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Organ Preservation Surgery for Laryngeal Cancer Following Failed Radiation Therapy

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Title: Organ Preservation Surgery for Laryngeal Cancer Following Failed Radiation Therapy


1
Organ Preservation Surgery for Laryngeal Cancer
Following Failed Radiation Therapy
  • Hedyeh Javidnia
  • January 14th, 2008
  • Grand Rounds
  • University of Ottawa Department of Otolaryngology
    and Head and Neck Surgery

2
Objectives
  • To evaluate a case of recurrent laryngeal cancer
    following radiotherapy.
  • To discuss the steps in diagnosis and
    preoperative assessment of recurrent laryngeal
    cancer following radiation.
  • To review the staging of laryngeal cancer
  • To discuss the evidence and literature for three
    common organ preservation surgeries for laryngeal
    cancer with regards to
  • Risks and benefits
  • Patient selection/indications/contraindications
  • Functional outcomes
  • Survival as compared to total laryngectomy
  • The Canadian perspective

3
Case of Mr. L
  • 71 yo M presents with gt1yr Hx of hoarseness
  • He is a gt25 pack year smoker who quit smoking 14
    yrs ago
  • FNL shows tumour involving the anterior 3/4 of
    the left vocal cord and crossing over to involve
    the anterior commissure and the very anterior
    part of the right vocal cord. Some degree of
    subglottic extension is apparent. Vocal cord
    mobility is normal.
  • No apparent clinical lymphadenopathy

4
Case of Mr. L
  • CT proves less subglottic extension as believed
    on FNL and no lymphadenopathy and no metastasis.
  • Biopsy shows spindle cell carcinoma AKA
    sarcomatoid squamous cell carcinoma.
  • Due to anterior commissure involvement, a
    multidiciplinary decision is made with the
    patient to go ahead with radiotherapy in order to
    maximize voice preservation.
  • He recieves 5260 cGy in 20 fractions over four
    weeks.

5
Case of Mr. L
  • 5 months post completion of radiation, on a
    routine follow-up there is evidence of recurrence
  • Anterior third of the right vocal cord involving
    the commissure without any bulk. There is normal
    cord mobility.
  • Repeat biopsy shows High-grade squamous
    intraepithelial lesion/squamous cell carcinoma in
    situ
  • Repeat CT shows no evidence of cartilage
    involvement, nodal, or distant metastasis.

6
Case of Mr. L
  • What are your management options?
  • Total Laryngectomy
  • OR OPS
  • Transoral Laser Surgery
  • Vertical Partial Laryngectomy
  • Supracricoid Partial Laryngectomy

7
What constitutes laryngeal organ preservation
surgery?
  • The goal of any organ preservation surgery is to
    preserve function without compromising cure rate
  • Functions of the larynx
  • Phonation
  • Respiration
  • Deglutition (swallowing)
  • Airway protection
  • The functions of the larynx must be maintained
    without the need for tracheostomy or feeding
    tube.

8
Principles of Organ Preservation Surgery 1
  1. Local control
  2. Accurate assessment of the 3D extent of tumor
  3. Cricoarytenoid unit is the basic functional unit
    of the larynx
  4. Resection of normal tissue to achieve an expected
    functional outcome

1. Tufano R. et. al. Organ preservation surgery
for laryngeal cancer. Otolaryngol Clin N Am.
2008 41 741-755
9
Radiation failure Total Laryngectomy
  • Radiotherapy reported failure rates of 9 - 21
    in T1 and 28 - 37 in T2. 2
  • Total Laryngectomy post radiation has survival
    rates of 78 - 81 in T1 and 64 - 67 in T2. 3

2. Grisen O et. al. Consecutive series of
patients with laryngeal carcinoma treated by
primary irradiation. Acta Oncol 1997 36279-282
3. Hawkins NV et al. The treatment of glottic
carcinoma an analysis of 800 cases.
Laryngoscope 1975 851485-93
10
Anatomy
11
Anatomy
12
First step is identification Challenges
  • Differentiation between cancer recurrence and
    sequelae of radiotherapy is often clinically and
    rediographically difficult. 4
  • Endoscopic evaluation followed by biopsies may
    exacerbate post-radiotherapy changes and initiate
    superimposed infection, perichondritis, healing
    failure, and further edema. 5

4. Zbaren P. et. al. Pretherapeutic staging of
recurrent laryngeal carcinoma clinical findings
and imaging studies compared with histopathology.
Otolaryngol Head and Neck Surg. 2007
137487-491. 5. De Bree R, et. al. A randomized
trial of PET scanning to improve diagonostic
yield of direct laryngoscopy in pateints with
suspicion of recurrent laryngeal carcinoma after
radiotherapy. Contemp Clin Trials 2007
28705-712
13
Diagnostic steps Clinical
  • Careful evaluation of clinical records of prior
    diagnosis including staging, pathological slides,
    clinical examination, radiotherapy approach
    (technique, doses, courses).
  • Fiberoptic laryngoscopy
  • Video Stroboscopy (?)
  • Direct layngoscopy under GA
  • In advanced case fibroscopic evaluation of the
    esophagus to R/O synchronous malignancy. 6

6. Marioni et. al. Current opinion in diagnosis
and treatment of laryngeal carcinoma. Cancer
Treatment Rev. 2006 32504-515
14
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 matastasis.
  • If cartilage invasion is suspected or imperative
    to be ruled out, MRI seems to be superior to CT. 7

7. Becker M. Neoplastic invasion of laryngeal
cartilage radiologic diagnosis and therapeutic
implications. Eur J Radiol 2000 33216-229.
15
TNM DefinitionsAJCC 6th Ed. 2002
  • Primary tumor (T)
  • TX Primary tumor cannot be assessed
  • T0 No evidence of primary tumor
  • Tis Carcinoma in situ

16
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 vocal cord mobility
  • T3- Tumor limited to larynx with vocal cord
    fixation or invades postcricoid area, medial wall
    of piriform sinus, or preepiglottic tissues
  • 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 medistinal
    structures

17
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

18
Subglottis
  • T1- 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

19
Regional lymph nodes (N)
  • NX Regional lymph nodes cannot be assessed
  • N0 No regional lymph node metastasis
  • N1 Metastasis in a single ipsilateral lymph node
    3 cm.

N2 Metastasis in a single ipsilateral lymph node
gt 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 gt 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 gt 6 cm
20
Distant metastasis (M)
  • MX- Distant metastasis cannot be assessed
  • M0- No distant metastasis
  • M1- Distant metastasis

21
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
22
Back to Case of Mr. L
  • Anterior third of the right vocal cord involving
    the commissure without any bulk. There is normal
    cord mobility.
  • Repeat CT shows no evidence of cartilage
    involvement, nodal, or distant metastasis.
  • His AJCC Staging?
  • T1, N0, M0
  • Stage I

23
Transoral Laser Surgery
24
Transoral Laser Surgery Inclusion Criteria 8
  • Complete endoscopic visualization of the
    carcinoma
  • Tumor extension to the contralateral VC lt 3mm
  • Absence of arytenoid involvement (except vocal
    process)
  • Subglottic extension lt 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.

8. Motamed M, et. al. Salvage conservation
laryngeal surgery after irradiation failure for
early laryngeal cancer. Laryngoscope 2006
116451-455
25
Transoral Laser Surgery Reported advantages 9
  • Good voice quality
  • Good swallowing
  • Lower complications rates
  • Lower costs
  • Shorter hospitalization
  • Tracheostomy and NG tubes not routinely required

9. Piazza C, et. al. Salvage surgery after
radiotherapy for laryngeal cancer from
endoscopic resections to open-neck partial and
total laryngectomies. Arch Otolaryngol Head and
Neck Surg 2007 1331037-1043
26
Transoral Laser Surgery Operative
considerations10
  • 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.

10. Bradley PJ, et. al. Options for salvage
after failed initial treatment of anterior vocal
commissure squamous carcinoma. Eur Arch
Otorhinolaryngol 2006 263889-894
27
Transoral Laser Surgery Outcomes
  • Steiner W, et. al. 11
  • One of the largest reported series of laser
    surgery post-radiation.
  • Adhered to selection criteria as above
  • Included 34 patients with early or advanced
    recurrent glottic CA after full course radiation.
    T111, T210, T310, T43
  • 71 cure with one or more laser procedures.
  • Subsequent TL required in 21
  • 5 year disease-specific survival of 86

28
Transoral Laser Surgery Outcomes Steiner W, et.
al. 11
  • 38
  • 41
  • 3
  • 6
  • Total 71 control with laser alone

29
Transoral Laser Surgery Outcomes
  • Motamed et. al. 8
  • In 40 of cases more than one laser-assisted
    surgery was required
  • Local control rate was 51-87 (Mean 65)
  • Subsequent total laryngectomy was necessary in
    25
  • Overall control rate including those requiring
    total laryngectomy was 80-100 (Mean 83)
  • Piazza et al. 9
  • 5 year disease specific survival 95
  • Disease-free survival 63
  • Laryngeal preservation 75

30
Transoral Laser Surgery Complications 8
  • Complication rates are lt5 and from most to least
    common include
  • Granuloma formation
  • Laryngeal edema
  • Laryngeal stenosis
  • Chondronecrosis

31
Vertical Partial Laryngectomy
32
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)

33
Vertical Partial LaryngectomyContraindications
  • Large T3 or any T4 lesion
  • 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 commissure or 5mm at the vocal process
    of the arytenoid
  • Poor pulmonary function

34
Vertical Partial LaryngectomyOperative
Considerations
  • The use of intraoperative frozen sections is
    imperative for maximal local control 12
  • 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. 8
  • The use of bipedicled flaps of strap muscles to
    replace excised intralarygeal soft tissue may
    facilitate post-op rehabilitation 13

12. Sewnaik A. et. al. Partial Laryngectomy for
recurrent glottic carcinoma after radiotherapy.
Head and Neck 2005 27101-107.
35
Vertical Partial LaryngectomyOutcomes 13
  • Yotakis et. al.
  • Retrospective review of 27 patients with early
    glottic CA who underwent partial laryngectomy for
    recurrence after radiation
  • 18 patients had VPL (T113, T25)
  • Cannulation time 6 17 days (Mean 11.5 days)
  • NGT removal in 7 81 days
  • Hospitalization time 10 40 days (Mean 25 days)
  • Disease-specific survival was 88.8 (92.3 for T1
    and 80 for T2)
  • Total laryngectomy was performed in 16.6
  • Laryngeal preservation rate was 77.8

13. Yotakis et. al. Partial laryngectomy after
irradiation failure. Otolaryngol Head and Neck
Surg. 2003 128 200-209
36
Vertical Partial LaryngectomyOutcomes 13
  • 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

37
Vertical Partial Laryngectomy Complications
  • Early - generally tracheostomy related
  • Infection
  • Aspiration and dysphonia (should not persist for
    gt 3 weeks)
  • Late
  • Aspiration
  • Chondritis
  • Laryngeal stenosis (Must rule out local
    recurrence)
  • Severe hoarseness
  • Granulation tissue (CO2 laser and keel)
  • Tumor recurrence

38
Supracricoid Laryngectomy
39
Supracricoid Laryngectomy
  • Removal 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

40
Supracricoid Laryngectomy Contraindications
  • Infiltration of both aryntenoid cartilages
  • Infiltration of cricoarytenoid joint or
    inter-arytenoid region
  • Subglottic extension gt1cm 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

41
Makeieff et. al. 14 Laryngoscope 2005
  • Retrospective series of 23 patients with T1-2
    Glottic CA post-radiation
  • 6 (26) went on to have TL
  • Disease specific survival 74
  • 5 yr survival of 69
  • Mean cannulation time 28 days
  • Mean NGT time 24 days
  • Mean Hospitalization time 30 days

42
Pellini et. al. 15 Head and Neck 2007
  • A multi-institutional retrospective analysis of
    78 patients
  • T136, T233, T38, T41
  • 5yr survival was 81.8
  • Disease-specific survival 95.5
  • Mean NGT time 15 days
  • Swallowing was preserved in 97.4
  • 97.4 of patients were successfully decannulated
  • 35.7 decannulated within 1 month, 92.3 within 3
    months
  • Mean hospitalization time 54 days

43
(No Transcript)
44
Supracricoid Laryngectomy Outcomes 16
  • Disease-free survival 84.5
  • Of the 15.5 failure of SCL, 66.7 successfully
    treated with Total laryngectomy
  • 3 year survival rate of 80 -100
  • 5 year survival rate of 69.4 -100

16. Marioni G, et. al. The role of supracricoid
partial laryngectomy for glottic carcinoma
recurrence after radiotherapy failure A
critical review. Acta Otolaryngol 2006
1261245-1251
45
Supracricoid Laryngectomy Complications 16
  • 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

46
Overall Review
  • Motamed et. al. Laryngoscope 2006

47
Motamed et. al. 8 Laryngoscope 2006
  • Meta Analysis of 22 studies fulfilling criteria
    Sample size gt10 and F/U gt24 mos
  • All retrospective for total of 552 cases
  • Majority early stages (T1-2)
  • 6 studies of TLS 145 cases
  • 13 studies of VPL 357 cases
  • 3 studies of SCPL 50 cases

48
Motamed et. al. Laryngoscope 2006
  • TLS
  • Local Control 51 87 65 overall
  • Required gt1 procedure 14.5
  • Required total Layngectomy 25
  • Ultimate local control 83

49
Motamed et. al. Laryngoscope 2006
  • VPL
  • Local Control 56 100 84 overall
  • Required total Layngectomy 15.6
  • Ultimate local control 91

50
Motamed et. al. Laryngoscope 2006
  • SCPL
  • Local Control 66 100 83 overall
  • Required total Layngectomy 2.4
  • Ultimate local control 91

51
Horizontal Partial Laryngectomy
  • Shaw et. al. in 1987 showed high rates of
    morbidity and mortality with HPL following
    radiation
  • Since then, there has been very limited use of
    this technique in this scenario and as such very
    limited studies.
  • Data is therefore inconclusive.

52
Complications of partial laryngectomies
exacerbated by previous radiation
  • Delayed wound healing, infection, fistula
    formation, and aspiration pneumonia in up to 25
    of cases 5
  • Less commonly laryngeal stenosis, larygeal edema
    or granuloma formation, perichondritis, and
    surgical emphysema

53
Neck Management
  • Neck dissection must be performed in all cases of
    laryngeal carcinoma recurrence with
    clinical/cytological evidence of regional
    matastasis 17
  • Elective neck dissection in patients with N0
    prior to salvage laryngeal surgery is
    controversial 18
  • The decision for elective neck dissection must be
    based on T staging, supraglottic or subglittic
    extension, and extralaryngeal involvement of
    recurrence.
  1. Farrang et. al. Neck management in patients
    undergoing postradiotherapy slavage laryngeal
    surgery for recurrenc/persistent laryngeal
    cancer. Laryngoscope 2006 1161864-1866
  2. Ganly I. et. al. Results of surgical salvage
    after failure of definitive radiation therapy for
    early stage squamous cell carcinoma of the
    glottic larynx. Arch otolaryngol Head and Neck
    Surg 2006 13259-66

54
Back to Case of Mr. L
  • T1, N0, M0
  • Stage I
  • Management Options
  • Meets all criteria for TLS
  • Local Control 65
  • May required gt1 procedure
  • Total Layngectomy remains a viable option
  • Ultimate local control 83

55
The Canadian Perspective
  • Taylor M et. al. Journal of Otolaryngology Head
    Neck Surgery 2008
  • Retrospective series of 36 patients who underwent
    transoral laser surgery for early glottic CA
  • Tis7, T117, T212
  • 2 year disease-free survival of 89
  • 60 of patients had no voice complaints

56
Conclusion
  • Conservation laryngeal surgery is a safe and
    effective treatment for recurrent localized
    disease after radiotherapy.
  • This however is predicated on meticulous patient
    selection for the most appropriate procedure.
  • Local control may be achieved without sacrifice
    of laryngeal function.
  • Total laryngectomy may be held in reserve as the
    ultimate option for salvage without compromising
    ultimate survival.
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