Transcript Cancer of the Hypopharynx

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
Cancer of the Larynx and Pharynx
The main principle is to minimize the
surgical morbidity while not compromising
time honored oncological principles
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
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
Cancer of the Glottis pT2/pT3
n=338
Therapy
pT2a
n=128
Laser
116 (91%)
Laser + ND
12
Laser + RAD
Laser + ND + RAD
-
University of Göttingen, Germany
pT2b
n=115
pT3
n=95
87 (76%)
15
11
2
42 (44%)
41
3
9
05/2005
Cancer of the Glottis pT2/pT3
n=338
Postoperative Complications
( n= 10 / 3 % )
pT2a
n=128
Postop. Bleeding
Glottic stenosis
Laryngeal edema
Tracheotomy
Pneumonia
(MLS)
(MLS)
(MLS)
Department of Otorhinolaryngology, Head and Neck Surgery
University of Goettingen, Germany
1
0
0
0
1
pT2b
n=115
pT3
n=95
1
0
0
0
0
1
1
2
3
0
04/2005
Cancer of the Glottis pT2/pT3
n=338
Recurrence-free Survival
Recurrence-free survival [%]
100
90
82,1%
pT2a
80
70
61,4%
pT2b
60 %
pT3
60
50
40
30
20
pT2a (n=129)
pT2b (n=115)
pT3 (n=95)
10
0
0
10
20
30
40
50
60
70
80
90
Time [months]
University of Göttingen, Germany
05/2005
Cancer of the Glottis pT2/pT3
n=338
Overall Survival
Overall survival [%]
100
90
80
74,5%
70
64,6%
60
57,6%
pT2a
pT2b
50
pT3
40
30
20
pT2a (n=129)
pT2b (n=115)
pT3 (n=95)
10
0
0
10
20
30
40
50
60
70
80
90
Time [months]
University of Göttingen, Germany
05/2005
Supraglottic Carcinoma
n=216
Therapy
Stage III
n=65
Laser
Laser + ND
Laser + RAD
Laser + ND + RAD
12
42
1
10
Stage IV
n=68
36
32
Universitäts-HNO-Klinik Göttingen
05/2005
Supraglottic carcinoma
n=216
Postoperative Complications
pT1/pT2
n=95
pT3/pT4
n=121
5
1
1
2
13
4
3
2
Postop. bleeding
(MLS)
Laryngeal edema (MLS)
Laryngeal stenosis
Pneumonia
Department of Otorhinolaryngology, Head and Neck Surgery
University of Goettingen, Germany
04/2005
Supraglottic carcinoma
n=216
Tracheotomy
Prophylactic
Aspiration
Edema
Stenosis
Postop. bleeding
pT1/pT2
n=95
pT3/pT4
n=121
1
0
1
0
0
3
2
1
2
1
Department of Otorhinolaryngology, Head and Neck Surgery
University of Goettingen, Germany
04/2005
pT3 and pT4 Supraglottic Carcinoma (n=121)
pT3
(n=76)
pT4
(n=45)
79
69
Salvage laryngectomy [%]
5
16
5y overall survival rate [%]
67
54
5y rec.-free survival rate [%]
67
60
5y local control rate [%]
median follow-up interval: 52 months
12/2002
Piriform Sinus Carcinoma (n=129)
Stage Distribution (UICC 1992)
Stage IVa
54%
Stage I
8%
Stage II
18%
Stage III
20%
Piriform Sinus Carcinoma (n=129)
Postoperative and late complications
Postoperative Hemorrhage
- endoscopic coagulation
- endoscopic coagulation, tracheotomy
Postoperative Edema
5 (3.9%)
4
1
1 (0.8%)
- microlaryngoscopic removal of mucosa
Posttherapeutic hypopharyngeal stenosis
- gastrostomy tube
1 (0.8%)
Piriform Sinus Carcinoma
n=129
Local recurrence
UICC 92
Loco-reg. rec.
No.
%
No.
%
pT1 n=24
2
8.3
0
0
pT2 n=74
5
6.7
3*
4.1
pT3 n=17
2
11.8
pT4 n=14
3
21.4
* 1 x kontralaterally
0
0
2
14.3
04/2000
Piriform Sinus Carcinoma (n=129)
Salvage Therapy
of Local and Locoregional Recurrences (n=17)
Laser microsurgery
Laser microsurgery + radiotherapy
Partial pharyngectomy with laryngeal preservation
Partial pharyngectomy with total laryngectomy
Palliative treatment
Unknown
No.
%
5
3
1
1
6
1
29
18
6
6
35
6
Piriform Sinus Carcinoma (n=129)
Recurrence-free Survival
100
recurrence-free survival [%]
stage I and II
95%
90
80
70
69%
60
stage III and IV
50
40
30
20
10
0
0
12
24
36
48
60
72
84
time [months]
01/2000
Piriform Sinus Carcinoma (n=129)
Overall Survival
100
stage I and II
recurrence-free survival [%]
90
80
71%
70
60
stage III and IV
47%
50
40
30
20
10
0
0
12
24
36
48
60
72
84
time [months]
01/2000
Advantages are based on the following:
 Transoral approach
 Use of the operating microscope
 Specific cutting properties of the CO2-laser
 Transecting tumor tissue
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
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
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
Glottic Cancer pT1a
n=333
(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 %
Results
Primary TNM
T1a
(n=158)
T1b
(n=30)
T2a
(n=75)
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)
Transoral Carbon Dioxide Laser
Microsurgery for Recurrent Glottic
Carcinoma after Radiotherapy
Department of Otorhinolaryngology – Head and Neck Surgery
34 patients with recurrent
glottic
carcinomas
after radiotherapy were treated
University
of Göttingen,
Germany
by laser microsurgery between 1987 and 1998
Primary tumor classification
before radiotherapy
Classification of recurrence
after radiotherapy
No. of cases
No. of cases
Tis
4
rT1
11
T1
19
rT2
10
T2
10
rT3
10
T3
1
rT4
3
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%.
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
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.