Laryngology Seminar
Stomal Recurrence
R3 許惇彥 2004/05/12


History
 Latella, 1951: 8 cases in 240 laryngectomee
 Keim, 1965: neoplastic tissue diffuse infiltration in the area of the
tracheal junction with the skin of the stoma
 Kowalski, 2003: 5.2%(957/18174, literature review)
Demography
 Synonyms: trachea metastasis, peritracheal recurrence, tracheal

recurrence, stomal recurrence, persistent paratracheal
tumor, tracheostomal metastasis
Prevalence: 1.7% ~ 25%
 98% noted in 2 years
 Dread, dismal, grave prognosis: median survival was 6months
 Pathophysiology: uncertain
Risk factors
 Site
Laryngeal > hypopharyngeal (12.7% > 5.7%, Kowalski)
Tumor extension to subglottis (17.6% > 6.3%, Kowalski)
 Stage
Advanced transglottic cancer or advanced hypopharyngeal cancer
Table 1. Incidence of stomal recurrence of
carcinoma according to site of primary lesion
Primary site
Number of
Stomal
patients
recurrence
Epiglottis
154
1(0.6%)
AE fold
77
1(1.3%)
Glottis
129
1(0.8%)
Subglottis involved
84
12(14.3%)
Table 2. Incidence of stomal recurrence of
carcinoma according to stage of primary lesion
Primary lesion
Number of patients Stomal
stage
recurrence
T1
64
0(0%)
T2
97
2(2%)
T3
202
6(2.9%)
T4
81
7(8.6%)
 Insufficient tracheal margins
 Thyroid invasion
Keim, Kowalski, Biel and Maisel: direct extension to thyroid gland was a
risk factor
 Tumoral implantation
Only possible while there was mucosal disruption
Lymphatics disruption due to pathological or therapeutic factors
Previous radiotherapy (29.2%, Kowalski)
 Prior tracheostomy
tracheostomy (+) > tracheostomy(-) (22.9% > 7%, Kowalski)
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Subglottis (+) (tracheostomy (+) > tracheostomy(-), 36.4% >
14.3%, Kowalski)
Molinari and Milanesi: Lymphatic metastasis was the main cause of stomal
recurrence, not tumor implant during trachostomy
 Prior partial laryngectomy
May tumor implantation
 Paratracheal lymph node metastasis
Weber: Paratracheal lymph node metastasis (+) in
Esophageal cancer (71%), laryngeal cancer (17.6%)
(26.7% while subglottis involved), hypopharyngeal
cancer (8%)
(Martin: Mediastinal metastasis (+) in
Esophageal cancer (62%), laryngeal cancer (0%),
hypopharyngeal cancer (73%) )
 Second primary tumor or second filed tumor
Field cancerization
(p53 expression or microsatellite assay)
Primary tracheal tumor was rare
 Classification
(1) Table I (Sisson, 1977)
Type I
Type II
Type III
Type IV
Localized to superior of stoma. No esophageal involvement
(Good prognosis)
Localized to superior of stoma with esophageal involvement
(Fair prognosis if limited involvement)
Originates from inferior aspect of stoma and involves superior
mediastinum (Palliation, but poor prognosis)
Extension laterally beneath clavicles and into superior
mediastinum (Palliation, but poor prognosis)
(2) Bignardi, 1983
Trachea, paratracheal lymphatic metastasis, tumor implantation
(3) Kowalski, 2003
A. Recurrence in the stomal area
(1) Peristomal (soft tissue) (2) Stomal (mucocutaneous)


B. Residual tumor in the stomal area
(1) Peristomal (2) Stomal
C. Second primary tumor in the stomal area
(1) Tracheal (2) Cutaneous
Thoracoscopic evaluation of trachea, esophagus, and great vessels
Prevention
 Davis, 1980: Endoscopic partial laser vaporization of tumor for
debulking
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 Vermund, 1970: Irradiation, antibiotics, and corticosteroid

 For precious tracheostomy patient:
Trachea sectioned 1cm below tracheostomy + peristomal
skin and soft tissue removal +paratracheal lymph node
dissection
 En bloc excision and vigorous irrigation and aware of implantation
Treatment
 Sisson’s operation, 1962: trans-sternal radical neck dissection or
mediastinum dissection
High morbidity and high mortality
 Emergent laryngectomy
Drawback: without proper investigation of systemic metastasis
 Radiotherapy or CCRT (along or post-operation)
Table 3. Preventive measures implemented in
our center in patients with SR risk
Subglottic involvement Extensive tracheal resection (>3cm)
Systemic hemithyroidectomy + Ithsmectomy (in case of no involvement)
Total thyroidectomy if invasion of the thyroid gland is suspected
Paratracheal lymph node dissection (no mediastinal dissections have
been carried out)
Postoperative radiotherapy on tracheostoma and upper mediastinum
(50-65 Gy depending on pathologic findings)
Previous tracheostomy Resection of the skin, peristoma soft tissues and portion of trachea
(>48 h before)
involved by the old stoma (creation of a new lower stoma)
Postoperative radiotherapy on tracheostoma (50-65 Gy depending on
pathologic findings)
Table 4. Patients with stomal recurrence
Clinical summary
No. of patients
224
No. of series
17
Sex
90% male; 10% female
Age (mean)
59 yr
Incidence (mean) (% of
5.8
patients)
Location of primary carcinomas
(no. of patients)
Suplaglottic
30
Glottic
37
Subglottic
104
Timing of recurrence after laryngectomy
6mo
29
6-12mo
67
12-24mo
27
24-48mo
11
48mo
3
Tracheal management
Emergency/Preoperative
15%
Intraoperative
8.6%
Outcome/Survival
2% at wk to 14 yr
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