RADIOLOGIA IUGOSLAVICA SUPPLEMENTUM II CONSERVATION SURGERY O F THE LARYNX LJUBLJANA 1977 RADIOLOGIA IUGOSLAVICA PROPRIETARII IDEMQUE EDITORES: SOCIETAS RADIOLOGIAE ET MEDICINAE NUCLEARIS INVESTIGANDAE ET SOCIETAS MEDICINAE NUCLEARIS INVE­STIGANDAE FOEDERATIVAE REI PUBLICAE IUGOSLAVIAE LJUBLJANA lonservation surgery Suppl. II 1977 oi the Iarynx Cohlegium redactorum: N. Allegretti, Zagreb -B. Bošnjakovic, Beograd -M. curcic, Beograd -M. Dedic, Novi Sad -A. Fajgelj, Sarajevo -V. Gvozdanovic, Zagreb -S. Hernja, Ljubljana -D. Ivancevic, Zagreb -B. Karanfilski, Skopje -B. Kastelic, Ljubljana -K. Kostic, Beograd -B. Mark, Zagreb -N. Martincic, Zagreb -Z. Merkaš, Beograd L. Milaš, Zagreb -J. Novak, Skopje -I. Obrez, Ljubljana -F. Petrovcic, Zagreb -S. Popovic, Zagreb -B. Ravnihar, Ljubljana -Z. Selir, Sremska Kamenica ­š. špaventi, Zagreb -G. Šestakov, Skopje -M. Špoljar, Zagreb -D. Tevcev, Skopje -B. Varl, Ljubljana R.edactor principalis: L. Tabor, Ljubljana Secretarius redactionis: J. škrk, Ljubljana Redactores: T. Benulic, Ljubljana -S. Plesnicar, Ljubljana -P. Soklic, Ljubljana -B. Tavcar, Ljubljana lzdavacki savet revije Radiologia Iugoslavica: M. Antic, Beograd -Xh. Bajraktari, Priština -M. Dedic, Novi Sad -N. Ivovic, Titograd -M. Kapidžic, Sarajevo -A. Keler, Niš -M. Kubovic, Zagreb -S. Ledic, Beograd -M. Lovrencic, Zagreb -M. Matejcic, Rijeka -Z. Merkaš, Beograd ­ P. Milutinovic, Beograd -J. Novak, Skopje -P. Pavlovic, Rijeka -S. Plesnicar, Ljubljana -L. Popovic, Novi Sad -M. Porenta, Ljubljana -V. Stijovic, Titograd -I. šimonovic, Zagreb -J. škrk, Ljubljana -L. Tabor, Ljubljana -I. Tadžer, Skopje -B. Tavcar, Ljubljana -B. Varl, Ljubljana Lektor za angleški jezile P,rof. Mija Oblak, Ljubljana Tajnica redakcije: M. Harisch, Ljubljana Izdajo tega suplementa so namensko materialno omogocili: Otorinolaringološka Klinika Klinicnega Centra v Ljubljani in Onkološki Institut v Ljubljani RADIOLOGIA IUGOSLAVICA Conservation surgery Suppl. II 1977 of the larynx TABLE OF CONTENTS lntroduction, Ravnihar, B. 7 Indications and limitations of conservation surgery of the larynx, Alajmo, E. 9 Conseirvation la:ryngeal surgery in the elderly patient, Tucker, H. M. 13 Limitations of partial horizontal surgery of the larynx, Cachin, Y. 17 Possibili.tics and limits of conservative Iarynx surgery-analysis of 15 year expe­ rience, Minnigerode, B. 21 Partial laryngectomy for recurrent cancer after irradiaton, Shaw, H. J. 25 Epiglottoplasty -new method for laryngeal reconstruction, Kambic, V. 33 Some aspects of conservation surgery of supraglottic carcinoma, Siirala, U. 45 The so-called »Glottic Horizontal Resection«, Gramowski, H. K. . 49 Treatment of early laryngeal carcinoma at the Institute of Oncology, Ljubljana, in the period of 1963-1971, Budihna, M., šmid, L., Furlan, L. . 51 Combined radiotherapy and conservative surgery in laryngeal carcinoma, S0­rensen, H. 57 Conservative surgery of the larynx, Sala, O. 59 Toluidine staining as a guide to biopsy in precancerous lesions of the larynx, Bosatra, A. 63 Histological and ultrastructural characteristics of laryngeal precanceroses, Su­gar, J., Szabo, E. 65 Gedanken liber lndikationen und Resultate der konservativen Therapie des Kehlkopf -Karzinoms, Kup, W. Management of laryngeal carcinoma, Pearson Dorothy 79 Treatment of larynx carcinoma and prognostic factors, Littbrand, B., Jakobsson, A. P., Killander, D. 81 Radiol. Iugosl. 1 UDK 615.849(05)(497.1) List oi Contributors Dr. Y. CACHIN, M. D. Institut Gustave -Roussy Department de Chirurgie Cervico -Faciale et O. R. L. Chef de Department VILLEJUIF 98800 16, bis, Avennue Paul-Vaillant-Couturier FRANCE Harvey M. TUCKER, M. D. Chairman Department of Otolaryngology and Communicative Disorders The Cleveland Clinic Foundation The Clinic Center 9500 Euclid Avenue, CLEVELAND, OHIO 44106 U. S. A. H. J. SHAW, MA, FRCS, Consultant Surgeon (Head and Neck/ENT) The Royal Marsden Hospital Fulham Road LONDON DSW3 6JJ ENGLAND Prof. Dr. B. MINNIGERODE, Vorstand U ni versi ta ts-Hals-N asen-Ohrenklinik und Poliklinik Essen 43 ESSE-HOLSTERHAUSEN Haufelandstr. 55 W.GERMANY Prof. Dr. Oscar SALA Universita di Padova Direttore Clinica Otorinolaringoiatrica PADOVA ITALIA Prof. Dr. Ettore ALAJMO Direttore Clinica Otolaringologica Universita 6 years: 1 (retains gastrostomy) (11 cases) Delayed swallow 1 year : 1 (temporary gastrostomy) Delayed swallow 2 -8 weeks: 3 Broncho-pneumonia: 3 Temporary small fistula: 1 Gross wound breakdown: 1 No complications: 4 R.N.T.E.H. 1961-1975 Vertical PL Surgical em-physema 5 days: 1 Delayed swallow 4 weeks: 1 (9 cases) Slight wound infection: 3 No complications: 4 Table 3 -Partial laryngectomy -complica­tions after full course irradiation five months eventualy settHng on prolon­ ged systemic antibriotios. The post-operative picture for the 11 post-sirradiation horizontal partial laryn­ gectomies gave 1more cause for concern. Only 4 patients healed per pDimam with no complicatiions and none of those was an extended procedure. Laryngeal spiUover was common in the early post-oper-avive per,iod a:nd resulted in a;t least 3 cases of severe bronchopneumo­ nia. In one this eventuaHy resulted 1in his death a year later although adequate swal­ low was regained. A variable degree of delayed swaUow was common. Although removal of feeding and ,tracheostomy tu­ bes was usually accomplished rin 2-3 weeks, one patient required gastrostomy for one year, and in another rit has become permanent for the intake of liiquids only, so1ids being swallowed ,normally. None the less, his voice remaiins weak though servi- J. H. ceable and the natural airway is a:ega1ined. This was ,an extended operation to ,include the ipselateral vocal cord. Large 1scale wound breakdown has occurred in only one patient and ,is tho­ught ,to be partily a consequence of inclu­sion of the torr1gue base iin the resection. Plastic closure was by delto-pectornl flap and the patient has so far regained a nor­mal swallow and good voice with no recurrent tumour at 8 ,months. Functional rehabilitation. -Healing is inev,itably delayed in irradiated patients to an unpredictable degree. However, no great problems have been encountered in patients after the vertical type of opera­tion, apart from the one case of laryngeal stenosis descJ1ibed already. Removal of the ala of the thyroid cartilage facilitates he­aling which is probably not complete for about 6 weeks. The assistance of the Speech Therapist is of great benefit to patients' morale after operation and to the eventual quality of speech regairned. Duioing the healing pe­J1iod attempted use of the voice must be rninimal with an absolute ban on smoking or excess alcohol. Followi:ng the hor,izontal supraglottic operation the greatest problem relates to regaining the natural swallow and the pre­vention of chest infection by spillover. Much has been wdtten on this subject and the problem 1is 3 yr: 12) Horizontal PL. 11 2 2 (O S) 5 4 1 5 5 (>3yr:4) B. ROYAL NATIONAL THROAT HOSPITAL: 196 1 -1975 Vertical 9 1 1 1 1 2 1 6 PL. (1 S) (>3yr: 6) Totals 37 7 6 6 6 4 7 26 (>3yr: 22 = 60%) Table 4 -Partial laryngectomy -end results and salvage after full irradiation In supraglottic cancer this thesis does not seem tenable for the majoiity of irra­cLiation faiJures, ancl pnimary operation by hor:izontal partial laryngectomy is Likely to 0ive the best surv,ivals w,ith the lowest rnorbiclity rates. For the fu1ly ,irradiated case of supra­glottic cancer, therefore, horizontal partial resection will be contrarindicated unless: 1. The pdmary les1ion is conf, inecl to the ante11ior vestibule from the start of irra­diation and is followed closely by the sur­geon ,thrioughout. 2. Irradiation is 1im:ited to 4,000 rads planned before operation ancl followed by the .surgeon throughout. 3. Fulfi11ing ,the above conditions the patient must also be uncler the age of 65 aJnd with good pulmonary function. 4. Exceptional circumstances in which a patient may refuse total laryngectomy. In all other UJnstances the safest treat­ment for persistent supraglottic cancer after a fuH course of 6,000 or more racls of Teleradiation ,is total laryngectomy. These cases call for considerable expe­rience ancl skill ,i;n this type of surgery. They are not for the occasional operator and should not be undertaken by anyone unpreparecl to dea,l with the complica­tions. Acknowledgements. -The Author wi­shes to thank Consultant colleagues at the RoyaJ Marsden Hospital and the Royal National Throat, Nose and Ear Hosp.ital for their cooperation ancl help. Partial laryngectomy for recurrent cancer after irradiation Summary This report seems to confirm the view that limited glottic cancer should initially be trea­ted by external irradiation. Failures of treat­ment would then have a good chance of cure by vertical partial laryngectomy. In supra­glottic cancer a primary operation by ho­rizontal partial laryngectomy is likely to give the best survival with the lowest morbidity rates. References l. Bocca, E., Pignataro, O. & Masciaro, O.: 1968 Ann. Otol, 77, 1005. 2. Duncan, W. & Dalby, J. E.: 1962, J. Laryn­gol & Otol, 76, 539. 3. Lederman, M.: 1970, J. Laryngol & Otol, 84, 867 4. Leroux-Robert, J.: 1961, Abstracts of Seventh Internat. Congress O. R. L., Paris pp 44-130 5. Ogura, J. H. & Mallen, W.: 1967, Chap­ter in »Cancer of the Head and Neck« Ed. J. Conley, Butterworths, Washington. 6. Ogura, J. H., M. L. Som & P. M. Stell: 1974, Centennial Conference on Laryngeal Cancer, Toronto; Proceedings of Workshop No 6. 7. Oloffson, J., Williams, G. T., Bryce, D. P. & Rider, W. D.: 1972, Arch Otolaryngol, 95, 240 8. Shaw, H. J.: 1966, J Laryngol & Otol, 80, 839 9. Som, M. L.: 1970, J Laryngol & Otol, 84, 655. EPIGLOTTOPLASTY -NEW METHOD FOR LARYNGEAL RECONSTRUCTION Kambic V. lntroduction. -There are very few sur­gical methods accepted with enthusiasm immediately after their innovation. Also the value and efficiency of the total laryn­gectomy, first performed in 1873 by Bill­roth for laryngeal cancer, became a topic of many discussions until later experien­ces proved that this was, and in some ca­ses still is, the only successful therapy for laryngeal carcinoma. The same occured in vertical hencilaryn­gectomy, also first performed by Billroth, in 1878 (Gosepath, 1972). This method was further developed by his pupils, Gluck and Soerensen. After some enthu­siasm in the beginning the method was rejected. Although, there have been nu­merous refinements of the technique with the extension of criteria and usefulness of these procedures since then, the effi­ciency of conservation laryngeal surgery is still being questioned by some otola­ryngologists. Some are of the opinion that vertical hemilaryngectomy is too conser­vative a procedure, others think that func­tional effects postoperatively are not sa­ tisfactory. Already in 1956, J. Pressman (Pressman, 1956) put an end to a wide discussion on the importance and value of vertical he­nrilaryngectomy and conservation laryn­geal surgery in general, in favour of these functional operative procedures in his study on the laryngeal lymphatic distri­bution. We may point out that already in 1891, Hajek (Hajek, 1891) reported on the same problem. With today's knowledge of laryngeal anatomy and embriology with respect to the lymphatic drainage, conservation sur­gery is becoming increasingly more reali­stic as an approach to tumor therapy and, as Som (1970) says, we may speak now of the revival of conservation laryn­geal surgery. On the other hand, patients with cancer of the larynx now come to the doctor earlier so that the disease is discovered in less advanced stages than previously. Laryngomicroscopy, which makes pos­sible the observation of very small lesi­ons, has helped a lot in establishing an early diagnosis. It also enables us to ob­tain material for histologic examination exactly from the site we wish to examine. In spite of this, nowadays, there are still many doctors in my country and in Eu­rope, including Great Britain, who refuse this type of surgery. Radiotherapists in particular, are against it. They want to treat all patients in stage T2 by radiothe­rapy, and only when they fail they are ready to send the patient to the surgeon who, unfortunately very often in such ca­ses, can only perform total laryngectomy. According to the localisation and cha­racteristic spreading of the malignancy of the larynx, various surgical techniques have been developed which all try to irradicate the disease and preserve the function of the organ. On the basis of the long term clinical statistics and pathohistological examina­tions, accurate indications for partial la­ryngectomy have been developed. Howe­ver, we cannot always define the exact limits of the tumor by mirror laryngo­scopy, direct laryngoscopy, laryngomicro­scopy and contrast laryngography, and so the final decision for the partial laryngeal surgery can be made very often only dur­ing the operation itself and not before it. Kambic V. Today, many patients are informed about partial laryngectomy by communi­cation media. They demand, very deter­minedly, a conservation larynx operation and want speech and respiration to func­tion normally after the surgery, also when we know that such an operation is not possible. We are of the opinion that in no case must we let ourselves be influ­enced by the patient, because we may compromise the method and harm the patient as well. Although, this report will not discuss the basic principles of partial laryngecto­my, we may outline very briefly the ge­neral problems of the partial vertical la­ryngectomy. Since it would be premature to discuss our postoperat ,ive results from the oncologic point, survival rates and recurrences will not be considered in this report. Basic principles of vertical laryngeal surgery. -Vertical hemilaryngectomy (frontal and frontolateral) is recommen­ded for the treatment of certain forms of glottic carcinoma where more than half of the larynx can be removed vertically and its functions, phonation, respiration, deglutition, are still preserved (Leonard, Holt and Maran, 1972), (Fig. 1). We would like to stress that postoperative oncologic results do not depend on the surgical technique for laryngeal reconstruction but that they should be considered in the light of proper indications for partial vertical laryngectomy; these are: l. A true cord lesion which extends to involve the anterior commissure. The first third of the opposite cord may be invol­ved, too. 2. A true cord lesion which involves the vocal process or the anterior and superior portions of the arytenoid. 3. A true cord lesion which extends to within 10 mm subglotticaly. 4. Certain selective cases of carcinoma of the vocal cord with extension laterally into the ventricle. 5. The vocal cord should be mobile. For many authors, these indications are too narrow, for others they are too broad. We must point out that for us, the pa­tient's age is not a prerequisite for the operation and, in this respect we absolu­tely agree With prof. Tucker (Tucker, 1976), however, we must take into consi­deration the patient's general state of health. The success of partial laryngectomy de­ pends on: -resolving the oncologic problem and -preserving laryngeal function (respi­ ration, glutition, phonation). The solution of the oncologic problem depends on: -the properties of the tumor, -the immunobiological state of the patient, -the radicality of the operation. It must be stressed that no compromise should be made between the radical ap­proach to the surgical procedure and the conservation of the laryngeal function. Obviously, the more radical the surgical procedure the more difficult reconstruc­tion becomes, which relates to the laryn­geal surgery in particular. The radicality of the operation is opposed to the possi­bility of reconstruction. The preservation of the laryngeal func­tion depends entirely upon the efficiency of the reconstructive procedure. Methods of reconstruction. -The sur­geons' s question is always: what is the best method for the laryngeal surgery to preserve the stable, rigid structure of the larynx, an adequate lumen and, a lining to prevent the formation of ob­structive granulation tissue and cicatrix. Postoperative laryngeal reconstruction following vertical hemilaryngectomy has been described by many authors. Informa­tive surveys of the development of laryn­geal surgery have been presented by Alonso (1970), Bailey (1971), Gosepath (1972), Schechter and Morfit (1965), and Epiglottoplasty -new method for laryngeal reconstruction many others. I am sure we are all fami­liar with the pioneer efforts of Gluck and Soerensen (1912), Alonso (1970), Hautant (1929), Leroux-Robert (1965), Miodonski (1962), Pressman (1956), Ogura (1972), Som (1951), Quinn (1970), Bailey (1971), and many others, for the functional sur­gery of the larynx despite the radical tu­n1or removal. Each of these authors has proposed a slightly different surgical approach to the laryngeal reconstruction following verti­cal hemilaryngectomy. Some of thern fa-vour mucosal graft from the hypofarynx or free grafts taken inside the lips, others recommend free skin grafts for endolaryngeal repair. Some prefer spl{t thickness grafts and foam rubber mold­staints for endolaryngeal repair and stric­ture prevention. Some propose also the technique for vocal reconstruction after vertical partial laryngectomy. We think that respiration and glutition are of pri­mary importance to the patient while phonation is secondary. Therefore, we are of the opinion that, after vertical he­milaryngectomy, the surgeon should not be burdened by the attempts of the com­plicated reconstruction of the glottis which might disturb postoperative func­tional result. Also the use of temporary stents or keels for lumen conservation by some authors, requires a long postoperative treatment with a long-term tracheostomy and is considered unpractical and awk­ward for the patient as well as for the surgeon (Goodyear, 1949; Som and Sil­ver, 1968), (Figs 1, 2). Fig. 1 -Goodyear's acrylic obturator Fig. 2 -Me Naugt's dilatator 3'' Kambic V. A careful view of the different pro­posed methods serves to emphasize the fact that no procedure is perfect. Each has at least one limitation or deficiency that prevents it from being an ideal sur­gical approach. Reconstruction with the epiglottis. ­It is our feeling that the best laryngeal reconstruction after vertical hemilaryn­gectomy can be achieved by repairing the deficiency with the epiglottis. This was first performed by Bouche. Freche and Husson (1965) and is called epiglottopla­sty. It was originally used for supraglot­tic stenosis after a trauma and only later . for laryngeal reconstruction following vertical hemilaryngectomy. Sedlacek (1965) also used the epiglottis for the la­ryngeal reconstruction. He did not know about the work of Bouche and his colla­borators and he performed the epiglotto­plasty independetly (Sedlacek, 1965). Some years ago we had the opportunity to observe epiglottoplasty and witness postoperative results. The method at once seemed extremely logical, simple and, what is most important, successful. There is no need for postoperative dila­tators and keels. As a result of our obser­vations, we began to perform the proce­dure for the larynx reconstruction after vertical hemilaryngectomy at our clinic. This method is used for the reconstruc­tion of the deficiency following frontal and fronto-lateral hemilaryngectomy per­formed according to the standard indi­ cations explained before. We must point that vertical hemila­ryngectomy is not performed when there is evidence of neck metastases since we estimate that, in this case, primary has passed beyond the limits for this kind of conservation surgery. Neck metastases in glottic cancer indi­cate a very agressive malign growth and Fig. 3 -Extent of resection possible with vertical hemilaryngectomy Epiglottoplasty -new method for laryngeal reconstruction Fig. 5 Interrupted line with arrow shows the di• rection of preparing the epiglottis (side view) Fig. 4 Part of the larynx removed by vertical he­milaryngectomy (striped field) also preepi­glottic soft tissue is removed (side view) Fig. 6 -Pulling the epiglottis downwards to cover the deficiency (side view) Epiglottoplasty new method for laryngeal reconstruction may denote that cancer has already ex­ceeded the limits of this region. In this case the conservation therapy is doubt­ful. We have to be very careful in the case of prelaryngeal nodes in particular, because they correspond to their lymph drainage function. Involvement of the prelaryngeal nodes is to be expected in subglottic growths only. When these are present in glottic or supraglottic tumors, it indicates a subglottic extension of the growth, whether this is seen macrosco­pically by indirect or direct laryngoscopy or not (Minnigerode, 1964). There is a big difference in supraglottic localisation Fig. 8 -The epiglottis covers the deficiency after vertical hemilaryngectomy (side view) where the lymphatic network is thick and the metastases correspond to it. In su­praglottic horizontal hemilaryngectomy, the metastases represent no disadvantage to conservation surgery. In such cases we always perform also the bilateral elec­tive RND in this operation, as suggested by Bocca (Bocca, 1968). Finally, let us come to the fundamental principles of the reconstruction of the larynx, after hemilaryngectomy, with the epiglottis. For the reconstruction, the epiglottis has to be completely healthy. A special advantage is that it provides, apart from mucosa, a cartilage which reinforces the laryngeal wall and prevents the forma­tion of stenosis. Verticofrontal or verticolateral hemila­ryngectomy done in the routine way is then followed by reconstruction with the epiglottis. After having performed the hemilaryngectomy and liberated the base of the epiglottis, the pre-epiglottic fat and soft tissue are carefully dissected. The epiglottic mucosa is then prepared on the pharyngeal side, i. e., the .ide turned toward the tongue. We then proceed with the operation without removing the hyoid bone, as in laryngectomy, but it may be removed too. Then, we cut the mucous membrane along the edges of the epiglot­tis. In this way we relax the epiglottis, pulling or moving it downwards. It is important to be particularly careful dur­ing the dissection not to cut the mucous membrane on the top of the epiglottis, since this would damage arteries that are of vital importance to the blood supply of this part of the larynx. The epiglottis, laterally mobilized and relaxed, is pulled down on the laryngeal defect made by hemilaryngectomy. The lateral edges of the epiglottic mucosa are sewn on to the rest of the thyroid cartilage first, and finally, the base of the epiglottis with the rest of the crico­thyroid membrane, or the rest of the cricoid cartilage. Sutures are reinforced Kambic V. by sewing cartilage to cartilage using catgut suture, to which additional strength is provided by covering with the perichondrium and muscles. If the epi­glottis or the deficiency after hemilaryn­ gectomy are very large we can sew the epiglottis to the overlaying tissue. In this way its eventual collapsing into the lu­men is prevented. It is evident that we must introduce a feeding tube and make tracheostomy. This surgical technique does not cause any difficulties, and there is no need for a special head positioning after the operation (Figs. 3, 4, 5, 6, 7, 8, 9, 10). Vascularization of the epiglottis. -In order to study the vascularization of this part of the larynx, which is important for the nutrition of the mobilized and clislocated epiglottis, we filled, on corp­ses, the arteria thyreoidea superior with suspension of cinnabar and India ink in fluid gelatine. After a thorough fixing in formaldehyde solution, the larynx toge­ther with muscles ancl subcutaneous tis­sue were removed and made transparent by Spalteholtz method. Photographs of the transparent preparations were ma­de. In the described techniqu., c::tpilaries and vein network were not filled with dyes on purpose. In total, 15 preparations were made. They all showed the bllow­ing properties: the upper laryngeal arte­ry delivers two branches, namely, ramus epiglottidis superior and inferior and not only one, as it is describecl in anatomic maps. For the survival of the dislocated epiglottis it is very important to preservc at least the upper branch (Fig. 11). If we sacrifice all of them we may compro­mise the blood supply of th:::: transposed epiglottis, which might be detrimental to the succes of the operation. Epiglottoplasty -new method for laryngeal reconstruction Fig. 10 -Lateral epiglottic edge is sewed on thyroicl cartilage eclge (sicle view) \ Fig. 11 -Vascularization of the epiglottis Art. laryngica superior a) Ramus epiglotticlis superior b) Ramus epiglottidis inferior Our results. -After vertical hemila­ryngectomy performed on 20 patients, we reconstructed the larynx using the clescri­becl method, namely, the following ope­rations were made: in 1972 two, in 1973 three, in 1974 four, in 1975 seven and in 1976 four. The localisation and spreading of the malignancy in our patients were the fol­lowing: three times cancer involvecl the left vocal cord with the anterior commis­sure extending to the anterior third of the right vocal cord; four times tu­mor involved the right vocal corcl with extension to the anterior commissurc ancl the anterior thircl of the left vocal cord: four times malignancy involvecl the left vocal cord with the vocal process; five times it involved the right vocal cord with the vocal process (twicc, it cxtc.1decl subglottically); tv10 times the left vocal cord was involved extending into the ventricle ancl twice, the rnalisnancy was . . .0 .0 .'9 ·.iitr;") ;.9 Wo Fig. 12 -Location ancl extent of malignancy on the right vocal cord with extension to the anterior and superior portion of the arytenoid (Fig. 12). In all the patients, the postoperative functional results were excellent. We will not discuss postoperative results from the oncologic point since, as we have al­ready stated, these do not depend on the reconstruction. They depend more on the exact indication for the conservation pro­cedure. Besides, the time for the evalu­ation of the oncologic results bas been too short. Four of our patients had been previously treated by cobalt therapy (each had received 700 Rtg to the tumor) with­out success and this did not influence the postoperative healing process. In all pa­tients the feeding tube was removed on the ninth or tenth postoperative day, an extubation was done by the fifteenth to the twentieth day. Respiration and deglu­tition are excellent in all patients, phona­tion is satisfactory. Conclusion. -The purpose of the pre­sent report is not to evaluate the oncolo­gic results of our work, because 20 ope­rated patients represent a modest ma­terial and the tirne after the operations has been too short. However, we feel that our results are excellent with respect to the laryngeal function following the reconstruction with the epiglottis, after hemilaryngectomy, when compared to the results obtained by authors using other, more complicated methods. In our opinion, the laryngeal recon­struction with the epiglottis following he­milaryngectomy is logical, simple and succesful method of the laryngeal recon­struction when the vertical hemilaryngec­tomy is indicated. Epiglottoplasty is an 4-1 ro --, H H E--j:§ .·.c. :s: sµ.. (/) ..o ­ PLE = Partial Laryngectomy TLE = Total Laryngectomy RT= Radiotherapy RND = Radical Neck Dissection Table 6 -Early Supraglottic Carcinoma (1963-1971). Failures. First Treatment Sur­gery Table 5 shows possible causes for un­successful irradiation in early supraglot­tic carcinoma. In one patient local recur­rence of stage I developed, probably be­cause the dose was too low. In 3 cases the tumor of stage II did not disappear after •irradiation. It is possible that the dose was too low for one patient and, Number of Patients ··;:,-; i., H ctl:::l -.·.c=a E--j] (/) (/) :s: sµ.. 5 TLE Stage I 23 7 'H l-<"' o-. Possible Cause ior laryngectomies werc performecl. The results of the partial surgical ,inter­ventions appear from Table 2. Local recurrences were liimitecl to totally 17 °/0 ancl the number of complications were few; thus only 12 % of the patients clevel- Supraglottic 0/2 Glottic T1" 4/27 15% Glottic T1 1, 0/2 T, 4120 20 11/o T, 1/2 50% Total 953 170/o / Table 2 -Local recurrence after hemilaryn­gectomy in irradiated patients 58 Sorensen H. oped fistulas that all closed spontaneo­usly after varying tirne. Tracheostomy that was performed in connection with the operation could also be closed 1in all cases. All the patients were controHed by direct laryngoscopy, and complete followup carried out fo-r more than three years. For comparison, the results after p1,imary hemilaryngectomy that was perforrned cin only a few patients are shown in Table 3. It appears that in these patients where no pre-or postoperative radiation was given local recur, rence occured in 50 % of the cases. Supraglottic 2/3 Glottic T, Glottic L 3/6 Glottic T, 1/1 Subglottic 1/4 --------··­Total -·-7/14 50% Table 3 -Local recurrence after primary hemilaryngectomy Discussion. -Principles of treatment rnust be evaluated 1in terms of the number of patients, in whom the larynx can be preserved, ,so that natural voice functiion is rnaintwiined. Generally the cornb1ned therapy of laryngeal carcinoma offers the best possibility of an acceptable cure-rate combined with a low percentage (20 %) of total laryngectomy. According to such a policy of treatment, surgery is essenti­aHy reserved for residual or recurring tu­mours. Thris often results in a high rate of fistulas after total laryngectomy (up to 30 %) and may be considered a prohibition for conservative surgery. In our experien­ce however, only few complications will appear after partii.al laryngectomy combi­ned with ,irradiation. The fistula rate is acceptable low and, as the recurrence rate after partial surgery ,is as low as 17 O/o, it adds to the low laryngectomy rate that can be obtained only by combined therapy. In our series only s,imple methods of re­section have been appliied, but 1in some cases plastic reconstructive procedures may also succeed (3). Summary In 103 patients with residual or recurring tumor after irradiation therapy, conserva­tive surgical operation was performed. The complication rate was low 12 010 and developed temporary fistulas that closed spontaneously. Local recurrences appeared in 17 % of the patients. Acknowledgement: I am indebted to dr. Hanne Sand Hansen for having placed at my disposal the material from The Finsens Insti­tut, Copenhagen, which also comprises pati­ents from the University ENT department, Rigshospitalet (Head prof. H. K. Kristensen). References l. Hansen, H. Sand: Neoplasma malignum laryngis, Polyteknisk Forlag, Copenhagen 1975. 2. Jorgensen, K.: Carcinoma of the laryinx, Arhus 1976. 3. Kambic, V., Radšel, Z. & šmid, L.: J. Laryng. Otol. 1976, 40, 467. CONSERVATIVE SURGERY OF THE LARYNX Sala O. Many techniques have been worked out for the conservative surgery of the larynx. The most common, important one -as well as the most debated -is that of transverse supraglottic laryngectomy, ori­ginal or modified. However, we believe that the indications for such surgical tech­nique are less numerous than one is in­clined to believe at present, and this for many reasons. The concept of the larynx being com­posed of two hemilarynges with a barrier at the point of the glottis, is based on embryologic criteria, but this concept does not apply to the neoplastic process, p3rticularly if the tumour is of a deeply infiltrating type. The tumour may spread beyond the laryngeal commissure and may also in­vade the subglottic region (Olofsson and van Nostrand, 1973; Ferlito, 1976). Fur­thermore, a neoplastic growth originating from the laryngeal ventricle may spill la­ terally and invade the subglottic region. Extended transverse lar yrHf=Ctomy and in particular the three-quarter .5 laryngectomy after Ogura are often followed by recur­rences -actually in about 40 % of cases within 2 to 5 years according to Bocca (1974). The main error in tumour diseas. is to consider the malignant lesion as a static entity and to evaluate it on the basis of the TNH system which takes into account only two parameters, that is, the site and extension of the tumour. A critical investigation now being car­ried out at our Department has demon­strated that a laryngeal neoplasm must be evaluated taking into consideration three additional factors, that is, the hi-stologic type, the histologic grading of malignancy and the tumour-host relation­ship. The course of the tumour disease is almost always predictable right from the moment the diagnosis is made, if the lesion is evaluated not in terms of sur­gical possibilities but from the biological point of view. A series of 104 patients with squamous cell carcinoma of the larynx has been studied with regard to tumour-host inter­action (Sala and Ferlito, 1976). Prog­nostic evaluation was based upon histo­logic grad'ing and morphological evidence of cellular immune response, judged by the presence and degree of lymphocyte and plasma cell infiltration in tumour stroma. Histologic grade and degree of immune response proved to correlate with the 5-year survival, though such re­active phenomenon seemed to be a fa­vourable prognostic sign only for well­differentiated tumours. In that series, all poor differentiated neoplasms showed minimal or no cellular response. The sur­vival rate, however, appeared to increase with the increasing intensity of cellular response within each class of tumour cell differentiation. Small lymphocytes are the basic elements of cell-mediated im­mune response. Upon antigenic stimula­tion, they change into immunoblasts which produce immune lymphocytes ca­pable of recognizing and destroying tu­mour cells. In some tumours, the histologic type, the histologic grading of malignancy and the tumour-host relationship are strictly consequential, as for instance in the case of verrucous squamous cell carcinoma of 60 Sala O. the larynx (Ferlito, 1975), the prognosis of which is always favourable. The oppo­site may be seen in undifferentiated tu­mours, and particularly in the cat cell carcinoma of the larynx for which the pro­gnosis is definitely poor (Ferlito, 1976). In most laryngeal tumours, th. above three factors may be associated in a va­rying combination and may be modified in the course of the disease for patholo­gical and iatrogenic reasons. For instan­ce, a virus disease, TBC infection and syphilis, by altering the mechanism of cellular immunity, reduce the body's ac­tive biologic defensive potential against the neoplastic growth. Among iatrogenic causes of cellular immunity disturbance there is radiation therapy, which if adop­ted for a lesion with intense cellular im­mune response such as the verrucous squamous cell carcinoma, may induce anaplasia leading to a rapid dissemina­tion. Treatment by means of ECG vacci­ne is increasingly being opposed as it seems to cause an easier, atypical meta­static spread of the tumour. What has just been said indicates our present position as to the possibilities and limits of transverse supraglottic la­ryngectomy. l. Transverse supraglottic laryngectomy may be adopted, if the site and extension of the tumour allow the choice of this technique, only if the neoplasm is well­or moderately well-differentiated and dis­plays marked or moderate cellular im­111tme response. 2. The tumour rnay be located in a site and have an extension which surgically would allow the choice of transverse supraglottic laryngectomy as the most adequate mode of treatment. However, a poorly differentiated tumour, with a high histologic grading of malignancy and a poor cellular immune reaction in the stroma makes it necessary to perform total laryngectomy, because of the pre­dictably unfavourable biologic behaviour of the lesion. Usually, these tumours are not markedly exophytic, appear to be al­cerated and display microscopic and ma­croscopic necrotic foci, with oedema of the surrounding tissue, at times very in­tense. 3. In the current practice, all the five factors mentioned -that is, site, exten­sion, histologic type, histologic grading of malignancy and tumour-host relation ­appear in a varying combination among them, and the clinical experience of the laryngologist, with the support of that of the pathologist-clinician, will make it pos­sible to adopt the most adequate treat­ment for each patient. Of course, the above considerations apply to conservative surgery of the la­rynx in general, though the example has been restricted on purpose to supraglot­tic laryngectorny. Likewise, removal of draining and regio­nal lymph nodes must be reconsindered in the light of these new acquisitions. Such removal is not necessary when the pnimary tumour exhibits an Jntense cel­fular irnmune response (as in case of ver­rucous squamous cell carcinoma of the larynx), whereas it becomes mandatory and must be as radical as possible and performed bilaterally at the same tirne when the laryngeal tumour shows mar­ked indications of biological malignancy for the reasons we have just mentioned. In the light of this knowledge, the choice of radiation therapy must be care­fully considered in each case, because it might be harmful when the cellular im­mune response in tumour ?troma is mar­ked. Radiation would cause lymphocyte depletion, thereby a d'iminished immune response. A thorough exarnination of the neo­plastic lesion in its different aspect and in particular in its biological characteri­stics will enable laryngologists to esta­blish a "tailor-made" treatment for each patient. It appears therefore that the TNM system of tumour classification is now incomplete and outdated. Conservative surgery of the larynx 61 References l. Bocca, E.: Considerazioni sulla laringeo­tomia conservativa orizzonto-verticale e ri­sultati personali. Tumori, 60, 523-526, 1974. 2. Ferlito, A.: Considerazioni biologiche, morfologiche, immunopathologiche e progno­stiche di trna varianta del carcinoma squamo­so della laringe: il carcinoma squarnoso ver­rucoso. XIII Congr. Naz. Soc. Ital. Patol., Siena-Chianciano, Giugno 1975. 3. Ferlito, A.: Histological classification of larynx and hypopharynx cancers and their clinical implications. Acta Otolaryngol. (Suppl.) (Stockh.), 1976. In press. 4. Olofsson, J. & van Nostrand, A. W. P.: Growth and spread of laryngeal ancl hypo­pharyngeal carcinoma with reflections on the effect of preoperative irradiation. 139 cases studiecl by whole organ serial sectioning. Ac­ta Otolaryngol. (Suppl.) (Stockh.) 308, 1973. 5. Sala, O. & Ferlito, A.: Morphological ob­servations of immunology of laryngeal can­cer. Evaluation of the clefensive activity of immunocompentent cells present in tumor stroma. Acta Otolaryngol. (Stockh.) 81, 353-363, 1976. TOLUIDINE STAINING AS A GUIDE TO BIOPSY IN PRECANCEROUS LESIONS OF THE LARYNX Bosatra A. During these recent years two major developments have increased the diag­nostic and therapeutic possibilities of La­ryngology. One of the developments is direct suspension microlaryngoscopy, the other is a wider application of conser­vative surgery, and you can easily see how they often pose to us perplexing ancl contradictory problems. Direct suspension microlaryngoscopy is a procedure well known at this ENT clinic of Ljubljana which, I believe, has been one of the first to follow Kleinsasser's pace. Its value is very great both from the cliagnostic ancl the surgical point of view, and the advantage of the methocl is greatly increased if an adequate anes­thesiological technique is adopted so that no orotracheal intubation is requirecl, ancl the full laryngeal fielcl is brought into view, over long periods of tirne, that is up to 45-60 minutes. In this case the condition of the whole mucosal layer can be observed together with the plasticity and the spontaneous mobility of the organ. It is under these conclitions that one fully appreciates how often the mucosous membrane has undergone pathological evolution asicle and beyond the localizecl change which is responsible for the more prominent clinical picture. In other words, besicle the polyp or the localized leucoplasic plaque or the chordal hyperthrophia which is respon­ sible for clisphonia, etc., ancl which brought the patient to the laryngologist, we can observe other alterations in ne­ arby or controlateral regions of the la­ rynx. This improvecl observation of the or­gan, therefore, shows with an even grea­ter evidence that severa! biopsies are ne­cesarry ancl that a choice of the appro­priate site shall be made. As it has been saicl previously, these observat'ions ancl the results of the multiple biopsies will often puzzle us about the feasibility of a very conservative surgical treatment, once a really cancerous lesion has been iclentified. It was with the purpose of giving a guide as to where the biopsies must be taken that a previous staining with tolu­idine blue of the entire laryngeal mucosa has been suggestecl. This method follows the experience of the gynecologists, concerned with analo­gus problems, and is based on the as­sumption that a stronger staining, easily observed under magnification, will reveal the sites where the epithelial layer has unclergone an etheroplastic evolution, or at least, where there is a greater concen­tration or enlargement of cellular nuclei, which retain the staining. The manouver is easily carriecl out: the mucous membrane is gently swept by a cotton swab soakecl in a 1 °/0 solution of toluicline blue: after S minutes the colour is washed away with another cotton swab soakecl in a 1 °/0 acetic acicl solution. Be­side the corpusclecl mucous also some areas of the epithelial layer may then ap­pear to be more strongly coloured ancl in these places the biopsy is taken toge­ther with other areas judgecl to be ab­normal. The inclentification of these areas •is quite easy uncler clirect microlaryngosco­ Bosatra A. py especially when no orotracheal tube is presen t. This procedure has been applied at our clinic for 2 years in 38 cases all showing a composite pathology of hypertrophy, polyps, leukoplakia, etc. scattered in va­rious areas of the larynx. The clinical impression has often been that beside the areas of mucosal reddish hypertrophy also the so called »leuko­plasik« areas had a tendency of retaining the dye. The areas showing the usual clinical sings of cancerziation: swelling, a.rregular surface easily bleeding, etc., were also strongly coloured. The pathological report has demonstra­ted that a positive correspondence exists between histological precancerous pictu­re and stronger staining only in whereas the proportion is nearly 100 % in the etheroplastic lesions already very suspioious for cancer on the clinical ground. In several instances the stronger stain­ing has been observed in cases of simple hypertrophy with keratinization but in other the appearance of an unsuspected area of staining has lead to the discovery of a patch of »precancerous« lesions. The number of cases examined till now is too small to draw absolute conclusions. W e are enlarging our researches also to the whole total-laryngectomy specimens and applying also different staining tech­niques. In any case we beleive that the staining procedure, which is quite easily and quickly carried out should be routi­nely adopted as a useful diagnostic tool. Su mmary The improved observation of the larynx due to direct suspension microlaryngoscopy shows that general biopsies are necessary and that a choice of the appropriate site should be made. It is with the purpose of giving a guide as to where the biopsies must be performed that a preliminary staining with toluidine blue of the entire laryngeal mucosa bas been suggested. HISTOLOGICAL AND ULTRASTRUCTURAL CHARACTERISTICS OFLARYNGEALPRECANCEROSES Sugar, J., Introduction. -The precursor lesions of laryngeal carcinoma may represent various stages of the process leading to cancer. A controversy exists as to which diseases can be considered as preneopla­stic alternations of the larynx (1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12). Precancerous alternati­ons are visible steps in the dynamic pro­ ,cess of tlleoplasia which may or may not progress. They allow us to establish histo­logic degrees of grav,ity. Degree »A« represents diffuse or multi­plex epithelial hyperlasia, degree »B« im­plies focal proliferation with initial sings of atypia and degree »C« indicates intra­epithelial or incipient carcinomas with possible micro'invasions. The 1incidence of pachyderma, papilloma in adults and intraepithelial cancer has been examinated in our laryngeal biopsy mate11ial taken rin the course of 20 years. Attempts have been made to define the period neecled for the malignant transfor­mat:ion of precancerous Jesions. Characte­ristic submicroscopic lesions can be cletected in the laryngeal precanceroses (13, 14). In acldition, our present paper deals with the ultrastructural changes that refer to clifferentiat:ion anomalies. Material and Methods. -Biopsies were taken from patients at the Otolaryngology Department, Nanional Institute of Onco­logy, Budapest. Laryngeal biopsies exami­ned by us from 1954 to 1975 totaled 869. Specirnens were generally taken from the glottic ancl supraglottic regions and, less frequently, firom ,the subglottic and hypo­pharyngeal areas. Microexcisions were rnade jf the lesions were ilocalizecl on the E. Szabo vocal cords. The rnatenial was fiixed in 4 per cent formalin solution, embedded in parafin and stained with hernatoxylin­eosin and, when required, with Gomoni silvenimpregnation, Van Gieson, -and/or PAS rnethod. In 12 cases, ,the Light microscopic stu­dies were complemented with electron microscopic examination, as well. For electron rnicroscopy the samples were fii­xed in 2,5 per cent glutaraldehycle solu­tion. Post fixation was done iin 1 per cent osmium tetroxide. Dehydration in alcohol was followed by embedding in Durcupan Fluka. After staining with 1 per cent tolu­idin blue, semi-thin sections were prepa­red from the matenial. For electron micro­scopic examination the most suitable tissue portrions were selected from these sections. The ultrathin sections were made with an LKB ultramicrotome, sta1ined with Raynold's lead stalining procedure and examined uncler JEM 6C electron micro­scope. Results. -Laryngeal carcinoma was predominant ,in rnales (94 per cent). Ne­arly 85 per cent of the patients were over 50 at examinatrion (Table I). Carainoma was not found in patients under 31. Analysing the age distribution of patients w,ith cancerous and non-cancerous lesions, it is conspicuous that the accumulation of precancerous cl,iseases in pabients with c