MANAGEMENT OF LARYNGEAL CANCER

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Treatment OF LARYNGEAL CANCERby aamir yousufgmc srinagar : 

Treatment OF LARYNGEAL CANCERby aamir yousufgmc srinagar AAMIR YOUSUF

An Actual Picture of a Laryngeal Cancer : 

An Actual Picture of a Laryngeal Cancer

Headings… : 

Headings… Introduction Supraglottic, glottic and subglottic cancer Classification and staging Modalities of Treatment for primary lesion Management of neck

Introduction : 

Introduction Laryngeal cancer is the 11th most common cancer in men worlwide . It comprises 2-5% of all cancers wordwide. The male/female incidence has dropped from 15:1 to now less than 5:1 in 2004. This statistical change has been hypothesized to be a result of women obtaining an equal place in the toxic work environment and increase in tabacco consumption.

Introduction : 

Introduction About 90-95% of laryngeal malignancies are squamous cell carcinoma with various grades of differentiation Squamous cell subtypes include keratinizing and nonkeratinizing and well-differentiated to poorly differentiated grade The rest 5-10% of lesions include verrucous carcinoma, spindle cell carcinoma, malignant salivary gland tumor and sarcomas. Glottic (59%)> Supraglottic (40%)> Subglottic (1%).. Widely prevalent in the Indian Sub-continent in comparison to the west

Introduction : 

Introduction The larynx is divided into the following three anatomical regions: The Supraglottic larynx includes the epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids. The Glottis includes the true vocal cords and the anterior and posterior commissures. The Subglottic region begins about 1 cm below the true vocal cords and extends to the lower border of the cricoid cartilage or the first tracheal ring. Ref. American Cancer Society.: Cancer Facts and Figures 2012. Atlanta, Ga: American Cancer Society, 2012. Last accessed January 5, 2012

Introduction.. : 

Introduction.. Anatomically larynx consists of three regions,few potential spaces. These spaces and spaces are anatomcally and embryologically distinct with separate lymphatics Patholgy in these regions vary in presentation spread and treatment.

INTRODUCTION.. : 

INTRODUCTION.. Preepiglottic space Superior: hyoepiglottic ligament Anterior: thyrohyoid membrane Inferior: thyroepiglottic ligament Posterior: epiglottis

INTRODUCTION.. : 

INTRODUCTION.. Paraglottic Space Superior: quadrangular membrane & medial pyriform sinus wall Inferior: conus elasticus Lateral: thyroid cartilage Reinkes space : Submucosal space between the mucosa of glottis and underlying vocalis muscle

Glottic cancer : 

Glottic cancer Most common- 59% Spread: Anteriorly- anterior commisure posteriorly- vocal process and arytenoid process Upward- ventricle and false cord Downward- Subglottic region Symptoms: Hoarseness of voice, stridor

Slide 11: 

Picture of glottic squamous cell carcinoma of the larynx.  The tumor involves the anterior half of the left vocal cord.

Supraglottic cancer : 

Supraglottic cancer Less frequent than glottic cancer Majority of lesion are seen on epiglottis,false cord followed by aryepiglottic fold, in that order May spread locally and invade the adjoining areas (vallecula, base of tounge and pyriform fossa) Nodal metastases occur early(T1- 20%,T2-35%,T3-50%,T4-65%) Upper and middle jugular nodes are often involved Bilateral metastases may be seen in cases of epiglottic cancer.

Supraglottic cancer : 

Supraglottic cancer Symptoms: often silent, may present with throat pain, dysphagia and referred pain-ear, mass in the neck

Slide 15: 

Epiglottic tumor

Supraglottic Cancer : 

Supraglottic Cancer Preepiglottic space involvement through foramen in infrahyoid epiglottis. Paraglottic space involvement through mucosa of the ventricle.

Subglottic cancer : 

Subglottic cancer Lesions rare(< 1%) Spread: Anterior wall, to the opposite side or downwards to the trachea May invade cricothyroid membrane, thyroid gland and muscles of neck Paratracheal LN involved Symptoms: Stridor

Slide 18: 

Transglottic cancers: tumours that involve glottis as well as the supraglottis and cause fixity of the vocal cord by definition they are always T3 lesions fixidity of cord— Infiltrationn of vocalis muscle Paraglottic space extention Cricoarytenoid joint involvement (fixed hemilarynx)

STAGING.. : 

STAGING.. The staging system for laryngeal cancer is clinical and based on the best possible estimate of the extent of disease before treatment. Staging of disease is very important it influences the choice of therapy and helps in predicting the overall prognosis, it provides confirmity amongst clinicians thereby helping in comparing the efficacy of various forms of therapy.

Slide 20: 

Supraglottis Tx :primary tumour canot be assessed Tis: CA in-situ T1: limited to subsite of supraglots w/normal cord mobility T2: invade mucosa of > 1 subsite of supraglottis, glottis, or outside of supraglottis w/out fixation of the larynx T3: limited to larynx w/vocal cord fixation and/or invades postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion T4a: invades thyroid cartilage and/or tissues beyond larynx T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures Glottis Tx :primary tumour cannot be assessed Tis: CA in-situ T1: limited to cord; T1a: one cord; T1b: two cords T2: extends to supraglottis, and/or subglottis, and/or w/impaired cord mobility T3: limited to larynx w/vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion T4a: invades thyroid cartilage and/or tissues beyond larynx T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures Subglottis Tis: CA in-situ T1: limited to subglottis T2: extends to vocal cord with normal or impaired mobility T3: limited to larynx w/vocal cord fixation T4a: invades cricoid or thyroid cartilage, and/or invades tissues beyond the larynx T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging… : AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 57-67

Slide 21: 

Subglottis Tx: primary tumour cannot be assessed T0 :no evidence of primary tumour Tis: CA in-situ T1: limited to subglottis T2: extends to vocal cord with normal or impaired mobility T3: limited to larynx w/vocal cord fixation T4a: invades cricoid or thyroid cartilage, and/or invades tissues beyond the larynx T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging Nodes N0: no regional node mets N1: single ipsilateral node, ≤ 3 cm N2a: single ipsilateral node, > 3 cm, ≤ 6 cm N2b: multiple ipsilateral nodes, ≤ 6 cm N2c: bilateral or contralateral nodes, ≤ 6 cm N3: node > 6 cm Mets Mx: unknown M0: no distant mets M1: distant mets Source: AJCC Cancer Staging Manual, 7th Ed (2010)

Stage Grouping : 

Stage Grouping Early stage Advanced stage

Decision making .. : 

Decision making .. T stage. Site of primary with in the region.(Anterior commissure lesions) Status of cervical lymph node metastsis Patient preferences General health and pulmonary reserve of patient Age of patient Verrucious carcinoma.surgical Prior radiation to larynx

Glottic cancer : 

Glottic cancer Carcinoma in situ(Tis):if b/l staged procedure /web formation

Slide 25: 

Mahieu et al : compared the results of radiation therapy versus endoscopic surgery or severe dysplasia/carcinoma in situ Radiotherapy Laser surgery Local control 87% 95% Laryngeal 89% 98% preservation

Slide 26: 

Zeitels..poineered phonomicrosurgical approach for CIS glottis It emphasizes preservation of lamina propia while superficial epithelium to it is stripped away

Early glottic carcinoma. : 

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.

T1 Glottic ca : 

T1 Glottic ca

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 Gy/d .5/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 scd. Hyperfractionation Accelerated fractionation

Slide 30: 

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.

Slide 31: 

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.

Dose Fractionation : 

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}

Radiotherapy for T1/T2 glottic carcinoma : 

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)

T1a mid cord cancer : 

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

Surgical optionsfor small T1 lesions : 

Surgical optionsfor small T1 lesions CO2 laser

Slide 36: 

Transoral endoscopic CO2 laser cordectomy Cure rates are uniformly above 90% Quality of voice depents on extend of resection Laryngofissure and cordectomy.. rarely used now When endoscopic exposure is very poor

CO2 laserIndications : 

CO2 laserIndications Tumor limited to the glottis (T1/T2/early T3)normal vocal cord mobility localised residual /recurrent disease following failure of RT for early cancer debulking of tumour for stridor

Endoscopic surgery(C02 laser) for T1/T2 glottic carcinoma : 

Endoscopic surgery(C02 laser) for T1/T2 glottic carcinoma Early studies showed local control rate from 88% to 96%* (Shapshay, 1990; Rudert, 1995; Mahieu 1999) * involved only T1a tumors Recent studies show local control rates for; T1a 100% T1b 94% T2** 91% ** minimal supraglottic/subglottic extension (Gallo, 2002;Pradhan, 2003) Voice quality in general is preserved but would depend largely on the site of the lesion and amount of tissue removed ( MacGuirt, 1992; Rydell, 1995; Mahieu, 1999)

Endoscopic surgery(C02 laser) for T1/T2 glottic carcinoma : 

Endoscopic surgery(C02 laser) for T1/T2 glottic carcinoma Advantages of C02 laser over radiotherapy Possibility of using the same modality (C02 laser) for a recurrence Radiotherapy can still be used as “back-up” treatment in cases of recurrence and second primaries Less morbidity and less treatment time for the patient Less cost

Anterior comm T1a/cord lesion into ant comm T1b : 

Anterior comm T1a/cord lesion into ant comm T1b Surgery is prefered option Failure rates with RT and End co2 excision are more due to understagind at this site (direct attachment to thyroid cartilage by broyle’s tendon witout intervening inner perichondrium. Vertical partial laryngectomy(frontal laryngectomy/fronto lateral laryngectomy preffered options Cure rates >90%

Slide 42: 

Posterior cord lesion extending to vocal process of arytenoids higher failure rates with RT Preferred endoscopic resection with CO2 laser

T2a gtottic cancer freely mobile cords : 

T2a gtottic cancer freely mobile cords

T2b glottic cancer(impaired cord mobility) : 

T2b glottic cancer(impaired cord mobility)

T3 glottic ca(cord fixed arytenoid mobile) : 

T3 glottic ca(cord fixed arytenoid mobile)

Surgical options in advanced glottic lesion : 

Surgical options in advanced glottic lesion Surgical options : SCPL-CHEP/VPL/Transoral endoscopic CO2 laser rescection. 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 Chevaliar et al reports local control rate of 94.6% in112 patients with T3 (22) rest T2b

Slide 47: 

Vertical partial laryngectomy: (hemilaryngectomy or frontolateral laryngectomy) Cord fixed & minimal subglottic extention Arytenoids mobile b/l No cartilage erosion

Slide 48: 

Near total laryngectomy: Preserves speech and swallowing bt nt 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%)

T3 glottic ca fixed hemilarynx : 

T3 glottic ca fixed hemilarynx

T4 LESION : 

T4 LESION T4a resectable lesion – total laryngectomy followed by RT non surgical option CTRT not effective once cartilage or gross soft tissue invasion is thr near total laryngectomy ..when lesion is well lateralised with uninvolved arytenoid region and2/3 of contralateral cord

Supraglottic : 

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

T1-T2 supraglottic : 

T1-T2 supraglottic

Slide 53: 

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

T3 Supraglottic capreepiglottic space invasion,cords mobile : 

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

T3 supraglottic ca cord fixity;arytenoids mobile : 

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

T3 supaglottic ca fixed hemilarynx : 

T3 supaglottic ca fixed hemilarynx Options CTRT Near total /total laryngectomy

T4 supraglottic ca : 

T4 supraglottic ca Wide field total laryngectomy +post operative RT Wide field NTL + post operative RT(for lateralised disease) SCPL-CHP (for minimal cartilage erosion;no gross soft tissue invasion minimal subglottic disease)

Subglottic cancer : 

Subglottic cancer Primary subglottic is very are unsutable for voice presevation surgeries treatment based on stage

STAGE I/II : 

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.

STAGE II : 

STAGE II Laryngectomy plus isolated thyroidectomy and tracheoesophageal node dissection usually followed by postoperative radiation therapy. 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.

STAGE IV LESION : 

STAGE IV LESION 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

Voice conservation surgery : 

Voice conservation surgery Organ preservation surgery done: Young patients when one prefers avoiding RT in those who either cannot tolerate CT or refuse CT plan Horizontal partial laryngectomy: T 3 pre-epigllotic space with free vocal cords and fit -withstand aspiration SCPL-CHEP: T3 SGC cord fixed bt arytenoid mobile or glotto supraglottic Three quarter laryngectomy : T3 SGC extended to glottic & spilling over to pyriform fossa,arytenoid should be mobile Transoral endoscopic resection with CO2 laser: vocal cords mobile

Non surgical voice preservation in advanced laryngeal cancer : 

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.

Landmark Studies : 

Landmark Studies The Department of Veterans Affairs Laryngeal Cancer Study Group (1991) The European Organization for Research and Treatment of Cancer (1996) Radiation Therapy Oncology Group Trial 91-11 (2003)

VA Study : 

VA Study Goal: to investigate whether induction chemotherapy and definitive XRT with laryngectomy reserved for salvage for patients with stage 3 or 4 laryngeal cancer represented a better initial treatment approach than total laryngectomy and post-operative XRT.

VA study Design : 

VA study Design Two arms (322 patients divided between groups): Experimental arm Patients received two cycles of chemotherapy consisting of cisplatin and fluorouracil; those found not to have at least a partial response at the primary site went on to laryngectomy; the remainder received a third round of chemotherapy and the vast majority of these patients went on to definitive XRT Control arm Patients received total laryngectomy and standard post-operative radiation therapy (PORT)

VA study results : 

VA study results The larynx was preserved in 107 patients (64%) of those assigned to induction chemotherapy 59 underwent total laryngectomy: 30 prior to XRT and 29 after radiation (persistent disease present on planned endoscopy 12 weeks after XRT) Late salvage surgery required in 11 additional patients (80% of these occurred in the year after treatment) Salvage laryngectomy required more often in those with glottic vs supraglottic CA (43 vs 31%); fixed vs mobile VCs (41 vs 29%); gross cartilage involvement vs no cartilage involvement (41 vs 35%)--but all this not statistically significant Significantly, salvage surgery was required in 44 % of pts with stage IV cancers as compared with 29% of pts with stage 3 cancer AND 56% of patients with T4 cancers as compared with 29% of patients with smaller primaries

Treatment – Advanced Stage (III/IV) – VA Study cont’ : 

Treatment – Advanced Stage (III/IV) – VA Study cont’ Of the 166 pts in the chemo arms - 107 (64%) patients had preserved larynx - 30 patients (18%)  laryngectomy before definitive XRT - 29 patients (18%)  laryngectomy after definitive XRT Department of Veterans Affairs Laryngeal Cancer Study Group, N Engl J Med 1991;324:1685-90.

Other VA study Findings : 

Other VA study Findings The estimated two year survival was 68% for the induction chemotherapy group and the surgery group. No significant differences in survival between treatments when pts grouped according to tumor stage or site. Survival rates similar for chemotherapy responders and non-responders Patients in the induction chemotherapy arm had a higher rate of local failure but a decreased rate of distant metastases

Treatment – Advanced Stage (III/IV) – VA Study cont’ : 

Treatment – Advanced Stage (III/IV) – VA Study cont’ Department of Veterans Affairs Laryngeal Cancer Study Group, N Engl J Med 1991;324:1685-90.

EORTC Study : 

EORTC Study Goal: To compare the results of treating patients with T2-T4, N0-N2b squamous cell carcinoma of the aryepiglottic fold with either induction chemotherapy followed by radiation or standard surgical therapy and PORT

EORTC Patients : 

EORTC Patients 94 patients randomized to the immediate surgery arm 100 patients randomized to the induction chemotherapy (cisplatin and fluorouracil) and XRT arm Patients in the induction chemo arm had to have a complete response in order to proceed to XRT

EORTC Results : 

EORTC Results Survival: Disease-free survival at 3 and 5 years essentially the same for the chemotherapy and immediate surgery arms: 43 and 25% for chemo arm and 32 and 27% for surgery arm At three years the overall survival rates appeared to favor the chemotherapy arm; the survival rates at 5 years were similar between groups but this estimate based on small number of patients at risk

EORTC Results, Laryngeal Preservation : 

EORTC Results, Laryngeal Preservation For the entire group of 100 patients randomized to induction chemotherapy, the rate of being alive and having a functional larynx at 3 and 5 years was 28 and 17% respectively The 3 and 5 year rate of retaining a functional larynx in the patients who completed treatment in the induction chemotherapy arm were 64% and 58% respectively

Summary of VA and EORTC studies : 

Summary of VA and EORTC studies Both trials suggest that organ preservation is possible in patients with advanced stage laryngeal ; The role of chemotherapy not elucidated; rates of organ preservation in the VA trial similar to published rates of organ preservation after radiation alone Distant metastases appear to be decreased with chemotherapy Suggest that head and neck squamous cell carcinoma is sensitive to cisplatin and fluorouracil

RTOG 91-11 trial : 

RTOG 91-11 trial Nov 2003 by Forastiere et al 3 arm study Goal: To investigate three radiation-based therapies in the treatment of stage 3 and stage 4 laryngeal cancer: Induction cisplatin and fluorouracil followed by XRT (identical to VA experimental arm protocol) Concurrent chemoradiation with cisplatin(1,22,43) Standard radiotherapy

Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study : 

Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study Eligible patients had stage 3 or 4 laryngeal cancer. T1 primary tumors were ineligible as well as T4 tumors that penetrated through cartilage or more than 1 cm into the base of tongue. XRT: 70Gy/35fx in all arms Induction – cisplatin + 5 FU x 2c  if complete or partial response, w/out neck progression  3rd cycle  XRT; else  laryngectomy  XRT Concurrent – cisplatin x 3c + XRT Forastiere AA et al, N Engl J Med 2003;349:2091-8.

Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study : 

Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study Induction Chemotherapy 173 assigned  168 completed chemo x 2c  144 complete or partial response  134  completed 3rd chemo cycle 84% of pts received ≥ 67 Gy Concurrent Chemoradiation 172 assigned  120 (70%) completed cisplatin x 3 cycle, 40 (23%) completed cisplatin x 2 cycles. 91% of pts received ≥ 67 Gy Radiation alone 95% of pts received ≥ 67 Gy Forastiere AA et al, N Engl J Med 2003;349:2091-8.

Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study : 

Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study AChemo therapy  significant decreased in dz free survival compared to XRT alone (P =0.02 compared w/induction, P = 0.06 compared w/conccurent Tx) BNo significant difference CDifference only significant comparing concurrent chemoXRT vs XRT alone. Forastiere AA et al, N Engl J Med 2003;349:2091-8.

Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study : 

Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study Laryngeal Preservation Forastiere AA et al, N Engl J Med 2003;349:2091-8. AForastiere AA et al, Journal of Clinical Oncology, Vol 24, No. 18S(June 20 Supplement),2006:5517.

Treatment – Advanced Stage (III/IV) – cont’ : 

Treatment – Advanced Stage (III/IV) – cont’ Forastiere AA et al, N Engl J Med 2003;349:2091-8.

RTOG 91-11 Results : 

RTOG 91-11 Results The rate of laryngeal preservation at a median follow-up of 3.8 years was significantly higher among patients receiving radiotherapy with concurrent cisplatin (84%) than among those receiving induction chemotherapy followed by XRT (72%) or those receiving radiotherapy alone (67%) Chemotherapy suppressed distant metastases Two and five year survival did not differ among treatment groups Patients who were treated with concurrent chemoradation had significantly fewer local failures than either induction chemotherapy + XRT or radiotherapy alone Two and five year disease free survival estimates Arm one: 52 and 38% Arm two: 61 and 36%(concurrent) Arm three: 44 and 27%

Conclusions : 

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

Management of neck in laryngeal cancer : 

Management of neck in laryngeal cancer Status of lymph node is most important factor influencing survival in laryngeal cancer Appropraiate 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 sig nodal metastasis Glottic cancer less common –lack of submucosal lymphatics in this area is responsible(1-4% in T1/T2)( 15-42% in T3/T4)

Slide 85: 

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

Management of neck : 

Management of neck Depends on site of primary T stage of primary Clinical N stage Choice of treatment modality for the primary

N0 neck in supraglottic cancer : 

N0 neck in supraglottic cancer Primary treatment plan CTRT(b/l neck irradiation) Surgery Endoscopic CO2 laser resection ( vigilant f/u of neck) Near total /total laryngectomy ( ipsilateral clearance of levels II,III,IV,VI & contalateral clearance of levels II,III,IV) Open partial laryngectomy sampling of lymph nodes level II,III U/L for lateralised lesion & B/L for midline lesion If frozen section positive for metastasis ( selective infrahyoid neck dissection) otherwise observe

N+ neck in supraglottic cancer : 

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 unilateral LAP N1/N2a (ipsilateral level 1 sparing neck dissection & contalateral II,III,IV clearance N2b/N3 ( ipsilateral RND and contralateral clearance of level II,III,IV) --If B/L LAP (b/l ND preserving atleast 1 IJV)

Neck in glottic cancer : 

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 and clearance of levels II,III,IV C/L side with B/L level IV clearance RT/CTRT ----N1 neck incl in field surgery reserved for salvage N2/N3 neck dissection prior to RT or salvage neck dissection after RT

Conclusion : 

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 laryngectomy combined 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.

Slide 91: 

THANKING YOU FOR YOUR ATTENTION

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