Peristomal recurrence: pathophysiology, prevention, treatment

Postlaryngectomy peristomal recurrence is the most devastating late complication of laryngeal carcinoma. Its development is most closely associated with emergency tracheotomy done prior to definitive treatment of the primary tumor and with subglottic tumor involvement. The pathophysiologic mechanism of the development of peristomal recurrence is by tumor seeding of the tracheotomy site, by metastatic spread to the pretracheal and paratracheal nodes (especially from the subglottis), and by direct extension of tumor through the thyroid cartilage, cricoid cartilage, or cricothyroid membrane. The best treatment is the prevention of peristomal recurrence. Intubation followed by partial laser excision of the primary tumor can be used to avoid tracheotomy in some cases. Patients showing subglottic involvement by tumor should undergo either postoperative irradiation of the stoma or prophylactic recurrent laryngeal lymphatic and superior mediastinal dissection by removal of the manubrium sterni and sternoclavicular joints. When peristomal recurrence develops, radiation alone offers the least chance of success. Induction chemotherapy should be considered when the condition of the patient allows this. This must be coupled with full course irradiation or mediastinal dissection in operable patients. Mediastinal dissection should be done only by those experienced with the technique and should be accompanied by appropriate postoperative support.