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Case Report

Literature Review

References

Late Stomal Recurrence 17 Years Post Total Laryngectomy; Case report and Review of Literature

Robert Deeb MD, Mausumi Syamal MS, Robert Stachler MD, Scott McLean MD PhD, Tamer Ghanem MD PhD

Department of Otolaryngology-Head & Neck Surgery Henry Ford Health System, Detroit, Michigan

Objective: Present a case of a late stomal recurrence and investigate the longest documented disease-free interval in patients with late stomal recurrence post total laryngectomy. Study Design: Case report Methods: Literature review of late stomal recurrences, defined as new primaries at the site of the stoma or neopharynx occurring more than 5 years after total laryngectomy. Results: We present a case of late stomal recurrence occurring in the neopharynx 17 years post total laryngectomy. Currently, the longest published disease-free interval post total laryngectomy, specifically dealing with latestomal recurrence, is 6.5 years. Thus, the present case represents the longest reported time interval for developing late stomal recurrent disease. Conclusions: Documentation of a case of stomal malignancy 17 years post-total laryngectomy is worthy of mention as it serves as a reminder to clinicians that while late stomal recurrence is rare, it is nonetheless a possibility of serious consequence. Thus, complete and thorough work-up is warranted for new complaints such as dysphagia, neck mass,or dyspnea in a patient with a history of laryngeal carcinoma.

W.W. is a 63 year old male who was diagnosed with T2N0MO squamous cell carcinoma of the left true vocal cord in February of 1991. He completed radiation therapy consisting of 7000 rads in April of 1991. He underwent salvage total laryngectomy for persistent disease in June of 1991. He was disease free until July of 2008, until he presented with dysphagia. An esophagoscopy was performed and a mass was noted in the neopharynx. Biopsy of this region revealed squamous cell carcinoma. The patient underwent cervical esophagectomy with stomal resection, bilateral selective neck dissections, free jejunal flap reconstruction of total laryngopharyngectomy defect as well as pectoralis major flap reconstruction of stoma in August 2008.

At time of discharge patient was tolerating PO diet and also speaking relatively well via esophageal (jejunal) method. He was discharged from hospital in stable condition.

Two months post-operatively, he was noted to have recurrence of disease bilaterally in the posterior triangles. He is currently undergoing chemotherapy.

1. Keim WF, Shapiro MJ, Rosin HD. Study of postlaryngectomy stomal recurrence. Ann Otol Rhinol Laryngol 1965;81:183-6. 2. Esteban F, Mreno JA, Delgado-Rodriguez M, Mochon A. Risk factors involved in stomal recurrence following laryngectomy. J Laryngol Otol 1993;107:527-531.3. Rubin J, Johnson JT, Myers EN. Stomal recurrence after laryngectomy: interrelated risk factor study. Otolaryngol Head Neck Surg. 1990;103:805-12.4. Modlin B, Ogura JH. Post laryngectomy tracheal stomal recurrences. Laryngoscope 1969;79:239-250. 5. Ritoe SC, Bergman H, et al. Cancer recurrence after total laryngectomy: treatment options, survival, and complications. Head Neck. 2006(5):383-8.6. Zbaren P, Greiner R, Kengelbacher M. Stoma recurrence after laryngectomy: an analysis of risk factors. Otolaryngol Head Neck Surg 1996;114:569-75. 7. Leon X, Quer M, Burgues J, et al. Prevention of stomal recurrence. Head Neck 1996;18:54-59. 8. Yotakis J, Davris S, Kontozoglou T, Adamopoulos G. Evaluation of risk factors for stomal recurrence after total laryngectomy. Clin Otolaryngol 1996;21:135-138.

Stomal recurrence is defined as a diffuse infiltrate of neoplastic tissue at the junction of amputated trachea and skin.[1] The overall incidence for squamous cell carcinoma stomal recurrence is 6% and varies anywhere from 2.5 to 15%.[2] Additionally, it is of note that the majority of stomal recurrences usually present within one year post-total laryngectomy with greater than 90% presenting within 2 years.[3] However, specifically stomal recurrence post-total laryngectomy has been explicitly noted after a disease-free interval of 6.5 years and has been implicitly suggested to be 8 years in a recent study.[4,5] The risk factors for stomal recurrence have been widely studied and include subglottic extension of the primary, size of primary tumor and pre-operative trachostomies.[6,7,8]

Excised stomal recurrence Harvested Jejunal Flap

Insetting of flap Post-op

Conclusion

This case represents stomal recurrence 17 years post-total laryngectomy. It is the longest published recurrence interval in the western literature. Current investigation comparing DNA from the original pathologic specimen to that of the recent specimen is underway. This may give insight into stomal recurrences at the molecular level.

Pre-op CT scan Pre-op CT scan