Organ transplantation is a critical tool for sustaining and improving lives in modern medicine. It’s easy to forget, though, that the field is continuously developing, and the organs that generally come to mind when thinking about transplantation — hearts, lungs, kidneys and livers — are not the only ones that can successfully be passed from one patient to another.
Non-vital organs, including the larynx (also known as the voice box), can also be transplanted. Now, surgeons at Vanderbilt University Medical Center have built a groundbreaking new laryngeal transplant program, and are ready for their first patient.
“We just need to find the patient who is going to benefit most from it and is interested in also being a pioneer in the transplant world. It takes a special person to want to do something that’s only been done a handful of times.”
Sarah Rohde, MD, MMHC
According to Sarah Rohde, MD, MMHC, associate professor of Otolaryngology-Head and Neck Surgery and lead surgeon of the burgeoning program, transplanting a larynx to a patient who has undergone a laryngectomy (the removal of the voice box) can restore function in critical aspects of a patient’s life.
“A laryngectomy is a surgery that’s been around a long time,” said Rohde. “It’s very successful in curing cancer, but at the expense of a lot of valuable real estate and normal function.”
Removal of the larynx can complicate a person’s ability to breathe, eat and communicate, and those hindrances are often socially debilitating.
“A transplant would restore that continuity in breathing, speech and eating, and allow people to be treated for laryngeal cancer but then be able to partake in society with less of a stigma,” Rohde added.
Anil Trindade, MD, associate professor of Medicine in the Division of Allergy, Pulmonary and Critical Care Medicine and medical director of the laryngeal transplant program, further explained that the reasons for transplants differ based on whether the organ being transplanted is what’s known as a solid organ, such as a heart, lung, kidney or liver, or a vascular composite allograft (VCA) that contains multiple tissues such as a hand, face or larynx.
“For solid organs, the main reason for a transplant is survival benefit, but there’s also a quality-of-life improvement as well,” Trindade said. “For VCA, including larynx, it’s a little bit different because there’s no survival benefit, per se. Somebody could live years and years and years with a laryngectomy, it’s just that their quality of life is really poor.”
Improving quality of life is the most significant motivation for a patient considering a laryngeal transplant. Trindade said one patient seeking to regain his voice is considering the procedure in large part because he wants to be able to read a bedtime story to his grandchild.
According to Robert Sinard, MD, professor of Otolaryngology-Head and Neck Surgery, discovering how difficult everyday life is after a laryngectomy can also be a strong motivating factor for patients.
“The thing that we find especially attractive is the thought of doing it secondarily, with somebody who’s already had a laryngectomy and knows and understands all the limitations that go with that,” said Sinard.
Sinard cautioned that transplanting a larynx into a patient who may need further treatment for head and neck cancer, including radiation or chemotherapy, poses the risk of the transplanted larynx getting “beat up” as treatment continues.
“Patients who have completed their cancer treatment may have a higher percentage chance of living longer and enjoying the benefits of larynx transplant,” he said.
When selecting an ideal patient to receive a laryngeal transplant, doctors must also weigh the benefits of transplanting a non-vital organ with the risks posed by the immunosuppressant drugs the patient must take to help their body accept the new organ.
Our post-transplant coordinators will ensure that laryngeal transplant patients are educated on how to care for their new transplanted organ throughout their lives.”
Dawn Eck, director of Thoracic Transplant and Organ Recovery
“The immune system has a vital role in fighting cancer, and the corollary is that if you turn off the immune system, maybe you give license for the cancer to run unchecked,” said Alexander Gelbard, MD, professor and vice chair for research in Otolaryngology-Head and Neck Surgery. “So, transplantation in the setting of active malignancy has always been very cautiously approached.”
However, Gelbard said, based on increasing positive outcomes, transplant surgeons have become more willing to use transplantation and immunosuppression to restore function after cancer and found success — thereby pushing the boundaries of who can undergo organ transplants.
“In particular, we believe the success in transplant after lung cancer may open the door for a new set of patients to get a laryngeal transplant,” said Gelbard, who holds the Robert H. Ossoff, DMD, MD Directorship for Translational Research in Otolaryngology.
To date, three laryngeal transplants have been completed at other institutions in the United States.
And while some elements of quality of life were restored to those patients, vocal cord paralysis is most often a consequence of laryngeal transplantation.
With the help of neural reinnervation techniques in use at Vanderbilt University Hospital (VUH), the movement of the vocal cords can be restored, allowing patients to both breathe and speak.
Another aspect of the laryngeal transplant program that leverages existing institutional expertise is the creation of patient education for those who may eventually undergo the procedure. As Dawn Eck, director of Thoracic Transplant and Organ Recovery, described, this is a crucial part of keeping patients and clinicians on the same page during every phase of the process.
“Our pre-transplant coordinators, along with speech pathologists, have developed education materials to help patients and families understand what to expect prior to transplant, along with risks and benefits of this procedure,” said Eck. “And likewise, our post-transplant coordinators will ensure that laryngeal transplant patients are educated on how to care for their new transplanted organ throughout their lives.”
Eben Rosenthal, MD, chair of the Department of Otolaryngology-Head and Neck Surgery and Barry and Amy Baker Professor of Laryngeal, Head and Neck Research, lauded the efforts of all involved to create a program that serves patients with innovation at every turn.
“The whole team has worked diligently to create one of the most unique transplant programs in the country,” Rosenthal said. “The quality of the patient selection process and surgical procedures developed by the surgeons and transplant team is outstanding.”
Above all, the development of the program illustrates the extent to which every innovation at VUMC is a collaborative effort focused on continually improving patient outcomes.
“The program springs from the desire to imagine a better way to take care of patients,” said Gelbard. “To be able to assemble a team of experts and drive a complex project forward is a core competency of our institution. I think the thing that makes it uniquely possible here is the collection of talents and a culture that places equal emphasis on collaboration and innovation to push the boundaries of the possible to help people fight their disease and recover after the treatments.”
As optimism abounds about what the program can accomplish, the surgeons now wait for the stars to align for the first procedure to take place at VUH.
“For right now, our primary challenge is finding the right patient,” said Rohde. “We have all of the logistics, protocols, expertise in place, and we just need to find the patient who is going to benefit most from it and is interested in also being a pioneer in the transplant world. It takes a special person to want to do something that’s only been done a handful of times.”
Additional background information on the laryngeal transplant program was provided by Roland Eavey, MD, SM, professor emeritus and former chair of the Department of Otolaryngology-Head and Neck Surgery, who initiated the project.
