Cancer of the Larynx and Pharynx

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Cancer of the Larynx and Pharynx

• Our therapeutic concept
• Transoral lasermicrosurgical resection
• if preservation of organ seems feasible
• Selective neck dissection ( N0 N2 )
• Postoperative radio (- chemo) therapy for
  advanced neck disease

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Cancer of the Larynx and Pharynx

• The main principle is to minimize the surgical
  morbidity while not compromising time honored
  oncological principles

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Cancer of the Larynx and Pharynx

• Prerequisites
• Experience of the surgeon
• Adequate exposure
• Careful histological examination
• Cooperation of the patient
• acceptance of possible re-resection, follow
  up and the abandoning of
• carcinogenic habits

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Cancer of the Larynx and Pharynx

• Preconditions for organ preservation
• Larynx preservation of at least one
  arytenoid cartilage
• Hypopharynx preservation of half of the
  larynx
• circumference of hypopharynx about 2 cm
• No extensive spread to the neck
  

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Cancer of the Glottis pT2/pT3 n338
Therapy
pT2a pT2b pT3
n128 n115 n95 Laser 116
(91) 87 (76) 42 (44) Laser ND
12 15 41 Laser RAD
- 11 3 Laser
ND RAD - 2 9
University of Göttingen, Germany
05/2005
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Cancer of the Glottis pT2/pT3 n338
Postoperative Complications ( n 10 /
3 )
pT2a pT2b pT3
n128 n115 n95 Postop. Bleeding (MLS) 1
1 1 Glottic stenosis (MLS) 0 0
1 Laryngeal edema (MLS) 0 0
2 Tracheotomy 0 0 3 Pneumonia 1
0 0
Department of Otorhinolaryngology, Head and Neck
Surgery University of Goettingen, Germany
04/2005
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Cancer of the Glottis pT2/pT3 n338
Recurrence-free Survival
82,1
pT2a
61,4
pT2b
Recurrence-free survival
pT3
60
Time months
05/2005
University of Göttingen, Germany
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Cancer of the Glottis pT2/pT3 n338
Overall Survival
74,5
Overall survival
64,6
pT2a
pT2b
57,6
pT3
Time months
05/2005
University of Göttingen, Germany
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Supraglottic Carcinoma n216
Therapy
Stage III Stage IV n65
n68 Laser 12 - Laser ND 42
36 Laser RAD 1 - Laser ND
RAD 10 32
Universitäts-HNO-Klinik Göttingen
05/2005
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Supraglottic carcinoma n216
Postoperative Complications
pT1/pT2 pT3/pT4
n95 n121 Postop. bleeding (MLS)
5 13 Laryngeal edema (MLS)
1 4 Laryngeal stenosis 1
3 Pneumonia 2 2
Department of Otorhinolaryngology, Head and Neck
Surgery University of Goettingen, Germany
04/2005
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Supraglottic carcinoma n216 Tracheotomy
pT1/pT2 pT3/pT4 n95
n121 Prophylactic 1
3 Aspiration 0
2 Edema 1 1 Stenosis 0 2 Postop.
bleeding 0 1
Department of Otorhinolaryngology, Head and Neck
Surgery University of Goettingen, Germany
04/2005
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pT3 and pT4 Supraglottic Carcinoma (n121)
pT3 pT4 (n76)
(n45) 5y local control rate 79 69 Salva
ge laryngectomy 5 16 5y overall
survival rate 67 54 5y rec.-free survival
rate 67 60
median follow-up interval 52 months
12/2002
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Piriform Sinus Carcinoma (n129)
Stage Distribution (UICC 1992)
a
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Piriform Sinus Carcinoma (n129)
Postoperative and late complications
Postoperative Hemorrhage 5 (3.9) -
endoscopic coagulation 4 - endoscopic
coagulation, tracheotomy 1 Postoperative
Edema 1 (0.8) - microlaryngoscopic
removal of mucosa Posttherapeutic
hypopharyngeal stenosis 1 (0.8) - gastrostomy
tube
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Piriform Sinus Carcinoma n129
Local recurrence
Loco-reg. rec.
UICC 92
No. No. pT1 n24 2
8.3 0 0 pT2 n74 5 6.7 3
4.1 pT3 n17 2 11.8 0 0 pT4 n14
3 21.4 2 14.3
1 x kontralaterally
04/2000
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Piriform Sinus Carcinoma (n129)
Salvage Therapy of Local and Locoregional
Recurrences (n17)
No. Laser microsurgery 5
29 Laser microsurgery radiotherapy 3
18 Partial pharyngectomy with laryngeal
preservation 1 6 Partial pharyngectomy
with total laryngectomy 1 6 Palliative
treatment 6 35 Unknown 1 6
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Piriform Sinus Carcinoma (n129)
Recurrence-free Survival
95
69
01/2000
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Piriform Sinus Carcinoma (n129)
Overall Survival
71
47
01/2000
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• Advantages are based on the following
• Transoral approach
• Use of the operating microscope
• Specific cutting properties of the CO2-laser
• Transecting tumor tissue

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Advantages ( 1 )

• Laser surgery repeatable at any time ( residual,
  recurrent, 2nd primary )
• All surgical options available during or after
  laser resection
• Integration into any therapeutic concept
• Early postoperative radiotherapy possible

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Advantages ( 2 )

• Low peri- and postoperative morbidity
  Rarely tracheotomy or feeding
  gastrostomy No blood transfusion
• Low complication rate
• No fistulas or carotid blow out
• Rarely significant edema
• Rarely perichondritis or chondronecrosis

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Advantages ( 3 )

• Duration of operation, hospital stay and
  rehabilitation
• are shorter
• Lower costs
• Professional and social reintegration earlier
  and more
• effective
• Favourable psycho-oncologic effects

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Glottic Cancer pT1an333
(5-year Kaplan-Meier Estimates)

• Local Control ? 96.2
• Disease specific surv. ? 100
• Overall Survival ? 86.8
• Larynx Preservation Rate ? 97.6
• Complication Rate ? 1.2
  

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Results
  Primary TNM Primary TNM Primary TNM Primary TNM Primary TNM Primary TNM
T1a (n158) T1a (n158) T1b (n30) T1b (n30) T2a (n75) T2a (n75)
AC AC- AC AC- AC AC-
Number of patients 28 (18) 130 (82) 16 (53) 14 (47) 45 (60) 30 (40)
Overall Survival 3-year 5-year 87 87 90 86 100 100 93 70 91 80 90 56
Local Control 3-year 5-year 84 84 94 90 81 73 92 92 82 79 74 74
Local Recurrence 14 (4/28) 5 (7/130) 25 (4/16) 7 (1/14) 22 (10/45) 17 (5/30)
Locoregional Recurrence 4 (1/28) - 6 (1/16) - 2 (1/45) -
Ultimate Local Control 100 100 94 100 98 97
Salvage Laryngectomy 7 (2/28) 1 (1/130) 13 (2/16) - 7 (3/45) 3 (1/30)
AC - anterior commissure involvement AC- - no
anterior commissure involvement LE - salvage
total laryngectomy for advanced recurrence.
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Transoral Carbon Dioxide Laser Microsurgery for
Recurrent Glottic Carcinoma after Radiotherapy
Department of Otorhinolaryngology Head and Neck
Surgery University of Göttingen, Germany
34 patients with recurrent glottic carcinomas
after radiotherapy were treated by laser
microsurgery between 1987 and 1998
Primary tumor classification before radiotherapy
Classification of recurrence after radiotherapy
No. of cases
rT1 11
rT2 10
rT3 10
rT4 3
No. of cases
Tis 4
T1 19
T2 10
T3 1
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Organ Preservation and Survival

• 24 patients (71) were cured with one or more (up
  to 4) laser procedures.
• In 9 patients (27) recurrences could not be
  controlled by laser microsurgery. 6 (18)
  patients underwent total laryngectomy, 3 patients
  (9) underwent palliative treatment.
• One patient received total laryngectomy because
  of chondronecrosis after laser treatment.
• Overall 3-year (5-year) survival rate was 74
  (53).
• The Kaplan-Meier 3-year and 5-year
  disease-specific survival was 86.

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Functional Results
No. of patients
Synechia of the anterior commissure 3
Laryngeal stenosis 1
Tracheostomy with the first laser procedure 0
Long term swallowing problems 0
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Conclusion

• In early and advanced stage recurrent glottic
  carcinomas after primary radiotherapy, C02 laser
  treatment can be recommended for early and
  advanced glottic carcinomas as a curative organ
  preserving procedure with favourable functional
  results.