56 Risk factors for local recurrence include transglottic or subglottic tumor extent,54 lymph node metastases,54–56 poor differentiation,54 lymphovascular invasion,56 preoperative tracheostomy,55,56 and positive resection margins.56 Salvage Treatment #selleck inhibitor randurls[1|1|,|CHEM1|]# With the increasing role of non-surgical management in the treatment of advanced larynx

cancer, total laryngectomy is increasingly becoming as a salvage treatment for cases which fail radiotherapy or chemoradiotherapy. Salvage laryngectomy Inhibitors,research,lifescience,medical is associated with an increased risk of major complications including pharyngocutaneous fistula,45 enlargement of the tracheo-esophageal puncture site,57 and dysphagia. Additional risk factors for Inhibitors,research,lifescience,medical these complications in the salvage setting include interval since radiotherapy45 and concomitant performance of bilateral neck dissection.45 In an effort to reduce the risk of these complications, several authors have advocated elective use of pectoralis major myogenous flaps, placed in onlay fashion, or free flaps interposed between the pharynx and skin/stoma.58 The use of a pectoralis major myogenous flap to bolster the pharyngeal repair

has been reported by some authors to reduce the incidence of pharyngocutaneous fistula, and shorten time to healing in Inhibitors,research,lifescience,medical cases which do fistulize.59,60 On the other hand, other authors found no significant difference in the incidence of fistula Inhibitors,research,lifescience,medical between patients undergoing and not undergoing pectoralis major flap.45,61 However, these studies were all retrospective, so it is not possible to exclude bias due to cases considered at Binimetinib higher risk of fistula having undergone pectoralis major flap. TREATMENT OF THE NECK No neck Supraglottic cancers have a marked propensity to give rise to nodal metastases, Inhibitors,research,lifescience,medical with an incidence of metastases detected by pathological examination in the N0 neck of 21%–30%.62,63 Metastases usually occur at levels II and III,64,65 but, in the setting of established disease at these levels, level IV may also be involved.66 Involvement of levels I and V are less

frequent.65 Bilateral neck metastases are common owing to the frequent midline Drug_discovery location of the primary tumor.67 Thus, all patients with supraglottic cancer, even with clinically N0 necks, should undergo elective neck treatment. This may take the form of elective neck dissection at the time of surgical treatment of the primary, or elective nodal irradiation of at-risk nodal groups postoperatively68,69 or concomitant with laryngeal irradiation in patients undergoing primary non-surgical treatment.69 Although the risk of nodal metastases in patients with glottic cancer and clinically N0 necks is much lower, elective treatment of the ipsilateral neck in patients with advanced (T3/4) glottic cancers is generally recommended. This will usually involve elective nodal irradiation for patients undergoing non-surgical treatment.