Organ preservation in laryngeal cancer

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1 Organ preservation in laryngeal cancer Wojciech Golusiński Department of Head and Neck Surgery The Great Poland Cancer Centre, Poznan, Poland Poznan University of Medical Sciences, Poznan, Poland

2 Silver C.E. et al.: Current trends in initial management of laryngeal cancer: the declining use of open surgery. Eur. Arch. ORL, 2009 Gourin Ch.G. et al.: Indications for primary surgical care of patients with squamous cell carcinoma of the head and neck. Laryngoscope, 2009 Pfister D.G. et al.: American Society of Clinical Oncology Clinical Practice Guideline for the use of larynx-preservation strategies in the treatment of laryngeal cancer, J Clin Oncol, 2006

3 5-years survival rate after radiotherapy surgery T 1 98% T % T % T2 95%

4 The success of every surgical operation depends on Diagnosis The concept of the operation Quality of the performance Adequate postoperative care

5 To avoid total laryngectomy we should first make a proper diagnosis before the partial operation.

6 Diagnosis of laryngeal cancer

7 Neoplasms of the larynx diagnosis History Physical examination of the larynx of the neck general physical examination of the patient Radiological examination Histological examination

8 The basic procedure is the direct laryngoscopy with biopsy of the pathological tissue, which can be used to the histological examination

9 history physical examination inspection and palpation indirect laryngoscopy stroboscopy telescopic laryngoscopy DIRECT LARYNGOSCOPY panendoscopy toluidine test microlaryngoscopy transconicoscopy neck examination examination of the lymphatic system ultrasonography radiological examination laryngotomography computed tomography magnetic resonance imaging histological examination antigens related to proliferation DNA ploidy analysis electron microscopy cytological examination

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11 Very IMPORTANT are the imaging examinations: computer tomography cartilage infiltration and magnetic resonance estimating very important tissue spaces within larynx.

12 history physical examination inspection and palpation indirect laryngoscopy stroboscopy telescopic laryngoscopy direct laryngoscopy panendoscopy toluidine test microlaryngoscopy transconicoscopy neck examination examination of the lymphatic system ultrasonography radiological examination laryngotomography COMPUTED TOMOGRAPHY magnetic resonance imaging histological examination antigens related to proliferation DNA ploidy analysis electron microscopy cytological examination

13 history physical examination inspection and palpation indirect laryngoscopy stroboscopy telescopic laryngoscopy direct laryngoscopy panendoscopy toluidine test microlaryngoscopy transconicoscopy neck examination examination of the lymphatic system ultrasonography radiological examination laryngotomography computed tomography MAGNETIC RESONANCE IMAGING histological examination antigens related to proliferation DNA ploidy analysis electron microscopy cytological examination tumours: of the supraglottis of the preepiglottic space of the paraglottic space of the laryngopharynx of the subglottis of the trachea

14 The SECOND IMPORTANT thing before a decision about partial operations is to establish the concept of the operation

15 Concept of the operation The surgeon should choose the type of the operation based on the results of diagnostic procedures, appropriate for the stage of the cancer. An appropriate operation concept allows one to achieve the initial aims of the surgery without unnecessary complications. Based on the treatment concept the surgeon chooses the optimal way of accessing the tumour, the range of resection and the type of reconstruction.

16 Concept of the operation The concept of laryngeal spaces is vital to understanding the growth and spread of laryngeal cancer and therefore, to the understanding of the principles of partial laryngeal surgery. The structure of the larynx and the arrangement of its membranes and cartilages plays an important role in the way laryngeal tumours spread.

17 Partial open resection in larynx cancer The patient's age, their occupation, ability to read and write, general health and co-morbid conditions, lifestyle issues such as refusal to stop smoking, distance from the hospital and family status need to be taken into account while planning treatment. The patient's opinion and preference for a particular treatment should be factored into the process of decision making.

18 Surgical access to tumour Transoral endoscopic approach Open approach

19 Partial open resection in larynx cancer-goals Reconstruction of the physiological airway Partial preservation of vocal function Protective function during swallowing the most difficult problem, swallowing rehabilitation during postop period.

20 The classification of partial laryngectomies according to authors and their experience differs a little bit in some cases

21 After the analysis of the literature data I have found that the classification suggested by MEDINA is the most legible

22 Surgical treatment of laryngeal cancer Partial laryngectomy A. Cordectomy via laryngofissure B. Vertical or frontolateral C. Horizontal 1. Supraglottic 2. Supracricoid permission for total laryngectomy should be obtained before operation D. Combinations and extensions of A, B and C with or without involvement of the ventricle, ventricular bands, aryepiglottic fold, and limited portion of medial wall of pyriform sinsus? Total laryngectomy A. Narrow field B. Wide field Loré & Medina, An Atlas of Head & Neck Surgery, 2005

23 Surgical treatment of laryngeal cancer Partial laryngectomy A. Cordectomy via laryngofissure B. Vertical or frontolateral C. Horizontal 1. Supraglottic 2. Supracricoid D. Combinations and extensions of A, B and C with or without involvement of the ventricle, ventricular bands, aryepiglottic fold, and juxtaposed limited portion of medial wall of pyriform sinsus Vertical or frontolateral laryngectomy may be divided into three basic types depending on the extent of the tumor along the edge of the membranous vocal cord. Total laryngectomy A. Narrow field B. Wide field

24 Surgical treatment of laryngeal cancer Vertical or frontolateral laryngectomy Basic type 1 Carcinoma is limited to membranous vocal cord at its middle third. 3 mm Basic type 2 Carcinoma of membranous vocal cord extends to the anterior commissure. 2-3 mm 3 mm

25 Surgical treatment of laryngeal cancer Vertical or frontolateral laryngectomy Basic type 3 Carcinoma of membranous vocal cord extends into the anterior one third of an opposite or a contralateral vocal fold. 4-5 mm 3 mm

26 Surgical treatment of laryngeal cancer Vertical or frontolateral laryngectomy Modification 1 Carcinoma of membranous vocal cord with 2 to 3 mm of subglottic extension. Modification 2 Carcinoma of the membranous vocal cord involves a portion of the vocal process arytenoid cartilage.

27 Surgical treatment of laryngeal cancer Partial laryngectomy A. Cordectomy via laryngofissure B. Vertical or frontolateral C. Horizontal 1. Supraglottic 2. Supracricoid D. Combinations and extensions of A, B and C with or without involvement of the ventricle, ventricular bands, aryepiglottic fold, and juxtaposed limited portion of medial wall of pyriform sinsus Supraglottic laryngectomy (horizontal partial laryngectomy) is primarily limited to malignant lesions of the epiglottis either on the laryngeal or the lingual surface. Total laryngectomy A. Narrow field B. Wide field

28 Surgical treatment of laryngeal cancer Partial laryngectomy A. Cordectomy via laryngofissure B. Vertical or frontolateral C. Horizontal 1. Supraglottic 2. Supracricoid D. Combinations and extensions of A, B and C with or without involvement of the ventricle, ventricular bands, aryepiglottic fold, and juxtaposed limited portion of medial wall of pyriform sinsus Extension of the lesion to the aryepiglottic fold or superior aspect of the false cords with tumor on the laryngeal surface or extension to the base of the tongue (1 to 1.5 cm) with tumors on the lingual surface can also be included in this type of resection. Total laryngectomy A. Narrow field B. Wide field

29 Surgical treatment of laryngeal cancer Partial laryngectomy A. Cordectomy via laryngofissure B. Vertical or frontolateral C. Horizontal 1. Supraglottic 2. Supracricoid D. Combinations and extensions of A, B and C with or without involvement of the ventricle, ventricular bands, aryepiglottic fold, and juxtaposed limited portion of medial wall of pyriform sinsus Total laryngectomy A. Narrow field B. Wide field

30 Surgical treatment of laryngeal cancer Partial laryngectomy A. Cordectomy via laryngofissure B. Vertical or frontolateral C. Horizontal 1. Supraglottic 2. Supracricoid D. Combinations and extensions of A, B and C with or without involvement of the ventricle, ventricular bands, aryepiglottic fold, and juxtaposed limited portion of medial wall of pyriform sinsus Supracricoid laryngectomy with CHEP resection of whole thyroid cartilage and paraglottic space connection of cricoid cartilage with hyoid bone and epiglottic space Total laryngectomy A. Narrow field B. Wide field

31 Surgical treatment of laryngeal cancer Partial laryngectomy A. Cordectomy via laryngofissure B. Vertical or frontolateral C. Horizontal 1. Supraglottic 2. Supracricoid D. Combinations and extensions of A, B and C with or without involvement of the ventricle, ventricular bands, aryepiglottic fold, and juxtaposed limited portion of medial wall of pyriform sinsus Total laryngectomy A. Narrow field B. Wide field

32 Surgical treatment of laryngeal cancer Partial laryngectomy A. Cordectomy via laryngofissure B. Vertical or frontolateral C. Horizontal 1. Supraglottic 2. Supracricoid D. Combinations and extensions of A, B and C with or without involvement of the ventricle, ventricular bands, aryepiglottic fold, and juxtaposed limited portion of medial wall of pyriform sinsus Supracricoid laryngectomy with CHP resection thyroid cartilage and epiglottis (vocal, vestibular folds, vestibule) connection of cricoid cartilage with base of the tongue and hyoid bone Total laryngectomy A. Narrow field B. Wide field

33 Surgical treatment of laryngeal cancer Partial laryngectomy A. Cordectomy via laryngofissure B. Vertical or frontolateral C. Horizontal 1. Supraglottic 2. Supracricoid D. Combinations and extensions of A, B and C with or without involvement of the ventricle, ventricular bands, aryepiglottic fold, and juxtaposed limited portion of medial wall of pyriform sinsus Total laryngectomy A. Narrow field B. Wide field

34 Indication Partial laryngectomy according to Calearo glottic space carcionoma extending on both side with fixation of one vocal fold or limited vocal fold movement

35 Partial laryngectomy according to Calearo inferior tracheotomy exposure of thyroid cartilage (preparation of external perichondrium) ligating vessel bundles preservation of superior laryngeal nerves removal of the glottis and of the lower 2/3 of the thyroid cartilage hyoid bone + larynx fragment X suture + two lateral stabilizing sutures (1/3 of the thyroid cartilage+ cricoid cartilage)

36 I would like to present a partial laryngectomy according to Calearo, which is some kind of combination of horizontal and supracricoid laryngectomy

37 The main indication to this is the tumor including both vocal folds with anterior commissure

38 history physical examination inspection and palpation indirect laryngoscopy stroboscopy telescopic laryngoscopy direct laryngoscopy panendoscopy toluidine test microlaryngoscopy transconicoscopy neck examination examination of the lymphatic system ultrasonography radiological examination laryngotomography computed tomography magnetic resonance imaging histological examination antigens related to proliferation DNA ploidy analysis electron microscopy cytological examination Preoperative evaluation

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51 The success of the operation depends on the proper post operational care including below elements

52 Appropriate postoperative care Proper positioning of the patient s head in relation to the chest Appropriate level of humidity in the patients rooms Patients should be encouraged to walk as soon as possible Daily dressing change Mild diet Anti-inflammatory and analgesic medications Psychological support Physiotherapy

53 For a short summary I would like to quote words of Patel, Evans, Montgomery, which show the idea of partial operation in the region of larynx:

54 The successful management of laryngeal cancer is dependent as much upon individualizing the plan of management to suit the particular patient and their expectations, as on close co-operation among members of a Head and Neck multidisciplinary team (Sneheal G Patel, Peter Rhys-Evans and Paul Q Montgomery: Tumours of the Larynx. Principles and Practice of Head and Neck Oncology ).

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safety margin, To leave a functioning i larynx i.e. respiration, phonation & swallowing.

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