2. Laryngeal carcinomaLaryngeal carcinoma
Most common head & neck carcinomaMost common head & neck carcinoma
worldwideworldwide
Highest rates in south America & MediterraneanHighest rates in south America & Mediterranean
Lowest in FinlandLowest in Finland
UKUK (2005)(2005)
Incidence 3.6 per 100,000Incidence 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 !
12. Topographic distribution of CATopographic distribution of CA
larynx A study from Pakistanlarynx A study from Pakistan
SANGI HA, MATIULLAH S, JAWAID MA, MARFANI MS.SANGI HA, MATIULLAH S, JAWAID MA, MARFANI MS. The Presentation ofThe Presentation of
Carcinoma of Larynx at Civil Hospital Karachi. Pakistan Journal of OtolaryngologyCarcinoma of Larynx at Civil Hospital Karachi. Pakistan Journal of Otolaryngology
2010;26:53-552010;26:53-55..
14. Retrospective analysis of cases ofRetrospective analysis of cases of
CA larynx in last 10 yearsCA larynx in last 10 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, 10% were T64% of cases were T4, 22% were T3, 10% were T
2 ,4% were T12 ,4% were T1
Topographic distributionTopographic distribution
Supraglottic 36%Supraglottic 36%
Glottic 14%Glottic 14%
Subglottic 2%Subglottic 2%
Transglottic 48%Transglottic 48%
15. Retrospective analysis of cases ofRetrospective analysis of cases of
CA larynx in last 10 yearsCA larynx in last 10 years
Nodal involvement in 12% of patientsNodal involvement in 12% of patients
ManagementManagement
All stage I and II patients were referred forAll stage I and II patients were referred for
curative Radiotherapycurative Radiotherapy
1 patient developed radio necrosis, underwent1 patient developed radio necrosis, underwent
total laryngectomy (TL)total laryngectomy (TL)
3 Stage II patients had recurrence3 Stage II patients had recurrence SalvageSalvage
surgery (TL)surgery (TL)
16. Retrospective analysis of cases ofRetrospective analysis of cases of
CA larynx in last 10 yearsCA larynx in last 10 years
All stage III and Operable Stage IV patientsAll stage III and Operable Stage IV patients
underwent Total Laryngectomy with or withoutunderwent Total Laryngectomy with or without
neck dissectionneck dissection
62% of these patients received Postoperative radiotherapy62% of these patients received Postoperative radiotherapy
12 % patients developed recurrence12 % patients developed recurrence
Non-operable Stage IV patients were referredNon-operable Stage IV patients were referred
for palliative Chemo radiotherapyfor palliative Chemo radiotherapy
Electric larynx(Servox) was advised to all thoseElectric larynx(Servox) was advised to all those
who had TL and none was offered TEPwho had TL and none was offered TEP
17. Retrospective analysis of cases ofRetrospective analysis of cases of
CA larynx in last 10 yearsCA larynx in last 10 years
None of the patients underwent partialNone of the patients underwent partial
laryngectomies or surgical functionallaryngectomies or surgical functional
preservationpreservation
All Operable advanced cases underwent TotalAll Operable advanced cases underwent Total
laryngectomy and none referred for organlaryngectomy and none referred for organ
preservation (Chemoradiation)preservation (Chemoradiation)
Non operable cases(primary or neck) wereNon operable cases(primary or neck) were
referred foe palliative chemoradiaionreferred foe palliative chemoradiaion
18. Retrospective analysis of cases ofRetrospective analysis of cases of
CA larynx in last 10 yearsCA larynx in last 10 years
Reasons for our management strategyReasons for our management strategy
Advanced stage at presentationAdvanced stage at presentation
Poor follow-up of patientsPoor follow-up of patients
Socioeconomic status of most of the patientsSocioeconomic status of most of the patients
20. Management of CA larynxManagement of CA larynx
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 strategy for functional preservation[The current role of partial surgery as a strategy for functional preservation
in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epub 2010 Aug 3.in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epub 2010 Aug 3.
21. 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 stoma inN.B: Patient does not have a permenant tracheostomy stoma in
these procedures except near total laryngectyomythese procedures except near total laryngectyomy
22. 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 (TYPE 1Laser resection is good alternative (TYPE 1
Subepithelial Laser cordectomy )Subepithelial Laser 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.
23. CordectomyCordectomy
T1a lesion limited to middle of free edge ofT1a lesion limited to middle of free edge of
membranous cord, not to be more than 2mmmembranous cord, not to be more than 2mm
Laryngofissure approachLaryngofissure approach
Inner perichondrium of thyroid cartilageInner perichondrium of thyroid cartilage
removed with the cordremoved with the cord
Endoscopic Laser cordectomy is a goodEndoscopic Laser cordectomy is a good
alternativealternative
24. Vertical Partial LaryngectomyVertical Partial Laryngectomy
IndicationsIndications
T1, T2 Glottic lesionsT1, T2 Glottic lesions
T3 due to direct invasion of thyroarytenoid muscle ?T3 due to direct invasion of thyroarytenoid muscle ?
ContraindicationsContraindications
Vocal cord fixation due to Cricoarytenoid jointVocal cord fixation due to Cricoarytenoid joint
Involvement of the posterior commissure or theInvolvement of the posterior commissure or the
thyroid cartilagethyroid cartilage
Extension above the aryepiglottic fold.Extension above the aryepiglottic fold.
25. Vertical Partial LaryngectomyVertical Partial Laryngectomy
Rodrigo JP, Coca-Pelaz A, Suárez C.Rodrigo JP, Coca-Pelaz A, Suárez C. [The current role of partial surgery as a strategy for[The current role of partial surgery as a strategy for
functional preservation in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-functional preservation in 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.
26. Supraglottic Partial LaryngectomySupraglottic Partial Laryngectomy
IndicationsIndications
T1- T2 Supraglottic cancersT1- T2 Supraglottic cancers
T3 and T4 supraglottic tumours affecting the pre-epiglottic spaceT3 and T4 supraglottic tumours affecting the pre-epiglottic space
or one of the arytenoids, or that extend to the pyriform sinus oror one of the arytenoids, or that extend to the pyriform sinus or
the base of the tonguethe base of the tongue
Adequate pulmonary functionAdequate pulmonary function
ContraindicationsContraindications
Cartilage erosion, subglottic extension or involvement ofCartilage erosion, subglottic extension or involvement of
the lateral wall of the pyriform sinusthe lateral wall of the pyriform sinus
27. Supraglottic Partial LaryngectomySupraglottic Partial Laryngectomy
Rodrigo JP, Coca-Pelaz A, Suárez C.Rodrigo JP, Coca-Pelaz A, Suárez C. [The current role of partial surgery as a strategy for functional[The current role of partial surgery as a strategy for functional
preservation in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epubpreservation in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8. Epub
2010 Aug 3.2010 Aug 3.
28. Supraglottic Partial LaryngectomySupraglottic Partial Laryngectomy
The resection can be extended to include an arytenoid, t heThe resection can be extended to include an arytenoid, t he
base of the tongue or the pyriform sinus.base of the tongue or the pyriform sinus.
The patient has an almost normal voice, but a majorThe patient has an almost normal voice, but a major
challenge is in the development of normal swallowing fromchallenge is in the development of normal swallowing from
the loss of the protective mechanisms (epiglottis and bands).the loss of the protective mechanisms (epiglottis and bands).
A temporary tracheostomy and a feeding tube (usuallyA temporary tracheostomy and a feeding tube (usually
nasogastric) are required in all patients, rehabilitation isnasogastric) are required in all patients, rehabilitation is
achieved within the first month after surgery in mostachieved within the first month after surgery in most
patients, with the removal of the feeding tube and closure ofpatients, with the removal of the feeding tube and closure of
the tracheostomythe tracheostomy..
29. Supracricoid LaryngectomySupracricoid Laryngectomy
Alternative to (chemo)radiotherapy, supraglotticAlternative to (chemo)radiotherapy, supraglottic
laryngectomy, and near-total and total laryngectomylaryngectomy, and near-total and total laryngectomy
in selected cases of supraglottic and transglotticin selected cases of supraglottic and transglottic
carcinoma.carcinoma.
A technique for function preservation and shouldA technique for function preservation and should
be considered as a laryngeal preservation technique,be considered as a laryngeal preservation technique,
as it preserves the physiological rehabilitation ofas it preserves the physiological rehabilitation of
speech, swallowing and breathing without the needspeech, swallowing and breathing without the need
for a permanent tracheotomy.for a permanent tracheotomy.
30. Supracricoid Partial LaryngectomySupracricoid Partial Laryngectomy
TypesTypes
With Cricohyoidoepiglotopexy (SCPL-CHEP)With Cricohyoidoepiglotopexy (SCPL-CHEP)
With Cricohyoidopexy (SCPL-CHP)With Cricohyoidopexy (SCPL-CHP)
31. SCPL-CHEPSCPL-CHEP
IndicationsIndications
Glottic tumours: T2 (especially with involvement ofGlottic tumours: T2 (especially with involvement of
the anterior commissure), T3 and selected cases ofthe anterior commissure), T3 and selected cases of
T4 (limited invasion of the thyroid cartilage)T4 (limited invasion of the thyroid cartilage)
ContraindicationsContraindications
Fixation of the cricoarytenoid joint, invasion of theFixation of the cricoarytenoid joint, invasion of the
posterior commissure, invasion of the cricoid,posterior commissure, invasion of the cricoid,
extralaryngeal spread of the tumour or poor lungextralaryngeal spread of the tumour or poor lung
function.function.
32. SCPL-CHPSCPL-CHP
IndicationsIndications
T2---T4 larynx tumours: forT2---T4 larynx tumours: for supraglottic tumourssupraglottic tumours
extending to the vocal cord or anterior commissureextending to the vocal cord or anterior commissure
and for transglottic tumours.and for transglottic tumours.
ContraindicationsContraindications
Same as for SCPL-CHEP, along with the invasion ofSame as for SCPL-CHEP, along with the invasion of
the hyoid bone.the hyoid bone.
33. Trans oral Laser surgeryTrans oral Laser surgery
Along with SCPL, it has been one of the twoAlong with SCPL, it has been one of the two
areas of greatest development in larynxareas of greatest development in larynx
conservation surgery in recent yearsconservation surgery in recent years
Violates one of the basic surgical principles,Violates one of the basic surgical principles,
because the tumour is sectioned and thenbecause the tumour is sectioned and then
removed part by part, through a laryngoscope.removed part by part, through a laryngoscope.
However, sectioning of the piece reveals theHowever, sectioning of the piece reveals the
depth of tumour penetration and allows a cleardepth of tumour penetration and allows a clear
view of the oncological surgical margins duringview of the oncological surgical margins during
the procedure.the procedure.
34. Trans oral Laser SurgeryTrans oral Laser Surgery
In contrast to open larynx surgery, theIn contrast to open larynx surgery, the
cartilaginous edges of the larynx and infrahyoidcartilaginous edges of the larynx and infrahyoid
muscles are preserved during endoscopicmuscles are preserved during endoscopic
resection, which is thought to improveresection, which is thought to improve
postoperative functionpostoperative function
36. Trans oral Laser SurgeryTrans oral Laser Surgery
IndicationsIndications
Supraglottic or T1---T2 glottic carcinomas (e.g. LaserSupraglottic or T1---T2 glottic carcinomas (e.g. Laser
cordectmies)cordectmies)
Selected T3 glottic tumours (vocal fold fixation dueSelected T3 glottic tumours (vocal fold fixation due
to direct invasion of the thyroarytenoid muscle byto direct invasion of the thyroarytenoid muscle by
the tumour)the tumour)
T3 supraglottic tumours (invasion limited to the pre-T3 supraglottic tumours (invasion limited to the pre-
epiglottic space), and also in some T4 cases (limitedepiglottic space), and also in some T4 cases (limited
invasion of the tongue base).invasion of the tongue base).
37. Trans oral Laser SurgeryTrans oral Laser Surgery
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
38. Trans oral Robotic SurgeryTrans oral Robotic Surgery
Gaining popularity in many specialtiesGaining popularity in many specialties
Main advantages proposed by the supporters ofMain advantages proposed by the supporters of
robot-assisted surgery :robot-assisted surgery :
Excellent three-dimensional visualization andExcellent three-dimensional visualization and
surgery with 2 or 3 hands through the minimallysurgery with 2 or 3 hands through the minimally
invasive approaches made possible by the deviceinvasive approaches made possible by the device
Ability to provide movement at the tip of theAbility to provide movement at the tip of the
instrument, with 7instrument, with 7◦◦ of freedom and 90of freedom and 90◦◦ of rotation andof rotation and
movement scale.movement scale.
39. Total Laryngectomy (TL)Total Laryngectomy (TL)
Workhorse for the Head & neck surgeon inWorkhorse for the Head & neck surgeon in
advanced cases of CA larynx !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 spreadT4 lesions with operable extraaryngeal spread
Transglottic tumours with cricoid involvementTransglottic tumours with cricoid involvement
Large supraglottic tumours with cartilage erosion,Large supraglottic tumours with cartilage erosion,
subglottic extension or involvement of the lateral wall ofsubglottic extension or involvement of the lateral wall of
the pyriform sinusthe pyriform sinus
42. Transcervical electrolarynxTranscervical electrolarynx
AdvantagesAdvantages
Short learning timeShort learning time
Volume controlVolume control
Does not rely on pulmonaryDoes not rely on pulmonary
systemsystem
Immediate post op usage withImmediate post op usage with
oral adapteroral adapter
44. Tracheoesophageal speechTracheoesophageal speech
Surgically made TE fistulaSurgically made TE fistula
Pulmonary air usedPulmonary air used
TypesTypes
PrimaryPrimary
SecondarySecondary
ProsthesisProsthesis
RemovableRemovable
IndwellingIndwelling
Ante grade or retrograde insertionAnte grade or retrograde insertion
Cost:Cost:
Expensive prosthesisExpensive prosthesis
45. Tracheoesophageal SpeechTracheoesophageal Speech
AdvantagesAdvantages
Rapid restoration of voiceRapid restoration of voice
Normal length of phrasesNormal length of phrases
Indwelling prosthesis need little maintenanceIndwelling prosthesis need little maintenance
Hands free optionHands free option
46. Problems with TEPProblems with TEP
Candidal colonizationCandidal colonization
Prosthesis needs to be changedProsthesis needs to be changed
CostCost
MaintenanceMaintenance
47. Intraoral electrolarynxIntraoral electrolarynx
Ulravoice plusUlravoice plusTMTM
Oral unitOral unit
FM ReceiverFM Receiver
Control unitControl unit
TransmitterTransmitter
Voice enhancerVoice enhancer
Hands free optionHands free option
Cost isCost is ~4500$~4500$
48. Non-Surgical Organ PreservationNon-Surgical Organ Preservation
(Chemo-radiation)(Chemo-radiation)
T1 T2 lesions where patient does not wantT1 T2 lesions where patient does not want
surgical treatment (Radiotherapy)surgical treatment (Radiotherapy)
Advanced lesions T3 T4 where non surgicalAdvanced lesions T3 T4 where non surgical
organ preservation is contemplatedorgan preservation is contemplated
Recent epidemiological observations have shownRecent epidemiological observations have shown
declining survival rates in laryngeal cancer patients,declining survival rates in laryngeal cancer patients,
raising concern about uncritical and too frequent use ofraising concern about uncritical and too frequent use of
this approach.this approach.
Rudat V,Rudat V, Pfreundner LPfreundner L,, Hoppe FHoppe F,, Dietz ADietz A.. Approaches to preserve larynx functionApproaches to preserve larynx function
in locally advanced laryngeal and hypopharyngeal cancer.in locally advanced laryngeal and hypopharyngeal cancer. Onkologie.Onkologie. 20042004
Aug;27(4):368-75.Aug;27(4):368-75.
50. Salvage surgery after radiotherapySalvage surgery after radiotherapy
failure in T1 – T2 glottic CAfailure in T1 – T2 glottic CA
Successful in 50-60 % of the patientsSuccessful in 50-60 % of the patients
Total laryngectomyTotal laryngectomy
Voice sparing procedures in selected patientsVoice sparing procedures in selected patients
May require completion total laryngectomyMay require completion total laryngectomy
McLaughlin MP, Parsons JT, Fein DA, Stringer SP, Cassisi NJ, Mendenhall WM,McLaughlin MP, Parsons JT, Fein DA, Stringer SP, Cassisi NJ, Mendenhall WM,
Million RR.Million RR.Salvage surgery after radiotherapy failure in T1-T2 squamous cellSalvage surgery after radiotherapy failure in T1-T2 squamous cell
carcinoma of the glottic larynx. Head Neck. 1996 May-Jun;18(3):229-35carcinoma of the glottic larynx. Head Neck. 1996 May-Jun;18(3):229-35
51. Advanced Carcinoma larynxAdvanced Carcinoma larynx
Results of Surgery + RadiationResults of Surgery + Radiation
116 patients with Stage III squamous cell carcinoma of the116 patients with Stage III squamous cell carcinoma of the
larynx underwent radical surgery and postoperative radiotherapylarynx underwent radical surgery and postoperative radiotherapy
with a curative intent.with a curative intent.
The local recurrence rate and the local disease-free survival rateThe local recurrence rate and the local disease-free survival rate
at 5 years were 22.5% and 76.3%at 5 years were 22.5% and 76.3%
Local prognosis and survival depend largely on nodalLocal prognosis and survival depend largely on nodal
involvement and capsular rupture while increasing doses ofinvolvement and capsular rupture while increasing doses of
radiation strategy is likely to reduce the risk of local and nodalradiation strategy is likely to reduce the risk of local and nodal
recurrencerecurrence
Nguyen TD, Malissard L, Théobald S, Eschwège F, Panis X, Bachaud JM, Rambert P, Chaplain G,Nguyen TD, Malissard L, Théobald S, Eschwège F, Panis X, Bachaud JM, Rambert P, Chaplain G,
Quint RQuint R.Advanced carcinoma of the larynx: results of surgery and radiotherapy without.Advanced carcinoma of the larynx: results of surgery and radiotherapy without
induction chemotherapy (1980-1985): a multivariate analysis. Int J Radiat Oncol Biolinduction chemotherapy (1980-1985): a multivariate analysis. Int J Radiat Oncol Biol
52. Advanced Carcinoma of LarynxAdvanced Carcinoma of Larynx
Comparision between Surgery &Comparision between Surgery &
RadiotherapyRadiotherapy
Radiotherapy + Salvage surgery (RRSS) for Eighty-two patientsRadiotherapy + Salvage surgery (RRSS) for Eighty-two patients
with untreated T2N+M0 or T3T4NM0 were compared withwith untreated T2N+M0 or T3T4NM0 were compared with
comparable patients in literature who underwent Totalcomparable patients in literature who underwent Total
laryngectomy +/- neck dissectionlaryngectomy +/- neck dissection
A policy of RRSS offers a good chance of laryngeal conservationA policy of RRSS offers a good chance of laryngeal conservation
without compromising ultimate locoregional control or survivalwithout compromising ultimate locoregional control or survival
when compared to primary laryngectomy and neck dissection inwhen compared to primary laryngectomy and neck dissection in
patients with locally advanced carcinoma of the larynx meetingpatients with locally advanced carcinoma of the larynx meeting
the surgical eligibility of clinical trials.the surgical 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. ComparingComparing
treatment outcomes of radiotherapy and surgery in locally advancedtreatment outcomes of radiotherapy and surgery in locally advanced
carcinoma of the larynx: a comparison limited to patients eligible for surgery.carcinoma of the larynx: a comparison limited to patients eligible for surgery.
Int J Radiat Oncol Biol Phys. 2000 Apr 1;47(1):65-71.Int J Radiat Oncol Biol Phys. 2000 Apr 1;47(1):65-71.
53. Advanced T3-4 Ca larynx .ReviewAdvanced T3-4 Ca larynx .Review
of treatment optionsof treatment options
Lower N-stage was a favorable prognostic factor forLower N-stage was a favorable prognostic factor for
Locoreigonal control RC and OverallSurvival.Locoreigonal control RC and OverallSurvival.
Surgery was a favorable prognostic factor for LRC butSurgery was a favorable prognostic factor for LRC but
did not impact on OverallSurvialdid not impact on OverallSurvial
Hgb levels > or = 12.5 g/dL during RT was a favorableHgb levels > or = 12.5 g/dL during RT was a favorable
prognostic factor for OS.prognostic factor for OS.
Nguyen-Tan PF, Le QT, Quivey JM, Singer M, Terris DJ, Goffinet DR, Fu KKNguyen-Tan PF, Le QT, Quivey JM, Singer M, Terris DJ, Goffinet DR, Fu KK..
Treatment results and prognostic factors of advanced T3--4 laryngealTreatment results and prognostic factors of advanced T3--4 laryngeal
carcinoma: the University of California, San Francisco (UCSF) and Stanfordcarcinoma: the University of California, San Francisco (UCSF) and Stanford
University Hospital (SUH) experience. Int J Radiat Oncol Biol Phys. 2001University Hospital (SUH) experience. Int J Radiat Oncol Biol Phys. 2001
Aug 1;50(5):1172-80.Aug 1;50(5):1172-80.
54. 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 survivalStatistically similar recurrence, complication, and survival
rates.rates.
Clear margins have a significant survival advantage compared withClear margins have a significant survival advantage compared with
patients with close and involved marginspatients with close and involved margins
Because postoperative radiation therapy in patients with positiveBecause postoperative radiation therapy in patients with positive
margins did not improve survival, formalmargins did not improve survival, formal re-resectionre-resection of the site ofof the site of
the positive margin should be consideredthe positive margin should be considered..
Patients treated with RT and CS had statistically similar rates ofPatients treated with RT and CS had statistically similar rates of
survival, maintenance of voice, and acquired permanent tracheal stomasurvival, maintenance of voice, and acquired permanent tracheal stoma
Sessions DG, Lenox J, Spector GJ, Newland D, Simpson J, Haughey BH, Chao KS.Sessions DG, Lenox J, Spector GJ, Newland D, Simpson J, Haughey BH, Chao KS.ManagementManagement
of T3N0M0 glottic carcinoma: therapeutic outcomes.Laryngoscope. 2002 Jul;112(7of T3N0M0 glottic carcinoma: therapeutic outcomes.Laryngoscope. 2002 Jul;112(7
Pt 1):1281-8Pt 1):1281-8
55. Partial Laryngectomy afterPartial Laryngectomy after
radiation faliureradiation faliure
27 patients with early-stage laryngeal carcinoma underwent salvage27 patients with early-stage laryngeal carcinoma underwent salvage
partial laryngectomy after irradiation failure.partial laryngectomy after irradiation failure.
Vertical laryngectomy was performed in 18 patients (13 with T1 N0 and 5 withVertical laryngectomy was performed in 18 patients (13 with T1 N0 and 5 with
T2 N0)T2 N0)
Horizontal-supraglottic laryngectomy in 9 patients (3 with T1 N0, 1 with T2Horizontal-supraglottic laryngectomy in 9 patients (3 with T1 N0, 1 with T2
N0, and 5 with T2 N1)N0, and 5 with T2 N1)
Vertical laryngectomy was not associated with an increasedVertical laryngectomy was not associated with an increased
complication ratecomplication rate
In early laryngeal cancer (glottic T1-T2, supraglottic T1) partialIn early laryngeal cancer (glottic T1-T2, supraglottic T1) partial
laryngectomy can be performed with good expectation of cure andlaryngectomy can be performed with good expectation of cure and
satisfactory laryngeal function. In T2 supraglottic lesions, thesatisfactory laryngeal function. In T2 supraglottic lesions, the
oncologic results are less satisfactoryoncologic results are less satisfactory
Yiotakis J, Stavroulaki P, Nikolopoulos T, Manolopoulos L, Kandiloros D, Ferekidis E,Yiotakis J, Stavroulaki P, Nikolopoulos T, Manolopoulos L, Kandiloros D, Ferekidis E,
Adamopoulos G.Adamopoulos G. Partial laryngectomy after irradiation failure. Otolaryngol HeadPartial laryngectomy after irradiation failure. Otolaryngol Head
Neck Surg. 2003 Feb;128(2):200-9Neck Surg. 2003 Feb;128(2):200-9..
56. Management of T1- T2 Glottic CAManagement of T1- T2 Glottic CA
The aim of the current study was to review the pertinent literatureThe aim of the current study was to review the pertinent literature
and discuss the optimal management of early-stage laryngealand discuss the optimal management of early-stage laryngeal
carcinomacarcinoma..
Local control, laryngeal preservation, and survival rates of patientsLocal control, laryngeal preservation, and survival rates of patients
were similar after transoral laser resection, open partial laryngectomy,were similar after transoral laser resection, open partial laryngectomy,
and radiotherapy.and radiotherapy.
Voice quality was superior in pts undergoing transoral LaserVoice quality was superior in pts undergoing transoral Laser
resection than partial laryngectomies & comparable to Dxtresection than partial laryngectomies & comparable to Dxt
Costs were similar for laser resection and radiotherapy, but openCosts were similar for laser resection and radiotherapy, but open
partial laryngectomy was more expensive.partial laryngectomy was more expensive.
Open partial laryngectomy was reserved for patients with locallyOpen partial laryngectomy was reserved for patients with locally
recurrent tumors.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-Management of T1-
T2 glottic carcinomas.Cancer. 2004 May 1;100(9):1786-92.T2 glottic carcinomas.Cancer. 2004 May 1;100(9):1786-92.
57. Laser microsurgery for recurrentLaser microsurgery for recurrent
glottic CA after Radiotherapyglottic CA after Radiotherapy
Thirty-four patients with early and advanced recurrent glotticThirty-four patients with early and advanced recurrent glottic
carcinoma after full-course radiotherapycarcinoma after full-course radiotherapy
Twenty-four patients (71%) were cured with one or more laserTwenty-four patients (71%) were cured with one or more laser
procedures. In nine patients, recurrences could not be controlled byprocedures. In nine patients, recurrences could not be controlled by
laser microsurgery: six patients underwent total laryngectomy and threelaser microsurgery: six patients underwent total laryngectomy and three
palliative treatment.palliative treatment.
Compared with salvage laryngectomy, results are superior with respectCompared with salvage laryngectomy, results are superior with respect
to preservation of laryngeal function. Great expertise is required,to preservation of laryngeal function. Great expertise is required,
especially in resections of advanced-stage recurrent carcinomas.especially in resections of advanced-stage recurrent carcinomas.
Steiner W, Vogt P, Ambrosch P, KronSteiner W, Vogt P, Ambrosch P, Kron M. Transoral carbon dioxide laser microsurgery forM. Transoral carbon dioxide laser microsurgery for
recurrent glottic carcinoma after radiotherapy. Head Neck. 2004 Jun;26(6):477-84.
58. Stage IV Glottic CAStage IV Glottic CA
5 Different Treatment options compared in 96 patients with stage IV5 Different Treatment options compared in 96 patients with stage IV
glottic CAglottic CA
Total laryngectomy with neck dissection (TL/ND) (n = 18), radiationTotal laryngectomy with neck dissection (TL/ND) (n = 18), radiation
therapy alone (RT) (n = 7) (median dose, 69.5 Gy), total laryngectomytherapy alone (RT) (n = 7) (median dose, 69.5 Gy), total laryngectomy
combined with radiation therapy (TL/RT) (n = 10), and totalcombined with radiation therapy (TL/RT) (n = 10), and total
laryngectomy and neck dissection combined with radiation therapylaryngectomy and neck dissection combined with radiation therapy
(TL/ND/RT) (n = 48).(TL/ND/RT) (n = 48).
The five treatment modalities had statisticallyThe five treatment modalities had statistically similarsimilar survival,survival,
recurrence, and complication rates. The overall 5-year DSS forrecurrence, and complication rates. The overall 5-year DSS for
patients with stage IV glottic carcinoma was 45%, and the OS waspatients with stage IV glottic carcinoma was 45%, and the OS was
39%39%
Patients whose N0 neck was treated with observation and appropriatePatients whose N0 neck was treated with observation and appropriate
treatment for subsequent neck disease had statistically similar survivaltreatment for subsequent neck disease had statistically similar survival
compared with patients whose N0 neck was treated prophylactically atcompared with patients whose N0 neck was treated prophylactically at
the time of treatment of the primarythe time of treatment 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 IVManagement of stage IV
glottic carcinoma: therapeutic outcomes. Laryngoscope. 2004 Aug;114(8):1438-46glottic carcinoma: therapeutic outcomes. Laryngoscope. 2004 Aug;114(8):1438-46..
59. Supracricoid laryngectomy withSupracricoid laryngectomy with
cricohyoidopexy for recurrence of early-cricohyoidopexy for recurrence of early-
stage glottic carcinomastage glottic carcinoma
In selected cases, SCL-CHP may be used to treat laryngeal carcinomasIn selected cases, SCL-CHP may be used to treat laryngeal carcinomas
after radiation failure, with good oncological and functional results.after radiation failure, with good oncological and functional results.
Seven cases of rT2-T3 laryngeal squamous cell carcinomas thatSeven cases of rT2-T3 laryngeal squamous cell carcinomas that
recurred after radiotherapy and were treated with salvage SCL-CHPrecurred after radiotherapy and were treated with salvage SCL-CHP
All patients were decannulated and recovered the ability to swallow.All patients were decannulated and recovered the ability to swallow.
Vocal quality was significantly rough and breathy but was satisfactorilyVocal quality was significantly rough and breathy but was satisfactorily
intelligible in all patientsintelligible 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.
60. CO2 laser cordectomy for early-stageCO2 laser cordectomy for early-stage
glottic carcinomaglottic carcinoma
Microendoscopic laser surgery is efficacious for early glottic carcinoma,Microendoscopic laser surgery is efficacious for early glottic carcinoma,
(Tis, T1a, T1b)with oncological results comparable to those observed(Tis, T1a, T1b)with oncological results comparable to those observed
following radiotherapy or conventional partial laryngectomy, however,following radiotherapy or conventional partial laryngectomy, however,
in this case, local recurrences have a greater range of re-treatmentin this case, local recurrences have a greater range of re-treatment
optionsoptions
79 patients included in this study.79 patients included in this study.
Depth and extension of excisions were graded according to EuropeanDepth and extension of excisions were graded according to European
Laryngological Society Classification, and included 5 types ofLaryngological Society Classification, and included 5 types of
cordectomy.cordectomy.
Only 8 Recurences….. treated with total laryngectomy (n:3),2Only 8 Recurences….. treated with total laryngectomy (n:3),2ndnd
timetime
laser excision(n:2), Partial laryngetomy(n:2),Radiotherapy(1)laser excision(n:2), Partial laryngetomy(n:2),Radiotherapy(1)
Bocciolini CBocciolini C,, Presutti LPresutti L,, Laudadio PLaudadio P..Oncological outcome after CO2 laser cordectomy forOncological outcome after CO2 laser cordectomy for
early-stage glottic carcinoma.early-stage glottic carcinoma. Acta Otorhinolaryngol Ital.Acta Otorhinolaryngol Ital. 2005 Apr;25(2):86-93.2005 Apr;25(2):86-93.
61. The role of laser microsurgery in theThe role of laser microsurgery in the
treatment of laryngeal cancertreatment of laryngeal cancer
This review elucidates the role of laser microsurgical partial resectionsThis review elucidates the role of laser microsurgical partial resections
of the larynx in comparison with other treatment modalitiesof the larynx in comparison with other treatment modalities
In patients with early or moderately advanced supraglottic carcinoma,In patients with early or moderately advanced supraglottic carcinoma,
laser microsurgery is comparable to open supraglottic laryngectomy inlaser microsurgery is comparable to open supraglottic laryngectomy in
terms of local control and survivalterms of local control and survival
Based on published results, primary laser therapy can achieve localBased on published results, primary laser therapy can achieve local
tumor control with a functional residual larynx in approximately 70-tumor control with a functional residual larynx in approximately 70-
80% of cases.80% of cases.
With regard to organ preservation, laser microsurgery is comparableWith regard to organ preservation, laser microsurgery is comparable
to open supraglottic laryngectomy but superior to radiotherapyto open supraglottic laryngectomy but superior to radiotherapy
Microsurgery can preserve functionally important structures, allowingMicrosurgery can preserve functionally important structures, allowing
for early swallowing rehabilitation while avoiding tracheotomy.for early swallowing rehabilitation while avoiding tracheotomy.
Ambrosch P.Ambrosch P. The role of laser microsurgery in the treatment of laryngeal cancer.The role of laser microsurgery in the treatment of laryngeal cancer.
Curr Opin Otolaryngol Head Neck Surg.Curr Opin Otolaryngol Head Neck Surg. 2007 Apr;15(2):82-82007 Apr;15(2):82-8
62. Voice outcomes following trans oral Laser microsurgeryVoice outcomes following trans oral Laser microsurgery
for early glottic squamous cell carcinomafor early glottic squamous cell carcinoma
Transoral laser microsurgery for T1 or T2 glottic cancerTransoral laser microsurgery for T1 or T2 glottic cancer
Survival outcomes following transoral laser microsurgery areSurvival outcomes following transoral laser microsurgery are
comparable to treatment with radiotherapy.comparable to treatment with radiotherapy.
Voice impairment is usually mild to moderate following transoral laserVoice impairment is usually mild to moderate following transoral laser
microsurgery for early glottic cancer but overall may be greater than inmicrosurgery for early glottic cancer but overall may be greater than in
radiotherapy patientsradiotherapy patients
The repeatability of transoral laser microsurgery may result in a lowerThe repeatability of transoral laser microsurgery may result in a lower
laryngectomy rate compared with published series using radiotherapy.laryngectomy rate compared with published series using radiotherapy.
The mean Oates Russell Voice Profile for T1 disease was 2.37 and forThe 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 moderate (3) degree ofT2 2.68 (range 1 to 4) indicating a mild (2) to moderate (3) degree of
voice impairment.voice impairment.
Kennedy JTKennedy JT,, Paddle PMPaddle PM,, Cook BJCook BJ,, Chapman PChapman P,, Iseli TAIseli TA.. Voice outcomes following transoralVoice outcomes following transoral
laser microsurgery for early glottic squamous cell carcinoma.laser microsurgery for early glottic squamous cell carcinoma.J Laryngol Otol.J Laryngol Otol. 20072007
Dec;121(12):1184-8. Epub 2007 Apr 20.Dec;121(12):1184-8. Epub 2007 Apr 20.
63. Treatment of early-stage glottic cancerTreatment of early-stage glottic cancer
by transoral laser resectionby transoral laser 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 wereThe 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 (14%).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 overall 5-yearThe 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 actuarial disease-actuarial recurrence-free survival rate was 89%, and the 5-year actuarial disease-
specific survival rate was 97.3%. There were 11 local recurrences (14%); 7 werespecific survival rate was 97.3%. There were 11 local recurrences (14%); 7 were
treated by another laser resection, 1 by radiotherapy, 1 by supracricoid partialtreated by another laser resection, 1 by radiotherapy, 1 by supracricoid partial
laryngectomy, and 2 by total laryngectomy.laryngectomy, and 2 by total laryngectomy.
Positive or suspicious margins were not related to recurrence, nor was anteriorPositive or suspicious margins were not related to recurrence, nor was anterior
commissure involvement. This study implies that suspicious margins can becommissure involvement. This study implies that suspicious margins can be
managed with a "watch-and-wait" attitude. Re-treatment with laser, external partialmanaged with a "watch-and-wait" attitude. Re-treatment with laser, external partial
laryngectomy, and radiotherapy remain therapeutic options for recurrences.laryngectomy, and radiotherapy remain therapeutic options for recurrences.
Hartl DM,Hartl DM, de Monès Ede Monès E,, Hans SHans S,, Janot FJanot F,, BrasnuBrasnu DD.Treatment of early-stage glottic cancer.Treatment of early-stage glottic cancer
by transoral laser resection. Ann Otol Rhinol Laryngol. 2007 Nov;116(11):832-6.
64. Partial surgery for functional preservationPartial surgery for functional preservation
in CA larynxin CA larynx Non-surgical treatment is offered as a strategy for organ preservation,Non-surgical treatment is offered as a strategy for organ preservation,
as opposed to total laryngectomy. However, we believe thatas opposed to total laryngectomy. However, we believe that there arethere are
two organ-preservation strategies, surgical and non-surgicaltwo organ-preservation strategies, surgical and non-surgical. A wide spectrum. A wide spectrum
of surgical techniques is available and such techniques lead toof surgical techniques is available and such techniques lead to
excellent results, both oncological and functional (speech andexcellent results, both oncological and functional (speech and
swallowingswallowing
In addition to classic approaches such as vertical partial laryngectomyIn addition to classic approaches such as vertical partial laryngectomy
and horizontal or supraglottic laryngectomy, options for conservativeand horizontal or supraglottic laryngectomy, options for conservative
laryngeal surgery have improved significantly over the past twolaryngeal surgery have improved significantly over the past two
decades.decades.
Minimally invasive surgery, transoral laser surgery, and supracricoidMinimally invasive surgery, transoral laser surgery, and supracricoid
partial laryngectomy have become important laryngeal preservationpartial laryngectomy have become important laryngeal preservation
approaches for patients with laryngeal cancerapproaches for patients with laryngeal cancer
Rodrigo JP, Coca-Pelaz A, Suárez C.Rodrigo JP, Coca-Pelaz A, Suárez C. [The current role of partial surgery as a strategy for functional[The current role of partial surgery as a strategy for functional
preservation in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8.preservation in laryngeal carcinoma].Acta Otorrinolaringol Esp. 2011 May-Jun;62(3):231-8.
Epub 2010 Aug 3.Epub 2010 Aug 3.
65. Functional organ preservation in LaryngealFunctional organ preservation in Laryngeal
and hypopharyngeal cancerand hypopharyngeal cancer
Comparing the various surgical approaches of laryngeal partialComparing the various surgical approaches of laryngeal partial
resections, the oncological outcome of the patients, as far as survivalresections, the oncological outcome of the patients, as far as survival
and organ preservation are concerned, are comparable, whereasand organ preservation are concerned, are comparable, whereas
functional results of the endoscopic procedures are superior with lessfunctional results of the endoscopic procedures are superior with less
morbidity.morbidity.
The surgical procedures put together, are all superior to radiotherapyThe surgical procedures put together, are all superior to radiotherapy
concerning organ preservation.concerning organ preservation.
Transoral laser microsurgery has been used successfully for vocalTransoral laser microsurgery has been used successfully for vocal
cord carcinomas with impaired mobility or fixation of the vocal cord,cord carcinomas with impaired mobility or fixation of the vocal cord,
supraglottic carcinomas with infiltration of the pre- and/or paraglotticsupraglottic carcinomas with infiltration of the pre- and/or paraglottic
space as well as for selected hypopharyngeal carcinomasspace as well as for selected hypopharyngeal carcinomas
Ambrosch P, Fazel A.Ambrosch P, Fazel A. [Functional organ preservation in laryngeal and[Functional organ preservation in laryngeal and
hypopharyngeal cancer].Laryngorhinootologie. 2011 Mar;90 Supplhypopharyngeal cancer].Laryngorhinootologie. 2011 Mar;90 Suppl
1:S83-109. Epub 2011 Apr 26.1:S83-109. Epub 2011 Apr 26.
66. Concurrent ChemoradiotherapyConcurrent Chemoradiotherapy
for Advanced Ca Larynxfor Advanced Ca Larynx
The introduction of concurrent administration of chemotherapyThe introduction of concurrent administration of chemotherapy
and radiotherapy (chemo radiotherapy) has been a majorand radiotherapy (chemo radiotherapy) has been a major
advancement. This has resulted in local control and survival ratesadvancement. This has resulted in local control and survival rates
comparable to those seen following radical surgery andcomparable to those seen following radical surgery and
postoperative radiotherapy, but with preservation of the larynx inpostoperative radiotherapy, but with preservation of the larynx in
most patients.most patients.
However, recent epidemiological observations have shownHowever, recent epidemiological observations have shown
declining survival rates in laryngeal cancer patients, raisingdeclining survival rates in laryngeal cancer patients, raising
concern about uncritical and too frequent use of this approachconcern about uncritical and too frequent use of this approach..
Rudat V, Pfreundner L, Hoppe F, Dietz A.Rudat V, Pfreundner L, Hoppe F, Dietz A. Approaches to preserveApproaches to preserve
larynx function in locally advanced laryngeal and hypopharyngeallarynx function in locally advanced laryngeal and hypopharyngeal
cancer. Onkologie. 2004 Aug;27(4):368-75.cancer. Onkologie. 2004 Aug;27(4):368-75.
67. Organ preservation withConcomitantOrgan preservation withConcomitant
radiochemotherapyradiochemotherapy
Organ preservation treatment is a valuable alternative to surgical procedure inOrgan preservation treatment is a valuable alternative to surgical procedure in
patients diagnosed with laryngeal and hypopharyngeal cancer in III and IVapatients diagnosed with laryngeal and hypopharyngeal cancer in III and IVa
clinical statusclinical status
The patients with diagnosed squamous cell laryngeal and hypopharyngealThe patients with diagnosed squamous cell laryngeal and hypopharyngeal
cancer in III and IVa clinical status were treated with concomitantcancer in III and IVa clinical status were treated with concomitant
radiochemotherapy with intention of the organ preservationradiochemotherapy 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 76%.Three years laryngectomy free survival (LFS) is 82% and 5-years LFS is 76%.
This group of patients is alive with larynx preservationsThis 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 palliativeThose patients underwent salvage surgery or were treated with palliative
chemotherapy. No severe life risking early and late complications werechemotherapy. No severe life risking early and late complications were
observed. Only 7% of patients have required temporary tracheostomyobserved. Only 7% of patients have required temporary tracheostomy
because of difficulties in breathing due to larynx edema.because of difficulties in breathing due to 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.[The results
and toxicity of organ preservation treatment for locoregionally advancedand toxicity of organ preservation treatment for locoregionally advanced
laryngeal and hypopharyngeal cancer]. [Article in Polish] Otolaryngol Pol.laryngeal and hypopharyngeal cancer]. [Article in Polish] Otolaryngol Pol.
68. Larynx preservation using inductionLarynx preservation using induction
chemotherapy plus radiation therapychemotherapy plus radiation therapy
Induction chemotherapy plus radiation therapy is an effective strategyInduction chemotherapy plus radiation therapy is an effective strategy
which can produce a high rate of larynx preservation, local control,which can produce a high rate of larynx preservation, local control,
and long-term survival in patients with advanced cancer of the larynx.and long-term survival in patients with advanced cancer of the larynx.
Since 1977, we have used induction chemotherapy (CT) plus radiationSince 1977, we have used induction chemotherapy (CT) plus radiation
therapy (RT) with curative intent in 35 advanced head and necktherapy (RT) with curative intent in 35 advanced head and neck
cancer (Ca) patients who otherwise would have required totalcancer (Ca) patients who otherwise would have required total
laryngectomy.laryngectomy.
Karp DD, Vaughan CW, Carter R, Willett B, Heeren T, Calarese P, Zeitels S, Strong MS, HongKarp DD, Vaughan CW, Carter R, Willett B, Heeren T, Calarese P, Zeitels S, Strong MS, Hong
WK.WK.Larynx preservation using induction chemotherapy plus radiation therapy as anLarynx preservation using induction chemotherapy plus radiation therapy as an
alternative to laryngectomy in advanced head and neck cancer. A long-term follow-upalternative to laryngectomy in advanced head and neck cancer. A long-term follow-up
report.Am J Clin Oncol. 1991 Aug;14(4):273-9report.Am J Clin Oncol. 1991 Aug;14(4):273-9
