Management of patients with cancer of the larynx in Suez Canal University Teaching Hospital: 5 years’ experience

Aim To evaluate the results of interventional protocols for patients with cancer of the larynx treated in Suez Canal University Hospital.


Introduction
Cancer of the larynx, which is the most common head and neck cancer and the second most common neoplasm of the respiratory tract, is the most common tumor presented to the otolaryngology departments [1][2][3].
Cancer of the larynx usually occurs in middle-aged men, representing about 1.6% of all malignant tumors in men and 0.4% in women [4,5].
Many studies have reported that the frequency of cancer of the larynx in urban areas is much higher than that in rural areas [6].
Squamous cell carcinoma is the most common pathological type in cancer of the larynx (98% approximately); unfortunately, 40% of patients with cancer of the larynx have late manifestation in stage III or IV disease when it is first evaluated [11].
Laryngeal carcinogenesis has survival rates in the range of 73-92% for early disease stages (I and II) and 50-64% for advanced disease stages (III and IV) [15].Factors

Management of patients with cancer of the larynx in Suez Canal University Teaching Hospital: 5 years' experience
Mohamed T. El Tabbakh a , Mohamed R. Ahmed a , Doaa F. Sedik b , Diaa El Hennawi a Background Suez Canal University Hospital, which is the only tertiary care facility in the Suez Canal and Sinai area, is estimated to service more than 5 million patients.Cancer of the larynx, which is the most common head and neck cancer, is also the most common tumor presented to the otolaryngology departments.

Aim
To evaluate the results of interventional protocols for patients with cancer of the larynx treated in Suez Canal University Hospital.

Patients and methods
This was a retrospective study carried out on 53 patients with cancer of the larynx reviewed from 1 January 2007 to 1 January 2012 according to demographic, clinical, radiological, operative, pathological data, and possible complications.

Results
Fifty-three patients, mean age 58 years (71.1% were from urban areas), were studied.The main presenting symptom was hoarseness of voice (66%).Glottis carcinoma was the most common type of cancer found in 41.1% patients.Stage IVa was the most common presenting stage in 39.6% of the patients.Emergent tracheostomy was performed for 39.6% of the patients.According to the treatment protocol, single treatment modality was recommended for 38 (71.6%) patients: 17 (32%) patients were recommended total laryngectomy, followed by radiotherapy in 11 (20.7%)patients, chemotherapy was recommended for eight (15.1%)patients, concurrent chemoradiotherapy was offered to one (1.9%)patient, and partial laryngectomy with preservation of both arytenoids was offered to one (1.9%)patient.In addition, 15 (28.4%) patients were subjected to combined therapy: total laryngectomy combined with radiotherapy in nine (17%) patients and total laryngectomy with chemoradiotherapy in six (11.4%) patients.

Conclusion
Although the standards of management of laryngeal carcinoma in Suez Canal University hospital are almost in compliance with regional and international standards, we need to deal with the time delay between the diagnosis and definitive treatment to revise the items in the medical records and its registration.
influencing the survival of the laryngeal cancer patients include resection margins [16] and treatment modality [17,18], whereas known clinical factors include site of origin, disease stage, and nodal involvement [19].
The aim of our study was to evaluate the results of patients with cancer of the larynx who were treated in Suez Canal University Hospital during the period from 2007 to 2012 according to demographic, clinical, radiological, operative, pathological data, and possible complications.

Patients and methods
A retrospective study was carried out in Suez Canal University Hospital, Ismailia, Egypt, from January 2007 to January 2012.All patients with cancer of the larynx admitted to the Otolaryngology -Head & Neck Surgery Department were included in our study.Any patient with a history of a previous management protocol was excluded from our study.
The following data were collected from all patients with cancer of the larynx: (

Results
Fifty-three patients with cancer of the larynx who fulfilled the previous inclusion criteria were admitted to Suez Canal University Hospital from January 2007 to January 2012.
Their ages ranged from 28 to 82 years, mean age 58 years.
Twenty-nine (54.7%) patients were from Ismailia city, five (9.4%) were from Port Said city, five (9.4%) were from North Sinai, four (7.5%) were from the Suez Governorate, two (3.8%) were from Fayed, two (3.8%) were from El Qantra Shark, and for six patients (11.4%) the address was missing from the record.
On the basis of the previous data, we found that 38 (71.7%) patients were from urban areas, whereas 15 (28.3%) were from rural areas.
In terms of habits, all patients were smokers, except one, and all of them were nonalcoholic.
According to the clinical presentation, the most common complaint was hoarseness of voice in 35 (66%) patients, followed by stridor in 21 (39.6%),dysphagia to solids in four (7.5%), odynophagia in two (3.8%), and dry cough and hemoptysis with referred otalgia in one (1.9%).
The glottis was the most common site involved with respect to the tumors, found in 22 (41.5%)patients; the second most common site involved was the supra glottis in 13 (24.5%)patients, followed by the transglottis in 12 (22.6%)patients, hypopharyngeal extension to pyriform, postcricoids, and posterior pharyngeal wall in two, one, and three (3.8,1.9, and 1.9, respectively) patients, and finally, the least common site involved was the subglottis, found in only two (3.8%) patients.
Cartilage and bone invasion was present in 12 (22.6%)patients as indicated with computed tomography with contrast of the neck.
According to the tumor staging system, it was found that the most common stage was IVa in 21 (39.6%)patients, followed by stage II in 13 (24.5%),stage III in 11 (20.8%),stage Ia in seven (13.2%), and the least common stage 0 in one patient (1.9%) (Fig. 2).Almost all the patients had infiltrating (invasive) squamous cell carcinoma, found in 52 (98.1%) patients, and only one patient (1.9%) had carcinoma in situ.
According to the clinical presentation of the patients and the severity of their symptoms, 21 (39.6%)patients needed an emergent tracheostomy, whereas 32 (60.4%) patients did not undergo tracheostomies as they did not require any urgent intervention.
According to the treatment protocol, single treatment modality was recommended for 38 (71.6%) patients; 17 (32%) patients were recommended total laryngectomy, the largest proportion of patients, followed by radiotherapy in 11 (20.7%)patients, chemotherapy for eight (15.1%)patients, concurrent chemoradiotherapy in one patient (1.9%), and partial laryngectomy with preservation of both arytenoids in one (1.9%)patient.In addition, 15 (28.4%) patients were subjected to combined therapy [total laryngectomy combined with radiotherapy in nine (17%) patients and total laryngectomy with chemoradiotherapy in six (11.4%) patients].
In terms of postoperative complications, hematoma occurred in two, pharyngocutaneous fistula in five patients, wound infection in one patient, and stomal stenosis in one patient.
Finally, two patients died 2 h after tracheostomy: massive myocardial infarction in one and respiratory failure in the other.Another patient died from hepatic coma 5 months postoperatively.

Discussion
To date, there are no published data on management protocols for cancer of the larynx in the Suez Canal area.All the patients studied were men as cancer of the larynx is much more common among men than women [20].In our study, the mean age of the patients was 58 years; the risk usually increases with age.The incidence increases three-fold between 45 and 65 years of age, whereas the mortality rate increases seven-fold [21].
In our study, the main presenting symptoms were hoarseness of voice in 69.8% of patients; Licitra et al. [22] reported that hoarseness is the main attending symptom.
In our study, a glottic tumor was found in 41.5% of patients and supraglottic cancer in 32% of patients.In a study in India, the overall incidence of supraglottic cancer was higher.This variation in demographics can be attributed to the higher prevalence of tobacco chewing rather than smoking in the Indian subcontinent, which results in tobacco-rich saliva coming in contact with the supraglottis; in contrast, smoke from tobacco smoking results in more contact with the glottis [17].
An emergency tracheostomy was performed in 39.6% of the patients and electively in 11.4% of patients.In a retrospective study of 270 patients with carcinoma of the larynx, tracheostomies were performed in 150 (55.6%) patients when the tumor interfered with endotracheal intubations [23,24].
In our study, 17 (32%) patients were recommended total laryngectomy and radiotherapy was performed in 11 (20.7%)patients.Cardesa et al. [19], in a retrospective study, found that primary surgical treatment is an effective modality against T3 glottic carcinomas.
In our study, partial laryngectomy with preservation of both arytenoids was performed in one patient (1.9%).Goodman et al. [25] reported that resection of the arytenoids may interrupt physiologic airway protection in the early postoperative period; thus, a carful postoperative follow-up is needed to prevent the risk of pneumonia.
In our study, neck dissection was performed in 30.2% [26] of patients; they underwent ipsilateral selective neck dissection.A total of 242 patients with a diagnosis of carcinoma of the larynx were studied by César and Javier [30].All of them underwent  surgery.A total of 160 patients underwent functional neck dissection, with a total of 206 performed.The results confirmed that functional neck dissection is the procedure of choice in cases with NO disease and in cases with mobile nodes [27].
In our patients, hematoma occurred in two patients, pharyngocutaneous fistula in five patients, wound infection in one patient, and stomal stenosis in one patient.A retrospective study was carried out at Ganesh Man Singh Memorial Academy of ENT and by Maharjan et al. [31] to observe the various complications following total laryngectomy, carried out in 54 patients; 20 patients developed complications, the most common complications being pharyngocutaneous fistula (six patients, 30%), wound infection (four patients, 20%), superficial flap necrosis (two patients, 10%), and chylous fistula (two patients, 10%) [28].
In our study, mortality was documented in 11.4% of patients; one patient (1.9%) died 2 h after tracheostomy, one (1.9%)died because of respiratory failure type I, one (1.9%)died because of postcricoid carcinoma, and one (1.9%)died because of hepatic metastases.SEER Cancer Statistics Review of National Cancer Institute, from 2005 to 2009, showed that the median age of populations in the USA at death because of cancer of the larynx was 68 years.The age-adjusted death rate was 1.2/100 000 men and women per year [29].
However, the limitations of the study should be kept in mind, which were the lack of standard medical records, a small sample size, and missing data in the records that limited our statistical results.

Conclusion
Although the standards of management of laryngeal carcinoma in Suez Canal University Teaching Hospital are almost compliant with regional and international standards, we need to deal with the time delay between the diagnosis and definitive treatment and to revise the items in the medical records and its registration.