THORASCOPIC STAGING OF STOMAL RECURRENCE

Background. Squamous cell carcinoma of the low cervical area may be se condary to stomal recurrence following laryngectomy, low cervical esop hageal disease, or peritracheal metastasis. Most often patients with d isease in this area have already received both surgery and radiotherap y. Prior to Sisson's description of the trans-sternal radical neck dis section or mediastinal dissection the management and prognosis was uni formly poor. Since then, a number of authors have reported their exper ience with mediastinal dissection. Survival remains poor but palliatio n has been acceptable. Unfortunately, resectability of the disease can not often be determined prior to the actual surgical procedure. A numb er of patients are explored only to have the procedure terminated. Tho racoscopy is a procedure that involves insertion of two or three troca rs into the right thoracic cavity with collapse of the right lung. A f orm of endoscopic surgery, it permits visualization and dissection of the important structures of the mediastinum. Tracheal, esophageal, and great vessel invasion by tumor can be evaluated. Methods. Prospective ly, all patients initially seen with stomal recurrence from 1991 to 19 94 were evaluated. CT scans, MRIs as well as thoracoscopy were perform ed when indicated, Results. One patient required conversion to a minit horacotomy involving a 7-cm chest incision. The patient was found to h ave unresectable disease with tumor involving the great vessels of the mediastinum, A second patient was found to have unresectable disease with tumor encasing the subclavian artery. The third patient was found to have no mediastinum involvement. The patient with no mediastinum i nvolvement underwent a stomal resection with mediastinal dissection. R econstruction with a pectoralis major myogenous flap was performed. Th e patient has remained disease free to date. The remaining two patient s were judged to have unresectable disease and were offered palliative treatment. Both of these patients died of the disease within 6 months . Conclusions. Thoracoscopy provides important information in judging the surgical resectability of patients with stomal recurrence. This pr ocedure has not been previously described in the otolaryngologic liter ature. We provide some suggestions for its use in the evaluation of th e mediastinal extent of disease. (C) 1995 John Wiley & Sons, Inc.