Carcinoma larynx journal

1. PRESENTER: DR
SUJITHA
MODERATOR:DR C P
DAS
Recent Advances in
Management of Laryngeal
Cancer

2. Anatomy

4.  Membranes:Extrinsic-thyrohyoid membrane
-cricotracheal membrane
Intrinsic-Quadrangular membrane
-conus elasticus

7. Ligaments & Folds OF
Larynx
 Epiglottic ligaments
 Aryepiglottic fold
 Vestibular ligament (vestibular folds or false vocal cords)
 Vocal ligaments

9. Laryngeal Spaces
 Internal laryngeal
spaces :
 vestibule,
 ventricles,
o subglottic or
infraglottic spaces
o External
laryngeal spaces
 Paraglottic space
 pre-epiglottic. Space

10. Pre-epiglottic fat space
 The pre-epiglottic fat is located in
the anterior and lateral aspects of
the larynx and is often invaded by
advanced cancers.

11. Paraglottic Spaces (
Tucker’s space)
 Bounded laterally by the thyroid
cartilage,
 inferomedially by the conus
elasticus,
 medially by the ventricle and
the quadrangular membrane

12. The supraglottic larynx
 It consists of epiglottis, false
vocal cords, ventricles,
aryepiglottic folds, and
arytenoids

13. The glottic larynx
 It consists of the true vocal
cords and anterior
commissure and posterior
commissure

14. The subglottic larynx
 It consists of the region
below the vocal cords and
the trachea.

15. Embryology
 The larynx developes from the respiratory n upper digestive tracts.
 Supraglottic larynx derived from arches 2 & 4th (buccopharyngeal anlage)
 Glottis & subglottis are derived from (tracheobronchial anlage) from 6th arch
 The division between respiratory n digestive tracts occurs laterally in the
ventricle
 Different embryological derivations creates natural barriers & restrict
laryngeal compartments in early stages cancer Form basis of laryngeal
conservation surgery

16. Barriers to spread
 Hyoid bone
 Laryngeal cartilages
 Hyoepiglottic ligament
 Thyrohyoid membrane
 Ventricle
 Anterior commisure
 Cricothyroid membrane
 Conus elasticus
 Quadrangular membrane

17. Lymphatics
 the vocal folds anteriorly and laterally act as the point of division of
lymphatic drainage and as such have very little lymphatic drainage
themselves.
 • supraglottis - via superior laryngeal vessels to levels I I and I I I ;
 • anterior glottis and subglottis ~ through cricothyroid ligament
anteriorly to level V I and laterally to level IV;
 • posterior glottis and subglottis - through cricotracheal membrane to
the paratracheal nodes i n level V I and laterally to level IV.

18. Epidemiology
 2.63% of all the body cancers in India
 40- 70 years
 M:F = 10:1
 Female incidence increasing

19. Risk factors
 Alcohol n smoking
Smoking –glottic ca
- only 1% of laryngeal ca occur in
non smokers
Alcohol – supraglottic ca
 Human Papilloma Virus 16 n 18
 Genetic Susceptibility
 Gastroesophageal reflux
 Prior history of head and neck
irradiation
 Diets lacking green leafy
vegetables, fruits & fibre
 Diets rich in salt preserved
meats and dietary fats
 Occupational
Metal/plastic workers
Exposure to paint
Exposure to diesel and
gasoline fumes
Exposure to asbestos
Exposure to radiation

20. Subtypes
 Glottic Cancer: 59%
 Supraglottic Cancer: 40%
 Subglottic Cancer: 1%
 Most subglottic masses are extension from glottic carcinomas

21. Mortality/Morbidity
 The prognosis for small laryngeal cancers that do not have lymph node
metastases is good,
 Advanced disease has a worse prognosis.
 Supraglottic cancers usually manifest late and have a poorer prognosis.

22. Histological Types
 85-95% of laryngeal tumors are squamous cell carcinoma
 Characterized by epithelial nests surrounded by inflammatory stroma
 Keratin Pearls are pathognomonic

23. Histological Types
 Verrucous Carcinoma
 Fibrosarcoma
 Chondrosarcoma
 Minor salivary carcinoma
 Adenocarcinoma
 Oat cell carcinoma
 Giant cell and Spindle cell carcinoma

24. Glottic cancer
 More common
 Anteriorly- anterior commisure
 Posteriorly- vocal process of
arytenoid
 Upward- ventricle and false cord
 Downward- Subglottic region

25. Symptoms
 Hoarseness of voice is an early sign
 Progressive dyspnoea & stridor
 Haemoptysis
 Referred otalgia
 There are no lymphatics in vocal cords and nodal metastasis are rarely
seen unless the disease spreads beyond the region of membranous cords.
 Good Prognosis : Early presentation and late spread

26.  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
tongue and pyriform fossa)
 Preepiglottic space involvement
through foramen in infrahyoid
epiglottis.
 Paraglottic space involvement
through mucosa of the ventricle
Supraglottic cancer

27.  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
 Symptoms: Often silent,
Hoarseness is a late symptom
Foreign body sensation
Lump in throat / throat pain
Muffled voice
Dysphagia
Referred pain in ear
Stridor
Swelling neck
 Bad Prognosis : Due to early spread and late presentation.

28. Subglottic Cancer
 Rare( 1 - 2%)
 Spread:
 superficially/submucosally to the opposite side or
downwards to the trachea May invade
 Anteriorly cricothyroid membrane, thyroid gland and
muscles of neck
 LN involvement seen in 10-34%
Symptoms:
Stridor is the earliest presentation.
Hoarseness is a late symptom as upward spread to the
vocal cords is late.

29. Diagnosis Of Laryngeal Cancer
History :
 Symptomatology of glottic, subglottic, supraglottic is as explained earlier
 Information regarding risk factors, medication & medical comorbidities
such as cardiovascular, pulmonary, renal disease
Examination Of Head & Neck :
a) Extralaryngeal spread of the disease.
b) Nodal metastasis

30.  Indirect Laryngoscopy :
A) Appearance & site of lesion
B) Vocal Cord Mobility – Fixation of vocal cords indicate deeper
infiltration.
 Direct Laryngoscopy : Gold standard
a) Hidden areas of larynx
b) Extent of disease.
c) Punch biopsy/ excision biopsy
 Microlaryngoscopy:
-For smaller lesions of vocal cord
- Accurate biopsy specimen can be taken

31.  Chest X Ray –
Essential for co-existent lung diseases, pulmonary metastasis and
mediastinal nodes.
 Barium swallow – recommended in advanced laryngeal cancer – to find
involvement of pyriform fossa , pharyngeal wall & post cricoid area
 Esophagoscopy : Performed to exclude synchronus primary tumor in
esophagus.
 Bronchoscopy : Usually not required if chest imaging is normal.

32.  CT Scan
To find the site & extent of the tumour, invasion of pre epiglottic and
paraglottic space, destruction of cartilage, extralaryngeal tissue,
prevertebral space, encasement of carotid and lymph node involvement.
 MRI
Superior to CT in evaluation of cartilage erosion
 PET/CT
Residual
Recurrent

33.  Supravital staining and biopsy:
Toluidine blue is applied to the laryngeal lesion and then washed and
examined. CIS and superficial carcinomas take up dye while leukoplakia
does not and thus helping in selecting the area for biopsy
 Videostroboscopy
- useful in CIS lesion of vocal cord
- deeper invasion into basement membrane produce distortion of
mucosal wave
- loss of synchrony between vocal cords

34. Optical coherence tomography
 Fibreoptically based
 Perform high resolution subepithelial imaging of tissue by measuring
backreflected infrared light from internal tissue structure
 Useful for diagnosis of hyperplasia, early stage keratosis of vocal fold
 Allow visualization of epithelium, basement membrane, and lamina
propria of vocal cord Ability to observe integrity of basement membrane
help in detecting early stage carcinoma of vocal cord

35. TNM STAGING
 It influences the choice of therapy
 Helps in predicting the overall prognosis
 helps in comparing the efficacy of various forms of therapy

36. Staging – Primary Tumour
Tx - Primary tumor cannot be assessed.
T0 - No evidence of primary tumor.
Tis - Carcinoma in situ.

37. Supraglottis
T1 - Tumor limited to one subsite with mobility.
T2 - Tumor invades mucosa of more than one adjacent subsite of
supraglottis or glottis or region outside the supraglottis (e.g., mucosa of
base of tongue, vallecula, medial wall of pyriform sinus) without fixation
of the larynx.
T3 - Tumor limited to larynx with vocal cord fixation and/or invades
postcricoid area, pre-epiglottic space, paraglottic space .
T4a - Tumor invades through the thyroid cartilage and/or invades tissues
beyond the larynx (e.g., trachea, soft tissues of neck including deep
extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
.
T4b - Tumor invades prevertebral space, encases carotid artery, or invades
mediastinal structures

38. Glottis
T1- Tumor limited to the vocal cord(s)(may involve anterior or posterior commissure) with
normal mobility.
T1a- Tumor limited to one vocal cord.
T1b -Tumor involves both vocal cords.
T2 -Tumor extends to supraglottis, subglottis, with impaired vocal cord mobility.
T3 -Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space
T4a- Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues
beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of
the tongue, strap muscles, thyroid, or esophagus).
T4b- Tumor invades prevertebral space, encases carotid artery, or invades mediastinal
structures

39. Subglottis
T1: Limited to subglottis
T2: Extends to vocal cord with normal or impaired mobility
T3: Limited to larynx with vocal cord fixation
T4a: Invades cricoid or thyroid cartilage, and/or invades tissues beyond the
larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle
of the tongue, strap muscles, thyroid, or esophagus).
T4b: Invades prevertebral space, encases carotid artery, or invades
mediastinal structures

40. – Nx: regional LN can’t be assessed
– N0: no regional node metastasis
– 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
– Mx: can’t be assessed
– M0: no distant metastasis
– M1: distant metastasis
Regional Lymph Nodes
(N)
Distant metastasis (M)

41. 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

42. Carcinoma in situ
 Is replacement of the full depth of epithelium by malignant cells, without
those transgressing the basement epithelium
 Tis should be regarded as part of the continuum of early laryngeal cancer and
managed as T1 carcinoma
 High possibilities of recurrent disease suggests holding back use of
radiotherapy for those lesions where resection would lead to significant
functional defcit and use of surgical technique wherever possible
 Successful management also requires implementation of tobacco & alcohol
cessation strategies,vigilant follow up

43.  Diffuse lesion
• Complete mucosal cord stripping with co2 laser
• Quit smoking/no RT
• Vigilant follow up
 Localised lesion
Excision of leukoplakia with microscissors/forceps
• Quit smoking/ no RT
• Vigilant f/u

44. T1 Glottic ca
 Mid – cord
- Radiation therapy - Offer best quality of voice
- Treatment of choice in professional voice users
 Surgery :-
 Transoral endoscopic CO2 laser cordectomy - TOC
- > 90% cure rates
 Laryngofissure & Cordectomy - Rarely used now
- Only done when endoscopic
exposure is poor

45. (Anterior commissure lesion /Cord lesion extending to
ant commissure )
 Vertical Partial laryngectomy – Frontal/ frontolateral
- > 90% cure rates
- Hospitalisation, temporary tracheostomy & NG tube feeding
 Transoral endoscopic CO2 laser resection
- Day-care procedure
- Higher recurrence due to unsatisfactory exposure of this
region
 Radiation therapy
- Also have higher failure rate
– Difficulty in delivery of adequate dose to this region
- Undetected cartilage erosion- lack of inner perichondrium

46. (Cord lesion extending posteriorly vocal process of
arytenoid )
 Transoral endoscopic CO2 laser resection
- Surgical treatment of choice
 Laryngofissure & Cordectomy
 Radiation therapy
- post placed cord lesion also have higher failuren rate

47. T2 Glottic carcinoma (freely mobile cords)
 Surgery is TOC
 Vertical Partial laryngectomy – Frontal/ frontolateral /Extended
hemilaryngectomy
- better quality of voice than SCPL with CHEP
- better tolerated by frail & COPD patients
 Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy
- offer superior cure rates with T2 glottic cancer
- poor quality of voice than VPL
- post operative aspiration problems
- best to reserve this procedure for very fit pts

48.  Transoral endoscopic CO2 laser resection
- best only in experienced hands
- satisfactory endoscopic exposure is most important
- well tolerated by elderly & frail pts
 Radiation therapy
- preferred only in mid cord lesion with extention to supraglottis
- good voice results

49. T2(impaired cord mobility)
 Open partial laryngectomy is treatment of choice
 VPL ( Hemilaryngectomy ) - lateralised lesion
(Frontolateral ) – lesion across ant comm.
– safer in elderly individuals
 SCPL-CHEP – reserve for very fit pts
 Chemo radiation – TOC - unfit/unwilling for surgery
-Neoadjuvant CT +RT in responders
 Radiation alone – reserve for
- unfit/unwilling for surgery
- unlikely to able tolerate chemoradiation

50. T3 and T4 glottic carcinoma
 Best treated by total laryngectomy combined with neck
dissection if lymph nodes are palpable.
 Can also be combined with post operative RT.
 Near-total laryngectomy + post op RT ( for lateralised disease )

51. Supraglottic Carcinoma
 T1-T2 Supraglottic Carcinoma
- Transoral endoscopic CO2 laser resection- treatment
ofchoice
-If endoscopic laser resection is not feasible
 Radiotherapy
 Supraglottic laryngectomy/SCPL-CHEP

52. T3 Supraglottic Carcinoma
 Treatment options in order of preference
 Chemo – radiotherapy
 Endoscopic CO2 laser resection if the pre epiglottic space invasion is
limited
 Supraglottic partial laryngectomy (for small volume disease) and
 SCPL—CHEP(if the growth is bulky or encroaching the glottis)
-in patients who are fit and have no significant chest problems.
 Near-total laryngectomy - lateralised lesion.
 Total Laryngectomy as a last resort
- if none of the above is feasible

53. T4 Supraglottic Carcinoma
 Total laryngectomy + post op RT
 Near-total laryngectomy + post op RT ( for lateralised disease )

54. Subglottic carcinoma
 T1 & T2 Subglottic carcinoma
- Radiotherapy alone
-treatment of choice with preservation of voice
-Surgery is reserved for failure of radiation therapy or for patients who
cannot be easily assessed for radiation therapy.
 T3 & T4 Subglottic carcinoma
-Total laryngectomy and post-op. RT (radiation should also include superior
mediastinum)
-Radiotherapy alone( who are unfit for surgery )

55. Management of Neck
 Main predictor of survival in squamous cell carcinoma is the presence,
number and extracapsular spread of lymph node metastases
Management of neck
-Depends on site of primary
-T stage of primary
-Clinical N stage
-Choice of treatment modality for the primary

56.  N0
 Elective neck dissection is commonly performed for management of
node negative T2-4 supraglottic,
T3-4 glottic cancer
 Elective neck irradiation

57.  N+
-Comprehensive neck dissection is procedure of choice followed by
postoperative radiotherapy or chemotherapy
- RT- Neck dissection prior to radiation or post radiation salvage surgery for
residual neck nodes

58. Radiotherapy
 Radiation therapy :
Cure rates with radiation therapy ranges from 80% -95%.
 Conventional radiotherapy consists of :
- Once daily treatment delivering 2 Gray/day.
- 5 doses/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 schedule:
• Hyper fractionation
• Accelerated fractionation

59.  Hyper fractionation
-Delivers a higher total dose over the same 7 weeks treatment period
using multiple smaller fractions of radiotherapy per day.
- The lower dose per fraction results in preferential sparing oflate
responding tissuethus reducing the incidence of late normal tissue
effects.
 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.

60.  Concurrent chemo-radiotherapy
- 66-70 Grays of radiation
-Concurrently Cisplatin 100mg/m2 is given on day 1,22, & 43
- Claims highest cure rates
-Carries high toxicity

61.  Neoadjuvant chemotherapy
- 2 cycles of Cisplatin(80-120mg/m2) + 5- FU(10- 15mg/m2) given within 3
weeks interval
- Only those with > 50% tumour regression will receive radiation therapy

62. Transoral Laser Surgery
Inclusion Criteria
 Complete endoscopic visualization of the carcinoma
 Tumor extension to the contralateral VC < 3mm
 Absence of arytenoid involvement (except vocal process)
 Subglottic extension < 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.

63.  Advantages
 Good voice quality
 Good swallowing
 Lower complications rates
 Lower cost
 Shorter hospitalization
 Tracheostomy and NG tubes
not routinely required
 Complications
 Complication rates are <5%
and from most to least
common include
 Granuloma formation
 Laryngeal edema
 Laryngeal stenosis
 Chondronecrosis

64. operation indication
Vertical partial
Laryngectomy
Lesions for mobile cord
extending to ant
commisure,i/l
vocalprocess n
anterosuperior portion of
arytenoid
subglotticextension,<5m
m
Fixed vc lesion not
crossing the midline
Not involving the ant 3rd
of the opp cord
Removes
adjacent
thyroid
cartilage
Removal one
tvc n upto 1/3
rd or 5mm of
other tvc
cordectomy Small lesions of early T1a
lesions of middle 1/3rd of
vocal cord
Involved
vocalcord

66. operation indication parts removed
supraglottic
laryngectomy(SGL)
-voice
preservation
for early
supraglottic
extension
- epiglottis
-aryepiglottic fold
- false cords
- upper 1/3-1/2 of
thyroid cartilage
- ±hyoid bone removed if
epiglottic space involved
-preserves one or
both arytenoids &
true vc
extended
supraglottic
laryngectomy
supraglottic
lesion
with<1cm
base of tongue
invasion
same as SGL with
removal of i/l bot
upto circumvallete
papillae

68. Supracricoid partial
laryngectomy (SCL)
Selected T2 n T3
glotttis d/s
Involving b/l post
commisure only
Lesion on
mobilecord
extending toant
commisure
Cord fixation in
anotherwise T2
lesion
Both true n false cords with
entire thyroid cartilage
May remove the arytenoids

70. Near total
laryngectomy
T3/T4 laterlised
transglottic lesions
with no extension to
arytenoids
-T3/T4 laterlised
lesions of Pyriform
Sinus with
involvement
of apex and causing
fixity of hemilarynx
-Interarytenoid ,
retroarytenoid &
postcricoid region
must be
free.
•Strap ms
• I/L thyroid crtilage
• Thyroid lobe
• I/L cricoid cartilage ring
• Upper tracheal ring
• Preepiglottic space
• Epiglottis
• Hyoid
• I/L VC with involved C/L VC
total
laryngectomy
Lesions with
transglottic or
extensive
(>1cm)subglottic
extension
Salvge for RT failure
removes hyoid,
thyroid,cricoidcartilage,epigl
ottis strap muscle.Patient
left with apermanent
tracheostoma
Total laryngectomy
+removal of varying

72.  Department of Otorhinolaryngology and Head and Neck
Surgery, Korea Cancer Center Hospital, Seoul, Korea

73. INTRODUCTION
 The first treatment of laryngeal cancer was a tracheostomy, which was
performed by Trousseau in 1837.
 In 1863, Sands obtained the first long-term control of cancer via a
laryngofissure.
 The use of a laryngofissure has continued over the years for the control of
smaller and intrinsic lesions of thelarynx, but was not thought to be
applicable to extrinsic tumors.
 After Billroth's first successful total laryngectomy in 1873 , more attention
has paid to the use of total extirpative surgery, which has continued to
the inclusion of a total laryngectomy, with en bloc radical neck dissection .

74.  In 1885, Roentgen discovered X-rays, and in 1903 Schepegrell first used X-
rays to treat laryngeal cancer.
 At the beginning of the twentieth century, cancer of the larynx was one of
the first tumors treated, and cured, with the use of radiotherapy.
 Radiotherapy has been use in the treatment of early, small malignancies,
and in attempts to palliate large tumors that were beyond the scope of
surgical removal.

75.  with early laryngeal cancer includes T stages 1 and 2, and patients with early
laryngeal cancer have a greater opportunity for preservation of the larynx
than those with advanced laryngeal cancer, or those at T stages 3 and 4.
 Patients with early stage laryngeal cancer are usually treated with multiple
surgical methods(transoral laser cordectomy, laryngofissure cordectomy,
vertical partial laryngectomy or supraglottic subtotal laryngectomy) or
radiotherapy alone.

76.  Many patients with advanced stage laryngeal cancer used to be treated with a total
laryngectomy, but recently, the combination therapy of neoadjuvant chemotherapy,
following an operation or radiotherapy, has been tried.
 The use of platinum salts at the end of the 1970s, and the combination of cisplatin
and 5-FU at the beginning of the 1980s, have changed the situation by leading to
the complete macroscopic disappearance of tumors in 30~40% of previously
untreated patients.
 It very soon became apparent that most chemosensitive tumors were also
radiosensitive.
 This provided the basis for the development of a new strategy, leading to the
preservation of the larynx in selected patients: after the initial chemotherapy, the
good responders received radiotherapy, and the poor responders underwent a total
laryngectomy

77.  A therapeutic neck dissection is performed at the time of initial surgery in
patients with clinical node involvement.
 An elective neck dissection is generally carried out in patients with cancer
of the supraglottic larynxPostoperative radiotherapy is given to the primary
site and neck, based on the clinicopathological risk factors: positive or
closed surgical margins, perineural invasion, multiple lymph node
involvement in the neck or extracapsular spread

78. Treatment of early laryngeal
cancer
1) Laser surgery versus radiotherapy
 Two treatment options are widely used for the cure of T1 glottic squamous
cell carcinomas: radiotherapy and surgical removal.
 There is ongoing controversy about whether laser excision should be offered
to patients with T1 glottic carcinomas.
 Carcinomas of the glottis are usually diagnosed in the early stage of the
disease, with malignant spread to regional lymph nodes seldom seen, and
distant metastases extremelrare .

79.  Transoral laser excision allows the surgeon to offer an effective, definitive
treatment for glottic cancers, and is less expensive and more convenient
than traditional external beam radiotherapy .
 Two studies were found to be comparative, i.e. as they included control
groups receiving radiotherapy . In a retrospective study, by Epstein et al., the
outcomes of 60 patients who received radiotherapy (43 T1a and 17 T1b) or
an endoscopic laser resection (17 patients with T1a) were compared.
 They found the local control rate was significantly higher in the radiotherapy
than in the laser treatment group, with 3-year local control rates of 89 and
77%, respectively (p= 0.042).

80.  A relatively large proportion of the laser-treated patients required
postoperative radiotherapy, due to residual carcinomas at resection borders
(30%).
 Laser treatment affords an additional line of treatment, as recurrences can
be treated with radiotherapy, thus sparing patients from a salvage
laryngectomy.
 However, one of the drawbacks of laser treatment, as a primary
intervention, might be that complete removal of the tumor is not possible in
every case, and additional therapy may be needed.
 This increases the treatment load on the patient, as well as increasing the
costs.
 Laser treatment should only be considered in small, mid-cord tumors at one
vocal cord, without impaired mobility.

81.  There is some controversy about the applicability of laser treatment for
malignant tumors localized at the anterior commissure.
 Most authors state that it is contraindicated to apply laser excision in this
region, while others advocate that, if the right surgical technique is used,
laser is the treatment of choice.
 However, the poorer outcome of these patients, regardless of the treatment
option used, might be due to unrecognized microinvasion of the thyroid
cartilage.
 In a study by Krespi , all patients with carcinomas localized at the anterior
commissure, treated with laser, had a tumor recurrence, and in most cases
additional treatment was necessary, i.e. laryngec tomy or radiotherapy

82.  However, patients with a tumor localized at the anterior commissure,
receiving radiotherapy, also face an increased risk of a recurrence.
 At present, it is generally accepted that tumors localized to the anterior
commissure are contraindicatory to laser resection, and radiotherapy is the
treatment of choice with this type of malignancy
 The effectiveness of a transoral laser excision directly depends on the
physician's ability to identify and visualized the limits of the tumor.
 When the tumor is obscured by a submucosal location or edematous tissue,
transoral laser excision becomes more difficult; and therefore, less reliable.

83.  Recommended indications for radiotherapy are:
1) recurrence after one or more prior vocal fold strippings,
2) recurrence in a short period after stripping,
3) an inability to follow closely after treatment,
4) the voice quality is critical (professional singers),
5) overall poor operative risks, and
6) anterior commissure lesion of inaccessible for complete endoscopic
ablation

84.  2) Partial laryngectomy
 The indications and problems of an organ-preserving vertical partial
laryngectomy (VPL), in T1b glottic or T2 glottic and subglottic cancers, are well
known.
 The first, and imperative, requirement for the surgeon is the adequate resection
of the tumor, while the second prerequisite is the safe and successful correction
of the excised portion of the anterolateral wall of the larynx.
 Krajina's method , for the reconstruction of the larynx, utilizes the pedicled
sternohyoid fascia, which is thin, elastic, well adaptable to defects and resistant
to infection or saliva. By providing a large surface for covering the
defects,granulations and synechiae can be prevented
 The conventional treatment of choice for supraglottic cancer, not involving a
vocal cord, is a horizontal supraglottic laryngectomy

85. Treatment of Advanced
Laryngeal Cancer
1) Conventional therapy
 There are two major conventional therapeutic options: radical surgery (such
as total laryngectomy), with optional postoperative or definitive
radiotherapy, with surgery kept in reserve for salvage in the case of a
respectable local recurrence.
 One of the most recent clinical report of a total laryngectomy presented local
control and 5-year survival rates of 86 and 67%, respectively .
 Despite this high success rate, a total laryngectomy has a low patient
compliance, as it is a mutilating procedure.

86. 2) Laryngeal preservation
-A supracricoid partial laryngectomy (SCPL) is a suitable conservative
procedure, which can be used as an alternative to a mutilating procedure for
advanced supraglottic and glottic cancers.
- SCPL, with a cricohyoidopexy, is indicated bysupraglottic cancer, with
involvement of the ventricle, vocal cord limited preepiglottic space and
paraglottic space, and by glottic cancer, with involvement of the anterior
commissure, paraglottic space and ventricle, or with limited thyroid
cartilage invasion.
-

87.  After World War II, chemotherapy became a new tool against cancer. Up to the
end of the 1970s, however, no regimens was sufficiently active against head and
neck squamous cell carcinomas, so chemotherapy was mainly used for palliation
(advanced unresectable, recurrent, or metastatic disease).
 The appearance of platinum-based chemotherapy, particularly the combination
of cisplatin and 5-fluorouracil (5-FU), completely modified the rationale, with the
possibility of integrating chemotherapy into protocols with curative intent.
 Impressive response rates, as high as 80%, for objective responses, and 40 to 50%
for complete responses, have been observed in previously untreated patients.

88.  It quickly became apparent that chemosensitive tumors were also
radiosensitive in most cases.
 This apparent ability, of neoadjuvant chemotherapy to predict
radiosensitivity, led some teams to assess the possibility of avoiding total
ablation of the larynx, using upfront chemotherapy, followed in the good
responders by radiotherapy, and in the poor responders by the initially
planned surgery

89.  Many series have assessed the reliability of neoadjuvant chemotherapy-
based protocols in a nonrandomized fashion.
 Roughly speaking, these series have presented that laryngeal preservation
can be achieved in one-third to one-half of patients. Only four randomized
trials (16~19) have been reported . There was no significant difference
insurvival between the mutilating surgery and neoadjuvant chemotherapy
groups, with the exception of the report by Richard.
 However, in this report a laryngeal preservation rate of over 50% was
achieved in the survivors.

90.  Ultimate local control in radiotherapy (including salvage surgery, in most
cases a total laryngectomy) was similar to that in the surgical series of
laryngeal cancers.
 An important retrospective study, from Christie Hospital, recently appeared.
 A total of 114 patients, with T3N0 glottic carcinomas, were treated by
radiotherapy, between 1986 and 1994.
 The 5-year overall survival was 54%, with a 5-year local control, after
radiotherapy alone, and after salvage surgery, of 68 and 80%, respectively.
 These results indicate the magnitude of the problem: In such cases surgery is
able to ensure local control in almost all cases, but the price paid is the loss
of voice.
 Incontrast, radiotherapy (including salvage surgery) achieved only 80% local
control, but two-thirds of the larynxes were preserved.

91.  There are two other radiotherapy-based protocols. One is the modified
fractionation schemes.
 The role of accelerated or hyperfractionated treatment is to increase the
total dose delivered and, if possible, shorten the overall treatment time.
 A study shows that a reduction in the treatment time resulted in a
significant benefit in tumor control and a similar but not significant
benefit was found regarding survival (21) The other is concomitant
chemoradiotherapy.
 Concomitant chemoradiotherapy could be a highly effective way of
increasing the locoregional control of advanced head and neck tumors.
 Merlano included 26% of tumors in a combined-therapy arm (four
courses of chemotherapy alternating with three courses of radiotherapy)
and 31% in a radiotherapy- alone.
 The complete tumor response and 3-year survival rates were significantly
in favor of the combinedtherapy).

92.  Finally, hyperfractionated radiotherapy (75 Gy twice daily in 1.25 Gy doses)
was compared with combined chemoradiotherapy (four courses of CDDP/5-
FU for 5 days with the same fractionation scheme).
 Of the 116 randomized patients, 36% presented with laryngeal and
hypopharyngeal tumors, mostly at stages T3 and 4 (88%).
 The overall and relapse-free survivals,and the locoregional control were
significantly in favor of the combined-therapy regimen .
 These preliminary results suggest, there was no difference in the overall
survival, fewer distant metastases when chemotherapy was delivered and a
trend for higher larynx preservationrates, with the concurrent
chemoradiotherapy.
 The long-term results are still to be assessed.

93. CONCLUSION
- Too many parameters remain to be evaluated to assess the efficacy of the
various modalities used to eradicate primary laryngeal tumors, and preserve
the laryngeal form and function. Many factors, in addition to local
extension, may influence decision-making.
-Little is known about the proportion of patients that can actually benefit from
preservation protocols.
-Finally, parameters, such as the quality of life, cost- effectiveness and the
reproducibility of various strategies, from one institution to another, have
been underevaluated.

94. -The lessons learnt from this intensive clinical research are difficult to
incorporate into daily practice, and the most appropriate way to select
patients to undergo the various strategies is still a concern.
-Some parameters are linked to the treating physician, others to the patient
and probably many to the tumor itself, particularly the biological
characteristics.
-At present, the preservation of the laryngeal form and function remains a
challenge that must be permanently assessed by multidisciplinary clinical
research.

95. Thank You