Dr. P. Gullane Wharton Chair Head & Neck Surgery Professor Department of Otolaryngology -Head & Neck Surgery University of Toronto

Transcription

1 Wharton Head and Neck Centre The Toronto General Hospital Dr. P. Gullane Wharton Chair Head & Neck Surgery Professor Department of Otolaryngology -Head & Neck Surgery University of Toronto Controversies in The Management of Head and Neck and Thyroid Cancer Royal College of Physicians London, December 5-6, 2013

2 Evolution of Organ Preservation Strategies 1960 s Laryngectomy/Pharyngectomy 1970 s Laryngectomy alone Planned radiation with surgery for salvage 1980 s Irradiation +/- Chemotherapy (5FU, Mitomycin C) 1990 s VA Trial, (Neoadjuvant Chemo/Rad or Laryngectomy) 2000 s Adoption of Organ Preservation Approaches s 100% TL Functional Larynx? 40% TL Quality of Life? I have seen the future and it doesn t work. Robert Fulford

3 Cancer of the Larynx- We have seen the future and yes some works. Lets explore in our Tumour Board.

4 Purpose of the Case Presentation Review the Management of early and late Complex laryngeal cases with a focus on Principles of Management How to minimise complications Management of recurrence and review Reconstructive Options when salvage Surgery needed in the chemoradiated patient.

5 Case #1 55 year old truck driver presents with an 8 month history of hoarseness 40 pack year smoker No comorbidity Biopsy- Microinvasive SCC

6 Questions Would you do any further investigations? What would be your primary treatment approach? If TOL what are your limitations for this approach? How do you inform patients regarding treatment options? If primary radiotherapy what volume and technique?

7 Case # 2.Does gender influence how you manage?? 36 year old female presents with longstanding history of hoarseness 10 pack year history of smoking No Comorbidity Examination Altered mobility

8 Treatment options for bulky T2? If non-surgical approach which approach? Altered Fractionation alone ChemoRT Induction followed by RT or Surgery What would you estimate the probability of local control? Do women have a better outcome-harwood et al PMH?

9 Case # 3 81 yo male with 6 mo h/o hoarseness, progressively worsening PMH: htn, gerd, asthma, prostate ca (primary RT) PSH: herniorrhaphy, appendectomy SH: worked in GM plant, quit tobacco 50yrs prior PE: ulceration left TVC extending into ventricle, normal mobility T2

10 Does age influence how you would treat him T2

11 Case # 4-Advanced Glottic Cancer 72 year old male presents with progressive hoarseness, odynophagia Diabetic Mild Emphysema CAD with stent 1yr ago 50pk year smoker Exam-fixed cord

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13 Questions What other investigations would you consider? What are the Current Organ Preservation Options? What Approach would you chose? Surgical Issues Primary Surgery Primary TEP (Y/N) Does he need a flap to bolster repair?

14 Case #5 T2NOMO 38 yo male, healthy mechanic, with 3 yr h/o intermittent hoarseness, with progressive changes over last 6 months PMH: htn, hypercholesterolemia PSH: knee surgery Meds: ramipril, HCTZ, losec SH: 20pk yrs, moderate ETOH Tx-RTOG bid protocol 66 Gy in 6/52 using in 35 fractions.

15 Tx-RTOG bid protocol 66 Gy in 6/52

16 One Year later following treatment with RTOG bid protocol 66 Gy in 6/52 Now c/olaryngeal Perichondritis- Management

17 1.Antibotics 2.Steroids. 3. Role of hyperbaric O2 4.How do you exclude residual cancer? 5.When do you resort to surgery? 6.Do you use a flap to bolster the repair,if so describe.

18 Don t close your pharynx too tightly. Liberal use of patch flaps. Savary fistula tube if repair is circumferential If dysphagia occurs how do you treat Expectant-PPIs Serial dilatations. Any Role for myotomy Botulinum toxin-how often to inject When do you stent? If so what type

19 Case #6 T2N0M0 Cancer of R.Hypopharynx 62 yr old female with 3month history of sore throat, some slight dysphagia diagnosed with ulcerative lesion R piriform sinus.cord mobile.no cervical adenopathy. Metastatic Survey clear. Biopsy- Sq.cell cancer-mod. Differentiated Patient co-morbidities - hypertension.type II Diabetes. Management options-

20 T2NOMO-What to do? Management options

21 What are the Options to treat? Management options- Radiation alone,concurrent chemo/rads. Primary surgery-partial pharyngectomy with flap repair.

22 Treatment Early (T1, T2) carcinoma - Piriform sinus - Posterior pharyngeal wall Laser excision/robotic excision ± neck dissection Partial pharyngectomy + neck (II, III, IV) - Trans hyoid or - Lateral pharyngectomy approach Radiation or Chemoradiation Overall 3 yrs. 70%

23 T4a Management Options?

24 Surgery

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26 Salvage Surgery You choose a non surgical approach patient returns 6 months after chemort with recurrent disease

27 Should we consider salvage for failure of organ preservation approaches? Goodwin, J: Laryngoscope, 2000

28 Primary Surgery or Concurrent Chemo/radiation What Investigations? What Operation? Extent of Neck Dissection? Primary TEP? Flap reconstruction; What and How?

29 What is Wrong with Chemotherapy Based Organ Preservation Strategies? As well as synergistic tumor effects, we are seeing increasing early and late toxicity. Rates of treatment related deaths are higher particularly patients with pre-treatment co-morbidity. (diabetes, vascular disease, immunosuppressive therapy) Pharyngeal dysfunction and stenosis is a major problem- up to 30% of patients remain G-tube dependant 6-9 months after therapy. ARE WE PRESERVING A NON-FUNCTIONAL STRUCTURE?

30 Quality of Life Outcomes in Organ Preservation RFP Recently Circulated by NCI reflects NCI s recognition of the critical importance. of the impact of cancer and its treatment on individuals living years beyond a cancer diagnosis Cognitive deficits Memory loss Other malignancies

31 Salvage Surgery Following Irradiation ± Chemotherapy Problems - Extent of recurrence - neck only - neck & primary - Hostile wound - High fistula rate - Need for flap repair

32 Grau C. Salvage laryngectomy & pharyngocutaneous fistulae after primary radiotherapy for head and neck cancer: a national survey from DAHANCA. Head & Neck. 25(9):711-6, 2003 Fistula Rate 9% to 57% Parikh, Gullane 1998

33 Reconstructive Options Following Salvage Laryngopharyngectomy 2010 Pectoralis Major Pedicled Flap Radial Forearm Flap Free Jejunal Graft Anterolateral Thigh Flap Gastro-omental Flap Gastric Transposition How do we decide?

34 When should we use a Pedicled Pectoralis Major Flap? minimum of 1.5cm residual pharyngeal mucosa In Repair of partial Pharyngeal defects

35 Radial Forearm Flap Savary Fistula tube vital

36 When should we use a Anterolateral Thigh Flap? Stricture rate No stent 33% Stent < 10% (p=0.571) Most commonly used flap in our centre for repair of total circumferential defects.

37 Gastro-Omental Flap In salvage pharyngectomy following organ preservation therapy in good performance patients.

38 Summary Advantages Free Gastro-Omental Transfer One Stage, Low Morbidity Unlimited tube diameter, Swallowing Speech Harvest with Omentum Disadvantages abdominal harvest, mucoid secretions *Patel R, Makitie A, Goldstein D, Gullane P, Brown D, Irish J, Gilbert R: Morbidity and Functional Outcomes Following Gastro-Omental Free Flap Reconstruction of Circumferential Pharyngeal Defects. Head and Neck Journal, ; May 2009

39 Options in Pharyngeal Reconstruction 2013 Flap - Speech Morbidity Gastric Pullup Forearm + Stent Free Gastro- Omental Free Jejunum Anterolateral Thigh +Stent IMAP Flap It s role to be evaluated