PARASTOMAL NEOPLASM AFTER LARYNGECTOMY - ETIOLOGY AND THERAPY

Background: Parastomal neoplasm after total laryngectomy for laryngeal carcinoma represents an extremely serious complication and one of the most formidable therapeutic problems encountered by the head and neck surgeon. Studies about the etiology of parastomal neoplasm have been controversial. The factors most strongly implicated in parastomal neop lasm have been recurrence spawned by metastases to deep cervical lymph nodes, undetected neoplasm at the margin of the laryngectomy resectio n, neoplastic cell implantation by pre-operative tracheotomy, and the development of an additional primary. Patients: To clarify the controv ersial aspects of parastomal neoplasm etiology, a systematic analysis of parastomal neoplasm after laryngectomy was performed using data fro m 10 patients who developed parastomal neoplasm. Results: Parastomal n eoplasm occured in 7.9%. The tumor site of the primary laryngeal carci noma was found in 9/10 cases in the subglottic, supraglottic, or trans glottic area. These tumor sites correlate with areas of a lymphatic ve ssel concentration and an increase of intralaryngeal lymphatic drainag e. In average the parastomal neoplasms appear 10.3 months after the la ryngectomy. Therapy was unsuccessful in spite of extensive surgical in terventions. Conclusions: If the laryngeal carcinoma was resected with margins of healthy tissue, lymphatic metastasis to the pretracheal an d paratracheal cervical lymph nodes is the probable cause of parastoma l neoplasm. This could be the consequence of the continuous lymphatic drainage between the supraglottic and subglottic area with a midline c rossing and an lymphatic outlet to the pretracheal and paratracheal ce rvical lymph nodes. The cervical metastasis formation cannot be detect ed due to the limitations in the assessment of small lymph nodes and t he inability to ascertain with confidence the presence or absence of m etastasis in any one lymph node in ultrasonography, computed tomograph y, and magnetic resonance imaging and due to the limitations in the re moval of lymph nodes in the pretracheal and paratracheal area by means of a functional or radical neck dissection. The method of treatment s hould be in cases of a subglottic or a supraglottic laryngeal carcinom a an ipsilateral and contralateral pretracheal and paratracheal lymph node removal in combination with the laryngectomy.