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First Voice-Box Transplant Patient Doing Fine

But procedure may not work for everyone in need

WEDNESDAY, May 30, 2001 (HealthDayNews) -- More than three years after undergoing the world's first voice-box transplant, a Pennsylvania man can say he's doing fine.

Tim Heidler received the laryngeal graft in 1998. Surgeons at the Cleveland Clinic Foundation used a mosaic of the larynx, pharynx and trachea from a man who had died of a ruptured blood vessel in his brain.

Heidler's voice box and pharynx were crushed in a motorcycle accident in the late 1970s, leaving him unable to speak. He was 40 at the time of the transplant.

Three days after the operation, Heidler uttered his first word, "Hello," followed a short time later with a "Hi, Mom." Three years after the operation his voice has a nearly normal quality, allowing him to go back to work -- as a motivational speaker.

The surgeons who performed the procedure, led by Dr. Marshall Strome, describe the progress of their patient in the May 31 New England Journal of Medicine.

In the first months after the transplant, Heidler had two bouts of infection in the graft area, which were cleared with antibiotics, his doctors say. Steroid treatment overcame a partial rejection of the new tissue 15 months after surgery.

The hospital paid the cost of the operation, reportedly $110,000, because it was not covered by insurance.

Strome's medical team is looking for a second transplant candidate, says Jim Armstrong, a Cleveland Clinic spokesman. Candidates would include patients who've suffered severe voice box trauma, destructive infections or benign tumors. It also may help people who've had surgery to remove malignant masses of the larynx and who have stayed cancer-free for at least five years. Indeed, Armstrong says the team would like to do their next graft on a cancer patient.

Roughly 10,000 Americans will be diagnosed with laryngeal cancer this year, and about 4,000 will die of the disease, says the American Cancer Society.

While larynx cancer patients might be among the best candidates for a transplant from a surgical perspective, they're the worst group for other reasons, says Dr. Todd Dray, chief of head and neck surgery at Kaiser Permanente in Santa Clara, Calif.

"They're just the wrong people who need to be on immuno-suppression therapy," says Dray. "Suppressing the immune system plays such a big role in preventing recurrence of cancer or preventing it from occurring in the first place."

Any patient who undergoes the graft, including Heidler, has to take a lifetime regimen of potent, highly toxic immune-suppressing drugs, which put them at increased risk of infection and certain cancers, experts say.

Retired Air Force Lt. Col. David "Dutch" Helms, a larynx cancer survivor and founder of the WebWhispers Nu-Voice Club, an online laryngectomee support group, says he and his members initially thought the voice-box transplant would be a revolution, but the risks of prolonged immune suppression therapy convinced them otherwise.

"When Cleveland Clinic did it, I was amazed. Many thought it might help us or other larynx cancer patients in the future," says Helms in an email interview with HealthDay. "However, it doesn't look that way. I don't think the laryngectomee community is looking to transplants as a realistic option."

Patients who undergo laryngectomy to remove the voice box can recoup at least some speech through three techniques: learning to use their esophagus to generate sounds, an electronic larynx, and the more popular tracheoesophageal puncture (TEP) voice prostheses, which use a one-way valve to force air over the esophagus and create a raspy but nearly natural voice.

Dr. Anthony P. Monaco, professor of transplantation surgery at Harvard Medical School and author of an editorial accompanying the journal article, says the success of the graft "will mean a lot for laryngectomee patients."

Monaco, director of the transplant center at Beth Israel Deaconess Medical Center in Boston, had his larynx removed seven years ago after being diagnosed with laryngeal cancer. "If [a transplant] were available when I was younger, I think I might have considered it, but it wasn't a reality then," he says in a scratchy but distinct voice produced with the help of his esophagus.

A transplant "is a feasible thing to do. You can return someone's voice," says Dr. Marvin Fried, professor and chair of otolaryngology at Montefiore Medical Center in the Bronx.

Fried, who has been watching the progress of the Cleveland work since it first began in rats, says the compound nature of the graft, with its blend of muscle, gland and cartilage, is more prone to rejection than a relatively simple heart or liver transplant. "Any of [those throat tissues] could establish a rejection, and it's in an environment that's prone to infection. It's the worst possible scenario for rejection, and yet it's still surviving, which is remarkable."

Still, Fried says, "It's all predicated on one patient. This success has to be followed by other successes."

What To Do

To find out more about the larynx, check the University of Washington. For more on the transplant procedure, visit the Cleveland Clinic.

For more on laryngeal cancer, try CancerLinks USA.

SOURCES: Interviews with David "Dutch" Helms, founder and Webmaster, WebWhispers Nu-Voice Club; Todd Dray, M.D., chief of head and neck surgery, Kaiser Permanente, Santa Clara, Calif.; Marvin Fried, M.D., professor and chair of otolaryngology, Montefiore Medical Center, Bronx, N.Y.; Anthony P. Monaco, M.D., professor of transplantation surgery, Harvard Medical School, Boston, and Jim Armstrong, spokesman, Cleveland Clinic Foundation;; May 31, 2001 New England Journal of Medicine
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