Preservation of the Larynx in Laryngeal and Hypopharyngeal Cancer

In the last decade the primary treatment of laryngeal and hypopharyngeal cancer was shifted towards organ preservation, i.e. preservation of the larynx. The treatment of laryngeal cancer was changed from standard radiotherapy towards hyperfractionated radiotherapy. Hypopharyngeal cancer is nowadays mostly treated with a combination of chemotherapy and radiotherapy instead of primary surgery. Therefore, the greatest shift in treatment protocols found was for hypopharyngeal cancer. The goal of this thesis was in the first place to find out whether recurrent laryngeal cancer can be treated with preservation of the larynx and the consequences of organ preservation for the function of the “new” organ. The second goal of this thesis was to find out which treatment protocols are used in the Netherlands for hypopharyngeal cancer. Also, to find the consequences of chemoradiation protocols for surgical treatment of recurrent hypopharyngeal cancer. Chapter I is a general introduction of laryngeal and hypopharyngeal cancer. The incidences of laryngeal and hypopharyngeal cancer are mentioned. Furthermore, the biggest risk factors, being smoking and alcohol, are described. Especially, the effect of tobacco smoke on the development of laryngeal and hypopharyngeal cancer is described. Tobacco smoke contains several substances, which can cause mutations in genes. The mutations deregulate several enzyme systems and cell regulation systems, which cause degeneration of squamous cell epithelium. An overview of the other chapters of this thesis is given. In Chapter II two partial laryngectomy techniques are described. The oncological and functional results of the endoscopic CO2 laser and the frontolateral partial laryngectomy for the treatment of the recurrent glottic laryngeal cancer are described. The indications of both techniques are mentioned. Both techniques have good oncological results and less functional problems were found. With the CO2 laser 44-58% of the patients are cured with preservation of the larynx; with the frontolateral partial laryngectomy 71% was cured. It is important to realize that in case of a new recurrence, a total laryngectomy can be performed without an extra risk of failure for therapy. Both partial laryngectomy techniques, CO2 laser and frontolateral partial laryngectomy, are good treatment modalities for recurrent glottic laryngeal cancer. However, the indications for the different techniques are important and should be followed strictly. In chapter III the functional and oncological results of the third partial laryngectomy technique, cricohyoidoepiglottopexy (CHEP), is described. With the CHEP 79% of the patients are cured with preservation of the larynx. In eight patients a Flexible Endoscopic Evaluation of Swallowing (FEES) was performed to objectify problems swallowing. In none of the patients aspiration was found. Before and after the operation the voice was recorded and judged. After the operation the voice is worst. However, most patients are satisfied with there voice. The CHEP appears oncologically safe and functional for the treatment of recurrent glottic laryngeal cancer in selected patients. In chapter IV was investigated whether the quality of life is different after a partial laryngectomy versus a total laryngectomy for recurrent laryngeal carcinomas after radiotherapy. Also the voice of both groups of patients was judged. The quality of life was investigated with the EORTC Quality of Life Questionnaire (QLQ) – C30 Dutch version 3.0 and the EORTC – H & N 35 questionnaire. The only difference found was smell and taste related. The voice was judged with the Voice Handicap Index. No differences between the two groups were found. There are no big differences in quality of life after treatment with a partial or a total laryngectomy. This is mainly caused by the unexpected good quality of life after a total laryngectomy. In chapter V the treatment of hypopharyngeal cancer in the Netherlands is described. The treatment of hypopharyngeal cancer in the period 1985 – 1994 was investigated. The biggest group of patients was treated with radiotherapy alone or with combined radiotherapy and surgery. The overall 5-year disease-free survival after treatment with curative intention was 32%. The disease-free survival is better after combined surgery and radiotherapy. In chapter VI, the complications after salvage surgery in patients prior treated with radiotherapy alone or chemoradiation is described. The post-operative complication rate is significantly higher (92% vs. 50%) in the chemoradiation group. The most frequent complication found was a pharygocutaneous fistula. The quality of life, after a longer post-operative period, showed a significant difference in social functioning in disadvantage of the chemoradiation group. In the general discussion (chapter VII) the found results are discussed. The most important conclusion is that there is place for organ preservation therapy, but we must remain critical of indications and side effects of organ preservation protocols while we should realize that quality of life after total laryngectomy are not as poor as we might sometimes think.