherapy and radiation were widely adopted as standard treatment for intermediate to advanced laryngeal cancers. The prevailing opinion was that surgery was not necessary for laryngeal cancer, and the role of surgeons has diminished.
Subsequently, RTOG 91–11, a definitive study published in 2003, confirmed that chemotherapy plus radiotherapy RTX achieved a long-term 84% control rate in patients with laryngeal cancer. This therapy allowed organ preservation, and the notion of organ preservation gained prominence as a treatment goal. However, over time it became clear that organ preservation did not necessarily equate to functional preservation, Dr. Holsinger explained. Dr. Weinstein noted that at two years, 15% of patients who underwent concurrent chemotherapy and radiation have swallowing difficulties and it is not clear from the study what percentage of those patients required a permanent gastrostomy tube.
More well-designed scientific studies are needed to explore which patients should receive chemotherapy and radiotherapy versus SCPL.
With greater experience using this nonsurgical approach, it became clear that despite preservation of the larynx with chemotherapy and radiotherapy, some patients had poor functional outcomes, requiring gastrostomy tubes and in some cases even a tracheotomy. Also, some patients treated with chemotherapy and radiotherapy developed disease progression.
More well-designed scientific studies are needed to explore which patients should receive chemotherapy and radiotherapy versus SCPL.
“We began to realize that while there is a role for radiotherapy and chemotherapy, preservation of function is as important as organ preservation. If the group with poor functional outcomes and/or tumor failure had received SCPL, functional outcomes might have been superior. This includes bulky T2-T3 glottic and supraglottic laryngeal cancers,” Dr. Holsinger said.
Patient Selection
Right now, there are no prospective randomized data to guide patient selection, Dr. Sturgis said. However, SCPL is a reasonable option for advanced or intermediate vocal cord cancers where the cricoarytenoid joint is still mobile.
According to Dr. Weinstein, SCPL is suitable for patients with selected T2, T3, or T4 cancers of the larynx and for selected patients who have failed radiation.
Dr. Sturgis said that recurrent vocal cord cancers with involvement of the anterior commissure but without significant supraglottic extension are probably the easiest radiation failure cases to justify the use of SCPL. He noted that patients selected for SCPL must be reasonably healthy with good pulmonary function to be able to clear secretions.
Despite the advantages of SCPL, a confluence of factors has kept this procedure from enjoying more widespread use in the United States.
Indications and Contraindications for SCPL with CHP and with CHEP
Dr. Weinstein said that indications for SCPL with CHP include (1) supraglottic carcinomas with glottic extension; (2) supraglottic carcinomas with preepiglottic space invasion; (3) transglottic carcinomas; and (4) selected supraglottic carcinoma with limited thyroid cartilage invasion.
Contraindications include (1) massive invasion of the preepiglottic space, because involvement of the hyoid bone would preclude preservation of this structure; (2) involvement of the pharynx or interarytenoid area; (3) cricoid cartilage invasion and infraglottic extension of the tumor reaching the cricoid; (4) arytenoid cartilage fixation; and (5) respiratory impairment (such as severe chronic obstructive pulmonary disease).
“As a more vocal group of surgeons has advocated for SCPL, surgery may find a greater role in primary treatment of intermediate-stage laryngeal cancer and certainly for selected radiation failures.” – Erich Sturgis, MD
For SCPL with CHEP, Dr. Weinstein said that indications include selected lesions with: (1) bilateral cord involvement (i.e., horseshoe lesions); (2) impaired true vocal cord mobility with limited subglottic and ventricular extension; or (3) true vocal cord fixation without arytenoid fixation.
Contraindications for SCPL with CHEP include: (1) preepiglottic space invasion (utilize SCPL with CHP in this case); (2) cricoid cartilage invasion or infraglottic invasion reaching the cricoid cartilage; (3) arytenoid cartilage fixation; or (4) respiratory impairment.
SCPL, though, is not possible in patients with cricoarytenoid joint fixation and those with spread of cancer between the arytenoids cartilages, to tongue base above, or far below the vocal cords, Dr. Holsinger commented.
A recent publication by Dr. Weinstein’s group at University of Pennsylvania suggests that SCPL can be safely performed in selected cancers with subglottic extension of 15 mm or less and without arytenoids fixation (Laryngoscope 2005;115:297–300). The surgery was found to achieve oncologically safe organ preservation in glottic cancers that extended beyond the traditionally accepted subglottic limit of 10 mm, Dr. Weinstein explained.
Which Procedure is Best?
At present, it is not clear which procedure provides the best functional outcomes in intermediate to advanced laryngeal cancer—chemotherapy and radiation, SCPL using CHEP or CHP, or laser surgery, which has gained popularity. Dr. Holsinger noted that laser surgery, removing laryngeal structures through the mouth, necessitates dividing the tumor in half, “and this violates Halsted’s classically accepted oncologic principles.”
“The choice between chemotherapy and radiation versus SCPL is up in the air. For diffuse tumors, SCPL is not optimal, but many patients who could benefit from SCPL are currently treated with chemotherapy and radiotherapy,” Dr. Holsinger said.
“Unfortunately, as surgeons, we don’t have level —A’ evidence-based medicine studies that support this approach, such as a randomized prospective trial—despite strong support for SCPL among otolaryngologists,” Dr. Holsinger said.
More well-designed scientific studies are needed to explore which patients should receive chemotherapy and radiotherapy versus SCPL. Dr. Sturgis said that academic centers like M.D. Anderson use a multidisciplinary approach with group decision-making to determine treatment recommendations. “As this multidisciplinary approach has gained acceptance in much of the US, radiotherapy or chemoradiotherapy became the standard for intermediate-stage laryngeal cancers. However, as a more vocal group of surgeons has advocated for SCPL, surgery may find a greater role in primary treatment of intermediate-stage laryngeal cancer and certainly for selected radiation failures,” Dr. Sturgis commented.
Dr. Weinstein stated, “When patients with early or advanced laryngeal cancer are candidates for surgical approaches that preserve the larynx, it is the standard of care to discuss the surgical and nonsurgical organ-preserving options with the patient and allow the patient to participate in the choice of appropriate treatment.”
In Dr. Holsinger’s opinion, the biology of the cancer should drive treatment. It is clear that some patients will respond well to radiotherapy, but other patients who have a tumor response to radiation may suffer impairment and poor functional outcome from radiation-induced scarring. Dr. Holsinger speculated that patients with this radioresistant aggressive disease might benefit from an upfront surgical approach (SCPL) to avoid the toxic effects of radiotherapy. He spoke of the need for future molecular studies that explore broader concepts, such as evaluating treatments based on tumor characteristics, such as genomic and proteomic studies—not on avoiding the perceived consequences of surgery.
“Chemoradiation isn’t a walk in the park either,” Dr. Holsinger commented.
Success of SCPL
Dr. Sturgis outlined several criteria that are required for successful SCPL procedures.
Patient selection is a critical factor, he noted, as is surgical experience in performing the procedure. Important technical aspects which ultimately result in limiting aspiration include preservation of laryngeal innervation and performing an adequate impaction (pexy) by pulling the base of the tongue and attaching it to the cricoid cartilage.
Patients who undergo SCPL must have adequate pulmonary function to clear secretions. It is also important for patients to be seen by an experienced speech pathologist after surgery for appropriate rehabilitation for swallowing. “It often takes time to learn how to swallow again after either chemoradiation or surgery,” Dr. Sturgis explained.
Although more research is needed to refine patient selection and to determine the relative benefits of procedures for treating intermediate to advanced laryngeal tumors, “SCPL should join the ranks of accepted procedures for T2 and T3 tumors,” Dr. Holsinger stated.
©2006 The Triological Society