Pathological T-staging in patients undergoing total laryngectomy with prior tracheostomy: A retrospective study

The 2018 American Joint Committee on Cancer (AJCC) classification for laryngeal cancer defines staging based on anatomical invasion but does not formally incorporate prior tracheostomy. Discrepancies between clinical staging (cT) and pathological staging (pT) often complicate therapeutic decision-making. The objective of this study was to determine if the clinical necessity of a prior tracheostomy serves as an independent preoperative predictor of pT4a staging in patients undergoing primary total laryngectomy, thereby assisting in clinical planning.

This retrospective study reviewed the histopathological records of patients surgically treated for advanced laryngeal squamous cell carcinoma over a 20-year period. Eligibility criteria required a preoperative clinical staging indicative of extensive disease justifying total laryngectomy, without the presence of prior chemoradiotherapy or partial laryngeal surgeries. Data regarding pathological staging, nodal involvement, and microscopic characteristics were extracted. Associations were assessed using Fisher's Exact Test, and the magnitude of effect was calculated using multivariate logistic regression, yielding an Odds Ratio (OR).

The final cohort comprised 96-patients (93.75% male; median age 65-years). A prior tracheostomy was required in 39.6% of the cohort. A statistically significant association was established between pT4a staging and prior tracheostomy, with 86.8% of tracheostomized patients revealing pT4a disease on final pathology (p = 0.013). Multivariate logistic regression confirmed that advanced pathological staging (T4a) was the sole independent predictor of the need for prior tracheostomy (OR = 4.41, 95% CI; p = 0.010). Other variables, including nodal staging, histological grade, perineural invasion, and angiolymphatic invasion, did not show significant independent associations with the requirement for prior tracheostomy.

The clinical requirement of a tracheostomy prior to definitive total laryngectomy is a robust, independent predictor of pT4a staging. In the context of ambiguous clinical imaging, prior tracheostomy serves as a surrogate marker for extensive anatomical compromise, providing critical adjunctive data to support multidisciplinary tumor boards in decisions favoring primary surgical resection.