10.14639/0392-100X-N0782
Objective. Open partial horizontal laryngectomies (OPHLs) nowadays represent the first line surgical choice for the conservative treatment of locally intermediate and selected advanced stage laryngeal cancers. Among the peculiarities of OPHLs, there is the possibility of intraoperatively modulating the procedure. It would be useful for the surgeon to recognise preoperative endoscopic and radiological factors that can predict the possibility to modulate the laryngectomy.
Methods. The present study retrospectively reviewed a cohort of 72 patients who underwent OPHL for glottic LSCC, in order to identify preoperative (endoscopic and radiological) parameters that are able to predict modulation surgery.
Results. The hypoglottic extension of the glottic tumour was the preoperative finding that was most informative in predicting OPHL modulation. However, it had no significant impact on oncological outcomes. Conclusions. Patients affected by tumours with hypoglottic extension and eligible for OPHL type II should be preoperatively informed about the possibility of an intraoperative switch towards OPHL type III.
application/xml
1827-675X
782
5
en
Giovanni Succo
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
hypoglottic extension
Modular approach in OPHL: are there preoperative predictors?
Text.Serial.Journal
https://www.actaitalica.it/
40
Laryngology
2020-12-03
2020-04-03
2020-12-04
2020-12-04
352-359
1
Giovanni Succo
2020/12/03
10.14639/0392-100X-N0782
352
Head and Neck Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO), Italy; 4 Department of Oncology, University of Turin, Orbassano (TO), Italy
1827-675X
5
hypoglottic extension
359
Modular approach in OPHL: are there preoperative predictors?
https://www.actaitalica.it/article/download/782/463
40
ACTA OTORHINOLARYNGOLOGICA ITALICA 2020;40:352-359; doi: 10.14639/0392-100X-N0782




Laryngology


Modular approach in OPHL: are there preoperative
predictors?
OPHL modulare: esistono parametri predittivi preoperatori?
Andy Bertolin1, Marco Lionello1, Marco Ghizzo1, Emanuela Barbero2, Erika Crosetti3, Giuseppe Rizzotto1, Giovanni Succo3,4
1
 Otolaryngology Unit, Vittorio Veneto Hospital, Italy; 2 Otorhinolaryngology Service, University of Eastern Piedmont, Novara, Italy;
3
 Head and Neck Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO), Italy; 4 Department of Oncology, University
of Turin, Orbassano (TO), Italy


SUMMARY
Objective. Open partial horizontal laryngectomies (OPHLs) nowadays represent the first line
surgical choice for the conservative treatment of locally intermediate and selected advanced
stage laryngeal cancers. Among the peculiarities of OPHLs, there is the possibility of intraopera-
tively modulating the procedure. It would be useful for the surgeon to recognise preoperative en-
doscopic and radiological factors that can predict the possibility to modulate the laryngectomy.
Methods. The present study retrospectively reviewed a cohort of 72 patients who under-
went OPHL for glottic LSCC, in order to identify preoperative (endoscopic and radiologi-
cal) parameters that are able to predict modulation surgery.
Results. The hypoglottic extension of the glottic tumour was the preoperative finding that
was most informative in predicting OPHL modulation. However, it had no significant im-
pact on oncological outcomes.
Conclusions. Patients affected by tumours with hypoglottic extension and eligible for
OPHL type II should be preoperatively informed about the possibility of an intraoperative
switch towards OPHL type III.                                                                        Received: April 3, 2020
                                                                                                     Accepted: May 19, 2020
KEY WORDS: OPHL, partial laryngectomy, modular, laryngeal carcinoma, hypoglottic
extension
                                                                                                     Correspondence
                                                                                                     Marco Lionello
RIASSUNTO                                                                                            Otolaryngology Unit, Vittorio Veneto Hospital, via
Obiettivi. La laringectomia parziale orizzontale open (OPHL) rappresenta al giorno d’oggi            Forlanini 71, Vittorio Veneto, Treviso, Italy
la scelta chirurgica di prima linea per il trattamento conservativo del carcinoma squamoso           E-mail: marcolionello@email.it
laringeo (LSCC) in stadio intermedio e di selezionati casi in stadio localmente avanzato. Fra
le peculiarità della OPHL c’è la possibilità di modulare intraoperatoriamente la procedura.          Funding
Sarebbe utile al chirurgo riconoscere parametri preoperatori endoscopici e/o radiologici che         None.
possano predire la possibilità di modulare intraoperatoriamente la laringectomia.
Metodi. Il presente studio ha considerato retrospettivamente una popolazione di 72 pazien-           Conflict of interest
                                                                                                     The Authors declare no conflict of interest.
ti sottoposti ad OPHL per LSCC, al fine di identificare parametri preoperatori (endoscopici
e radiologici) in grado di predire la modulabilità della OPHL.
Risultati. L’estensione ipoglottica del tumore è risultata essere il parametro preoperatorio           How to cite this article: Bertolin A, Lionello M,
più informativo nel predire la modulazione della OPHL. Tale condizione, tuttavia, non                  Ghizzo M, et al. Modular approach in OPHL:
impattava in maniera significativo sull’outcome oncologico.                                            are there preoperative predictors? Acta Otorhi-
Conclusioni. I pazienti affetti da tumori con estensione ipoglottica e candidabili ad OPHL             nolaryngol Ital 2020;40:352-359. https://doi.
                                                                                                       org/10.14639/0392-100X-N0782
tipo II dovrebbero essere informati preoperatoriamente sulla possibilità di uno switch in-
traoperatorio verso una OPHL tipo III.
                                                                                                     © Società Italiana di Otorinolaringoiatria
PAROLE CHIAVE: OPHL, laringectomia parziale, modulare, carcinoma laringeo,                           e Chirurgia Cervico-Facciale
estensione ipoglottica
                                                                                                                    OPEN ACCESS

                                                                                                     This is an open access article distributed in accordance with
Introduction                                                                                         the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                     Commercial-NoDerivatives 4.0 International) license. The
Open partial laryngectomies have undergone worldwide diffusion from the                              article can be used by giving appropriate credit and mentio-
                                                                                                     ning the license, but only for non-commercial purposes and
second half of the 20th century thanks to the efforts of some excellent surgeons.                    only in the original version. For further information: https://
Alonso described supraglottic laryngectomy, indicated for tumours limited to                         creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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the supraglottic region 1. A few years later Meyer, Piquet        derwent salvage OPHL; iii) patients with a follow-up < 24
and Labayle standardised supracricoid laryngectomies              months; iv) a final histology other than LSCC.
with and without conservation of the suprahyoid epiglot-          Laryngeal tumours were staged according to the 8th clas-
tis, respectively 2,3. These became the most performed open       sification of the Union Internationale Contre le Cancer and
partial laryngectomies worldwide, given their satisfying          the American Joint Committee on Cancer 7.
and reproducible results. In the 1970s, Serafini described a      Preoperative diagnostic work-up included laryngeal indi-
near-total laryngectomy, defined by a supratracheal caudal        rect flexible video-endoscopy, contrast-enhanced neck CT
resection 4, that was subsequently revised by Rizzotto who        scan or MRI, chest X-ray; under general anaesthesia laryn-
codified the tracheohyoidopexy as a supracricoid laryngec-        goscopy was then performed using rigid 0°, 30° and 70°
tomy that extended toward the cricoid 5. The requisite for        telescopes in white light and narrow band imaging to com-
the functional success of this technique was the possibility      plete the diagnostic work-up.
of sparing at least one crico-arytenoid unit (CAU).               All patients preoperatively signed an informed consent
Open partial laryngectomies nowadays represent the first          form for modular surgery and total laryngectomy.
line surgical choice for conservative treatment of locally in-    All procedures performed were in accordance with the
termediate and selected advanced stage laryngeal cancers.         ethical standards of the institutional Ethics Review Board
According to the most recent guidelines of the European           and with the 1964 Helsinki declaration and its later amend-
Laryngological Society (ELS), OPHL represents the cur-            ments or comparable ethical standards.
rent classification of horizontal partial laryngectomies 6.
Both classifications are characterised by distinction of          Surgery
surgical subcategories according to the level of the caudal       Indications to perform OPHL were: i) selected cases of ear-
horizontal resection. We can therefore distinguish supra-         ly glottic cancer (cT2) not fit for transoral laser microsur-
glottic laryngectomies (OPHL type I), supracricoid laryn-         gery (TLM), and ii) selected cases of locally intermediate-
gectomies (OPHL Type II) and supratracheal laryngecto-            advanced disease (cT3-4a) with at least one disease-free
mies (OPHL type III).                                             CAU, no massive extralaryngeal spread (i.e. a limited dif-
Among the peculiarities of OPHLs, there is the possibility        fusion to prelaryngeal tissues without invasion of the thy-
to intraoperatively modulate the procedure.                       roid gland or of the infrahyoid muscles) and iii) acceptable
It would be useful for the surgeon to identify preoperative       general conditions and comorbidities.
endoscopic and radiological factors that can predict the pos-     General patient-related contraindications to OPHL includ-
sibility to modulate the laryngectomy. These factors should       ed alcohol and drug abuse, or major comorbidities (heart
be considered and mentioned during preoperative counseling        failure, lung diseases, mellitus diabetes, or severe neuro-
in order to allow the patient to participate in the therapeutic   cognitive decay).
choice.                                                           The open partial laryngectomies were performed and re-
The main aim of the present study was to investigate, in          corded according to the ELS classification 6. According to
a cohort of glottic LSCC patients undergoing OPHL, the            the “modular” approach, the patients with glottic LSCC
preoperative factors that are related to modulation of the        were initially approached with supracricoid resection; the
procedure. Secondary aims were to analyse the oncologi-           procedure could intraoperatively change to supratracheal
cal outcomes of the cohort and the prognostic relevance of        laryngectomy, according to macroscopic extension of the
clinical, surgical and pathological parameters.                   tumour and microscopic findings at frozen sections (posi-
                                                                  tive or negative status of mucosal margins), with progres-
                                                                  sive widening of the resection, sparing at least one crico-ar-
Methods                                                           ytenoid unit. All margins were also checked postoperatively
Patients                                                          on final histology and classified as positive/close/negative.
From 2015 to 2017, 119 patients underwent OPHL for                A radical or modified radical neck dissection (RND and
glottic LSCC at the Otolaryngology Service of Vittorio            MRND, respectively) were performed in the event of clinical-
Veneto Hospital, and the Otolaryngology Service of San            ly or radiologically proven lymph node involvement. Selec-
Luigi Gonzaga University Hospital in Turin (Italy). Clini-        tive neck dissection (SND) of levels II-III-IV was performed
cal charts were retrospectively reviewed.                         electively for cT3-4a N0 disease, or with curative intent for
Exclusion criteria were: i) patients with supraglottic cancer     clinically or radiologically limited node metastases. Bilateral
treated with supraglottic laryngectomy (OPHL I), since the        neck dissection was routinely performed in cases of supra-
primary aim of our study was to examine the factors influ-        glottic spread. An ipsilateral paratracheal neck dissection was
encing modularity in glottic cancer; ii) patients who un-         used in the event of disease extending to the hypoglottis.



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A. Bertolin et al.




Postoperative radiotherapy (RT) was considered in locally                      The cases of LSCC were classified as follows: cT2 in 16;
advanced cases (pT3-T4a) with positive margins or multi-                       cT3 in 49; and cT4a in 8. Regional node status was classi-
ple node metastases (pN2-3); chemo-radiotherapy (CRT)                          fied as: cN0 in 56 cases; cN1 in 7; cN2 in 7; and cN3 in one.
was scheduled in cases with extranodal extension, and an-                      The pathological classification was: pT1 in 3 cases; pT2 in
gio-vascular or perineural invasion.                                           6; pT3 in 44; and pT4a in 19. The pathological classifica-
                                                                               tion of cervical nodes was: pNX-0 in 56 cases; pN1 in 7;
Statistical analysis                                                           pN2 in 5; and pN3 in 4.
Fisher’s exact test was used to calculate the association be-                  An ipsilateral neck dissection was performed in 63 cases,
tween different clinical and pathological parameters with                      while a bilateral neck dissection in 4 cases with lesions
OPHL modulation and disease recurrence rate. The log-                          crossing the midline. There was evidence of extranodal dis-
rank test and Kaplan-Meier survival function were used to                      semination in 6 cases. Eleven patients received postopera-
calculate disease-free survival (DFS) for patients stratified                  tive radiotherapy or CRT.
by the selected variables.
A multivariate logistic model (Wald test) was applied to                       Pathological findings
the same parameters (Fisher’s exact test, p < 0.10) to iden-                   At pathology, 10 patients had positive surgical margins, 45
tify independent prognostic factors in relation to recurrence                  negative and 17 closed. The positive margin was lateral (on
rate and modulation surgery, and the relative 95% confi-                       the side of the spared arytenoid) in 6 cases, deep in 4, and cau-
dence intervals were calculated.                                               dal in 1 case. Vascular and perineural invasion were detected
A p-value < 0.05 was considered significant. The STATA                         in 38 and 27 cases, respectively. As for pathological grade,
14 statistical package (Stata Corp., College Station, TX)                      this was well differentiated in 12 cases, moderately differenti-
was used for all analyses.                                                     ated in 28, poorly differentiated in 24 and indeterminate in 8.

Results                                                                        Oncological outcomes
                                                                               Sixty-two patients had no relapse of disease, while 10 pa-
Open partial horizontal laryngectomies                                         tients (13%) experienced a disease recurrence after 15 ± 6
In this study a cohort of 72 LSCC patients (62 men and 10                      months. The mean follow-up was 34 ± 6 months (range
women; mean age 61.1 ± 8.6 years, median 62) met the                           26-71 months). At latest follow-up, 61 patients (85%) were
inclusion criteria.                                                            alive and disease-free, 7 (9%) were alive with disease, 2
An OPHL type II was performed in 49 cases, while a type                        (3%) died of their disease and 2 (3%) died with no evidence
III was carried out in 23 cases.                                               of disease. The final overall and disease-specific survival
OPHL was modulated (from type II to type III) in 6 cases.                      rates were 94% and 97%, respectively.
Table I shows the distributions of preoperative clinical pa-                   Considering the 10 cases with positive margins, 3 patients
rameters in relation to the modulation of surgery. Hypo-                       underwent postoperative radiotherapy, chemo-radiotherapy
glottic tumour extension was the preoperative parameter                        was scheduled in 1 case with neck metastasis, while close
that was significantly related with OPHL modulation.                           follow-up was adopted in the remaining 6 cases. Two of
                                                                               the 10 patients experienced a local recurrence of disease
                                                                               and were submitted to total laryngectomy: one patient died
Table I. Distributions of modulated OPHLs according to preoperative clinical   of disease, the other was disease free at last follow-up. The
(endoscopic/radiological) parameters.
                                                                               OPHL was modulated in 1 patient, with caudal positive
 Parameter                                  Modulated OPHL           p*
                                                                               margin, who experienced no recurrence of disease.
    Posterior glottis                               5/36            0.19
    Anterior glottis                                1/36                       Univariate and multivariate analysis of prognostic factors
    Impaired/absent arytenoid motility              5/44            0.39       Results of the univariate analysis are shown in Table II. Pa-
    Normal arytenoid motility                       1/28                       tients with lymph node metastases had significantly higher
    Radiological TCAS invasion                      5/47            0.65       recurrence rates and shorter DFS compared with pN0 pa-
    No radiological TCAS invasion                   1/25                       tients. Statistical analysis found that patients who under-
    Radiological CAU invasion                       5/30            0.07       went OPHL type III and those with CAU involvement had
    No radiological CAU invasion                    1/42                       significantly lower DFS compared with patients undergone
    Hypoglottic extension                           6/32            0.00       OPHL type II and those without CAU involvement by the
    No hypoglottic extension                        0/40                       tumour. These patients had also higher recurrence rates, al-
*
    Fisher’s exact test                                                        though no significant p values emerged from our analysis.



354
                                                                                                                                         Modulated OPHL




Table II. Distribution of recurrence rate and disease-free survival (months) by main clinical and pathological parameters.
                                                     No. of patients            Recurrence rate              p*               DFS              p **
                                                            (%)                       (%)                                  (Mean ± SD)
    Age
    Age ≥ 65                                              24                     4 (16%)                0.72               22 ± 21            0.83
    Age < 65                                              48                     5 (10%)                                    43 ± 6
    Pathological T classification
    pT1                                                    3                     2 (22%)                0.60               24 ± 31            0.35
    pT2                                                    6
    pT3                                                   44                     8 (12%)                                   47 ± 30
    pT4a                                                  19
    Pathological N classification
    pNX-0                                                 56                     7 (12%)                0.05               49 ± 4             0.06
    pN1                                                    7                     3 (18%)                                   17 ± 9
    pN2                                                    5
    pN3                                                    4
    Resection margins
    Negative                                              62                     10 (16%)               0.66               31 ± 22            0.95
    Positive                                              10                     2 (20%)                                    39 ± 8
    Vascular invasion
    Negative                                              34                     4 (11%)                0.73               43 ± 4             0.86
    Positive                                              38                     6 (15%)                                   40 ± 10
    Perineural invasion
    Negative                                              45                     7 (15%)                0.73               29 ± 25            0.44
    Positive                                              27                     3 (11%)                                   43 ± 13
    OPHL type
    II                                                    49                      4 (8%)                0.06               40 ± 9             0.05
    III                                                   23                     6 (26%)                                   12 ± 15
    Anterior vs posterior
    Posterior glottis                                     36                     8 (22%)                0.08               22 ± 1             0.04
    Anterior glottis                                      36                      2 (5%)                                   34 ± 8
    Arytenoid motility
    Impaired/absent arytenoid motility                    45                     9 (20%)                0.02               16 ± 6             0.07
    Normal arytenoid motility                             27                      0 (0%)                                   18 ± 8
    TCAS involvement
    Radiological TCAS invasion                            47                     8 (17%)                0.47               17 ± 8             0.43
    No radiological TCAS invasion                         25                      2 (8%)                                   27 ± 1
    CAU involvement
    Radiological CAU invasion                             30                     7 (23%)                0.08               31 ± 11            0.04
    No radiological CAU invasion                          42                      3 (7%)                                    25 ± 4
    Hypoglottic extension
    Endoscopic hypoglottic extension                      32                     7 (21%)                0.09               20 ± 4             0.10
    No endoscopic hypoglottic extension                   40                      3 (7%)                                   26 ± 4
*
    Fisher’s exact test; ** Log-rank test




Patients with normal arytenoid motility experienced sig-                        mediate-advanced stage disease (pT3-4), positive margins,
nificantly lower recurrence rates compared with patients                        posterior glottic tumours and radiological involvement of
with impaired/absent motility. Patients with locally inter-                     thyro-crico-arytenoid space (TCAS) and hypoglottic region



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A. Bertolin et al.




had a higher recurrence rate and shorter DFS, although the                        It is worth noting that every type of conservative surgery,
differences were not significant.                                                 including OPHL, necessarily needs a very accurate pre-
Multivariate analysis confirmed that hypoglottic extension                        operative diagnostic work-up in order to analyze the real
of the tumour was the only independent predictive factor                          extension of the tumour, as well as intraoperative confirma-
for surgical modulation (Wald test, p = 0.05; odds ratio 2.1;                     tion of surgical margins with frozen sections. In the case
95% confidence interval 1.25-4.35). The pathological find-                        of modular surgery, the role of histological examination is
ing of neck metastasis was an independent negative prog-                          even more relevant since it determines modulation towards
nostic factor in terms of recurrence rate (Tab. III).                             the more radical procedure.
                                                                                  In the present study, a relatively high number of positive
Discussion                                                                        margins was reported (13.9%). This could be related to:
                                                                                  i) the discrepancy between intraoperative and definitive
Modular surgery is a patient- and tumour-tailored surgical                        results of the pathological examination, ii) the final posi-
approach that is gaining increasing importance in modern                          tivity of deep margins, since we intraoperatively sent only
surgery. Considering laryngeal cancer, OPHL is the modu-                          superficial mucosal margins, and iii) to the high number of
lar procedure par excellence. As previously reported, when                        locally advanced tumours (pT3-T4a: 63 cases, 87%).
approaching an OPHL, the surgeon should refer to a surgi-                         The possibility to modulate the level of the caudal resection
cal plan rather than to a single procedure 8.                                     represents a peculiarity and one of the main advantages of
Modular surgical approaches to organ resection, related to                        partial horizontal laryngectomies. The diffusion and the
the tumour site and extension, have already been proposed                         standardisation of OPHL are due to ELS, and in particular
for other cancers, including gastric, liver and pancreatic                        to the efforts of Succo and coworkers 6.
cancers 9-13. In dermatological surgery, Mohs micrographic                        This surgical modular approach was demonstrated to be a
surgery (MMS) has become the gold standard for treatment                          valid and effective therapeutic choice for selected patients
of cutaneous malignancies. It consists with removal of the                        with glottic or transglottic laryngeal cancer with subglottic
neoplasm, in a step-by-step fashion, with progressive tis-                        extension, not only in terms of oncologic results, but also in
sue exeresis checked with frozen sections, up to complete                         terms of functional outcomes 15,16.
removal of the lesion. Histopathologic examination is key                         However, OPHL type II had been demonstrated to warrant
to the high cure rates achieved with MMS 14.                                      overall better functional results and lower complication


Table III. Multivariate analysis of main clinical and pathological parameters.
                                                                         Odds ratio             p*        95% confidence interval      p **
    Pathological N classification
    pN+                                                                    2.35                0.05           Reference group         0.05
                                                                                                                 1.55-7.85
    OPHL type
    III                                                                    1.80                0.06           Reference group         0.07
                                                                                                                 0.85-2.35
    Anterior vs posterior
    Posterior glottis                                                      1.50                0.08           Reference group         0.08
                                                                                                                 1.15-5.55
    Arytenoid motility
    Impaired/absent arytenoid motility                                     3.20                0.02           Reference group         0.07
                                                                                                                 1.35-15.5
    CAU involvement
    Radiological CAU invasion                                              2.30                0.08           Reference group         0.10
                                                                                                                 1.65-3.35
    Hypoglottic extension
    Endoscopic hypoglottic extension                                       1.55                0.09           Reference group         0.25
                                                                                                                 0.65-8.55
*
    Fisher’s exact test; ** Wald test




356
                                                                                                                                                    Modulated OPHL




rates. In 2017, Lucioni et al. reported that postoperative la-                        cedure can even be converted to total laryngectomy. In most
ryngeal obstruction of the neoglottis after OPHL occurred                             cases, however, correct preoperative staging can predict the
in 49 of 446 patients who had OPHL type II (11%) and in                               possibility of conservative surgery, rather than the need for
36 of 105 patients who had OPHL type III (34%). Such a                                radical laryngectomy. For the same reasons, OPHL type I is
complication in most cases can be managed with transoral                              not usually part of the modularity issue, since correct endo-
laser microsurgery (TLM) to resolve the neolaryngeal ste-                             scopic and radiological diagnostic work-up can exclude the
nosis. Also, the number of procedures necessary to treat                              involvement of the glottis by a supraglottic cancer.
the stenosis differed between the procedures. Actually, the                           To our knowledge, on the other hand, there are no clear
authors reported that 1.6 ± 1.2 TLM procedures were nec-                              predictive parameters of the modulation of OPHL. In the
essary to manage the stenosis after OPHL type II, while                               present study, we investigated the relevance of clinical (en-
2.2 ± 1.8 were necessary after OPHL type III. The final                               doscopic and radiological) parameters to predict the modu-
decannulation rate after OPHL type II was 92% vs 86%                                  lation of the OPHL.
after OPHL type III 17.                                                               Univariate and multivariate analysis found that hypoglottic
In 2015, Schindler and coworkers published an exhaustive                              extension of the tumour was the most significant preopera-
comparison of functional outcomes of OPHL type IIa and                                tive parameter to predict the possibility of intraoperatively
IIIa, in terms of swallowing, voice and quality of life. Their                        modulating the OPHL.
results, showing the effectiveness of OPHL type IIIa, de-                             In cases with endoscopic and radiological suspicion of
noted a trend toward better functional outcomes of OPHL                               the hypoglottic region, OPHL lets the surgeon start with
IIa, although significant differences were found in swal-                             a supracricoid approach, with the possibility to lower the
lowing only for residue with solids and for voice intelligi-                          resection, modulating the procedure to a supratracheal lar-
bility 18.                                                                            yngectomy, according to the results of intraoperative frozen
All patients must be preoperatively informed about the                                sections.
eventuality of shifting from supracricoid to supratracheal                            Clearly, the possibility to modulate the OPHL must not
laryngectomy. Specific consent including all possible ex-                             reduce the importance of a scrupulous preoperative stag-
tensions of the procedure, to be signed by the patient, is                            ing. In the present study, all patient underwent preopera-
thus needed 8. At our Institution, patients are routinely in-                         tive flexible endoscopy in an outpatient setting, contrast-
formed about the possibility of intraoperative modulation                             enhanced neck MRI, if available, or CT scan and direct
of partial laryngectomy and that, in extreme cases, the pro-                          laryngoscopy under general anaesthesia using rigid 0°, 30°




  A                                                    B                                                                C

Figure 1. A. Opening the larynx during supracricoid approach to assess the tumour extension. B. After frozen sections results, the caudal incision is lowered
under the cricoid cartilage (supratracheal resection). C. Removal of the cricoid ring en bloc with the specimen. Captions. c: cricoid ring; g: glottis; h: hypoglottis;
lcau: left crico-arytenoid unit; t: trachea; *: tumour.



                                                                                                                                                                 357
A. Bertolin et al.




and 70° telescopes in white light and narrow band imaging          Acknowledgements
to assess the mucosal margins of the neoplasm 19.
                                                                   The authors thank all the medical and paramedical staff
On the other hand, the hypoglottic extension did not sig-
                                                                   at the Otolaryngology Unit - Vittorio Veneto Hospital, for
nificantly impact oncological outcomes (Tab. II). This is
                                                                   collecting the follow-up data, and the Association “Amici
probably due to the good tumour control by OPHL type III
                                                                   della voce” (Friends of the Voice) for support in preparing
in cases with initial hypoglottic extension of the tumour.
                                                                   the manuscript.
Moreover, the only patient with caudal positive margins
who had modulation of the OPHL did not experience local
recurrence of the disease.                                         References
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preoperative selection of cases. Actually, patients with en-            mlg.0000236085.85790.d5
doscopic evidence of posterior glottic lesions or impaired/
                                                                   6
                                                                        Succo G, Peretti G, Piazza C, et al. Open partial horizontal laryn-
                                                                        gectomies: a proposal for classification by the working committee
absent arytenoid mobility were directly approached with                 on nomenclature of the European Laryngological Society. Eur Arch
OPHL type III because of the high risk of crico-arytenoid               Otorhinolaryngol 2014;271:2489-96. https://doi.org/10.1007/s00405-
joint involvement by the tumour. Similarly, in case of radi-            014-3024-4
ological suspicion of TCAS or CAU invasion, these struc-
                                                                   7
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In the present study, multivariate analysis (Tab. III) con-        8
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                                                                   10
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                                                                   15
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