Debulking Surgery On Recurrent Dermal Neck Tumor Above Stoma

After Total Laryngectomy

Gilbran Ayyubi1,* Benny Kurnia1, Lily Setiani1

1
Otorhinolaryngology Head and Neck Surgery Department, Faculty of Medicine University of Syiah
Kuala/dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
*
Corresponding author. Email: gilbran2006@gmail.com

ABSTRACT
Background: Patients who underwent total laryngectomy for primary tumor or for salvage therapy
had recurrence. The presence of regional nodal spread reduces overall survival by nearly half. Dermal
lymphatic invasion has also been considered to have negative prognostic significance. Debulking
surgery has been advocated for subsets of advanced malignant tumors with the expectation of
prolonged survival
Objective: To describe tumor debulking as surgical management on recurrent dermal neck tumor after
total laryngectomy.
Case Report: A 53 year old male with chief complaint of mass on front side of the neck since 6 month
prior. He has a history of Squamous Cell Carcinoma (SCC) of Larynx and underwent Total
Laryngectomy (TL). Physical examination showed a solitary ulcerative mass in the anterior part of the
neck above the stoma, 6 x 6.7 x 3.5 cm in size with irregular surface, mobile, firm in consistency and
bounderies, and prone to bleed.
Methods: Using PubMed, medline, and manual research for evidences and literatures.
Result: Tumor debulking was chosen based on the characteristic of the mass. The excised tumor
appeared to be an isolated malignant enlargement of dermal lymph node. Simple rotational flap is used
to close the skin defect. Postoperative histopatology suggests an invasive moderately differentiated
squamous cell carcinoma.
Conclusion: Debulking surgery is considered an appropriate choice of therapy for an isolated
malignant mass. Concomitant radiotherapy should also be considered for better prognosis.

Keywords: Debulking, Recurrent Tumor, Total Laryngectomy, Dermal Lymph

ABSTRAK
Latar Belakang: Pasien yang menjalani laringektomi total untuk tumor primer atau untuk terapi
penyelamatan bisa mengalami kekambuhan. Penyebaran nodal regional dapat mengurangi
kelangsungan hidup secara keseluruhan hingga hampir setengahnya. Invasi limfatik dermal juga
dianggap memiliki signifikansi prognostik yang negatif. Tindakan debulking telah dianjurkan untuk
beberapa tumor ganas dengan harapan memberikan kelangsungan hidup lebih panjang.
Tujuan: Untuk menggambarkan tindakan pembedahan pada tumor leher rekuren yang terisolir setelah
Laringektomi Total
Laporan Kasus: Seorang laki-laki berumur 53 tahun dengan keluhan utama benjolan di leher depan
sejak 6 bulan lalu. Pasien memilki Riwayat SCC laring dan telah menjalani laringektomi total. Dari
pemeriksaan fisik didapatkan massa soliter di leher anterior tepat diatas stoma. Dengan ukuran 6 x 6.7
x 3.5 cm, permukaan ireguler, mobile, konsistensi keras, berbatas tegas dan mudah berdarah.
Metode: Pencarian literatur dan referensi menggunakan PubMed, medline, and secara manual.
Hasil: Tindakan debulking dipilih bedasarkan karakteristik massa. Tumor yang diangkat tampak
berupa pembesaran malignan yang terisolir dari limfe dermal. Jabir rotasional sederhana digunakan
untuk menutup defek pada kulit. Histopatologi didapatkan karsinoma sel skuamosa berdiferensiasi
sedang yang invasif.
Kesimpulan: Tindakan debulking dianggap sebagai pilihan terapi yang tepat untuk massa ganas yang
terisolasi. Radioterapi lanjutan sebaiknya dipertimbangkan untuk prognosis yang lebih baik.

Kata Kunci: Debulking, Tumor Rekuren, Laringektomi Total, Limfe Dermal

1. BACKGROUND within the first 2 years after diagnosis,
Recurrent squamous cell carcinoma of whereas locoregional recurrence is
the head and neck is a major cause of usually seen within the first year.6
morbidity and portends poor survival The presence of regional nodal
outcomes. Locoregional recurrence, spread reduces overall survival by nearly
which is seen in 15 to 50 percent of half, and distant metastasis greatly
patients with squamous cell carcinoma reduces survival, with extremely low
of the head and neck, is a major factor cure rates. Other tumor factors such as
contributing to mortality from head and perineural spread, infiltrating borders, or
neck cancer.1–3 In a recent study, invasion into cartilage, bone, or adjacent
approximately 31% of patients who angiolymphatic structures have also
underwent a TL for primary tumor or for been associated with a poor prognosis.
salvage therapy had recurrence, defined Dermal lymphatic invasion has also been
as locoregional recurrence, second considered to have negative prognostic
primaries, or distant metastases.4 The significance in Head And Neck
mean interval between TL and detection Squamous Cell Carcinoma (HNSCC),
of recurrence was 11.6 months. Almost though this has not been well studied.7–9
60% of patients had loco-regional Debulking surgery is a surgical
recurrence, most commonly in the neck cytoreduction of the tumor by removing
or tracheostomal recurrence. as much of it as possible when complete
Approximately 25% had metastatic resection is essentially impossible
disease, and most of the remaining because of the advanced disease of the
patients had a second primary tumor and is also called cytoreductive
malignancy.5 surgery, surgical debulking or just
Metastasis of laryngeal cancer is debulking. Debulking surgery has been
an important factor for the high advocated for subsets of advanced
recurrence rate, which usually involves malignant tumors with the expectation of
the lymphogenous pathway. Less prolonged survival.10
commonly, metastases to the lungs,
bone, liver, and skin through the 2. CASE REPORT
hematogenic pathway are seen. The A 53 year old male with chief
majority of distant metastases occur complaint of mass on front side of the
neck since 6 month prior to admission to The mass covers more than half of
the hospital. The mass had grown the stoma but air passage is still
gradually from the size of an egg to a size sufficient. There is no neck node
of a baseball and sometimes produces enlargement palpated. Hematologic
pus with foul odor. He has a history of studies show normal result with high
Squamous Cell Carcinoma (SCC) of blood glucose (272 mg/dL). Chest X-
Larynx and underwent Total Ray appears to be normal.
Laryngectomy (TL) in 2017, leaving a Suspicion of recurrent neck tumor
stoma on his neck. TL was done with is made as working diagnosis and the
neck dissection and the patient declined patient is planned to have tumor
the concomitant radiotherapy treatment. debulking surgery solely based on
He is also diagnosed with Type 2 anamnesis and physical examination.
Diabetes but poorly controlled. Consultation to the internal medicine
General status is fairly good with department is done for diabetes therapy.
normal vital signs. Physical examination Consultation for surgery tolerance to
showed a solitary ulcerative mass in the cardiology and anasthesia department is
anterior part of the neck above the stoma, done with moderate tolerance and ASA
6 x 6.7 x 3.5 cm in size with irregular III as results.
surface, mobile, firm in consistency and Tumor debulking procedure is
bounderies, and also prone to bleed completed under general anasthesia. The
(Figure 1). tumor margin is identified and incision
margin is made following the edges of
the mass. After circular insicion, the
tumor is carefully excised until all part of
it is removed and no invasion to the
surrounding structures were found.
Necrotic tissues on the stoma is also
removed. During excision, the tumor is
located in the superficial layer of the
neck and appears to be an isolated
Figure 1. Clinical appearance of the mass malignant enlargement of dermal lymph
node. The excised mass is sent to the invasive moderately differentiated
laboratory for histopathologic study. squamous cell carcinoma. Radiotherapy
Removal of the tumor left a defect is planned as the next step of the
on the skin (Figure 2). Defect closure is treatment.
done by making a simple rotational flap.
A semicircular line is made with the
length approximately 2 times of the
defect base from the superior part of the
stoma to the left superolateral neck.
Incision is made based on the line and the
skin is widely undermined along the
incision wound thus making the skin
flap. The flap is then retracted in
rotational fashion to cover the defect.
The wound is sutured with 3.0 non
absorbable thread with simple
interrupted technique.

Figure 3. Postoperative Wound

3. METHOD
The literature search was
conducted on August 18th, 2022 with
“Debulking”, “Reccurent Tumor”,
“Total Laryngectomy”, “Dermal
Figure 2. Skin defect after tumor Lymph”, as keywords. Searches were
removal conducted on Medline, PubMed, and
manual searches for evidence.
The patient’s condition after The literature search also
surgery is good, the wound is intact and conducted using the following inclusion
dry with no sign of infection (Figure 3). criteria: 1) Laryngeal Malignancy, 2)
Postoperative histopatology suggests an HNSCC, 3) Rotational Flap. Literatures
about other treatment is excluded from undergoing radiation (RT) or
the analysis. chemoradiation for laryngeal squamous
cell carcinoma (LSCC) will develop
4. RESULT recurrent disease. Five-year disease-free
Debulking of the tumor is survival rates for advanced LSCC treated
successfully done with minor with organ preservation protocols ranges
hemorrhage. The excised mass have from 30-60% for most with
malignant characteristicis (Figure 4) and recurrent/persistent disease, salvage
appeared to be an isolated enlargement laryngectomy is often the only remaining
of dermal lymph node. Simple rotational curative therapeutic modality.11
flap is used to close the skin defect. Tumor debulking was chosen
Postoperative histopatology suggests an based on the characteristic of the mass
invasive moderately differentiated and was done to completely remove the
squamous cell carcinoma isolated malignant mass. The most
important principle in surgical oncology
is complete removal of the tumors both
macroscopically and microscopically.
Residual neoplastic cells are certain to
regrow, and debulking surgery
theoretically cannot provide a cure of
disease. However, debulking surgery has
been considered to have a potential
survival benefit in the following specific
Figure 4. Excised Mass scenarios. The first scenario is for
patients with unresectable but slow-
5. DISCUSSION growing and locoregionally proliferating
Tumor recurrence in this case is tumors in order to delay tumor
presumably associated with previous TL progression and even prolong survival.
surgery in 2017. The patient declined The second scenario, which is possibly
concomintant radiotherapy after TL the main one, is for patients in whom a
which makes recurrence rate higher. synergetic effect of debulking surgery
Notably, a significant subset of patients and systemic/radiation therapy may be
expected. Debulking of a large primary tumors that were cutaneous in
proportion of resting cells during the cell origin. All patients had T4 tumors and
cycle might be useful to enhance the 5/12 developed regional metastasis.14
effectiveness of systemic therapy. Simple rotational flap is used to
Reduction of tumor volume might also close the skin defect caused by tumor
be beneficial to decrease the radiation debulking. Rotation flaps allow for the
field and enhance the toxic effect of redirection of tension vectors and for the
radiotherapy. The third scenario is for mobilization of tissue utilizing laxity that
patients with metastatic disease, in lies at a distance from the operative
which bulk tumor mass might cause wound. Rotation flaps are versatile
adverse events affecting systemic because wound closure tensions may be
therapy. In all scenarios, debulking redirected by simply altering suture
surgery may also be useful for placement. In some cases, the tensions
preventing deterioration for Quality of may be equally shared between the
Life (QOL), especially if the main tumor primary and secondary motions, whereas
potentially develops life-threatening in other cases all tension may be directed
symptoms during nonsurgical along one vector, thus preventing pull in
treatments.7,10,12,13 the direction where the result would be
The excised tumor is located in the adverse (pull on a free margin, ectropion,
superficial layer of the neck and appears for example). Rotation flaps should be
to be an isolated malignant enlargement elevated within the loose deeper subcutis
of dermal lymph node. Postoperative or within a deeper plane in order to
histopatology suggests an invasive preserve needed vascular supply. The
moderately differentiated squamous cell flap's pedicle or its arc of rotation must
carcinoma. Spektor et al showed Twelve be undermined beneath the point of
patients with HNSCC who had skin pivotal restraint in order to allow for
resected at the time of surgery and whose appropriate flap motion. The most
preoperative CT scans suggested dermal aesthetic rotation flaps incorporate
lymphatic invasion. Four patients had designs that place suture lines along
primary tumors of the nasal natural standing cosmetic junctions. The
cavity/paranasal sinuses, 4 had primary concepts of rotation flaps are defining
tumors of the oral cavity, and 4 had aspects of reconstructive surgery, and
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repair of challenging operative 337-Patient, Multi-Institutional
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