Abstract
Background/Aim: Total glossectomy without laryngectomy for large tongue carcinomas still remains controversial, as these defects may go along with dramatic effects on respiration, speech and swallowing. As a consequence, these procedures significantly impact quality of life. Therefore, larger case series are rare. Nevertheless, with the development of free tissue transfer, functional reconstruction has become increasingly popular and encouraging results are reported in the literature. Patients and Methods: We present our experience with complete glossectomy without laryngectomy and free flap reconstruction. A retrospective monocenter cohort-study was conducted. Reconstructive principles, which in our view lead to optimal functional results, are presented. Oncologic, as well as functional results are reported. Functional results were assessed in terms of swallowing ability, decannulation and intelligible speech. Results: A total of 14 patients met the inclusion criteria. All patients were reconstructed using an anterolateral thigh flap. Complications occurred in 4 patients, 3 of which developed fistula formation. Oral feeding without the need for a gastrostomy tube was resumed in 11 patients (78.6%), 12 patients (85.7%) were able to be permanently decannulated and speech was at least acceptable in 12 patients (85.7%). The three-year survival was 57.1%. Conclusion: Following meticulous reconstructive principles, as well as a proper patient selection, total glossectomy without laryngectomy is a feasible treatment option for advanced cancer of the tongue.
Total glossectomy as treatment for advanced tongue cancers was first described by Kremen in 1951. As reconstructive options were limited at that time functional results were devastating for the affected patients (1). The tongue is essential for speech and swallowing, so these operations lead to a significant impairment or loss of function. As a consequence, patients suffer from aspiration, so a simultaneous laryngectomy had to be performed in the majority of the patients. Only when Ariyan introduced the pectoralis major musculocutaneous flap, larger head and neck defects could be reconstructed in a satisfactory manner (2). Still, total laryngectomy remained challenging as the required bulk, that allows for intelligible speech and swallowing postoperatively, can hardly be achieved using a pectoralis major flap (3). The introduction and increasing use of free flaps led to a significant improvement in reconstructive techniques, that allowed for the reconstruction of most complex defects with satisfactory functional results, including the total glossectomy.
The objective of this study was to present our findings for patients reconstructed with a free flap after total glossectomy. Functional as well as oncological results are presented. Furthermore, we illustrate surgical principles, that in our view are crucial for a satisfactory outcome.
Patients and Methods
Ethics approval was granted by the Ethics Board committee of the Ludwig-Maximilians-University of Munich.
Patient selection.
Inclusion criteria
Advanced squamous cell cancer of the tongue (oral tongue, base of tongue or both) with resection of 100% tongue volume (tip to vallecular), as well as large parts of the floor of mouth.
Surgical approach: mandibular lingual release approach.
Exclusion criteria
Resections of less than 100% of tongue volume
Carcinomas other than squamous cell cancer
Resections extending into the oropharynx outside the tongue base
Infiltration of the mandible
Infiltration of the supraglottis
Surgical approach different to mandibular lingual release approach (e.g. mandible split)
Second head and neck cancer outside the tongue
Treatment. Prior to establishing a treatment regimen all patients underwent a panendoscopy and a metastatic workup, including a CT scan of the neck and thorax, and a MRI of the neck if regarded as advantageous. All cases were discussed in the interdisciplinary tumor board. Patients with severe premorbid conditions as decreased pulmonary function or pre-existing cerebral dysfunction were considered poor candidates for glossectomy without laryngectomy, as functional results are significantly worse in the literature (4). All patients were provided a gastrostomy tube before the operation.
Resection. The surgical approach was a mandibular lingual release approach as described by Stanley et al. (5). Bilateral neck dissection was performed if not already performed in a prior surgery or if the neck had been irradiated before. The superior laryngeal nerve was identified bilaterally and preserved in all cases. A perioperative tracheostomy was performed in all of the cases.
Reconstructive principles. The neotongue was created from an anterolateral thigh flap (ALT) in all of the cases. It is absolutely essential for intelligible speech and swallowing function that the neotongue has contact to the palate (6, 7) (see Figure 1). Therefore, bulky flaps, like the ALT, that can be harvested with vastus lateralis muscle to achieve an adequate protuberance, are used for reconstruction. As flaps tend to decrease in volume over the time, it is mandatory to use flaps bigger than the initial defect (7). Most authors recommend using flaps 30% larger than the original defect for the reconstruction (8). Sensory and motor innervation of the flap remains at least controversial (9), as there is a lack of adequate studies comparing reinnervated and non-reinnervated flaps. As a result, we do not perform any reinnervation, neither sensory nor motor reinnervation in our reconstructions.
Additional to a bulky flap, a laryngeal suspension is mandatory to achieve sufficient swallowing function after total glossectomy. As reported by Weber et al. permanent circumhyoid sutures, that suspend the larynx superiorly and anteriorly, bring the larynx into an elevated position, as it occurs during a normal swallow. Patients with laryngeal suspension benefit significantly regarding swallowing function compared to patients without suspension after total glossectomy (10). To achieve an adequate suspension, we perform the tracheostomy at the end of the surgery whenever possible. Prior attachment of cervical skin to the trachea hinders laryngeal suspension significantly, which is the case when tracheostomy is performed before the tumor resection.
Rehabilitation. Patients were enrolled in a postoperative speech and swallowing rehabilitation, starting as soon as postoperative day three.
Functional results. The assessment of oral diet and speaking was carried out 6 months after surgery. The ability to swallow was rated using a four-grade scale:
1: good oral diet with the ability to eat soft food without the need for a gastrostomy tube,
2: acceptable oral diet with the ability to drink enough high-calorie food supplement without the need for a gastrostomy tube,
3: poor oral diet with the need for a gastrostomy tube,
4: no swallowing possible, oral diet completely dependent on gastrostomy tube.
According to the method proposed by Yanai et al. speech intelligibility was assessed using a three-grade scale (11):
1: good speech without the need for repetition,
2: acceptable, difficult to understand with the need for repetitions,
3: poor, speech is only occasionally understandable.
Results
One hundred and one patients treated between 2007 and 2015 were retrospectively reviewed, 14 met all of the inclusion criteria. Patient characteristics including complications and functional as well as oncological results are presented in Table I. In eight patients total glossectomy without laryngectomy was performed as a salvage procedure after failed previous surgery and/or unsuccessful treatment with radiochemotherapy. At the time of surgery seven patients had been irradiated before. In seven patients, the operation was performed as primary treatment. All patients that had not been treated with radiotherapy before glossectomy received adjuvant radio(chemo)therapy afterwards.
Pathological analysis of resection and frozen sections showed positive margins in two patients, both irradiated before. All tumors were negative for HPV. No flap losses occurred within the cohort. Four patients developed postoperative complications, all of them irradiated before: three patients developed a fistula formation which was treated conservatively in two of the patients. One patient underwent reconstruction with an additional pectoralis major pedicled flap to treat the fistula. Another patient developed haemorrhage on day 5 after surgery. The bleeding, originating from a branch of the left facial vein, was stopped successfully under general anaesthesia. Another three patients developed dehiscence of sutures intraorally, but did not develop a fistula. As the dehiscence healed by secondary wound healing without any consequences, these were not numbered among complications. We believe this is due to the use of bulk ALT flaps containing large amounts of subcutaneous tissue. As long as no mandibular bone is exposed, the large amount of tissue allows for satisfying secondary healing in this area.
A total of 12 out of 14 patients were permanently decannulated. One patient was decannulated but the tracheostomy had to be reopened four weeks later due to a severe pharyngotonsillitis with consecutive dyspnoea. The tracheostomy was closed again for a second time after another 3 months. The median time to decannulation was 56 days (ranging from 10-225 days). Speech intelligibility was good in seven patients and acceptable in five patients. Two patients, both irradiated before, were not able to develop acceptable speech intelligibility. Concerning oral diet, seven patients achieved good results, whereas four patients achieved acceptable oral diet. Two patients were still dependent on their gastrostomy tube although swallowing of fluids was possible. One patient did not regain swallowing ability at all. Patients that had a poor speech intelligibility also performed worse regarding swallowing.
Bulky neotongue reconstructed with an anterolateral thigh flap one year postoperatively after total glossectomy without laryngectomy.
Median follow-up of patients was 19.5 months, ranging from 9 to 72 months. Overall three-year survival was 57.1%. Local disease control was achieved in 10 patients. All patients with local recurrence died from the disease. Both patients showing positive margins initially developed a local recurrence. Thus, local disease control for patients with free resection margins was 83.3% (10/12). One patient developed regional neck metastasis and one patient distant metastasis (lung), both of them dying from the disease. One patient developed an independent lung cancer, and being treated with chemotherapy.
Discussion
Locally advanced cancer of the tongue is a severe menace to function and survival of the affected patients. Usually, treatment options combine a multimodal approach including surgery and chemoradiotherapy. When surgical resection requires a total glossectomy it becomes absolutely mandatory to restore functional aspects as well as possible. Several options of reconstruction exist, including pedicled and free flaps. In the literature, reconstruction with pectorals major myocutaneous flaps allows recovery of swallowing function in up to 60% of the patients, although in many cases only when a simultaneous laryngectomy is performed (12, 13). Free flaps usually allow transfer of larger tissue-volume, the ALT and the rectus abdominis flap being the most frequently flaps used, as these flaps contain the most bulk of soft tissue (14, 15). In a series of 30 patients, Kimata et al. assessed the connection of shape and volume of the reconstruction with the functional results (6). Their findings showed a significant improvement of function when tongue reconstruction was protuberant, as bulky flaps allow bolus propulsion by closure of the mandible to initiate the pharyngeal phase of swallowing.
As there is now standardized outcome evaluation, it is difficult to compare results in the literature. Yanai et al. made an attempt to standardize speech outcome when they presented their three-stage classification system. They achieved an acceptable or good speech quality in 82% of their 17-patient cohort. Our results, achieving 85.9% good or acceptable quality of speech seem comparable. While these results are encouraging, it is important to keep in mind that patient numbers are low. Additionally, negative results might not be published in the literature by other institutions. Regarding swallowing it is even more difficult to compare results in the literature. Many authors chose gastrostomy tube dependency as a criterion, but this might be to imprecise as a measure for swallowing ability. Some patients are able to consume oral diet, but feel more secure when they still have a gastrostomy tube as supporting measure. Swallowing takes significantly more time and some patients feel exhausted by the duration of their meals. Therefore, we chose a more precise differentiation of swallowing quality. Nevertheless, with a gastrostomy tube dependency of 21% our results seem to be at the upper end compared to the available literature (9, 16-18). Decannulation rates in the literature vary between 65 and 95% depending on the reconstructive approach used by the different authors (8). Laryngeal suspension, as proposed by Weber et al. and described above, may significantly reduce aspiration and improve decannulation rates (10). As laryngeal suspension sutures are regularly used in our patient collective, we were able to achieve of 85.7% decannulation rate.
Patient characteristics including functional and oncological results.
As expected, survival rates of patients treated with glossectomy as a primary treatment is better than survival of patients treated with salvage surgery. Weber et al. and Barry et al. found significantly better survival rates when they analysed their cohorts for patients that had not undergone radiotherapy before (10, 19). They observed an overall two-year survival of 51% and a three-year-survival of 32%, respectively. We believe that our promising 3-year survival rate of 57% is due to only 50% of patients that received the surgery as a salvage procedure. Again, patient numbers are low, so one has to very careful with statistical statements. In a larger series of patients treated with glossectomy with and without laryngectomy, prognostic factors associated with worse survival rates were T4-stadium, preoperative radiotherapy, male sex and presence of positive lymph nodes (20). Barry et al. found that free margins and bone invasion were significantly correlated with poor survival (19). This correlates with our observation, as both patients with postoperative positive margins deceased of local recurrence. It also reflects the agreement in the literature, as clear margins are a crucial factor for local disease control. Furthermore, it seems more likely that positive margins are achieved when patients underwent radiotherapy before surgery (18).
As with every retrospective evaluation, there are limitations to this study. Patient numbers are small and data were collected from only one study center. As a consequence, patient selection might have been significantly biased. On the other hand, only few larger case series exist in the literature. As mentioned the comparability is sometimes limited, as other institutions have different standards concerning intraoperative techniques and decisions. Furthermore, postoperative evaluation of function differs significantly. However, we believe that our study contributes valuable information to show that glossectomy without laryngectomy is a reasonable therapy regimen for patients with advanced carcinoma of the tongue.
Conclusion
Total glossectomy without laryngectomy is a successful treatment regimen for patients with advanced cancer of the tongue as a primary treatment. As a salvage treatment survival rates remain poor. Following meticulous reconstructive principles, as well as a proper patient selection, the procedure may lead to good functional results, regarding the dependency on tracheostomy, intelligibility of speech, and swallowing.
Footnotes
Conflicts of Interest
The Authors declare that they have no conflict of interest.
- Received June 18, 2017.
- Revision received June 30, 2017.
- Accepted July 3, 2017.
- Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved
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