复发性喉癌挽救性手术保留喉功能初步临床分析

Preliminary report of laryngeal preservation in the surgical salvage of recurrent laryngeal cancer

目的探讨复发性喉癌挽救性手术治疗保留喉功能的可行性。方法通过对患者和肿瘤进行全面、细致的临床和影像学评估，合理选择手术方式及其适应证。对36例放疗、激光手术和开放式喉部分切除术后复发的喉癌患者，实施挽救性手术治疗同时保留喉功能。术后对所有患者进行正规随访，Kaplan-Meier法计算术后生存率。结果实施经口激光二次肿瘤切除术4例，喉水平部分切除4例，喉垂直部分切除术13例，环状软骨上切除术（Majer—Piquet）手术15例，18例患者同时接受了颈清扫术。术后6例患者发生不同程度的并发症，其中主要是局部感染和咽瘘，没有院内死亡和其他严重并发症发生。5例术后近期并发症均经适当处理后治愈，1例接受喉垂直部分切除术的喉裂开肿瘤切除术后复发患者因切缘病理阳性接受术后放疗，导致喉狭窄及喉腔闭塞失去喉发音和呼吸功能。术后肿瘤局部复发5例，局部和颈部同时复发1例，肿瘤局部控制率为83．3％（30／36）。术后3年生存率80．6％，死亡原因分别为肿瘤复发3例，远处转移3例，其他非肿瘤原因（心脏病）1例。结论初步临床观察表明，对于喉癌治疗后早期和局限性复发的患者，在对肿瘤进行全面细致评估和严格把握手术适应证的基础上，可以选择性实施保留喉功能的挽救性外科手术，从而提高这类肿瘤患者的生存质量。

Objective To explore the plausibility of laryngeal preservation in salvage surgery of recurrent laryngeal carcinoma. Methods Comprehensive clinical and radiological assessments on a specific group of patients with recurrent laryngeal cancer and their relapsed tumors were carried out to determine the methods and indications of salvage surgery for preservation of laryngeal functions. Salvage surgery with preservation of larynx was performed in a selective of 36 laryngeal cancer patients with relapsed tumors in their larynges after radiotherapy or partial laryngectomies. All patients were regularly followed up after discharge from the hospital. Postoperative survival was calculated by Kaplan-Meier＇s method. Results Among various laryngeal preservation regimens given, a second transoral laser surgery was carried out in 4 cases, horizontal hemilaryngectomy in 4 cases, vertical hemilaryngectomy in 13 cases and Majer-Piquet＇s operation in 15 cases, respectively. Simultaneous neck dissection was conducted in 18 cases. Postoperative complications were encountered in 6 cases, most common of which were local infection and laryngeal fistula with no hospital mortality and other major morbidities. Five cases with immediate postoperative complications were cured with proper management. The remained one case undergone vertical partial laryngectomy for recurrence after tumor resection via laryngeal fissure received postoperative radiation due to positive surgical margin, and complicated laryngeal atresia and obstruction with loss of his laryngeal functions. Local recurrence was observed in 5 cases and simultaneous locoregional recurrence was seen in 1 case, with the resulting local control rate of 83.3% （30/36）. The 3-year postoperative survival rate was 80. 6%. The cause of death was tumor recurrence in 3 cases, distant metastasis in 3 cases and non-tumor-associated disease （heart attack） in 1 case, respectively. Conclusions Salvage surgery with laryngeal preservationcan be carried out in the selected cases with early or locally-confined recurrent lesions within the larynx, on the condition that the recurrent tumors be assessed thoroughly and indications for associated surgical techniques be evaluated properly.