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• The larynx plays a central role in coordinating the functions of the upper aerodigestive tract, including respiration, speech, and swallowing
• The larynx is the second most common site for squamous cell carcinoma in the head and neck, which is causally related to tobacco and alcohol exposure.
• The larynx is divided into:
  • Supraglottic, glottic, and subglottic regions:
    • These anatomic divisions are based on embryologic development and have important clinical implications
• Lymphatic drainage of the supraglottic larynx:
  • Is very rich compared with the scanty lymphatic network in the submucosal plane of the true vocal cords
  • The patterns of regional spread of laryngeal cancer therefore depend on the site of origin and the local extent of the primary tumor
• Each of the three regions of the larynx is divided into various sites.
  • The sites in the supraglottic region are:
    • The laryngeal surface of the epiglottis, the aryepiglottic folds, the arytenoids, the ventricular bands or false vocal cords, and the ventricles, which are potential spaces between the false and true vocal cords
  • In the glottic larynx:
    • The right and left vocal cords and anterior commissure represent the three designated sites
  • The subglottic region:
    • Is generally considered as one site and is divided into its right and left lateral walls
• Squamous cell carcinomas:
  • Constitute more than 95% of primary malignant tumors of the larynx
• The remaining tumors are those arising from the minor salivary glands, neuroepithelial tumors, soft tissue tumors, and, rarely, the cartilaginous laryngeal framework
• In 2018, the American Cancer Society estimated that approximately 13,150 new cases of cancer of the larynx would be diagnosed in the United States, which represents 0.8% of all new cancers
• Death rate estimates vary, depending on the site and stage of the primary tumor:
  • Overall, 3,710 cause-specific deaths for cancer of the larynx were estimated for 2018 in the United States
• Worldwide, the incidence of laryngeal cancer varies in different countries:
  • Southern Europe has by far the highest incidence of laryngeal cancer in men in the world:
    • The geographic variation in the incidence rates and anatomic site distribution may be a reflection of lifestyle and habits of the patient population in different parts of the world, as well as other environmental factors

• The glottic region is by far the most common site for primary malignant tumors in the larynx

• The larynx is divided into three regions:
  • Supraglottis
  • Glottis
  • Subglottis
• The distribution of cancers is as follows:
  • 30% to 35% in the supraglottic region
  • 60% to 65% in the glottic region
  • 5% in the subglottic region
• The incidence and pattern of metastatic spread to regional nodes vary with the primary region:
  • The lymphatic drainage of the glottis is:
    • Sparse and early-stage primaries rarely spread to regional nodes
  • Because hoarseness is an early symptom:
    • Most glottic cancers are early stage at diagnosis
  • Thus, glottic cancer has an excellent cure rate of 80% to 90%
  • Nodal involvement adversely affects survival rates and is rare in T1 to T2 disease
• More than 50% of patients with supraglottic primaries:
  • Present with spread to regional nodes because of an abundant lymphatic network that crosses the midline:
    • Bilateral cervical metastases are not uncommon with early-stage supraglottic primaries:
      • Thus, supraglottic cancer is often locally advanced at diagnosis

• Multiple techniques have been used to aid in cardiac sparing, including:
  • Assisted breathing control
  • Accelerated partial breast irradiation
  • Intensity-modulated radiation therapy
  • Prone positioning
• A study from Mulliez et al:
  • Found that prone technique in conjunction with respiratory gating:
    • Was associated with a reduction in mean heart dose, as well as dose to the left anterior descending coronary artery
• At this time, there are limited data regarding long-term cardiac outcomes (e.g., myocardial infarctions) with any cardiac-sparing technique:
  • Due to the length of follow-up required
• Outcomes with prone breast irradiation have demonstrated:
  • Low rates of local recurrence
  • Excellent cosmetic outcomes
  • No suggestion of higher rates of skin toxicity
  • Lower doses to the lungs and heart
  • No suggestion of higher rates of pneumonitis
• References
  • Mulliez T, Speleers B, Mahjoubi K, et al. Prone left-sided whole-breast irradiation: significant heart dose reduction using end-inspiratory versus end-expiratory gating. Cancer Radiother. 2014;18(7):672-677.
  • Mulliez T, Veldeman L, Speleers B, et al. Heart dose reduction by prone deep inspiration breath hold in left-sided breast irradiation. Radiother Oncol.2015;114(1):79-84.
  • Osa EO, DeWyngaert K, Roses D, et al. Prone breast intensity modulated radiation therapy: 5-year results. Int J Radiat Oncol Biol Phys. 2014;89(4):899-906.
  • Shah C, Badiyan S, Berry S, et al. Cardiac dose sparing and avoidance techniques in breast cancer radiotherapy. Radiother Oncol. 2014;112(1):9-16.
  • Taylor, CW, Wang Z, Macaulay E, et al. Exposure of the heart in breast cancer radiation therapy: a systematic review of heart doses published during 2003 to 2013. Int J Radiat Oncol Biol Phys. 2015; 93(4):845-853.

• This triangle described by Lore et al., is also for identification of recurrent laryngeal nerve:
  • Medial border of the triangle is formed by:
    • The trachea / esophagus
  • The lateral border by:
    • The carotid artery
  • Superior border by:
    • The surface of inferior pole of thyroid

• Performing an immediate breast reconstruction with a tissue expander or breast implant:
  • Carries a higher complication rate than a mastectomy alone
• Surgical complications and delayed wound healing:
  • May lead to a delay in adjuvant radiation therapy
• Obesity with a BMI >30:
  • Increases complication rates leading to adjuvant radiation therapy delays
• Age over 50 has also been implicated to increase post-operative complications which may be related to other pre-existing comorbidities that occur with advancing age
• References
  • Teotia SS, Venutolo C, Haddock NT. Outcomes in patients receiving neoadjuvant chemotherapy undergoing immediate breast reconstruction: effect of timing, postoperative complications, and delay to radiation therapy. Plast Reconstr Surg. 2019;144(5):732e-742e.
  • Paprottka FJ, Schlett CL, Luketina R, Paprottka K, Klimas D, Radtke C, et al. Risk factors for complications after skin-sparing and nipple-sparing mastectomy. Breast Care (Basel). 2019;14(5):289-296.

• Smoking and obesity:
  • Increase the risk of complications for all types of breast reconstruction:
    • Whether with implant or flap
• Smoking and obesity:
  • Are therefore considered a relative contraindication to breast reconstruction:
    • Patients should be made aware of increased rates of wound healing complications and partial or complete flap failure:
      • Among smokers and obese patients
• Alcohol intake:
  • Has not been shown to be a significant risk factor for complication with breast reconstruction
• While age greater than 70 alone has not been shown to increase risk of complication in patients undergoing autologous tissue breast reconstruction:
  • Patients over 70 years may be more likely to have other comorbidities
• Patients undergoing immediate autologous breast reconstruction following neoadjuvant chemotherapy have a similar complication and reoperation rates to patients not receiving neoadjuvant chemotherapy
• References
  • National Comprehensive Cancer Network. Breast Cancer (Version 3.2019). https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed January 13, 2020.
  • Angarita FA, Dossa F, Zuckerman J, McCready DR, Cil TD. Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database. Breast Cancer Res Treat. 2019;177(1):215-224. 
  • Beugels J, Meijvogel JLW, Tuinder SMH, Tjan-Heijnen VCG, Heuts EM, Piatkowski A, et al. The influence of neoadjuvant chemotherapy on complications of immediate DIEP flap breast reconstructions. Breast Cancer Res Treat. 2019;176(2):367-375.
  • Schaverien MV, Munnoch DA. Effect of neoadjuvant chemotherapy on outcomes of immediate free autologous breast reconstruction. Eur J Surg Oncol. 2013;39(5):430-436.
  • Hu YY, Weeks CM, In H, Dodgion CM, Golshan M, Chun YS, et al. Impact of neoadjuvant chemotherapy on breast reconstruction. Cancer. 2011;117(13):2833-2841.

• Expander / implant breast reconstruction:
  • Has been shown to have a lower risk of overall complication compared to autologous reconstruction techniques:
    • According Bennet et al:
      • The overall complication rate for breast reconstruction was 33%
• Expander / implant reconstruction:
  • Had the lowest risk at 26.6% compared to autologous flap techniques:
    • Which were reported to have complication rates of 36% to 74%
• When the autologous techniques are compared:
  • The fTRAM flap had the lowest risk of complication:
    • At 35.8%
• Latissimus dorsi flap was found to have complication rate of 39.4%:
  • Followed by pTRAM at 41.2%
• The technique with the highest risk of complications were deep inferior epigastric artery perforator (DIEP) flap at 47.4%, and the superficial inferior epigastric artery perforator flap at 74%
• References
  • Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg. 2018;153(10):891-899.
  • Bennett KG, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Comparison of 2-year complication rates among common techniques for postmastectomy breast reconstruction. JAMA Surg. 2018;153(10):901-908.
  • Wilkins EG, Hamill JB, Kim HM, Kim JY, Greco RJ, Qi J, et al. Complications in postmastectomy breast reconstruction: one-year outcomes of the Mastectomy Reconstruction Outcomes Consortium (MROC) study. Ann Surg. 2018;267(1):164-170.
  • Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2002;109(7):2265-2274.

• Performing a partial mastectomy using an oncoplastic approach:
  • Has been shown to be safe with the additional benefit of larger tissue volume resection, lower re-excision rates, and low rates of disease recurrence while minimizing cosmetic deformity of the breast
• Proximity of tumor to the nipple areolar complex:
  • Is not an absolute indication for mastectomy
• Neoadjuvant chemotherapy:
  • Has not been shown to improve overall breast cancer survival
• Obesity and diabetes:
  • Have not been shown to be independent risk factors for complication in patients undergoing oncoplastic surgery:
    • Therefore should not be contraindications for consideration of oncoplastic surgery
• References
  • Chakravorty A, Shrestha AK, Sanmugalingam N, Rapisarda F, Roche N, Querci Della Rovere G, et al. How safe is oncoplastic breast conservation? Comparative analysis with standard breast conserving surgery. Eur J Surg Oncol. 2012 May;38(5):395-8.
  • Piper M, Peled A, Sbitany H. Oncoplastic breast surgery: current strategies. Gland Surg. 2015;4(2):154-163.
  • Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Long-term outcomes for neoadjuvant versus adjuvant chemotherapy in early breast cancer: meta-analysis of individual patient data from ten randomised trials. Lancet Oncol. 2018;19(1):27-39.
  • Tong WM, Baumann DP, Villa MT, Mittendorf EA, Liu J, Robb GL, et al. Obese women experience fewer complications after oncoplastic breast repair following partial mastectomy than after immediate total breast reconstruction. Plast Reconstr Surg. 2016;137(3):777-791.
  • Crown A, Scovel LG, Rocha FG, Scott EJ, Wechter DG, Grumley JW. Oncoplastic breast conserving surgery is associated with a lower rate of surgical site complications compared to standard breast conserving surgery. Am J Surg. 2019;217(1):138-141.

• Oncoplastic breast surgery (OBS):
  • Combines principles of oncology and plastic surgery:
    • Toward achieving sound oncological and aesthetically pleasant results for breast tumors amenable to segmental mastectomies in patients with a favorable tumor to breast volume
• OBS expands the indications for breast conservation:
  • Allowing the resection of much larger tumors, and is now an option for the surgical treatment of tumors larger than 4 cm and locally advanced cancers especially in large-breasted patients
  • When compared to conventional breast-conserving surgery (BCS):
    • OBS commonly results in higher specimen resection volumes and lower re-excision rates 
  • OBS does not eliminate or change the need for adjuvant therapies; most, if not all, patients undergoing segmental mastectomy for invasive breast cancers will benefit from adjuvant radiation therapy
  • OBS training is widely accepted as a prerequisite for performing these surgeries and should be represented in any multidisciplinary team, treating breast cancer and offering OBS^: 
    • While no definitive test exists to assess aesthetic results and compare these between OBS and BCS for matched defects, most studies report favorable aesthetic results following OPS, in the majority of patients
• References
  • Behluli I, Le Renard PE, Rozwag K, Oppelt P, Kaufmann A, Schneider A. Oncoplastic breast surgery versus conventional breast-conserving surgery: a comparative retrospective study. ANZ J Surg. 2019;89(10):1236-1241.
  • Strach MC, Prasanna T, Kirova YM, Alran S, O’Toole S, Beith JM, et al. Optimise not compromise: the importance of a multidisciplinary breast cancer patient pathway in the era of oncoplastic and reconstructive surgery. Crit Rev Oncol Hematol.2019;134:10-21.
  • Papanikolaou IG, Dimitrakakis C, Zagouri F, Marinopoulos S, Giannos A, Zografos E, et al. Paving the way for changing perceptions in breast surgery: a systematic literature review focused on oncological and aesthetic outcomes of oncoplastic surgery for breast cancer. Breast Cancer. 2019;26(4):416-427.

• Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL):
  • Is an uncommon lymphoma that has only been reported in patients with a history of a textured breast implant device
• Suggested theories of the cause of BIA-ALCL include:
  • Textured implant particulate
  • Chronic allergic inflammation, and / or response to a biofilm
• Following National Comprehensive Cancer Network (NCCN) guidelines:
  • A swollen breast can be evaluated with ultrasound for either a:
    • Fluid collection
    • Capsular mass
    • Lymph node swelling
  • Fluid collections should be aspirated percutaneously:
    • A minimum of 20 ml but ideally as much fluid available should be sent for:
      • CD30 immunohistochemistry
      • Cell block cytology and flow cytometry evaluation and labeled to “rule out BIA-ALCL
    • CD30 testing is critical to direct pathologists
    • Efforts should be made to establish a diagnosis:
      • Prior to any surgical intervention
• References
  • American Society of Plastic Surgeons (July 30, 2018). BIA-ALCL Resources: Frequently Asked Questions. Available at https://www.plasticsurgery.org/for-medical-professionals/health-policy/bia-alcl-physician-resources/frequently-asked-questions. Accessed February 6, 2020. (login required)
• Brody GS, Deapen D, Taylor CR, Pinter-Brown L, House-Lightner SR, Andersen JS, et al. Anaplastic large cell lymphoma occurring in women with breast implants: analysis of 173 cases. Plast Reconstr Surg. 2015;135(3);695-705.