carcinoma larynx- a wider perspective
TRANSCRIPT
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PRIYANKO CHAKRABORTY
JUNIOR RESIDENT, M.S.Otolaryngology & Head and Neck SurgeryBanaras Hindu University , Varanasi
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Introduction 11,000 new cases reported in U.S. every year
25% of head and neck cancer and 1% of all cancers
One-third of these patients die of their disease
Most prevalent in the 6th and 7th decades of life
4:1 male predilection
Downward shift from 15:1 post WWII
Increasing public acceptance of female smoking
More in lower socioeconomic class diagnosed at more advanced stages
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Incidence 11K new cases of laryngeal cancer in U.S. annually
3,900 deaths annually
Gender Since 1950- M:F ratio 15:1 4:1 in 2004 women have equal place in the toxic work environment cigarette smoking
Risk factors: Tobacco
13-fold risk for laryngeal cancer for smokers risk increases with increasing tobacco use
Alcohol 34-fold risk for laryngeal cancer if consume >1.5 L wine/day
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SubtypesGlottic Cancer: 59%
Supraglottic Cancer: 40%
Subglottic Cancer: 1%
Most subglottic masses are extension from glottic carcinomas
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Risk FactorsProlonged use of tobacco and excessive alcohol use
primary risk factors
The two substances together have a synergistic effect on laryngeal tissues
90% of patients with laryngeal cancer have a history of both
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Risk FactorsHuman Papilloma Virus 16 &18
Chronic Gastric Reflux
Occupational exposures
Prior history of head and neck irradiation
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Genetics/ Risk factors Aneuploidy
Tumor suppressor gene inactivation Gene locus 17p13 : mutant p53 ………………………….DNA repair, apoptosis Gene locus 9p21 : mutant p16 …………………………. Cell cycle regulation
Proto-oncogene activation Proto-oncogene (11q13) amplifies cyclin D1………. Cell cycle regulation
Mutagen-induced chromosome breaks
HPV Types 16 and 18: E6 and E7 viral protein-mediated degradation of p53 Oropharyngeal malignancy
GERD Koufman: n=31 with glottic SCC, GERD documented in 84%; only 58% were smokers
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Embryology Frazer (1909)
Supraglottis originates from the buccopharyngeal primordium while glottis develops from tracheobronchial primordium high risk of bilateral neck disease vs. glottic tumors - metastasize ipsilaterally
Pressman (1956) separate derivation from glottis- supraglottic tumors of substantial bulk
do not spread across the laryngeal ventricle to the vocal cord
Tucker and Smith (1982) Dye studies anatomically based confirmation : elastic tissue barriers
Formed basis of partial laryngeal surgery• Already advocated by Biller
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Anatomy
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SITE SUBSITE
Supraglottis Suprahyoid epiglottis
Infrahyoid epiglottis
Aryepiglottic folds
Arytenoids
Ventricular bands (false
vocal cords)
Glottis True vocal cords+ ant and
post. Commissure +rima
glottidis(slit)
Subglottis Subglottic space upto lower
border of cricoid
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BARRIERS TO SPREAD Hyoid bone
Laryngeal cartilages
Hyoepiglottic ligament
Thyrohyoid membrane
Ventricle
Anterior commisure
Cricothyroid membrane
Conus elasticus
Quadrangular membrane
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Anatomy
Fibroelastic membranes
Barriers to carcinoma spread
Quadrangular membrane Superior free edge= AE fold
Inferior free edge= False cord
Conus elasticus Supports vocal fold
Lateral attachment at cricoid
Medial attachment at anterior thyroid cartilage
Free edge forms vocal ligament
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Pathways to spread Pre epiglottic space via multiple fenestrations in
epiglottis
Paraglottic space
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Pre-epiglottic space & Para-glottic space
Pre-epiglottic space Anterior: thyrohyoid membrane &
thyroid cartilage Posterior: epiglottis elastic
cartilage Inferior: Petiole attachment to
thyroid cartilage Conduit :
elastic epiglottic cartilage has perforations -direct extension of infrahyoid supraglottic cancer into this fascia-bound space
Bilateral neck drainage
Paraglottic space quadrangular membrane inferiorly conus elasticus anteriorly and medially thyroid cartilage laterally
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SubtypesGlottic Cancer: 59%
Supraglottic Cancer: 40%
Subglottic Cancer: 1%
Most subglottic masses are extension from glottic carcinomas
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Transglottic tumors
Tumors crossing ventricle in vertical axis
Usually initiate as supraglottic or glottic cancers
McGravan (1961)
must cross three regions: false cords, ventricle, true cord
alters prognosis
Fail the compartmentalization hypothesis
direct mucosal extension
paraglottic space
.
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Presentation Hoarseness
Most common symptom
Small irregularities in the vocal fold result in voice changes
Changes of voice in patients with chronic hoarseness from tobacco and alcohol can be difficult to appreciate
Indirect mirror exam and/or flexible laryngoscope evaluation
Malignant lesions can appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color
Videostrobe laryngoscopy may be needed to follow up these subtler lesions
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PresentationOther symptoms include:
Dysphagia
Hemoptysis
Throat pain
Ear pain
Airway compromise
Aspiration
Neck mass
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Pointers to disease extent Hemoptysis> supraglottic tumors
Dysphonia> TVC/glottic lesions
Airway Obstruction> insidious subglottic tumors
Aspiration> supraglottic (also with incompetent glottis)
Otalgia> Pyriform sinus and supraglottic (infiltration of musculature)
Dysphagia: any location, muscle, sensory, motor, joint
Neck mass: supraglottic tumors
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PresentationGood neck exam looking for cervical
lymphadenopathy and broadening of the laryngeal prominence is required
The base of the tongue should be palpated for masses as well
Restricted laryngeal crepitus may be a sign of post cricoid or retropharyngeal invasion
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Work upBiopsy is required for diagnosis
Performed in OT with patient under anesthesia
Other benign possibilities for laryngeal lesions include: Vocal cord nodules or polyps, papillomatosis, granulomas, granular cell neoplasms, sarcoidosis, Wegner’s granulomatosis
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Diagnostic steps: Clinical
Careful evaluation of clinical records of prior diagnosis including staging, pathological slides, clinical examination, radiotherapy approach (technique, doses, courses).
Fiberoptic laryngoscopy
Direct layngoscopy under GA
In advanced case fiberoptic evaluation of the esophagus to R/O synchronous malignancy.
Video Stroboscopy
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Diagnostic steps: Radiographic CT or MRI
Provide information regarding
primary tumor volume, cartilage
involvement, invasion of preepiglottic
space, extension beyond the larynx
and finally neck metastasis.
If cartilage invasion is suspected or imperative to be ruled out, MRI seems to be superior to CT.
.
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Radiology• Tumor extent (limitations of endoscopy)• MRI:
• high-density tumor vs fat in the preepiglottic space• Soft tissue invasion• Nodal disease
• EXTRACAPSULAR SPREAD
• CT: thyroid cartilage destruction • presence mandates a total laryngectomy• Cartilage invasion
PET-CT:• Residual disease• Recurrence
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Natural HistorySupraglottic tumors more aggressive:
Direct extension into pre-epiglottic space
Lymph node metastasis
Direct extension into lateral hypopharnyx, glossoepiglottic fold, and tongue base
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Natural HistoryGlottic tumors grow slower and tend to metastasize
late owing to a paucity of lymphatic drainage
They tend to metastasize after they have invaded adjacent structures with better drainage
Extend superiorly into ventricular walls or inferiorly into subglottic space
Can cause vocal cord fixation
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Natural HistoryTrue subglottic tumors are uncommon
Glottic spread to the subglottic space is a sign of poor prognosis
Increases chance of bilateral disease and mediastinal extension
Invasion of the subglottic space associated with high incidence of stomal reoccurrence following total laryngectomy (TL)
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TNM DefinitionsAJCC 6th Ed. 2002 Primary tumor (T)
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
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Supraglottis
T1- Tumor limited to one subsite of supraglottis
or glottis with normal vocal cord mobility
T2- Tumor invades more than one subsite of supraglottis with normal/impaired vocal cord mobility
T3- Tumor limited to larynx with vocal cord fixation or invades postcricoid area, medial wall of pyriform sinus, or preepiglottictissues
T4a- Tumor invades through thyroid cartilage or extends to other tissues beyond the larynx (e.g., to oropharynx, soft tissues of neck)
T4b- Tumor invades prevertebral space, encases the carotid artery, or invades the mediastinal structures
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Glottis
T1- Tumor limited to vocal cord(s) (may involve anterior or posterior commissures) with normal mobility
T2- Tumor extends to supraglottis or subglottis, or with impaired vocal cord mobility
T3- Tumor limited to the larynx with vocal cord fixation and/or paraglottic space involvement or minor thyroid cartilage invasion (inner cortex)
T4a- Tumor invades through thyroid cartilage or extends to other tissues beyond the larynx, (e.g., to oropharynx, soft tissues of neck)
T4b- Tumor invades prevertebral space, encases the carotid artery, or invades the mediastinal structures
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SubglottisT1- Tumor limited to the subglottis
T2- Tumor extends to vocal cord(s) with normal or impaired mobility
T3- Tumor limited to the larynx with vocal cord fixation
T4a- Tumor invades through cricoid or thyroid cartilage or extends to other tissues beyond the larynx (e.g., to oropharynx, soft tissues of neck)
T4b- Tumor invades prevertebral space, encases the carotid artery, or invades the medistinal structures
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Regional lymph nodes (N)
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph
N2: Metastasis in a single ipsilateral lymph node > 3 cm but ≤ 6 cm, or in multiple ipsilateral lymph nodes ≤ 6 cm, or in bilateral or contralateral lymph nodes ≤ 6 cm.
N2a: Metastasis in a single ipsilateral node > 3 cm but ≤ 6 cm N2b: Metastasis in multiple ipsilateral nodes ≤ 6 cm N2c: Metastasis in bilateral or contralateral nodes ≤ 6 cm
N3: Metastasis in a lymph node > 6 cm
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Distant metastasis (M)
MX- Distant metastasis cannot be assessed
M0- No distant metastasis
M1- Distant metastasis
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AJCC Stage Groupings Stage 0
Tis, N0, M0
Stage I
T1, N0, M0
Stage II
T2, N0, M0
Stage III
T3, N0, M0
T1, N1, M0
T2, N1, M0
T3, N1, M0
Stage IVA
T4a, N0, M0
T4a, N1, M0
T1, N2, M0
T2, N2, M0
T3, N2, M0
T4a, N2, M0
Stage IVB
T4b, any N, M0
Any T, N3, M0
Stage IVC
Any T, any N, M1
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Histology >95% SCC
Variations : verrucous carcinoma, spindle cell carcinoma, basaloid SCC, and papillary
SCC
Other types of carcinoma: neuroendocrine carcinoma lymphepitheliomatous carcinoma adenocarcinoma others (sarcomas, lymphomas) adenoid cystic (trachea more than subglottis)
Underlying: hyperplasia, dysplasia, CIS
Overlying: surface keratinization may be present.
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Histology Mucosa: 5-7 cell layers
stratified squamous epithelium, (eg, ventricle, false cord, and subglottis)
Mitotic figures: present in the basal layer should be absent above this second layer
CIS: full-thickness atypia of the squamous cells
Atypia is characterized by the cell architecture: mitoses count per hpf, high NC ratio, large nucleoli
Differentiation is characterizes by the tissue architecture: well, moderately, or poorly differentiated
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Points to ponder Patients with glottic tumors are seen early because of hoarseness….
Biopsy !!!!!
D/D fungal laryngitis, sarcoidosis, tuberculosis, or Wegener's granulomatosis ,
pseudoepitheliomatous hyperplasia (granular cell myoblastoma)
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Premalignant lesions Most cancers of larynx are Carcinomas- often develop
from premalignant lesions
Dysplasia Carcinoma in situ Invasive carcinoma
Lesions:
Chronic laryngitis
Keratosis
Leucoplakia
Erythroplakia
Erythroleukoplakia
Hyperplastic dysplastic lesions
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Leucoplakia Hyperkeratosis
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Pathology: Premalignant lesions The five categories of laryngeal squamous cell
abnormality (from benign to clearly malignant): hyperkeratosis hyperkeratosis with atypia carcinoma in situ (CIS) superficially invasive carcinoma invasive carcinoma
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H, H+A, CIS hyperkeratosis +/- atypia and CIS
conservative management: stripping of VC
5%–30% with future invasive cancer
follow-up and possible re-biopsy 6 - 12 weeks
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Superficially invasive vs. Invasive SCC
•Optical coherence tomography : New diagnostic modality •Can be used intra –op to look for microinvasion
•Results similar to histology. Uses Infra-red technology
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Management of precancerous lesions
Radiotherapy failure (10%) no future option for XRT T1 / T2
Surgery Generous stripping Informed consent for multiple treatments Good compliance (years) Supravital staining with toluidine blue Rapid or frequent recurrence
Smoking cessation program must be part of management!!!!
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Early glottic carcinoma T1 glottic cancer:
Options – EBRT
Open partial laryngectomy
Transoral endoscopic CO2 laser resection
Dey et al published a systematic review comparing RT,open surgery and endoscopic excision (with or without CO2) for early glottic cancer.
They all confer similar survival advantages with endoscopic excision becoming more common now.
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T1 Glottic ca
Mid cord T1a
• RT
• Endoscopic laser resection
• Laryngofissure and cordectomy
Ant commissure(T1a)
Cord + AC (T1b)
• Frontal /frontolaterallaryngectomy
• Endoscopic laser resection
• RT
Posterior cord (T1a)
• Endoscopic laser resection
• Laryngofissure & cordectomy
• RT
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Surgical options for small T1 lesions
CO2 laser: Transoral endoscopic CO2 laser cordectomy
Cure rates are uniformly above 90%
Quality of voice depends on extend of resection
CO2 laser Indications : Tumor limited to the glottis (T1/T2)
normal vocal cord mobility
localised residual /recurrent disease following failure of RT for early cancer
debulking of tumour for stridor
Laryngofissure and cordectomy.. rarely used now When endoscopic exposure is very poor
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Surgical optionsfor small T1 lesions
CO2 laser
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T1a mid cord cancer Surgery alternative to RT in:
young patients where it is best to avoid radiotherapy
For verruccous cancer since it responds poorly to radiotherapy
In patients who desire a short treatment time and are willing to accept some compromise in voice
surgical options are
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Anterior commisure(T1a)/Cord lesion into ant commisure (T1b) Surgery is prefered option.
Vertical partial laryngectomy(frontal laryngectomy/fronto lateral laryngectomy preferred options
Cure rates >90%
Failure rates with RT and Endoscopic CO2 excision are more due to understaging at this site (direct attachment to thyroid cartilage by broyle’s tendon witout intervening inner perichondrium.)
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Surgical options in T2 and advanced glottic lesion :
Surgical options :
SCPL-CHEP Supracricoid partial laryngectomy-cricohyoidoepiglottopexy
VPL Vertical partial laryngectomy
Transoral endoscopic CO2 laser resection.
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Surgical options in advanced glottic
lesion : SCPL-CHEP offers superior cure rates preferred over
VPL
But problems of aspiration with SCPL-CHEP reserves this procedure for very fit patients
Feasible in those T3 lesions with fixed vocal cords but not hemilarynx and minimal subglottic extention
Preserves voice and nasal respiration
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Surgical options in advanced glotticlesion : Vertical partial laryngectomy: (hemilaryngectomy or
frontolateral laryngectomy) Cord fixed & minimal subglottic extention
Arytenoids mobile
b/l No cartilage erosion
Near total laryngectomy: Preserves speech and swallowing but not nasal respiration
Done in Subglottic extention and fixed hemilarynx
Procedure is oncologically safe and physiologically acceptable even in elderly because incidence of aspiration is very low(<1%
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T2a glottic cancerfreely mobile cords
Mid cord glotto -supraglotic
• RT
• Endoscopic laser resection
• VPL/SCPL-CHEP
Anterior glottosupraglottic
• SCPL-CHEP
• Endoscopic laser resection
• RT
Posterior glottosupraglottic
• Endoscopic laser resection
• Extended hemilaryngectomy
• SCPL-CHEP
• RT
Glottosubglottic
• VPL/SCPL-CHEP
• Endoscopic laser resection
• RT
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T2b glottic cancer(impaired cord mobility)
• VPL(hemilarynx)
• SCPL-CHEP
• Chemo RT
• RT
Lateralisedlesion
• SCPL-CHEP
• VPL(fronto lateral)
• CRT
• RT
Lesion across ant
commissure
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T3 glottic ca(cord fixed arytenoid mobile)
• SCPL-CHEP
• Concurrent CTRT
Performance status good
• VPL
• Neoadjuvant CTRT
• RT
Performance status poor
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T3 glottic ca fixed hemilarynx
• Concurrent CTRT
• Near total laryngectomy(lat disease)
• Total laryngectomy
Performance status good
• Near total laryngectomy
• Total laryngectomy
• Neo adjuvant CT RT
Performance status poor
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T4 LESION
T4a resectable lesion –
A) Total laryngectomy followed by RT
• Non surgical option CTRT not effective once cartilage or gross soft tissue invasion is there.
B) Near total laryngectomy
when lesion is well lateralised with uninvolved arytenoid region and2/3 of contralateral cord
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Supraglottic Preferentially spreads in upward direction above
ventricle, lately involves larynx below ventricle.
epiglottic tumours
Tumours of false cord
Tumour of ventricle
Tumour of arytenoids and AE folds
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T1-T2 supraglotticEndoscopic laser resection +ND(N+)
IF NOT FEASIBLE
Supraglotticlaryngectomy/SCPL-
CHP+ND(N+)
IN
1.Infrahyoid supraglottic cancer
2.T2 rather than T1bulky nodal disease
3.Fit patient no COPD
4.Young patient
RT to Primary + ND
IN
1.Lesions at marginal zone
2.Smaller lesions
3.Minimal neck disease
4.Poor pulmonary reserve
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Local control rates T1/T2 supraglottic cancer with endoscopic laser excision – 80-100%
T 2 3year disease free intervall rates with RT is reported to be 50%-80%.
Two types of open partial laryngectomy are possible for supraglottic cancer.
Horizontal SGPL T1/ small T2
For bulkyT 2 tumours SCPL –CHEP ensures better and yields superior rates
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T3 Supraglottic capreepiglottic space invasion,cords mobile
Options
CTRT
Endoscopic CO2 laser resection if the epiglottic space invasion is limited
Supraglottic partial laryngectomy (for small volume disease) SCPL-CHP (if growth is bulky or encroaching the glottis)in patients who are fit and have no significant chest problem
Near total laryngectomy if none of above is possible
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T3 Supraglottic ca cord fixity;arytenoids mobile
Options
CTRT
SCPL-CHP if chemo rad is refused or response to neoadjuvant chemotherapy is poor
NTL if SCPL-CHP not feasible
total laryngectomy if not rest
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T3 Supraglottic ca fixed hemilarynx
Options CTRT
Near total /total laryngectomy
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T4 Supraglottic ca Wide field total laryngectomy +post operative RT
Wide field NTL + post operative RT(for lateraliseddisease)
SCPL-CHP (for minimal cartilage erosion;no gross soft tissue invasion minimal subglottic disease)
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Subglottic cancer Primary subglottic is very are unsuitable for voice
preservation surgeries
Total laryngectomy necessary as laryngeal cartilage involvement often present
Ipsilateral thyroidectomy with Paratracheal lymph node dissection done.
Treatment based on stage
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Subglottic cancer-STAGE I/II Lesions can be treated successfully by radiation
therapy alone with preservation of normal voice.
Surgery is reserved for failure of radiation therapy or for patients who cannot be easily assessed for radiation therapy.
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Subglottic cancer-STAGE III Laryngectomy plus isolated thyroidectomy and
tracheoesophageal node dissection usually followed by postoperative radiation therapy.
Extended tracheal resection may be necessary
Treatment by radiation therapy alone is indicated for patients who are not candidates for surgery. Patients should be closely followed, and surgical salvage should be planned for recurrences that are local or in the neck.
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Subglottic cancer-STAGE IV Laryngectomy plus total thyroidectomy and bilateral
tracheoesophageal node dissection usually followed by postoperative radiation therapy.
Treatment by radiation therapy alone is indicated for patients who are not candidates for surgery
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Voice conservation surgery Organ preservation surgery done:
Young patients when one prefers avoiding RT
I. Horizontal partial laryngectomy: T 3 pre-epiglotticspace with free vocal cords and fit -withstand aspiration
II. SCPL-CHEP: T3 supraglottic ca cord fixed but arytenoidmobile or glotto-supraglottic
III. Three quarter laryngectomy : T3 supraglottic ca extended to glottic & spilling over to pyriform fossa, one arytenoid should be mobile. Disease should be lateralised .
IV. Transoral endoscopic resection with CO2 laser: vocal cords mobile
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Non surgical voice preservation in advanced laryngeal cancer
Advanced stage laryngeal cancer traditionally has been treated with surgery, most often total laryngectomy, and post-operative radiation therapy (PORT)
In Past two decades there has been change in objective of non surgical treatment approach.
Several randomized trials have demonstrated the feasibility of organ preservation in patients with advanced laryngeal.
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Management of neck in laryngeal cancer Status of lymph node is an important factor
influencing survival in laryngeal cancer
Appropriate treatment of neck is as important as primary cancer(level II/III/IV/VI)
Supraglottic ( 23-50%) present with cervical lymph node even T1/T2 lesions have significant nodal metastasis
Glottic cancer less common –lack of submucosallymphatics in this area is responsible(1-4% in T1/T2)( 15-42% in T3/T4)
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Delphian node (also known as midline anterior metastatic node or poirer’s prelaryngeal ganglia node is rarely associated with T3/T4 tumors with significant subglottic extention.
Larynx is midline organ b/l neck involvement is high
N0 neck ipsilateral risk of contalateral neck is very low vice versa
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Management of neck Depends on site of primary
T stage of primary
Clinical N stage
Choice of treatment modality for the primary
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N0 neck in supraglottic cancerPrimary treatment plan
RT(B/L neck irradiation)
Surgery1. Endoscopic CO2 laser resection ( vigilant f/u of neck)
2. Near total /total laryngectomy ( ipsilateral clearance of levels II,III,IV,VI & contralateral clearance of levels II,III,IV)
3. Open partial laryngectomy
sampling of lymph nodes level II,III U/L for lateralisedlesion & B/L for midline lesion
If frozen section positive for metastasis ( selective infrahyoid neck dissection)
otherwise follow up
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N+ neck in supraglottic cancer Primary treatment with
CTRT /RT- Neck dissection prior to radiation or post radiation salvage surgery for residual neck nodes
Endoscopic laser resection – interval neck dissection after 4-5 days
Open surgery -– if unilateralo N1/N2a (ipsilateral level 1 sparing neck dissection & contalateral II,III,IV
clearance
o N2b/N3 ( ipsilateral RND and contralateral clearance of level II,III,IV)
--If B/L (b/l ND preserving atleast one IJV)
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Neck in glottic cancer Clinically N0 NECK T1/T2 : no treatment of neck T3/T4 : treatment plan surgery then b/l ND
treatment plan RT then b/s incl. RT N+ NECK Surgery --- level I sparing neck dissection on ipsilateral side clearance of levels II,III,IV on C/L side with B/L level VI
clearance RT/CTRT ----N1 neck include in field surgery reserved for salvage N2/N3 neck dissection prior to RT or salvage neck dissection
after RT
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Radiation therapy :
Radiation therapy :Cure rates with radiation therapy ranges from 80% -95%.(wide variation RTOG )
Conventional radiotherapy consists of :
Once daily treatment delivering 2 Gray/day.
5 doses/week to total dose of 70 Gy over period of 7 weeks.
Attempts to improve outcome of RT schedules ..focus upon modification of radiotherapy fractionation schedules.
Two altered fractionation schedule:• Hyperfractionation
• Accelerated fractionation
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Hyperfractionation Delivers a higher total dose over the same 7 week
treatment period using multiple smaller fractions of radiotherapy per day.
The lower dose per fraction results in preferential sparing of late responding tissues thus reducing the incidence of late normal tissue effects.
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Accelerated fractionation: Delivers the same total dose over a shorter overall
treatment time
Aimed at overcoming treatment failures caused by tumour cell repopulation during longer courses of treatment.
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Dose Fractionation :
RTOG (radiation therapy oncology group) carried out a phase III study comparing four fractionation schedules:
Conventional fractionation:
Hyperfractionation:(1.2Gy 2D /Td 81.6Gy){ 8% at 5 yr}
Acclerated radiotherapy(1.8Gy 1D, 5d/week with second fraction of 1.5Gy 1D, during final 12 days /TD 72Gy{2% at 5 yr} 1.6 Gy 2D with a 2 week break to deliver TD 67.2 Gy.{1.7% at 5 yr}
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Radiotherapy for T1/T2 glotticcarcinoma : Radiotherapy for T1/T2 glottic carcinoma
Local control rate
approximating 90% for T1
70 to 80% for T2
5 year local control- T1a 94% T1b 93% T2a 80% T2b
72% (Spriano, 1997; Fletcher 1994, Mendenhall, 2001)
Voice quality after radiotherapy tend to be less when
compared to pre-radiotherapy but almost normal 2-3 years
after treatment
(Verdonck,1999;Hirano,1994;Heeneman,1994)
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Transoral Laser Surgery
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Transoral Laser Surgery: Inclusion Criteria
Complete endoscopic visualization of the carcinoma
Tumor extension to the contralateral VC < 3mm
Absence of arytenoid involvement (except vocal process)
Subglottic extension < 5mm
Supraglottic extension no further than lateral extension of ventricle
Mobile vocal folds
No cartilage involvement
Strict correlation between recurrent lesion and 1° lesion before radiation.
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Transoral Laser Surgery: Reported advantages
Good voice quality
Good swallowing
Lower complications rates
Lower costs
Shorter hospitalization
Tracheostomy and NG tubes not routinely required
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Transoral Laser Surgery: Operative considerations
Increased difficulty in identification of recurrent carcinoma in irradiated tissue leads to routine use of frozen section
All margins to be confirmed by permanent section post-op
Strict follow-up with fibroscopic examination and serial imaging allowing early detection of recurrence
The use of CO2 laser excision after radiation failure does not preclude its use for persistent or multiple recurrent disease.
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Transoral Laser Surgery: Complications
Complication rates are <5% and from most to least common include:
Granuloma formation
Laryngeal edema
Laryngeal stenosis
Chondronecrosis
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Vertical Partial Laryngectomy
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Vertical Partial Laryngectomy TYPES
Hemilaryngectomy
Frontal laryngectomy
Frontolateral laryngectomy
Extended Hemilaryngectomy
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Vertical Partial Laryngectomy
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Vertical Partial Laryngectomy:
Removal of:
One vocal fold - from anterior commissure to vocal process
½ of opposite vocal fold may also be removed if involved
Ipsilateral false vocal cord
Ventricle
Paraglottic space (and overlying thyroid cartilage)
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Vertical Partial Laryngectomy:Contraindications
Large T3 or any T4 lesion More than 1/3 rd of contralateral VC.
Intrarytenoid or cricoarytenoid joint involvement
Bilateral arytenoid cartilage involvement or bilaterally diminished vocal cord mobility
Thyroid cartilage penetration
Supraglottic extension exceeding 10mm at the anterior commissureor 5mm at the vocal process of the arytenoid
Poor pulmonary function
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Vertical Partial Laryngectomy:Operative Considerations
The use of intraoperative frozen sections is imperative for maximal local control
All margins should be confirmed with permanent section postoperatively
In the event of failure of salvage VPL total laryngectomy remains an option and this will not ultimately affect local control.
The use of bipedicled flaps of strap muscles to replace excised intralarygeal soft tissue may facilitate post-op rehabilitation
.
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Vertical Partial Laryngectomy:Outcomes
Meta-analysis performed in the same study showed:
Local control rate 50-100% (mean 78%)
Approximately 15% of patients require completion laryngectomy for second recurrence
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Vertical Partial Laryngectomy: Complications
Early - generally tracheostomy related
Infection
Aspiration and dysphonia (should not persist for > 3 weeks)
Late Aspiration
Chondritis
Laryngeal stenosis (Must rule out local recurrence)
Severe hoarseness
Granulation tissue (CO2 laser and keel)
Tumor recurrence
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Supracricoid LaryngectomyRemoval of: Entire thyroid cartilage
Bilateral true and false vocal cords
Ventricles
Paraglottic and Preepiglottic spaces
Epiglottis
Hyoid bone
One arytenoid (may spare both if not involved)
- At least one arytenoid must be spared to preserve phonation and sphincter functions
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Supracricoid partial laryngectomy with cricohyoidoepiglottopexy
Supracricoid partial laryngectomy with cricohyoidopexy—exposure of malignancy. 1, Arytenoid; 2, external thyroid perichondrium; 3, vocal process; 4, thyroid cartilage; 5, epiglottis; 6, false and true cord.
Supracricoid partial laryngectomy with cricohyoidopexy—laryngoplasty using three circumferential cricoid, hyoid, and tongue base stitches.
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Supracricoid partial laryngectomywith cricohyoidoepiglottopexy
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Supracricoid Laryngectomy: Contraindications Infiltration of both aryntenoid cartilages
Infiltration of cricoarytenoid joint or inter-arytenoid region
Subglottic extension >1cm below the vocal fold
Extension to the glossoepiglottic valecula
Major preepiglottic space invasion
Hyoid bone invasion
Invasion of outer perchondrium of thyroid cartilage
Extra-laryngeal spread
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Supracricoid Laryngectomy: Complications Swallowing disorders are the most common in the
short term
Voice quality is hoarse, rough, breathy but with acceptable intelligibility.
Aspiration Pneumonia is the most frequent complication (17.5%)
Neo-laryngeal edema
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Supraglottic laryngectomy T1,2, or 3 if only by
preepiglottic space invasion
Mobile cords
No anterior commissure involvement
FEV1 >50%
No tongue base disease past circumvallate papillae
Apex of pyriform sinus not invloved
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Supraglottic laryngectomy Laryngoplasty
performed with three closure stitches circumferentially around the inferior half of the thyroid cartilage and submucosally into the tongue base, as is done in the supracricoidpartial laryngectomies.
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Near total laryngectomy INDICATIONS:
T3/T4 laterlised transglottic lesions with no extension to arytenoids
T3/T4 laterlised lesions of PFS with involvement of apex and causing fixity of hemilarynx
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Near total laryngectomy
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Total Larygectomy Indications:
T3 or T4 unfit for partial
Extensive involvement of thyroid and cricoidcartilages
Invasion of neck soft tissues
Tongue base involvement beyond circumvallate papillae
Recurrence following RT/Residual disease
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Incision optionsA, Long apron flap without separate incision for tracheostomy from mastoid tip to mastoid tip intersecting the midline at approximately the level of the
cricoid cartilage, usually about 2 cm above the sternal notch in the midline. B, Short apron flap with separate tracheostome incision 2 to 3 cm inferior to the flap incision. A U-shaped incision (not shown) is rarely used, but feasible when
neck dissection is not performed
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Skeletonisation of larynx and hyoidA, Division of the strap musculature after elevation of a subplatysmal flap
. B, Division of suprahyoidmusculature
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Division of constrictor musculature along the lateral aspect of the thyroid cartilage and dissection of the thyroid.
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Entry into larynx A, Use of a Freer elevator to
mobilize the pyriform sinus and internal perichondrium from the thyroid cartilage. This should not be performed if the pyriformsinus is likely to be involved by the tumor. B,
The trachea is transected, and the ligamentous attachments are divided permitting dissection of the trachea away from the upper esophagus up to the level of the posterior cricoarytenoid musculature. C, Dissection follows the hyoepiglottic ligament to the epiglottis and vallecula to avoid entry into the preepiglottic space. D, If
clinically uninvolved, the vallecula is entered on the nontumor side
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A, Closure of pharynx with detail of suturing technique. B, T-closure. C, Vertical closure. D, Horizontal closure.
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Conclusions More patients with advanced disease can enjoy
organ preservation
Work is ongoing to define the ideal protocols for organ preservation
More work needs to be done to define which patients are acceptable for aggressive organ preservation and what quality of life and functional outcomes they can expect
Role of the surgeon is changing
Medical oncologist should come to tumor board
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Conclusion “I conclude by saying that many things have changed in the surgical
management of supraglottic cancer, but changes concern the techniques and not the principles of cancer surgery, that is, the necessity of being radical in both the primary and the neck. Supraglottic laryngectomycombined with functional elective or curative neck dissection is fully in line with those principles and it represents a priceless contribution to saving lives while sparing mutilation…I am persuaded that the solution to the problem of supraglottic cancer in its entirety is still in the surgeon’s hands, provided that we remember that we are waging a war against cancer in the larynx and in the lymph nodes of the neck, and not against the larynx and the neck.”
Ettore Bocca
Ann Otol Rhinol Laryngol, 1991; 100: pp261-267.