Carcinoma larynx recent trends in management

Carcinoma larynxCarcinoma larynxCurrent Treatment OptionsCurrent Treatment Options

Laryngeal carcinomaLaryngeal carcinoma

Most common head & neck Most common head & neck carcinoma worldwidecarcinoma worldwide Highest rates in south America & Highest rates in south America &

MediterraneanMediterranean Lowest in FinlandLowest in Finland

UKUK (2005) (2005) Incidence 3.6 per 100,000 Incidence 3.6 per 100,000 Mortality 1.3 per 100,000Mortality 1.3 per 100,000 5 Years Survival 60 % 5 Years Survival 60 %

US has exactly the same figures !US has exactly the same figures !

Incidence of laryngeal Incidence of laryngeal carcinoma in UKcarcinoma in UK

Mortality of laryngeal Mortality of laryngeal cancer in UK in 2006cancer in UK in 2006

5 year survival rates for 5 year survival rates for laryngeal carcinoma in UKlaryngeal carcinoma in UK

PAKISTANPAKISTAN

Topographic distribution of Topographic distribution of CA larynx A study from CA larynx A study from

PakistanPakistan

SANGI HA, MATIULLAH S, JAWAID MA, MARFANI MS. SANGI HA, MATIULLAH S, JAWAID MA, MARFANI MS. The The Presentation of Carcinoma of Larynx at Civil Hospital Karachi. Presentation of Carcinoma of Larynx at Civil Hospital Karachi. Pakistan Journal of Otolaryngology 2010;26:53-55Pakistan Journal of Otolaryngology 2010;26:53-55..

Experience at Experience at Shaikh Zayed Shaikh Zayed

Hospital , LahoreHospital , Lahore

Retrospective analysis of Retrospective analysis of cases of CA larynx in last cases of CA larynx in last

10 years10 years Total no. of 85 casesTotal no. of 85 cases 95 % male preponderance95 % male preponderance 82% of patients had history of smoking82% of patients had history of smoking 64% of cases were T4, 22% were T3, 64% of cases were T4, 22% were T3,

10% were T 2 ,4% were T110% were T 2 ,4% were T1 Topographic distributionTopographic distribution

Supraglottic 36%Supraglottic 36% Glottic 14%Glottic 14% Subglottic 2%Subglottic 2% Transglottic 48%Transglottic 48%


10 years10 years Nodal involvement in 12% of Nodal involvement in 12% of

patientspatients ManagementManagement

All stage I and II patients were All stage I and II patients were referred for curative Radiotherapyreferred for curative Radiotherapy 1 patient developed radio necrosis, 1 patient developed radio necrosis,

underwent total laryngectomy (TL)underwent total laryngectomy (TL) 3 Stage II patients had recurrence 3 Stage II patients had recurrence

Salvage surgery (TL)Salvage surgery (TL)


10 years10 years All stage III and Operable Stage IV All stage III and Operable Stage IV

patients underwent Total Laryngectomy patients underwent Total Laryngectomy with or without neck dissectionwith or without neck dissection

62% of these patients received Postoperative 62% of these patients received Postoperative radiotherapyradiotherapy

12 % patients developed recurrence12 % patients developed recurrence

Non-operable Stage IV patients were Non-operable Stage IV patients were referred for palliative Chemo referred for palliative Chemo radiotherapyradiotherapy

Electric larynx(Servox) was advised to all Electric larynx(Servox) was advised to all those who had TL and none was offered those who had TL and none was offered TEPTEP


10 years10 years None of the patients underwent partial None of the patients underwent partial

laryngectomies or surgical functional laryngectomies or surgical functional preservation preservation

All Operable advanced cases underwent All Operable advanced cases underwent Total laryngectomy and none referred Total laryngectomy and none referred for organ preservation (Chemoradiation)for organ preservation (Chemoradiation)

Non operable cases(primary or neck) Non operable cases(primary or neck) were referred foe palliative were referred foe palliative chemoradiaionchemoradiaion


10 years10 years

Reasons for our management Reasons for our management strategystrategy Advanced stage at presentation Advanced stage at presentation Poor follow-up of patientsPoor follow-up of patients Socioeconomic status of most of the Socioeconomic status of most of the

patientspatients

Different Different Management Plans Management Plans Currently in Use for Currently in Use for

CA larynx CA larynx

Management of CA Management of CA larynxlarynx

Functional/Organ PreservationFunctional/Organ Preservation Surgical (Partial resections)Surgical (Partial resections) Non- Surgical (Chemo radiation) Non- Surgical (Chemo radiation)

Total LaryngectomyTotal Laryngectomy

Other AspectsOther Aspects Management of nodal diseaseManagement of nodal disease Post operative RadiationPost operative Radiation

Palliation (Chemoradiation)Palliation (Chemoradiation)

Rodrigo JP, Coca-Pelaz A, Suárez C.Rodrigo JP, Coca-Pelaz A, Suárez C. [The current role of partial surgery as a [The current role of partial surgery as a strategy for functional preservation in laryngeal carcinoma].Acta strategy for functional preservation in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epub 2010 Aug 3.Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epub 2010 Aug 3.

Partial ResectionsPartial Resections Vocal cord strippingVocal cord stripping CordectomyCordectomy LASER resectionLASER resection Vertical Partial laryngecotmyVertical Partial laryngecotmy Supraglottic Partial LaryngectomySupraglottic Partial Laryngectomy Supracricoid partial LaryngectomySupracricoid partial Laryngectomy Near Total LaryngectomyNear Total Laryngectomy

N.B: Patient does not have a permenant tracheostomy N.B: Patient does not have a permenant tracheostomy stoma in these procedures except near total stoma in these procedures except near total laryngectyomylaryngectyomy

Vocal cord strippingVocal cord stripping

Suspiciously malignant lesionsSuspiciously malignant lesions LeukoplakiaLeukoplakia KeratosisKeratosis

Carcinoma in situCarcinoma in situ Radiotherapy plays no part in managementRadiotherapy plays no part in management

Laser resection is good alternative Laser resection is good alternative (TYPE 1 Subepithelial Laser (TYPE 1 Subepithelial Laser cordectomy )cordectomy )

Le QT, Takamiya R, Shu HK, Smitt M, Singer M, Terris DJ, Fee WE, Goffinet DR, Fu KK.Treatment results of carcinoma in situ of the glottis: an analysis of 82 cases. Arch Otolaryngol Head Neck Surg. 2000 Nov;126(11):1305-12.

CordectomyCordectomy

T1a lesion limited to middle of free T1a lesion limited to middle of free edge of membranous cord, not to be edge of membranous cord, not to be more than 2mm more than 2mm

Laryngofissure approachLaryngofissure approach

Inner perichondrium of thyroid Inner perichondrium of thyroid cartilage removed with the cordcartilage removed with the cord

Endoscopic Laser cordectomy is a good Endoscopic Laser cordectomy is a good alternativealternative

Vertical Partial Vertical Partial LaryngectomyLaryngectomy

IndicationsIndications T1, T2 Glottic lesionsT1, T2 Glottic lesions T3 due to direct invasion of thyroarytenoid T3 due to direct invasion of thyroarytenoid

muscle ? muscle ?

ContraindicationsContraindications Vocal cord fixation due to Cricoarytenoid Vocal cord fixation due to Cricoarytenoid

jointjoint Involvement of the posterior commissure Involvement of the posterior commissure

or the thyroid cartilageor the thyroid cartilage Extension above the aryepiglottic fold.Extension above the aryepiglottic fold.

Vertical Partial Vertical Partial LaryngectomyLaryngectomy

Rodrigo JP, Coca-Pelaz A, Suárez C.Rodrigo JP, Coca-Pelaz A, Suárez C. [The current role of [The current role of partial surgery as a strategy for functional preservation in partial surgery as a strategy for functional preservation in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epub 2010 Aug 3.Jun;62(3):231-8. Epub 2010 Aug 3.

Supraglottic Partial Supraglottic Partial LaryngectomyLaryngectomy

IndicationsIndications

T1- T2 Supraglottic cancersT1- T2 Supraglottic cancers

T3 and T4 supraglottic tumours affecting the pre-T3 and T4 supraglottic tumours affecting the pre-epiglottic space or one of the arytenoids, or that epiglottic space or one of the arytenoids, or that extend to the pyriform sinus or the base of the tongueextend to the pyriform sinus or the base of the tongue

Adequate pulmonary functionAdequate pulmonary function

ContraindicationsContraindications Cartilage erosion, subglottic extension or Cartilage erosion, subglottic extension or

involvement of the lateral wall of the pyriform involvement of the lateral wall of the pyriform sinussinus


Rodrigo JP, Coca-Pelaz A, Suárez C.Rodrigo JP, Coca-Pelaz A, Suárez C. [The current role of partial [The current role of partial surgery as a strategy for functional preservation in laryngeal surgery as a strategy for functional preservation in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epub 2010 Aug 3.Epub 2010 Aug 3.


The resection can be extended to include an The resection can be extended to include an arytenoid, t he base of the tongue or the pyriform arytenoid, t he base of the tongue or the pyriform sinus.sinus.

The patient has an almost normal voice, but a The patient has an almost normal voice, but a major challenge is in the development of normal major challenge is in the development of normal swallowing from the loss of the protective swallowing from the loss of the protective mechanisms (epiglottis and bands).mechanisms (epiglottis and bands).

A temporary tracheostomy and a feeding tube A temporary tracheostomy and a feeding tube (usually nasogastric) are required in all patients, (usually nasogastric) are required in all patients, rehabilitation is achieved within the first month rehabilitation is achieved within the first month after surgery in most patients, with the removal of after surgery in most patients, with the removal of the feeding tube and closure of the tracheostomythe feeding tube and closure of the tracheostomy..

Supracricoid Supracricoid LaryngectomyLaryngectomy

Alternative to (chemo)radiotherapy, Alternative to (chemo)radiotherapy, supraglottic laryngectomy, and near-total supraglottic laryngectomy, and near-total and total laryngectomy in selected cases and total laryngectomy in selected cases of supraglottic and transglottic of supraglottic and transglottic carcinoma. carcinoma.

A technique for function preservation and A technique for function preservation and should be considered as a laryngeal should be considered as a laryngeal preservation technique, as it preserves preservation technique, as it preserves the physiological rehabilitation of speech, the physiological rehabilitation of speech, swallowing and breathing without the swallowing and breathing without the need for a permanent tracheotomy.need for a permanent tracheotomy.

Supracricoid Partial Supracricoid Partial LaryngectomyLaryngectomy

Types Types With Cricohyoidoepiglotopexy (SCPL-CHEP)With Cricohyoidoepiglotopexy (SCPL-CHEP) With Cricohyoidopexy (SCPL-CHP)With Cricohyoidopexy (SCPL-CHP)

SCPL-CHEPSCPL-CHEP

IndicationsIndications Glottic tumours: T2 (especially with Glottic tumours: T2 (especially with

involvement of the anterior commissure), involvement of the anterior commissure), T3 and selected cases of T4 (limited T3 and selected cases of T4 (limited invasion of the thyroid cartilage)invasion of the thyroid cartilage)

ContraindicationsContraindications Fixation of the cricoarytenoid joint, invasion Fixation of the cricoarytenoid joint, invasion

of the posterior commissure, invasion of the of the posterior commissure, invasion of the cricoid, extralaryngeal spread of the cricoid, extralaryngeal spread of the tumour or poor lung function.tumour or poor lung function.

SCPL-CHPSCPL-CHP

IndicationsIndications T2---T4 larynx tumours: for T2---T4 larynx tumours: for supraglottic supraglottic

tumours extending to the vocal cord or tumours extending to the vocal cord or anterior commissure and for anterior commissure and for transglottic tumours. transglottic tumours.

ContraindicationsContraindications Same as for SCPL-CHEP, along with the Same as for SCPL-CHEP, along with the

invasion of the hyoid bone.invasion of the hyoid bone.

Trans oral Laser surgeryTrans oral Laser surgery Along with SCPL, it has been one of the Along with SCPL, it has been one of the

two areas of greatest development in two areas of greatest development in larynx conservation surgery in recent yearslarynx conservation surgery in recent years

Violates one of the basic surgical Violates one of the basic surgical principles, because the tumour is sectioned principles, because the tumour is sectioned and then removed part by part, through a and then removed part by part, through a laryngoscope. However, sectioning of the laryngoscope. However, sectioning of the piece reveals the depth of tumour piece reveals the depth of tumour penetration and allows a clear view of the penetration and allows a clear view of the oncological surgical margins during the oncological surgical margins during the procedure.procedure.

Trans oral Laser SurgeryTrans oral Laser Surgery

In contrast to open larynx surgery, In contrast to open larynx surgery, the cartilaginous edges of the larynx the cartilaginous edges of the larynx and infrahyoid muscles are and infrahyoid muscles are preserved during endoscopic preserved during endoscopic resection, which is thought to resection, which is thought to improve postoperative functionimprove postoperative function



IndicationsIndications

Supraglottic or T1---T2 glottic carcinomas Supraglottic or T1---T2 glottic carcinomas (e.g. Laser cordectmies)(e.g. Laser cordectmies)

Selected T3 glottic tumours (vocal fold Selected T3 glottic tumours (vocal fold fixation due to direct invasion of the fixation due to direct invasion of the thyroarytenoid muscle by the tumour)thyroarytenoid muscle by the tumour)

T3 supraglottic tumours (invasion limited to T3 supraglottic tumours (invasion limited to the pre-epiglottic space), and also in some T4 the pre-epiglottic space), and also in some T4 cases (limited invasion of the tongue base).cases (limited invasion of the tongue base).


ContraindicationsContraindications:: Subglottic extension (≥5 mm)Subglottic extension (≥5 mm) Post cricoid extensionPost cricoid extension Invasion of the pyriform sinusInvasion of the pyriform sinus Cartilage invasionCartilage invasion Vocal fold fixation (relative)Vocal fold fixation (relative) Arytenoid extension (relative)Arytenoid extension (relative) Involvement of the base of the tongueInvolvement of the base of the tongue

Trans oral Robotic Trans oral Robotic SurgerySurgery

Gaining popularity in many specialtiesGaining popularity in many specialties

Main advantages proposed by the Main advantages proposed by the supporters of robot-assisted surgery :supporters of robot-assisted surgery : Excellent three-dimensional visualization and Excellent three-dimensional visualization and

surgery with 2 or 3 hands through the surgery with 2 or 3 hands through the minimally invasive approaches made possible minimally invasive approaches made possible by the deviceby the device

Ability to provide movement at the tip of the Ability to provide movement at the tip of the instrument, with 7instrument, with 7◦ ◦ of freedom and 90of freedom and 90◦ ◦ of rotation of rotation and movement scale.and movement scale.

Total Laryngectomy (TL)Total Laryngectomy (TL)

Workhorse for the Head & neck surgeon Workhorse for the Head & neck surgeon in advanced cases of CA larynx !in advanced cases of CA larynx !

IndicationsIndications Consent for TL in cases of partial resectionsConsent for TL in cases of partial resections Salvage surgery & RadionecrosisSalvage surgery & Radionecrosis T4 lesions with operable extraaryngeal T4 lesions with operable extraaryngeal

spreadspread Transglottic tumours with cricoid involvementTransglottic tumours with cricoid involvement Large supraglottic tumours with cartilage Large supraglottic tumours with cartilage

erosion, subglottic extension or involvement erosion, subglottic extension or involvement of the lateral wall of the pyriform sinus of the lateral wall of the pyriform sinus

Voice Voice Rehabilitation Rehabilitation

after Total after Total LaryngectomyLaryngectomy

Alaryngeal speech Alaryngeal speech optionsoptions

External sound sourcesExternal sound sources

Esophageal speechEsophageal speech

Tracheoesophageal speech Tracheoesophageal speech (TEP(TEP))

Transcervical Transcervical electrolarynxelectrolarynx

AdvantagesAdvantages

Short learning timeShort learning time Volume controlVolume control Does not rely on Does not rely on

pulmonary systempulmonary system Immediate post op Immediate post op

usage with oral usage with oral adapteradapter

Esophageal speechEsophageal speech

Basic principleBasic principle

MethodsMethods Consonant Consonant

injectioninjection GlossopharyngeaGlossopharyngea

l pressl press InhalationInhalation

Tracheoesophageal Tracheoesophageal speechspeech

Surgically made TE fistulaSurgically made TE fistula Pulmonary air usedPulmonary air used TypesTypes

Primary Primary SecondarySecondary

ProsthesisProsthesis RemovableRemovable IndwellingIndwelling Ante grade or retrograde insertionAnte grade or retrograde insertion

Cost:Cost: Expensive prosthesisExpensive prosthesis

Tracheoesophageal Tracheoesophageal SpeechSpeech

AdvantagesAdvantages

Rapid restoration of voiceRapid restoration of voice Normal length of phrasesNormal length of phrases Indwelling prosthesis need little Indwelling prosthesis need little

maintenancemaintenance Hands free optionHands free option

Problems with TEPProblems with TEP

Candidal colonizationCandidal colonization Prosthesis needs to be changedProsthesis needs to be changed

CostCost MaintenanceMaintenance

Intraoral electrolarynxIntraoral electrolarynxUlravoice plusUlravoice plusTMTM

Oral unitOral unit FM ReceiverFM Receiver

Control unitControl unit TransmitterTransmitter Voice enhancerVoice enhancer

Hands free optionHands free option Cost is Cost is ~4500$ ~4500$

Non-Surgical Organ Non-Surgical Organ PreservationPreservation

(Chemo-radiation)(Chemo-radiation) T1 T2 lesions where patient does not want T1 T2 lesions where patient does not want

surgical treatment (Radiotherapy)surgical treatment (Radiotherapy) Advanced lesions T3 T4 where non Advanced lesions T3 T4 where non

surgical organ preservation is surgical organ preservation is contemplatedcontemplated

Recent epidemiological observations have Recent epidemiological observations have shown declining survival rates in laryngeal shown declining survival rates in laryngeal cancer patients, raising concern about uncritical cancer patients, raising concern about uncritical and too frequent use of this approach. and too frequent use of this approach.

Rudat V, Rudat V, Pfreundner L, , Hoppe F, , Dietz A. . Approaches to preserve Approaches to preserve larynx function in locally advanced laryngeal and hypopharyngeal larynx function in locally advanced laryngeal and hypopharyngeal cancer.cancer. Onkologie. 2004 Aug;27(4):368-75. 2004 Aug;27(4):368-75.

Different studiesDifferent studies

Salvage surgery after Salvage surgery after radiotherapy failure in radiotherapy failure in

T1 – T2 glottic CAT1 – T2 glottic CA Successful in 50-60 % of the patientsSuccessful in 50-60 % of the patients Total laryngectomyTotal laryngectomy Voice sparing procedures in selected Voice sparing procedures in selected

patientspatients May require completion total laryngectomyMay require completion total laryngectomy

McLaughlin MP, Parsons JT, Fein DA, Stringer SP, Cassisi NJ, McLaughlin MP, Parsons JT, Fein DA, Stringer SP, Cassisi NJ, Mendenhall WM, Million RR.Mendenhall WM, Million RR.Salvage surgery after radiotherapy Salvage surgery after radiotherapy failure in T1-T2 squamous cell carcinoma of the glottic larynx. failure in T1-T2 squamous cell carcinoma of the glottic larynx. Head Neck. 1996 May-Jun;18(3):229-35Head Neck. 1996 May-Jun;18(3):229-35

Advanced Carcinoma Advanced Carcinoma larynxlarynx

Results of Surgery + Results of Surgery + RadiationRadiation 116 patients with Stage III squamous cell carcinoma of 116 patients with Stage III squamous cell carcinoma of

the larynx underwent radical surgery and postoperative the larynx underwent radical surgery and postoperative radiotherapy with a curative intent.radiotherapy with a curative intent.

The local recurrence rate and the local disease-free The local recurrence rate and the local disease-free survival rate at 5 years were 22.5% and 76.3%survival rate at 5 years were 22.5% and 76.3%

Local prognosis and survival depend largely on nodal Local prognosis and survival depend largely on nodal involvement and capsular rupture while increasing doses involvement and capsular rupture while increasing doses of radiation strategy is likely to reduce the risk of local of radiation strategy is likely to reduce the risk of local and nodal recurrenceand nodal recurrence

Nguyen TD, Malissard L, Théobald S, Eschwège F, Panis X, Bachaud JM, Nguyen TD, Malissard L, Théobald S, Eschwège F, Panis X, Bachaud JM, Rambert P, Chaplain G, Quint RRambert P, Chaplain G, Quint R.Advanced carcinoma of the larynx: results .Advanced carcinoma of the larynx: results of surgery and radiotherapy without induction chemotherapy (1980-1985): a of surgery and radiotherapy without induction chemotherapy (1980-1985): a multivariate analysis. Int J Radiat Oncol Biol Phys. 1996 Dec 1;36(5):1013-8.multivariate analysis. Int J Radiat Oncol Biol Phys. 1996 Dec 1;36(5):1013-8.

Advanced Carcinoma of LarynxAdvanced Carcinoma of LarynxComparision between Surgery Comparision between Surgery

& Radiotherapy& Radiotherapy Radiotherapy + Salvage surgery (RRSS) for Eighty-two Radiotherapy + Salvage surgery (RRSS) for Eighty-two

patients with untreated T2N+M0 or T3T4NM0 were patients with untreated T2N+M0 or T3T4NM0 were compared with comparable patients in literature who compared with comparable patients in literature who underwent Total laryngectomy +/- neck dissectionunderwent Total laryngectomy +/- neck dissection

A policy of RRSS offers a good chance of laryngeal A policy of RRSS offers a good chance of laryngeal conservation without compromising ultimate locoregional conservation without compromising ultimate locoregional control or survival when compared to primary control or survival when compared to primary laryngectomy and neck dissection in patients with locally laryngectomy and neck dissection in patients with locally advanced carcinoma of the larynx meeting the surgical advanced carcinoma of the larynx meeting the surgical eligibility of clinical trials.eligibility of clinical trials.

MacKenzie RG, Franssen E, Balogh JM, Gilbert RW, Birt D, Davidson J.MacKenzie RG, Franssen E, Balogh JM, Gilbert RW, Birt D, Davidson J. Comparing treatment outcomes of radiotherapy and surgery in Comparing treatment outcomes of radiotherapy and surgery in locally advanced carcinoma of the larynx: a comparison limited to locally advanced carcinoma of the larynx: a comparison limited to patients eligible for surgery. Int J Radiat Oncol Biol Phys. 2000 Apr patients eligible for surgery. Int J Radiat Oncol Biol Phys. 2000 Apr 1;47(1):65-71.1;47(1):65-71.

Advanced T3-4 Ca Advanced T3-4 Ca larynx .Review of larynx .Review of treatment optionstreatment options

Lower N-stage was a favorable prognostic Lower N-stage was a favorable prognostic factor for Locoreigonal control RC and factor for Locoreigonal control RC and OverallSurvival. OverallSurvival.

Surgery was a favorable prognostic factor for Surgery was a favorable prognostic factor for LRC but did not impact on OverallSurvialLRC but did not impact on OverallSurvial

Hgb levels > or = 12.5 g/dL during RT was a Hgb levels > or = 12.5 g/dL during RT was a favorable prognostic factor for OS.favorable prognostic factor for OS.

Nguyen-Tan PF, Le QT, Quivey JM, Singer M, Terris DJ, Goffinet DR, Nguyen-Tan PF, Le QT, Quivey JM, Singer M, Terris DJ, Goffinet DR, Fu KKFu KK. Treatment results and prognostic factors of advanced T3--. Treatment results and prognostic factors of advanced T3--4 laryngeal carcinoma: the University of California, San Francisco 4 laryngeal carcinoma: the University of California, San Francisco (UCSF) and Stanford University Hospital (SUH) experience. Int J (UCSF) and Stanford University Hospital (SUH) experience. Int J Radiat Oncol Biol Phys. 2001 Aug 1;50(5):1172-80.Radiat Oncol Biol Phys. 2001 Aug 1;50(5):1172-80.

T3N0M0T3N0M0 7 different Rx modilities compared7 different Rx modilities compared

TL, TL+ND,Conservation surgery, Dxt aone,TL+Dxt, TL, TL+ND,Conservation surgery, Dxt aone,TL+Dxt, TL+ND+Dxt,Consevation Surgery+DxtTL+ND+Dxt,Consevation Surgery+Dxt

Statistically similar recurrence, complication, and Statistically similar recurrence, complication, and survival rates.survival rates.

Clear margins have a significant survival advantage Clear margins have a significant survival advantage compared with patients with close and involved marginscompared with patients with close and involved margins

Because postoperative radiation therapy in patients with Because postoperative radiation therapy in patients with positive margins did not improve survival, formalpositive margins did not improve survival, formal re- re-resection resection of the site of the positive margin should be of the site of the positive margin should be

consideredconsidered.. Patients treated with RT and CS had statistically similar Patients treated with RT and CS had statistically similar

rates of survival, maintenance of voice, and acquired rates of survival, maintenance of voice, and acquired permanent tracheal stomapermanent tracheal stoma

Sessions DG, Lenox J, Spector GJ, Newland D, Simpson J, Haughey BH, Sessions DG, Lenox J, Spector GJ, Newland D, Simpson J, Haughey BH, Chao KS.Chao KS.Management of T3N0M0 glottic carcinoma: therapeutic Management of T3N0M0 glottic carcinoma: therapeutic outcomes.Laryngoscope. 2002 Jul;112(7 Pt 1):1281-8outcomes.Laryngoscope. 2002 Jul;112(7 Pt 1):1281-8

Partial Laryngectomy Partial Laryngectomy after radiation faliureafter radiation faliure

27 patients with early-stage laryngeal carcinoma underwent 27 patients with early-stage laryngeal carcinoma underwent salvage partial laryngectomy after irradiation failure.salvage partial laryngectomy after irradiation failure. Vertical laryngectomy was performed in 18 patients (13 with T1 N0 Vertical laryngectomy was performed in 18 patients (13 with T1 N0

and 5 with T2 N0) and 5 with T2 N0) Horizontal-supraglottic laryngectomy in 9 patients (3 with T1 N0, 1 Horizontal-supraglottic laryngectomy in 9 patients (3 with T1 N0, 1

with T2 N0, and 5 with T2 N1)with T2 N0, and 5 with T2 N1) Vertical laryngectomy was not associated with an increased Vertical laryngectomy was not associated with an increased

complication ratecomplication rate In early laryngeal cancer (glottic T1-T2, supraglottic T1) In early laryngeal cancer (glottic T1-T2, supraglottic T1)

partial laryngectomy can be performed with good expectation partial laryngectomy can be performed with good expectation of cure and satisfactory laryngeal function. In T2 supraglottic of cure and satisfactory laryngeal function. In T2 supraglottic lesions, the oncologic results are less satisfactorylesions, the oncologic results are less satisfactory

Yiotakis J, Stavroulaki P, Nikolopoulos T, Manolopoulos L, Kandiloros D, Yiotakis J, Stavroulaki P, Nikolopoulos T, Manolopoulos L, Kandiloros D, Ferekidis E, Adamopoulos G. Ferekidis E, Adamopoulos G. Partial laryngectomy after irradiation Partial laryngectomy after irradiation

failure. Otolaryngol Head Neck Surg. 2003 Feb;128(2):200-9failure. Otolaryngol Head Neck Surg. 2003 Feb;128(2):200-9..

Management of T1- T2 Management of T1- T2 Glottic CAGlottic CA

The aim of the current study was to review the The aim of the current study was to review the pertinent literature and discuss the optimal pertinent literature and discuss the optimal management of early-stage laryngeal carcinomamanagement of early-stage laryngeal carcinoma..

Local control, laryngeal preservation, and survival rates Local control, laryngeal preservation, and survival rates of patients were similar after transoral laser resection, of patients were similar after transoral laser resection, open partial laryngectomy, and radiotherapy.open partial laryngectomy, and radiotherapy.

Voice quality was superior in pts undergoing transoral Voice quality was superior in pts undergoing transoral Laser resection than partial laryngectomies & Laser resection than partial laryngectomies & comparable to Dxtcomparable to Dxt

Costs were similar for laser resection and radiotherapy, Costs were similar for laser resection and radiotherapy, but open partial laryngectomy was more expensive.but open partial laryngectomy was more expensive.

Open partial laryngectomy was reserved for patients Open partial laryngectomy was reserved for patients with locally recurrent tumors.with locally recurrent tumors.

Mendenhall WM, Werning JW, Hinerman RW, Amdur RJ, Villaret DB.Mendenhall WM, Werning JW, Hinerman RW, Amdur RJ, Villaret DB. Management of T1-T2 glottic carcinomas.Cancer. 2004 May Management of T1-T2 glottic carcinomas.Cancer. 2004 May 1;100(9):1786-92.1;100(9):1786-92.

Laser microsurgery for Laser microsurgery for recurrent glottic CA after recurrent glottic CA after

RadiotherapyRadiotherapy Thirty-four patients with early and advanced recurrent glottic Thirty-four patients with early and advanced recurrent glottic

carcinoma after full-course radiotherapy carcinoma after full-course radiotherapy

Twenty-four patients (71%) were cured with one or more laser Twenty-four patients (71%) were cured with one or more laser procedures. In nine patients, recurrences could not be procedures. In nine patients, recurrences could not be controlled by laser microsurgery: six patients underwent total controlled by laser microsurgery: six patients underwent total laryngectomy and three palliative treatment.laryngectomy and three palliative treatment.

Compared with salvage laryngectomy, results are superior Compared with salvage laryngectomy, results are superior with respect to preservation of laryngeal function. Great with respect to preservation of laryngeal function. Great expertise is required, especially in resections of advanced-expertise is required, especially in resections of advanced-stage recurrent carcinomas.stage recurrent carcinomas.

Steiner W, Vogt P, Ambrosch P, Kron Steiner W, Vogt P, Ambrosch P, Kron M. Transoral carbon dioxide laser M. Transoral carbon dioxide laser microsurgery for recurrent glottic carcinoma after radiotherapy. Head microsurgery for recurrent glottic carcinoma after radiotherapy. Head

Neck. 2004 Jun;26(6):477-84Neck. 2004 Jun;26(6):477-84..

Stage IV Glottic CAStage IV Glottic CA 5 Different Treatment options compared in 96 patients with 5 Different Treatment options compared in 96 patients with

stage IV glottic CAstage IV glottic CA Total laryngectomy with neck dissection (TL/ND) (n = 18), Total laryngectomy with neck dissection (TL/ND) (n = 18),

radiation therapy alone (RT) (n = 7) (median dose, 69.5 radiation therapy alone (RT) (n = 7) (median dose, 69.5 Gy), total laryngectomy combined with radiation therapy Gy), total laryngectomy combined with radiation therapy (TL/RT) (n = 10), and total laryngectomy and neck (TL/RT) (n = 10), and total laryngectomy and neck dissection combined with radiation therapy (TL/ND/RT) (n dissection combined with radiation therapy (TL/ND/RT) (n = 48). = 48).

The five treatment modalities had statistically The five treatment modalities had statistically similarsimilar survival, recurrence, and complication rates. The overall 5-survival, recurrence, and complication rates. The overall 5-year DSS for patients with stage IV glottic carcinoma was year DSS for patients with stage IV glottic carcinoma was 45%, and the OS was 39%45%, and the OS was 39%

Patients whose N0 neck was treated with observation and Patients whose N0 neck was treated with observation and appropriate treatment for subsequent neck disease had appropriate treatment for subsequent neck disease had statistically similar survival compared with patients whose statistically similar survival compared with patients whose N0 neck was treated prophylactically at the time of N0 neck was treated prophylactically at the time of treatment of the primarytreatment of the primary

Spector GJ, Sessions DG, Lenox J, Newland D, Simpson J, Haughey BH. Spector GJ, Sessions DG, Lenox J, Newland D, Simpson J, Haughey BH. Management of stage IV glottic carcinoma: therapeutic outcomes. Management of stage IV glottic carcinoma: therapeutic outcomes. Laryngoscope. 2004 Aug;114(8):1438-46Laryngoscope. 2004 Aug;114(8):1438-46..

Supracricoid laryngectomy Supracricoid laryngectomy with cricohyoidopexy for with cricohyoidopexy for recurrence of early-stage recurrence of early-stage

glottic carcinoma glottic carcinoma In selected cases, SCL-CHP may be used to treat laryngeal In selected cases, SCL-CHP may be used to treat laryngeal carcinomas after radiation failure, with good oncological and carcinomas after radiation failure, with good oncological and functional results.functional results.

Seven cases of rT2-T3 laryngeal squamous cell carcinomas Seven cases of rT2-T3 laryngeal squamous cell carcinomas that recurred after radiotherapy and were treated with that recurred after radiotherapy and were treated with salvage SCL-CHPsalvage SCL-CHP

All patients were decannulated and recovered the ability to All patients were decannulated and recovered the ability to swallow. Vocal quality was significantly rough and breathy but swallow. Vocal quality was significantly rough and breathy but was satisfactorily intelligible in all patientswas satisfactorily intelligible in all patients

Marchese-Ragona R, Marioni G, Chiarello G, Staffieri A, Pastore A. Supracricoid laryngectomy with cricohyoidopexy for recurrence of early-stage glottic carcinoma after irradiation. Long-term oncological and functional results. Acta Otolaryngol. 2005 Jan;125(1):91-5.

CO2 laser cordectomy for CO2 laser cordectomy for early-stage glottic early-stage glottic

carcinomacarcinoma Microendoscopic laser surgery is efficacious for early glottic Microendoscopic laser surgery is efficacious for early glottic carcinoma, (Tis, T1a, T1b)with oncological results comparable carcinoma, (Tis, T1a, T1b)with oncological results comparable to those observed following radiotherapy or conventional to those observed following radiotherapy or conventional partial laryngectomy, however, in this case, local recurrences partial laryngectomy, however, in this case, local recurrences have a greater range of re-treatment optionshave a greater range of re-treatment options

79 patients included in this study.79 patients included in this study. Depth and extension of excisions were graded according to Depth and extension of excisions were graded according to

European Laryngological Society Classification, and included European Laryngological Society Classification, and included 5 types of cordectomy.5 types of cordectomy.

Only 8 Recurences….. treated with total laryngectomy (n:3),2Only 8 Recurences….. treated with total laryngectomy (n:3),2ndnd time laser excision(n:2), Partial time laser excision(n:2), Partial laryngetomy(n:2),Radiotherapy(1)laryngetomy(n:2),Radiotherapy(1)

Bocciolini C, , Presutti L, , Laudadio P..Oncological outcome after CO2 laser Oncological outcome after CO2 laser cordectomy for early-stage glottic carcinoma.cordectomy for early-stage glottic carcinoma. Acta Otorhinolaryngol Ital. 2005 Apr;25(2):86-93.2005 Apr;25(2):86-93.

The role of laser The role of laser microsurgery in the microsurgery in the

treatment of laryngeal treatment of laryngeal cancercancer This review elucidates the role of laser microsurgical partial This review elucidates the role of laser microsurgical partial

resections of the larynx in comparison with other treatment resections of the larynx in comparison with other treatment modalitiesmodalities

In patients with early or moderately advanced supraglottic In patients with early or moderately advanced supraglottic carcinoma, laser microsurgery is comparable to open supraglottic carcinoma, laser microsurgery is comparable to open supraglottic laryngectomy in terms of local control and survivallaryngectomy in terms of local control and survival

Based on published results, primary laser therapy can achieve Based on published results, primary laser therapy can achieve local tumor control with a functional residual larynx in local tumor control with a functional residual larynx in approximately 70-80% of cases.approximately 70-80% of cases.

With regard to organ preservation, laser microsurgery is With regard to organ preservation, laser microsurgery is comparable to open supraglottic laryngectomy but superior to comparable to open supraglottic laryngectomy but superior to radiotherapyradiotherapy

Microsurgery can preserve functionally important structures, Microsurgery can preserve functionally important structures, allowing for early swallowing rehabilitation while avoiding allowing for early swallowing rehabilitation while avoiding tracheotomy.tracheotomy.

Ambrosch P.Ambrosch P. The role of laser microsurgery in the treatment of laryngeal The role of laser microsurgery in the treatment of laryngeal cancer.cancer. Curr Opin Otolaryngol Head Neck Surg. 2007 Apr;15(2):82-8 2007 Apr;15(2):82-8

Voice outcomes following trans oral Laser Voice outcomes following trans oral Laser microsurgery for early glottic squamous microsurgery for early glottic squamous

cell carcinomacell carcinoma Transoral laser microsurgery for T1 or T2 glottic cancerTransoral laser microsurgery for T1 or T2 glottic cancer Survival outcomes following transoral laser microsurgery Survival outcomes following transoral laser microsurgery

are comparable to treatment with radiotherapy.are comparable to treatment with radiotherapy. Voice impairment is usually mild to moderate following Voice impairment is usually mild to moderate following

transoral laser microsurgery for early glottic cancer but transoral laser microsurgery for early glottic cancer but overall may be greater than in radiotherapy patientsoverall may be greater than in radiotherapy patients

The repeatability of transoral laser microsurgery may The repeatability of transoral laser microsurgery may result in a lower laryngectomy rate compared with result in a lower laryngectomy rate compared with published series using radiotherapy.published series using radiotherapy.

The mean Oates Russell Voice Profile for T1 disease was The mean Oates Russell Voice Profile for T1 disease was 2.37 and for T2 2.68 (range 1 to 4) indicating a mild (2) to 2.37 and for T2 2.68 (range 1 to 4) indicating a mild (2) to moderate (3) degree of voice impairment.moderate (3) degree of voice impairment.

Kennedy JT, , Paddle PM, , Cook BJ, , Chapman P, , Iseli TA.. Voice Voice outcomes following transoral laser microsurgery for early glottic outcomes following transoral laser microsurgery for early glottic squamous cell carcinoma.squamous cell carcinoma.J Laryngol Otol. 2007 Dec;121(12):1184-8. 2007 Dec;121(12):1184-8. Epub 2007 Apr 20.Epub 2007 Apr 20.

Treatment of early-stage Treatment of early-stage glottic cancer by transoral glottic cancer by transoral

laser resectionlaser resection 142 patients treated with curative intent142 patients treated with curative intent

The tumors were classified pTis (n = 21), pT1a (n = 51), or pT1b (n = 7) and The tumors were classified pTis (n = 21), pT1a (n = 51), or pT1b (n = 7) and were treated by cordectomy types I (23%), II (30%), III (27%), IV (6%), and V were treated by cordectomy types I (23%), II (30%), III (27%), IV (6%), and V (14%). The average follow-up was 56 months (range, 24 to 150 months). The (14%). The average follow-up was 56 months (range, 24 to 150 months). The overall 5-year actuarial recurrence-free survival rate was 89%, and the 5-year overall 5-year actuarial recurrence-free survival rate was 89%, and the 5-year actuarial disease-specific survival rate was 97.3%. There were 11 local actuarial disease-specific survival rate was 97.3%. There were 11 local recurrences (14%); 7 were treated by another laser resection, 1 by recurrences (14%); 7 were treated by another laser resection, 1 by radiotherapy, 1 by supracricoid partial laryngectomy, and 2 by total radiotherapy, 1 by supracricoid partial laryngectomy, and 2 by total laryngectomy.laryngectomy.

Positive or suspicious margins were not related to recurrence, nor was Positive or suspicious margins were not related to recurrence, nor was anterior commissure involvement. This study implies that suspicious margins anterior commissure involvement. This study implies that suspicious margins can be managed with a "watch-and-wait" attitude. Re-treatment with laser, can be managed with a "watch-and-wait" attitude. Re-treatment with laser, external partial laryngectomy, and radiotherapy remain therapeutic options for external partial laryngectomy, and radiotherapy remain therapeutic options for recurrences.recurrences.

Hartl DM, Hartl DM, de Monès E, , Hans S, , Janot F, , Brasnu D.Treatment of early-stage glottic .Treatment of early-stage glottic cancer by transoral laser resection.cancer by transoral laser resection. Ann Otol Rhinol Laryngol. 2007 2007 Nov;116(11):832-6.Nov;116(11):832-6.

Partial surgery for functional Partial surgery for functional preservation in CA larynxpreservation in CA larynx

Non-surgical treatment is offered as a strategy for organ Non-surgical treatment is offered as a strategy for organ preservation, as opposed to total laryngectomy. However, preservation, as opposed to total laryngectomy. However, we believe that we believe that there are two organ-preservation there are two organ-preservation strategies, surgical and non-surgicalstrategies, surgical and non-surgical. A wide spectrum of . A wide spectrum of surgical techniques is available and such techniques lead to surgical techniques is available and such techniques lead to excellent results, both oncological and functional (speech excellent results, both oncological and functional (speech and swallowingand swallowing

In addition to classic approaches such as vertical partial In addition to classic approaches such as vertical partial laryngectomy and horizontal or supraglottic laryngectomy, laryngectomy and horizontal or supraglottic laryngectomy, options for conservative laryngeal surgery have improved options for conservative laryngeal surgery have improved significantly over the past two decades.significantly over the past two decades.

Minimally invasive surgery, transoral laser surgery, and Minimally invasive surgery, transoral laser surgery, and supracricoid partial laryngectomy have become important supracricoid partial laryngectomy have become important laryngeal preservation approaches for patients with laryngeal preservation approaches for patients with laryngeal cancerlaryngeal cancer

Rodrigo JP, Coca-Pelaz A, Suárez C.Rodrigo JP, Coca-Pelaz A, Suárez C. [The current role of partial surgery as [The current role of partial surgery as a strategy for functional preservation in laryngeal carcinoma].Acta a strategy for functional preservation in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epub 2010 Aug 3.Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epub 2010 Aug 3.

Functional organ preservation in Functional organ preservation in Laryngeal and hypopharyngeal Laryngeal and hypopharyngeal

cancercancer Comparing the various surgical approaches of laryngeal Comparing the various surgical approaches of laryngeal

partial resections, the oncological outcome of the patients, partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity.endoscopic procedures are superior with less morbidity.

The surgical procedures put together, are all superior to The surgical procedures put together, are all superior to radiotherapy concerning organ preservation.radiotherapy concerning organ preservation.

Transoral laser microsurgery has been used successfully Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomashypopharyngeal carcinomas

Ambrosch P, Fazel A. Ambrosch P, Fazel A. [Functional organ preservation in [Functional organ preservation in laryngeal and hypopharyngeal laryngeal and hypopharyngeal cancer].Laryngorhinootologie. 2011 Mar;90 Suppl 1:S83-cancer].Laryngorhinootologie. 2011 Mar;90 Suppl 1:S83-109. Epub 2011 Apr 26.109. Epub 2011 Apr 26.

Concurrent Concurrent Chemoradiotherapy for Chemoradiotherapy for

Advanced Ca LarynxAdvanced Ca Larynx The introduction of concurrent administration of The introduction of concurrent administration of

chemotherapy and radiotherapy (chemo radiotherapy) chemotherapy and radiotherapy (chemo radiotherapy) has been a major advancement. This has resulted in has been a major advancement. This has resulted in local control and survival rates comparable to those local control and survival rates comparable to those seen following radical surgery and postoperative seen following radical surgery and postoperative radiotherapy, but with preservation of the larynx in radiotherapy, but with preservation of the larynx in most patients.most patients.

However, recent epidemiological observations have However, recent epidemiological observations have shown declining survival rates in laryngeal cancer shown declining survival rates in laryngeal cancer patients, raising concern about uncritical and too patients, raising concern about uncritical and too frequent use of this approachfrequent use of this approach. .

Rudat V, Pfreundner L, Hoppe F, Dietz A. Rudat V, Pfreundner L, Hoppe F, Dietz A. Approaches to Approaches to preserve larynx function in locally advanced laryngeal preserve larynx function in locally advanced laryngeal and hypopharyngeal cancer. Onkologie. 2004 and hypopharyngeal cancer. Onkologie. 2004 Aug;27(4):368-75.Aug;27(4):368-75.

Organ preservation Organ preservation withConcomitant withConcomitant

radiochemotherapyradiochemotherapy Organ preservation treatment is a valuable alternative to surgical Organ preservation treatment is a valuable alternative to surgical procedure in patients diagnosed with laryngeal and hypopharyngeal procedure in patients diagnosed with laryngeal and hypopharyngeal cancer in III and IVa clinical statuscancer in III and IVa clinical status

The patients with diagnosed squamous cell laryngeal and The patients with diagnosed squamous cell laryngeal and hypopharyngeal cancer in III and IVa clinical status were treated with hypopharyngeal cancer in III and IVa clinical status were treated with concomitant radiochemotherapy with intention of the organ preservationconcomitant radiochemotherapy with intention of the organ preservation

Five years overall survival is 75% and disease free survival is 63%Five years overall survival is 75% and disease free survival is 63% Three years laryngectomy free survival (LFS) is 82% and 5-years LFS is Three years laryngectomy free survival (LFS) is 82% and 5-years LFS is

76%. This group of patients is alive with larynx preservations76%. This group of patients is alive with larynx preservations In 17.3% patients local recurrence was observedIn 17.3% patients local recurrence was observed Those patients underwent salvage surgery or were treated with Those patients underwent salvage surgery or were treated with

palliative chemotherapy. No severe life risking early and late palliative chemotherapy. No severe life risking early and late complications were observed. Only 7% of patients have required complications were observed. Only 7% of patients have required temporary tracheostomy because of difficulties in breathing due to temporary tracheostomy because of difficulties in breathing due to larynx edema.larynx edema.

Kiprian D, Kawecki A, Jarząbski A, Michalski W, Pawłowska-Sendułka BKiprian D, Kawecki A, Jarząbski A, Michalski W, Pawłowska-Sendułka B..[The results and toxicity of organ preservation treatment for [The results and toxicity of organ preservation treatment for locoregionally advanced laryngeal and hypopharyngeal cancer]. [Article locoregionally advanced laryngeal and hypopharyngeal cancer]. [Article in Polish] Otolaryngol Pol. 2011 Sep-Oct;65(5):363-8.in Polish] Otolaryngol Pol. 2011 Sep-Oct;65(5):363-8.

Larynx preservation using Larynx preservation using induction chemotherapy plus induction chemotherapy plus

radiation therapyradiation therapy Induction chemotherapy plus radiation therapy is an Induction chemotherapy plus radiation therapy is an

effective strategy which can produce a high rate of larynx effective strategy which can produce a high rate of larynx preservation, local control, and long-term survival in preservation, local control, and long-term survival in patients with advanced cancer of the larynx.patients with advanced cancer of the larynx.

Since 1977, we have used induction chemotherapy (CT) Since 1977, we have used induction chemotherapy (CT) plus radiation therapy (RT) with curative intent in 35 plus radiation therapy (RT) with curative intent in 35 advanced head and neck cancer (Ca) patients who advanced head and neck cancer (Ca) patients who otherwise would have required total laryngectomy. otherwise would have required total laryngectomy.

Karp DD, Vaughan CW, Carter R, Willett B, Heeren T, Calarese P, Zeitels S, Karp DD, Vaughan CW, Carter R, Willett B, Heeren T, Calarese P, Zeitels S, Strong MS, Hong WK.Strong MS, Hong WK.Larynx preservation using induction chemotherapy Larynx preservation using induction chemotherapy plus radiation therapy as an alternative to laryngectomy in advanced head plus radiation therapy as an alternative to laryngectomy in advanced head and neck cancer. A long-term follow-up report.Am J Clin Oncol. 1991 and neck cancer. A long-term follow-up report.Am J Clin Oncol. 1991 Aug;14(4):273-9Aug;14(4):273-9

Health & Medicine

Carcinoma larynx recent trends in management