UZ Leuven

Laryngeal repair after resection of advanced cancer: an optimal reconstructive protocol. Delaere P, Vander Poorten V, Vranckx J, Hierner R.Eur Arch Otolaryngol 2005;262:910-6.Abstract: Tracheal autotransplantation allows for reconstruction of extended hemilaryngectomy defects after resection of laryngeal cancer. With this technique, optimalfunctional results were obtained after a learning curve of more than 50 patients. The objective of this paper is to present the final reconstructive concept with the typical indications. Unilateral glottic cancer and lateralized chondrosarcomas of the cricoid cartilage are resected with a hemilaryngectomy including one-half of the cricoid cartilage. After tumor resection, a radial forearm flap with a skin paddle and a fascial paddle are taken. The skin paddle restores the laryngeal defect temporarily, and the fascial paddle wraps the upper 4 cm of cervical trachea. A tracheostomy is preserved in the area between the reconstructed larynx and the fascia-wrapped trachea. The radial forearm vessels are sutured to the neck vessels. After 4 months, the skin island of the radial forearm flap is removed from the defect and the revascularized, fascial enwrapped trachea is  transplanted to the laryngeal defect. The tracheal continuity is re-established with preservation of a tracheostoma. The tracheotomy can be closed after 6 weeks. Two case reports are presented: a unilateral T3 glottic cancer and a chondrosarcoma of the cricoid cartilage. The two patients showed normal oral feeding 1 week after the operation. Hand-free speaking was possible after closure of the tracheostomy. Tracheal autotransplantation after vascular induction of the trachea with the radial forearm flap leads to optimal repair of extended hemilaryngectomy defects.

Tracheal autotransplantation as a new and reliable technique for the functional treatment of advanced laryngeal cancer. Delaere P, Hermans R. Laryngoscope 2003;113:1244-51. Abstract: Objectives/Hypothesis : Tracheal autotransplantation allows for reconstruction of  extended hemilaryngectomy defects (including half of the cricoid cartilage) after resection of laryngeal or hypopharyngeal cancer. A series of 38 patients underwent the operation. The technique involved a two-stage procedure (stage 1, tracheal revascularization; stage 2, hemilaryngectomy and tracheal autotransplantation) because the trachea requires at least 2 weeks for revascularization. The objective was to improve the oncological reliability of the procedure by performing a one-stage tumor resection. Study Design: Five patients who underwent a one-stage tumor resection are presented. They had T2 (n = 3) to T3 (n = 2) N0 laryngeal tumors. Methods: Neck dissection, tumor resection, and tracheal revascularization were all performed during the first operation. The radial forearm fascia flap was designed with a distal fascial paddle and a proximal skin paddle. A 4-cm segment of cervical trachea was wrapped with the fascial paddle for revascularization, and the skin paddle was used for temporary closure of the extended hemilaryngectomy defect. The definitive reconstruction consisted of tracheal autotransplantation and was performed 4 months after the first procedure. Medical records were reviewed to determine time to oral intake, time to decannulation, length of hospital stay, and postoperative complications. Results : After the first operation the skin paddle of the radial forearm flap succeeded in a restoration of the sphincteric function. The mean time to oral intake for solids was 9.0 days (SD = 2.6 d) and the mean length of hospital stay was 11.2 days (SD = 2.2 d). All patients were able to speak with the tracheal cannula in place. All laryngeal functions were restored after the second operation. The mean time to oral intake for solids was 8.2 days (SD = 5.2 d). The mean time to oral intake for liquids was 16.6 days (SD = 6.3 d), and the mean length of hospital stay was 9.6 days (SD = 2.3 d). The mean time to closure of the tracheostomy and removal of the gastric tube was 27.0 days (SD = 5.8 d). Conclusion: Tracheal autotransplantation allows for a functional treatment of advanced laryngeal cancers and is compatible with a one-stage tumor resection.

The development of a prognostic score for patients with parotid carcinoma. Vander Poorten VLM, Balm AJM, Hilgers FJM, Tan IB, Loftus Coll BM, van Leeuwen FE, Hart AAM. Cancer 1999;85:2057-67. Abstract: Background : Understanding of prognostic factors in parotid carcinomas has grown considerably. In particular, clinical tumor staging and histological classification have been found to be prognostically important. Univariate and multivariate analyses have indicated other variables, such as age, pain, skin invasion and facial nerve impairment, are important predictors as well. In an actual patient, some of  these factors are present and others are absent. However, a clinical tool incorporating this information, resulting in an individualized prognosis based on the combined effects of present adverse prognostic factors, has never been devised. Methods: Out of a cohort of 168 patients, 151 patients were evaluated to assess the prognostic value of clinical and pathologic factors in a multivariate proportional hazards analysis. Followup ranged from 1 to 278 months (median 37 months). The end point was tumor recurrence. Identified prognostic factors and their hazard ratios were combined into prognostic scores. Results : Clinical T classification, clinical N classification, pain, age at diagnosis, skin invasion, facial nerve dysfunction, perineural growth, and positive surgical margins acted as major factors predicting recurrence. A prognostic score (PS), generated by the weighted combination of the factors present in the individual patient, placed the patient in one of four subgroups with markedly different prognoses. In the subgroups based on the preoperative prognostic score, 5-year recurrence free percentages ranged from 92% (in the group PS1=1) to 23% (in PS1=4). In the subgroups based on the postoperative prognostic score, which took into account the histologic details from the resected specimen, 5-year recurrence free percentages ranged from 95% (in the group PS2=1) to 42% (in PS2=4). Conclusions: The proposed subgrouping, which is based on the combined effects of key prognostic preoperative and postoperative factors, provides a practical prognostic grouping system for the clinician treating patients with parotid carcinoma.

Prognostic index of patients with parotid carcinoma: external validation using the 1985-1994 Dutch Head and Neck Oncology Cooperative Group Database. Vander Poorten V, Hart AAM, van der Laan BFAM,Baatenburg de Jong RJ, Manni JJ, Marres HAM, Meeuwis CA, Lubsen H, Terhaard CHJ, Balm AJM. Cancer 2003;97:1453-63. Abstract: Background : Validation of the prognostic indices for recurrence free interval of patients with parotid carcinoma, the development of which was described in Chapter IV, is needed to be confident of their generalizability. Patients and methods: The NWHHT database contains 231 patients with parotid carcinoma from 6 tertiary referral centers from 1985 to 1994. This database was used to validate the predictive value of the prognostic indices PS1 (pretreatment index predicting recurrence)and PS2 (posttreatment index predicting recurrence) in patients with parotid carcinoma. Validation methods included calculation of both indexes for each patient, comparison of coefficients, construction of survival curves using the published cut off points and calculation of concordance measure C. Wald tests for optimization of scale and weights of the contributing variables, and for possible score improvement by including other variables, were also performed. Results : Five year disease free percentage was 62% (SE 5%). For PS1, the previously set cut-off points resulted in 5 years disease free percentages ranging from 92% (PS1=1) to 42% for the least favorable group (PS1=4). Concordance measure C was 0.74. For the postoperative score, PS2, previous cut-off points resulted in 5 year disease free percentages ranging from 90% (PS2=1) to 40% (PS2=4). Concordance measure C was 0.71. Both PS1 and PS2 could not be improved using the findings in this independent material. Conclusion: The prognostic indices performed adequately in this validation sample. This markedly increases the degree of statistical and clinical reliability of the indices . A user-friendly translation and computerized calculation of the indices should be the next step towards generalized prospective use and repetitive evaluation of the indices.

BOOK: Laryngotracheal Reconstruction - P. Delaere Springer Verlag 2004. From Lab to Clinic. 2004, XII, 298 p. 770 illus., 720 in color. With DVD, Hardcover About this book: This volume is a practical, hands-on guide to reconstruction of the larynx and trachea. It is the first book to cover reconstruction of the larynx and trachea on the basis of auto- and allotransplants with the emphasis on blood supply of the repair tissue. The work focuses on difficult-to-repair defects of the larynx and trachea: - Tracheal autotransplantation after extended hemilaryngectomy - Repair of a tracheal restenosis after segmental resection - Repair of a long segment tracheal stenosis The book walks you through the entire process, from experimental design to clinical  application, and is updated with a thorough review of potential complications and how to avoid them. A complementary DVD that features several video clips (of nearly 2 hours of footage) is included, highlighting different aspects of wound healing and reconstruction of the larynx and trachea. The volume is illustrated throughout and is important reading for otolaryngologists, head and neck surgeons, plastic and reconstructive surgeons, and other specialists involved in wound healing and repair of  the larynx and trachea. Written for: Otorhinolaryngologists, head- and neck surgeons, plastic and reconstructive surgeons, and other specialists involved in wound healing and repair of the larynx and trachea.

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