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Chondrosarcoma Treated with Transoral Near Total Resection of the Cricoid

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Chondrosarcoma Treated with Transoral Near Total Resection of the Cricoid B-ENT, 2014, 10, 121-125 Chondrosarcoma treated with transoral near total resection of the cricoid D. Pantazis1, G. Liappi2 and M. Riga3 1ENT Department, Thriassio General Hospital of Athens, Greece; 2Laboratory of Pathology, Thriassio General Hospital of Athens, Greece; 3ENT Department, University Hospital of Alexandroupolis, Greece Key-words. Chondrosarcoma; cricoid cartilage; partial laryngectomy; transoral LASER surgery Abstract. Chondrosarcoma treated with transoral near total resection of the cricoid. Introduction: Chondrosarcomas of the larynx are usually slow-growing tumours. Their prognosis is reportedly unaffected by local tumour recurrence. Nevertheless, total laryngectomy is often performed in fear that resection of the posterior lamina of the cricoid cartilage may cause laryngeal collapse and stenosis. Transoral laser surgery (TLS) is not considered among the treatment options. This case report supports the feasibility of a radical yet organ- and function-preserving tumour excision using TLS. Case report: A female patient presented with dyspnoea due to an extensive low-grade laryngeal chondrosarcoma. TLS treatment involved total resection of the posterior lamina of the cricoid cartilage. The patient was decannulated 8 months later with normal swallowing and satisfactory voice quality, which allowed her to have a normal personal and social life. Conclusion: TLS excision of the posterior lamina of the cricoid cartilage seems to be a feasible and radical yet function- and organ-preserving technique with minimal morbidity. Introduction In this study, we present the case of a 42-year- old female patient with a chondrosarcoma in the Chondrosarcomas of the larynx are usually low- posterior lamina of the cricoid cartilage. The aim of grade, slow-growing tumours that rarely this report is to advocate the potential role of metastasize. The prognosis for these tumours is transoral CO2 laser microsurgery in the radical reported to be unaffected by local tumour but laryngeal- and voice-preserving treatment of recurrence.1,2 Approximately 70-77% of chondro- such tumours, and the feasibility of cricoidectomy sarcomas of the larynx arise from the posterior using this technique. Open surgical approaches lamina of the cricoid cartilage.3 This location of the are compared with TLS in terms of morbidity, tumour often raises concern about the structural hospitalization length, and quality of life. Transoral integrity of the larynx after tumour resection. The LASER surgery (TLS) has mainly been reported fear of causing laryngeal collapse and stenosis as a method of restricted vaporization of the rather than tumour size often seems to lead recurrences of laryngeal chondrosarcomas within the treating surgeon to decide to perform total the laryngeal lumen in order to maintain an adequate laryngectomy, which may be done in as many as patent airway, or as a technique of partial resection one third of these patients according to the results of primary lesions,2,10 but rarely as a method of of an analysis of 111 cases.3 Alternatively, other radical excision11 for smaller tumours. surgeons prefer to perform an incomplete tumour resection and treat the inevitable subsequent tumour Case report regrowths with repeated debulking procedures.4 In other cases of chondrosarcoma presented in the A 42-year-old female patient with dyspnoea and a literature, open-surgical techniques are performed, history of hoarseness was referred to our hospital, most often accompanied by interposition grafts5,6 or which had progressively deteriorated over the past tracheal advancement.2,6-9 Therefore, a conservative 8 years. The laryngoscopic examination revealed a but radical surgical excision that maintains a submucosal subglottic neoplasm under the facet of functional cricoid stent and preserves the voice the left cricoarytenoid joint at the posterior lamina seems to be a surgical challenge, with increased of the cricoid cartilage, which completely suspended morbidity. Performing a tracheostomy and inserting the mobility of the respective true vocal cord. The a stent T-tube also seems to be mandatory. mass projected into the respiratory tract causing 06-pantazis-.indd 121 12/06/14 13:10 122 D. Pantazis et al. Figure 1 Figure 2 Preoperative magnetic resonance imaging (axial) Preoperative magnetic resonance imaging (coronal) considerable stenosis. The motility of the contra- nification. Due to metaplastic ossification of the lateral (right) vocal cord was somewhat impaired. cartilage, it was not possible to evaluate the frozen Evaluation was difficult due to the substantial sections. In cases of thyroid cartilage sections, we projection of the tumour into the larynx. The tumour usually document our surgical margins by excising most likely sustained the motility of the right vocal an additional section of the cartilage and marking cord mechanically through its large size rather than the external surface with Indian ink. In this case, no through infiltration. Magnetic resonance imaging such surgical margins were dissected in order to verified the clinical findings, showing a moderately preserve as much healthy and functionally important enhancing tumour mass with multiple calcifica­ tissue as possible. tions and no nodal extension (Figures 1,2). Total Three weeks later, the patient could eat normally, laryngectomy had been proposed at another medical although minimal aspirations were noted with thin centre, but the patient refused this treatment. liquid swallowing. The patient was released from The patient was initially subjected to tracheotomy the hospital with a fenestrated tracheostomy tube because a) orotracheal intubation was difficult with a speaking valve. According to the pathology owing to the expansion of the tumour, b) aspirations report, the tumour was a well differentiated chondro- were expected postoperatively, and c) the airway sarcoma (grade I) with clear surgical margins. needed to be ensured in case of postoperative Three months later, laryngoscopy revealed laryngeal collapse. The tumour was exposed with synechia of the vocal cords in their posterior the Steiner distending laryngoscope. Dissection of endings. Inferiorly, at the site where the posterior the left arytenoid cartilage preceded the removal of quadrate lamina of the cricoid cartilage had been the tumour and the posterior lamina of the cricoid removed, there was no connective tissue formation. cartilage using a CO2 laser in continuous super- Since this vocal cord synechia was probably helpful pulse mode at 8-15 Watts, depending on the phase in protecting the trachea during swallowing, a of the operation. The tumour was excised in a unilateral Dennis-Kashima posterior cordectomy stepwise technique, with blocks of tumour being was performed in order to improve breathing consecutively removed under microscopic mag- without jeopardizing the patient’s swallowing nification. The tumour blocks were specified and function. Three months later, it was still not feasible oriented for the pathology examination. The to decannulate the patient. After explaining the specific tissue­cutting characteristics of the CO2 possible risks to the patient’s ability to swallow, it laser helped the surgeon to differentiate between was decided to cut through the synechia, thereby healthy and tumour tissues. The dissection of the unifying the remaining larynx and the trachea. Two surgical margins through the remaining cricoid months later, the patient was able to swallow cartilage was performed last under high mag- normally. Postoperatively, the right vocal cord 06-pantazis-.indd 122 12/06/14 13:10 Laryngeal chondrosarcoma 123 Figure 3 Figure 4 Postoperative CT scan (axial) Postoperative CT scan (coronal) showed impaired motility, possibly due to the from advocating for the feasibility of this approach, postoperative formation of fibrous tissue. She had this case report supports that TLS may actually a satisfactory voice quality and was successfully be advantageous compared with open-surgical decannulated. “Satisfactory” voice quality was techniques. The ability to perform precise and determined at first in terms of voice intensity effective resection of laryngeal tumours according permitting the patient to participate in normal to the expansion of the neoplasm without interfering conversation, although she was hoarse and her with the unaffected structures of the larynx13 is the voice of lower intensity. Upon re-examination, we first obvious advantage of TLS. asked the patient to evaluate her voice with regard A second obvious advantage of a TLS approach to its impact on her social and personal life, as well is in preserving the integrity of the overlying strap as the psychological consequences of her abnormal muscles and the thyroid cartilage. This may explain voice. The patient, who is an architect, felt that her why no stent was placed in our patient. Open- voice met her social, personal, and professional surgical techniques include midline division of the needs and that her abnormal voice did not affect her overlying strap muscles and, in some cases, psychologically. Four years after her first surgery, resection of the lower half of the thyroid cartilage. laryngoscopic and imaging follow up of the patient This may further compromise the stability of the have shown no signs of recurrence (Figures 3,4). larynx and jeopardise the function of the crico- No graft, intraluminar, or T-tube stent was placed at arytenoid joint, the recurrent laryngeal nerves, and any stage of the treatment. the continuity of the cricotracheal
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