The International Federation          of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and O...
TUMORS OF THE LARYNX                      EPIDEMIOLOGY       •   Second most common       malignancy of the UADT       •  ...
TRANSORAL LASER SURGERYDISEASE                    TREATMENTCONTROL                    MORBIDITY OPEN NECK CONSERVATIVE SUR...
DIAGNOSTIC WORK-UP                         TARGETS                                               OP	                      ...
DIAGNOSTIC WORK-UP                PREOPERATIVE•      Flexible panendoscopy•      Videolaryngostroboscopy•      Autofluores...
DIAGNOSTIC WORK-UP                PREOPERATIVE              • Flexible panendoscopy                            MACROSCOPIC...
DIAGNOSTIC WORK-UP                    PREOPERATIVE            • Narrow Band Imaging (NBI)         Type I:                 ...
DIAGNOSTIC WORK-UP                    PREOPERATIVE        Imaging (CT, MRI) check list:                                   ...
DIAGNOSTIC WORK-UP                 PREOPERATIVE                       PARAGLOTTIC SPACE                        INVOLVEMENT...
DIAGNOSTIC WORK-UP              INTRAOPERATIVE                                              30°                           ...
TRANSORAL LASER SURGERY FOR              GLOTTIC TUMORS       INDICATIONS Tis-T1 and selected T2-T3N0 SCC                 ...
TRANSORAL LASER SURGERY        ENDOSCOPIC CORDECTOMIES       Type I   Type II   Type III2012                             R...
TRANSORAL LASER SURGERY       ENDOSCOPIC CORDECTOMIES2012          TYPE I and TYPE II
TRANSORAL LASER SURGERY        ENDOSCOPIC CORDECTOMIESType IV    Type Va    Type Vb   Type Vc Type Vd                     ...
TRANSORAL LASER SURGERY          PIECEMEAL TECHNIQUE2012
TRANSORAL LASER SURGERY       ENDOSCOPIC CORDECTOMIES          PIECEMEAL TECHNIQUE2012            ENDOSCOPIC PARTIAL      ...
TRANSORAL LASER SURGERY FOR            SUPRAGLOTTIC TUMORS        INDICATIONS•  T1-T2 and selected T3 (with limited       ...
TRANSORAL LASER SURGERYENDOSCOPIC SUPRAGLOTTIC LARYNGECTOMIES2012                              Remacle et al. 2009
TRANSORAL LASER SURGERYENDOSCOPIC SUPRAGLOTTIC LARYNGECTOMIES2012                              Remacle et al. 2009
TRANSORAL LASER SURGERYENDOSCOPIC SUPRAGLOTTIC LARYNGECTOMIES2012
TRANSORAL LASER SURGERY                ONCOLOGIC RESULTS (Level III)                                                      ...
ENDOSCOPIC CORDECTOMIES                            FUNCTIONAL RESULTS Patients treated by Type I and II cordectomies prese...
ENDOSCOPIC CORDECTOMIES                    FUNCTIONAL RESULTS In a recent review Spielmann et al. examined 21 papers evalu...
2012
OPEN-NECK CONSERVATIVE SURGERY             INDICATIONS   •  T2 and selected T3/T4a glottic/supraglottic                   ...
OPEN-NECK CONSERVATIVE SURGERY       Vertical partial laryngectomy2012
OPEN-NECK CONSERVATIVE SURGERY              Horizontal supraglottic laryngectomy2012
OPEN-NECK CONSERVATIVE SURGERY                   Supracricoid partial laryngectomy2012                                    ...
OPEN-NECK CONSERVATIVE SURGERY                Supracricoid partial laryngectomy                                  CHP2012
OPEN-NECK CONSERVATIVE SURGERY                   ONCOLOGIC RESULTS (Level III)                                            ...
OPEN-NECK CONSERVATIVE SURGERY                          FUNCTIONAL RESULTS                     Vertical Partial Laryngecto...
OPEN-NECK CONSERVATIVE SURGERY                       FUNCTIONAL RESULTS             Supracricoid Partial LaryngectomiesAsp...
OPEN-NECK CONSERVATIVE SURGERY                         FUNCTIONAL RESULTS                 Supracricoid partial laryngectom...
Highest-Level Evidence for Treatment Options for Early             Laryngeal Cancer (Level III)        Reference     N° of...
CONSERVATIVE SURGERY                        CONCLUSIONS       TLS in early-intermediate glottic and supraglottic tumors al...
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Endoscopic Surgery for Laryngeal Function Preservation by P. Nicolai

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Endoscopic Surgery for Laryngeal Function Preservation by P. Nicolai

  1. 1. The International Federation of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and Oncology 2012 Endoscopic Surgery forLaryngeal Function Preservation Piero Nicolai
  2. 2. TUMORS OF THE LARYNX EPIDEMIOLOGY •  Second most common malignancy of the UADT •  Over 11,000 case/yr in US (2007) with 3,660 deaths • M:F=3.8:1 • 90% of pts are older than 40 yrs • 85%-95% squamous cell carcinoma • Tobacco and alcohol are the two most important risk factors2012 Data from Cummings, Otolaryngology Head and Neck Surgery, 5th Ed.
  3. 3. TRANSORAL LASER SURGERYDISEASE TREATMENTCONTROL MORBIDITY OPEN NECK CONSERVATIVE SURGERY 2012
  4. 4. DIAGNOSTIC WORK-UP TARGETS OP KERATOSIS •  Histology•  Superficial spreading SCC •  Deep/Submucosal invasion•  Multifocality O •  Synchronous lesions 2012
  5. 5. DIAGNOSTIC WORK-UP PREOPERATIVE•  Flexible panendoscopy•  Videolaryngostroboscopy•  Autofluorescence•  Narrow Band Imaging•  Imaging2012
  6. 6. DIAGNOSTIC WORK-UP PREOPERATIVE • Flexible panendoscopy MACROSCOPIC APPEARANCE2012 LARYNGEAL MOBILITY
  7. 7. DIAGNOSTIC WORK-UP PREOPERATIVE • Narrow Band Imaging (NBI) Type I: Type II:well-demarcated brownish undemarcated area witharea with thick dark spots scattered irregular and winding vessels Type III: 2012 presence of an afferent hypertrophic vessel branching out in small vascular loops in the context Piazza et al.2009 of the lesion
  8. 8. DIAGNOSTIC WORK-UP PREOPERATIVE Imaging (CT, MRI) check list: PS T• Laryngeal framework• Paraglottic and preepiglottic PESspace• Submucosal spread C• Soft tissues A• N status C 2012
  9. 9. DIAGNOSTIC WORK-UP PREOPERATIVE PARAGLOTTIC SPACE INVOLVEMENT and ARYTENOID SCLEROSIS2012 PREEPIGLOTTIC SPACE LARYNGEAL FRAMEWORK INVOLVEMENT INFILTRATION
  10. 10. DIAGNOSTIC WORK-UP INTRAOPERATIVE 30° 70°• Microlaryngoscopy with 0° andangled telescopes 0°• Narrow Band Imaging with HDTV• Saline infusion into Reinke s space 2012
  11. 11. TRANSORAL LASER SURGERY FOR GLOTTIC TUMORS INDICATIONS Tis-T1 and selected T2-T3N0 SCC Inadequate exposureSalvage surgery after RT in rT1 and rT2 lesions Crico-arytenoid joint and/or posterior Poorly radiosensitive histologies paraglottic space involvement Posterior commissure involvement Laryngeal framework infiltration Transcommissural vertical extension (?) CONTRAINDICATIONS2012
  12. 12. TRANSORAL LASER SURGERY ENDOSCOPIC CORDECTOMIES Type I Type II Type III2012 Remacle et al. 2000
  13. 13. TRANSORAL LASER SURGERY ENDOSCOPIC CORDECTOMIES2012 TYPE I and TYPE II
  14. 14. TRANSORAL LASER SURGERY ENDOSCOPIC CORDECTOMIESType IV Type Va Type Vb Type Vc Type Vd Type VI 2012 Remacle et al. 2000, 2007
  15. 15. TRANSORAL LASER SURGERY PIECEMEAL TECHNIQUE2012
  16. 16. TRANSORAL LASER SURGERY ENDOSCOPIC CORDECTOMIES PIECEMEAL TECHNIQUE2012 ENDOSCOPIC PARTIAL LARYNGECTOMY
  17. 17. TRANSORAL LASER SURGERY FOR SUPRAGLOTTIC TUMORS INDICATIONS•  T1-T2 and selected T3 (with limited •  Inadequate exposure involvement of the PES) •  Crico-arytenoid joint and/or•  Salvage surgery after RT for rT1-rT2 paraglottic space involvement •  Poorly radiosensitive histologies •  Massive PES involvement •  Laryngeal framework infiltration •  Extension to the glottis CONTRAINDICATIONS 2012
  18. 18. TRANSORAL LASER SURGERYENDOSCOPIC SUPRAGLOTTIC LARYNGECTOMIES2012 Remacle et al. 2009
  19. 19. TRANSORAL LASER SURGERYENDOSCOPIC SUPRAGLOTTIC LARYNGECTOMIES2012 Remacle et al. 2009
  20. 20. TRANSORAL LASER SURGERYENDOSCOPIC SUPRAGLOTTIC LARYNGECTOMIES2012
  21. 21. TRANSORAL LASER SURGERY ONCOLOGIC RESULTS (Level III) Local control Author Site N° of pts. (5 yrs) Eckel, 1998 Supraglottic 46 (T1-T2) 91 12 (T1) 100Ambrosch,1998 Supraglottic 36 (T2) 89 Rudert, 2000 Supraglottic 56 (T1-T4) 77 Davis, 2004 Supraglottic 46 (T2) 97 84 (T2a) Steiner, 2005 Glottic 212 (T2a-b) 74 (T2b) Motta, 2005 Glottic 236 T2 61Mortuaire, 2006 Glottic 104 T1a-b 84 Puxeddu, 2006 Glottic 96 T1a-b 98.3 Peretti, 2010 Glottic 109 T2 982012 Peretti, 2010 Supraglottic 80 (Tis-T3) 97 Peretti, 2010 Glottic 404 (312 T1a; 92 T1b) 99
  22. 22. ENDOSCOPIC CORDECTOMIES FUNCTIONAL RESULTS Patients treated by Type I and II cordectomies present vocal outcomes comparable to those of a control (normal) population Peretti et al, Ann Otol Rhinol Laryngol, 2003Patients affected by T1a glottic tumors without involvement of the anterior commissure present comparable vocal outcomes when treated by RT or endoscopic surgery Wedman et al, Eur Arch ORL, 2002A metanalysis of the VHI related data in the literature about patients treated by endoscopic resections or RT for T1 glottic tumors doesn t show any statistical significant difference among the two groups Cohen et al, Ann Otol Rhinol Laryngol, 2006A comparison between functional outcomes in patients treated by endoscopic partial laryngectomies for T2-T3 glottic tumors and those treated by supracricoid partial laryngectomies for similar lesions shows comparable vocal outcomes but reduced postoperative morbidity and better swallowing in the endoscopic group Peretti et al, COSM, 2007 2012
  23. 23. ENDOSCOPIC CORDECTOMIES FUNCTIONAL RESULTS In a recent review Spielmann et al. examined 21 papers evaluating quality of life and functional outcomes in the management of early glottic carcinoma comparing radiotherapy and transoral laser surgery. No randomized controlled trials were identified.For vocal outcomes the majority of studies found no significant difference between RT and laser surgery.Nine studies reported QOL outcomes; seven showed no difference in overall scores. No study that assessed swallow function was identified. The evidence base to date demonstrates comparable voice and quality of life outcomes. There is a need for consensus on which measures of vocal quality and 2012 life satisfaction to be used in research trials to allow comparison between studies. Spielmann et al, Clinical Otolaryngology, 2010
  24. 24. 2012
  25. 25. OPEN-NECK CONSERVATIVE SURGERY INDICATIONS •  T2 and selected T3/T4a glottic/supraglottic lesions •  Unfavorable endoscopic laryngeal exposure •  Salvage surgery after RT or endoscopic failure for rT1-rT2 • Good pulmonary performance CONTRAINDICATIONS•  Invasion of the crico-arytenoid joint and/or posterior parglottic space •  Involvement of the posterior commissure •  T4a for invasion through the cartilage or invasion beyond the larynx •  Advanced T category after RT, CHT-RT, or 2012 conservative surgery failure •  Advanced age (?)
  26. 26. OPEN-NECK CONSERVATIVE SURGERY Vertical partial laryngectomy2012
  27. 27. OPEN-NECK CONSERVATIVE SURGERY Horizontal supraglottic laryngectomy2012
  28. 28. OPEN-NECK CONSERVATIVE SURGERY Supracricoid partial laryngectomy2012 CHEP
  29. 29. OPEN-NECK CONSERVATIVE SURGERY Supracricoid partial laryngectomy CHP2012
  30. 30. OPEN-NECK CONSERVATIVE SURGERY ONCOLOGIC RESULTS (Level III) Local control Organ Author Surgery T category (5 yrs) preservation T1 (25) 98 Mohr, 1983 VPL - T2 (27) 99 T1 (146) 89 Laccourreye, 1991 VPL - T2 (102) 74 T1 (2) T2 (41) Chevalier, 1994 CHP 97 - T3 (14) T4 (4) Laccourreye, 1997 CHEP T1b-T2 (62) 98 100 Spriano, 1997 HSL T1-T2 (54) 96 - T2 (22) Chevalier, 1997 CHEP 97 95.5 T3 (90) T1 (9) 100 Isaacs, 1998 HSL T2 (24) 78 95.0 T3 (9) 72 Bron, 2000 CHEP T1- T4 (59) 84 87.0 Laccourreye, 2000 VPL T2 (85) 69 78.0 T1 (62) 100 Giovanni, 2001 VPL - T2 (65) 94 Dufour, 2004 CHEP T3 (37) 93 89.8 CHP T3 (81) 93 89.82012 T1 (16) Bron, 2005 HSL T2 (46) 92 89.6 T3 (13) Nakayama, 2008 CHEP T1-T4 (47) 100 70
  31. 31. OPEN-NECK CONSERVATIVE SURGERY FUNCTIONAL RESULTS Vertical Partial LaryngectomyThe functional outcome after standard vertical hemilaryngectomy is some degree ofpermanent hoarseness. Hirano el al. compared the vocal function after a variety ofreconstruction and noted that poor outcome was ofter associated with free mucosalgrafts.Chronic dysphagia is not associated with standard vertical partial laryngectomy, with orwithout resection of the vocal process, and 92% of patients resumed a normalpostoperative diet in one month. From Cummings, Otorhinolaryngology Head and Neck Surgery, 5th Ed. Horizontal Supraglottic LaryngectomyPrades reported a rate of permanent aspiration between 1.5% and 21%, and between0% and 50% of non decannulated patients. Prades, Eur Arch Otorhinolaryngol, 2005Sevilla et al. reported a 9% incidence of total laryngectomy due to aspirationpneumonia, and 15% of permanent tracheostomy due to laryngeal stenosis or edema. 2012 Sevilla et al, Eur Arch Otorhinolaryngol 2008
  32. 32. OPEN-NECK CONSERVATIVE SURGERY FUNCTIONAL RESULTS Supracricoid Partial LaryngectomiesAspiration pneumonia is the most common complication after SCPL. In a seriesof 457 patients, normal swallowing was observed in 58.9%. Aspiration correlatedwith increased age, CHP, not repositioning of the piriform sinus, and removal ofone arytenoid. However, management of aspiration required a permanentgastrostomy in only 0.6% of patients and completion total laryngectomy in Benito et al, Head Neck, 20111.5%.Laccourreye reported tracheal tube removal in 97.2% of patients, and 52.1%achieved normal swallowing in the first postoperative month. Aspirationpneumonia developed in 21.7% and by the end of the first year the incidence ofcompletion total laryngectomy and permanent gastrostomy was 1.4%. 2012 Laccourreye et al, Laryngoscope 1998
  33. 33. OPEN-NECK CONSERVATIVE SURGERY FUNCTIONAL RESULTS Supracricoid partial laryngectomies Functional Functional laryngectomy Author Surgery Patients Duration NGT laryngectomy for aspiration for aspiration (%)Guerriet et al CHEP 58 9-50 1 1,7Traissac and CHEP 97 10-33 1 1 Verhulst Piquet and CHEP 104 21-45 0 0 ChevalierLaccourreye CHEP 67 11-40 0 0 et al CHEP 46 10-90 0 0 Piquet CHP 72 ? 3 4,2Labayle and CHP 101 ? 3 3 Dahan 2012Maurice et al CHP 43 17-120 1 2,3 Data from Cummings, Otolaryngology Head and Neck Surgery, 5th Ed."
  34. 34. Highest-Level Evidence for Treatment Options for Early Laryngeal Cancer (Level III) Reference N° of patients Methodology Group Outcome Stoeckli et Final laryngeal Retrospective preservation: initial al. 101 nonrandomized, glottic RT vs laser surgery better than 2003 tumors RT Gourin etT1 Retrospective Survival: no al. 89 nonrandomized, all RT vs surgery difference 2009 laryngeal sites Retrospective Jones et al. 364 nonrandomized, glottic RT vs surgery (laser or open Local control: no 2010 and supraglottic resection) difference Marandas Initial local control Retrospective surgery 88%, RT 79% et al. 66 nonrandomized, T2 with RT vs open surgery (no statistical 2002 impaired motility analysis) Initial local control Stoeckli et and Retrospective al. 39 nonrandomized RT vs laser final laryngeal 2003T2 preservation: initial surgery better than RT Gourin et Retrospective al. 98 nonrandomized, all RT vs surgery Survival: no difference 2009 laryngeal sites 2012 Jones et al. 124 Retrospective RT vs surgery (laser or open Local control: no 2010 nonrandomized resection) difference
  35. 35. CONSERVATIVE SURGERY CONCLUSIONS TLS in early-intermediate glottic and supraglottic tumors allows diagnosis and treatment in the same surgical procedure, and is associated with oncological outcomes comparable to those obtained with other surgical and not-surgical therapeutic approaches. Open-neck conservative surgery offers the patients with intermediate- advanced glottic and supraglottic tumors an excellent local control of the disease counterbalanced by a long hospitalization time and recovery of swallowing function. Waiting for Level II studies comparing different conservative surgical strategies or conservative surgical treatment vs a non-surgical organ preservation protocol, selection of treatment should be customized based2012 on tumor and patient factors, with an accurate discussion on quality of life issues and specific needs of the patient.

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