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Principles of Conservative
Surgery in Head & Neck
Oncology
Dr Zeeshan Ahmad
M.S.(ENT,PGY2)
Department of ENT
NMCH, Patna.2...
Introduction
 Surgery on Head and Neck has major impact on swallowing,
speech and aesthetic appearance.
 Organ preservin...
Neck
Conservation surgery for Neck
 Single most imp factor for prognosis of SCC of HN – cervical nodes.
 5yr survival rate re...
N0 disease – Neck dissection
 N0 – 15-20% risk of occult metastatic disease.
 Selective neck dissection
 Spares all non...
Types of Selective Neck Dissection
 SupraOmoHyoid Neck Dissection
 Extended SupraOmoHyoid Neck Dissection
 Anterolatera...
SupraOmoHyoid Neck Dissection
 SCC of Oral Cavity
 Lymph nodes of level I to III
 Submandibular Gland
Extended SupraOmoHyoid Neck
Dissection
 SCC of Lateral Tongue
 Small but increased risk of Skip Metastasis to level IV
...
Anterolateral Neck Dissection
 Also called Jugular Neck Dissection.
 SCC of Larynx or Pharynx
 If primary tumour crosse...
Posterolateral Neck Dissection
 Primary cutaneous malignancies of Posterior Scalp.
 Lymph nodes of level II to IV and su...
Central compartment Neck Dissection
 Diferentiated Thyroid carcinoma.
 Lymph nodes of level VI to VII and
 Delphian
 P...
N+ disease - Neck Dissection
 Comprehensive neck dissection – removal of all lymphatic tissue in
lateral neck.
 Classifi...
Structures removed in RND along
with level I to V LN
 RND
 SSG
 IJV
 SCM
 Sp Acc N
Structures removed in MRND along
with level I to V LN
 MRND type I – (Spinal Accessory spared)
 SSG
 IJV
 SCM
Structures removed in MRND along
with level I to V LN
 MRND type II –( Spinal Accessory + SCM spared)
 SSG
 IJV
Structures removed in MRND along
with level I to V LN
 MRND type III – (Spinal Accessory + SCM + IJV spared)
 SSG
N+ Disease post Chemoradiation
 Generally acepted that N0 and N1 disease can be treated by
Chemoradiation alone.
 Insuff...
Larynx
Conservation surgery for cancer of
Larynx
 Main aim is to
 Maintain speech
 Maintain swallowing
 Avoid tracheostomy
 ...
Crico-arytenoid unit
 It is the basic functional unit of larynx.
 Consists of
 An Arytenoid cartilage
 Cricoid cartila...
Open Partial Laryngeal surgery
 General principles
 Consent for Total Laryngectomy
 Speech rehabilitation – patient and...
Types
 Glottic
 Vertical Partial Laryngectomy
 Lateral
 anterolateral
 Supracricoid Partial laryngectomy with Cricohy...
GLOTTIC
Vertical Partial Laryngectomy
 Vertical cuts through laryngeal cartilage
 Removal of majority of
 Ipsilateral thyroid c...
Vertical Partial Laryngectomy
 Criteria for selection
 Lesion of mobile cord extending to anterior commissure
 Lesion o...
Vertical Partial Laryngectomy
 Oncological results
 T1 glottic cancer
 Recurrence rates are <10%
 If ant comm not invo...
Vertical Partial Laryngectomy
 Functional results
 Some degree of hoarseness
 Most impairment – if no reconstruction
 ...
Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Resection of
 Both true cords and Both false cords
 En...
Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Reconstruction is done using
 Hyoid bone, Epiglottis, C...
Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Local recurrence rate
 T2 4.5% (3 of 67)
 T3 10% (2 of...
SUPRAGLOTTIC
Horizontal Supraglottic Partial
Laryngectomy
 Parts removed
 Epiglotis and Pre-epiglottic space
 Hyoid bone
 Thyrohyoi...
Horizontal Supraglottic Partial
Laryngectomy
 Closure is by approximating base tongue to lower half of thyoid
cartilage
...
Horizontal Supraglottic Partial
Laryngectomy
 Selection criteria
 At least 5mm margin at anterior commissure
 True VC m...
Horizontal Supraglottic Partial
Laryngectomy
 High local control for T1 and T2
 75% for T3 and 67% for T4
Other Laryngectomies
 Subtotal Laryngectomy =
supralottic partial laryngectomy+ipsilateral vertical partial
laryngectomy
...
Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Supraglottic carcinomas not amenable to supraglottic
lar...
Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Operation involves resection of
 Both true cords and bo...
Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Reconstruction using
 Hyoid bone
 Cricoid
 tongue
 T...
Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Indications
 T1 and supraglottic lesions with ventricle...
Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Contraindications
 Bulky pre-epiglottic space involveme...
Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 No local recurrence reported by Laccourreye et al
 3.3%...
Transoral Endoscopic LASER Resection
 Outpatient procedure possible
 Shorter operating time
 Less overtreatment
 Bette...
Transoral Endoscopic LASER Resection
 As compared to radiotherapy it has similar oncologic and
functional results, lower ...
Hypopharynx
Conservation surgery for cancer of
Hypopharynx
 Cancer of hypopharynx includes
 Cancer of pyriform sinus (70%)
 Postcri...
Conservation surgery for cancer of
Hypopharynx
 T1 and small volume T2 without neck metastasis
 Usually treated by radia...
Conservation surgery for cancer of
Hypopharynx
 Large volume T2 / T3 / T4
 Radical surgery
 Excision of primary tumour
...
Oral cavity
Conservation surgery for cancer of the
Oral cavity
 Limited resection of oral cavity is to be condemned
 However it is p...
 Segmental mandibulectomy is carried out if
 Gross invasion by cancer
 Tumour close to mandible in irradiated patient
...
 Marginal mandibulectomy is done if
 Superficial aspect of cortical bone is involved
 Marginal mandibulectomy is contra...
Oropharynx
Conservation surgery for cancer of
Oropharynx
 Transoral laser resection is an alternatve to chemoradiation and
radical s...
Nose and PNS
Conservation surgery for cancer of
Nose and PNS
 Certainly, endoscopic approach for benign disease has advantage
over ope...
Conservation surgery for cancer of
Nose and PNS
 Indications
 Midline lesions with limited lateral extension
 Benign tu...
Conservation surgery for cancer of
Nose and PNS
 Contraindications
 Lateral extension of tumour
 Intracranial invasion
...
Parotid
Conservation surgery for Tumours of
Parotid Gland
 Warthin’s tumour excision without parotidectomy
 Preservation of faci...
NEXT 
05.09.13 Dr Sonu Kumar Singh
M.S.(ENT,PGY2)
Benign tumours of
mouth and jaw
Conservative surgery for head and neck cancer
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Conservative surgery for head and neck cancer

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by Dr Zeeshan Ahmad, PGY2

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Transcript of "Conservative surgery for head and neck cancer"

  1. 1. Principles of Conservative Surgery in Head & Neck Oncology Dr Zeeshan Ahmad M.S.(ENT,PGY2) Department of ENT NMCH, Patna.29-08-13
  2. 2. Introduction  Surgery on Head and Neck has major impact on swallowing, speech and aesthetic appearance.  Organ preserving radiation techniques.  New chemotherapeutic regimens.  Greater understanding of tumour biology.  Introduction of CO2 laser- transoral.  endoscopes
  3. 3. Neck
  4. 4. Conservation surgery for Neck  Single most imp factor for prognosis of SCC of HN – cervical nodes.  5yr survival rate reduces by 50% if nodes involved.  Memorial Sloan-Kettering Cancer Center – Levels I to VII.
  5. 5. N0 disease – Neck dissection  N0 – 15-20% risk of occult metastatic disease.  Selective neck dissection  Spares all non-lymphatic tissue including SCM, IJV and SpAN.  Only selected nodes on involved site removed.
  6. 6. Types of Selective Neck Dissection  SupraOmoHyoid Neck Dissection  Extended SupraOmoHyoid Neck Dissection  Anterolateral Neck Dissection  Posterolateral Neck Dissection  Central compartment Neck Dissection
  7. 7. SupraOmoHyoid Neck Dissection  SCC of Oral Cavity  Lymph nodes of level I to III  Submandibular Gland
  8. 8. Extended SupraOmoHyoid Neck Dissection  SCC of Lateral Tongue  Small but increased risk of Skip Metastasis to level IV  Lymph nodes of level I to IV  Submandibular Gland
  9. 9. Anterolateral Neck Dissection  Also called Jugular Neck Dissection.  SCC of Larynx or Pharynx  If primary tumour crosses midline A.N.D. is carried out bilaterally.  Not required if Radiotherapy planned.  Lymph nodes of level II to IV
  10. 10. Posterolateral Neck Dissection  Primary cutaneous malignancies of Posterior Scalp.  Lymph nodes of level II to IV and suboccipital LN.
  11. 11. Central compartment Neck Dissection  Diferentiated Thyroid carcinoma.  Lymph nodes of level VI to VII and  Delphian  Perithyroid  Tracheo-osophageal groove  Anterior-superior mediastinum
  12. 12. N+ disease - Neck Dissection  Comprehensive neck dissection – removal of all lymphatic tissue in lateral neck.  Classified into Radical and Modified Radical depending upon other structures removed.  Gold standard – Radical Neck Dissection.  Modified Radical Neck Dissection three types
  13. 13. Structures removed in RND along with level I to V LN  RND  SSG  IJV  SCM  Sp Acc N
  14. 14. Structures removed in MRND along with level I to V LN  MRND type I – (Spinal Accessory spared)  SSG  IJV  SCM
  15. 15. Structures removed in MRND along with level I to V LN  MRND type II –( Spinal Accessory + SCM spared)  SSG  IJV
  16. 16. Structures removed in MRND along with level I to V LN  MRND type III – (Spinal Accessory + SCM + IJV spared)  SSG
  17. 17. N+ Disease post Chemoradiation  Generally acepted that N0 and N1 disease can be treated by Chemoradiation alone.  Insufficient data for N2 and N3  Brizel et al – reported 4yr disease free survival rate  75% in RT + ND  53% in RT only  Therefore ND is recommended for N2/N3.
  18. 18. Larynx
  19. 19. Conservation surgery for cancer of Larynx  Main aim is to  Maintain speech  Maintain swallowing  Avoid tracheostomy  Conservation laryngeal surgery may be  Open  endoscopic  securing negative margins is crucial to success of procedure.
  20. 20. Crico-arytenoid unit  It is the basic functional unit of larynx.  Consists of  An Arytenoid cartilage  Cricoid cartilage  Associated musculature  Nerve suply  Allows physiological speech and swallowing without the need for tracheostomy.
  21. 21. Open Partial Laryngeal surgery  General principles  Consent for Total Laryngectomy  Speech rehabilitation – patient and family active  Good pulmonary function  No medical problem
  22. 22. Types  Glottic  Vertical Partial Laryngectomy  Lateral  anterolateral  Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.  Supraglottic  Horizontal SPL  Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.
  23. 23. GLOTTIC
  24. 24. Vertical Partial Laryngectomy  Vertical cuts through laryngeal cartilage  Removal of majority of  Ipsilateral thyroid cartilage  True vocal cord  Portions of subglottic mucosa  False cord  Tracheostomy 3-7 days.
  25. 25. Vertical Partial Laryngectomy  Criteria for selection  Lesion of mobile cord extending to anterior commissure  Lesion of mobile cord involving vocal process and anterosuperior arytenoid  Subglottic extension ≯5mm  Fixed cord lesion not extending midline  Anterior commissure/ VC lesion ≯ anterior 1/3 of opposite VC
  26. 26. Vertical Partial Laryngectomy  Oncological results  T1 glottic cancer  Recurrence rates are <10%  If ant comm not invoved 93% local control  If ant comm invoved 75% local control( subglottic recurrence)  T2 glottic cancer  Failure rates of 4-26% ( cricoid and thyroid involvement)  T3 glottic cancer  Higher recurrence rates of 11-46%
  27. 27. Vertical Partial Laryngectomy  Functional results  Some degree of hoarseness  Most impairment – if no reconstruction  Least – replacement of glottis with adjacent false cord flap
  28. 28. Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy  Resection of  Both true cords and Both false cords  Entire thyroid cartilage and One arytenoid  Paraglottic spaces bialterally
  29. 29. Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy  Reconstruction is done using  Hyoid bone, Epiglottis, Cricoid and tongue  Temporary tracheostomy and feeding tube  Used for T1b with ant commissure involvement and selected T2 / T3 glottic carcinoma.
  30. 30. Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy  Local recurrence rate  T2 4.5% (3 of 67)  T3 10% (2 of 20)  Temporary dysphagia and aspiration is expected  Nasogastric feeding tube for 9 to 50 days.  Hyoid necrosis and neolaryngeal stenosis  Voice quality is initially poor but improves over several months
  31. 31. SUPRAGLOTTIC
  32. 32. Horizontal Supraglottic Partial Laryngectomy  Parts removed  Epiglotis and Pre-epiglottic space  Hyoid bone  Thyrohyoid membrane  Upper half of thyroid cartilage  Supraglottic mucosa
  33. 33. Horizontal Supraglottic Partial Laryngectomy  Closure is by approximating base tongue to lower half of thyoid cartilage  Temporary tracheostomy is required.  Bilateral selective lymph node dissection is carried out at the same time  It is important to identify and preserve internal and external branches of superior laryngeal nerve
  34. 34. Horizontal Supraglottic Partial Laryngectomy  Selection criteria  At least 5mm margin at anterior commissure  True VC must be mobile  Only one arytenoid may be removed  No cartilage invasion by the tumour  Tongue mobility should be normal  No extension to interarytenoid or postcricoid area  Apex of pyriform sinus should be free  Generally lesions should be <3cm
  35. 35. Horizontal Supraglottic Partial Laryngectomy  High local control for T1 and T2  75% for T3 and 67% for T4
  36. 36. Other Laryngectomies  Subtotal Laryngectomy = supralottic partial laryngectomy+ipsilateral vertical partial laryngectomy  Near Total Laryngectomy = this is a technically complex procedure to create a physiological voice shunt based around one mobile arytenoid. Requires permanent stoma
  37. 37. Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy  Supraglottic carcinomas not amenable to supraglottic laryngectomy due to  Glottic level involvement through anterior commissure or ventricle  Pre-epiglottic space invasion  Decreased cord mobility  Limited thyroid invasion
  38. 38. Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy  Operation involves resection of  Both true cords and both false cords  Entire thyroid cartilage  Both paraglottic spaces  Maximum of one arytenoid  Thyrohyoid membrane  epiglottis
  39. 39. Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy  Reconstruction using  Hyoid bone  Cricoid  tongue  Temporary tracheostomy tube and feeding tube is required.
  40. 40. Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy  Indications  T1 and supraglottic lesions with ventricle extension  T2 infrahyoid epiglottis or posterior 1/3 of false cord  Supraglottic lesions extending to glottis or anterior commissure  T3 transglottic carcinoma  Selective t4 lesions invading thyroid cartilage
  41. 41. Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy  Contraindications  Bulky pre-epiglottic space involvement  Gross thyroid cartilage destruction  Interarytenoid involvement  Fixed arytenoids  Subglottic extension >10mm anteriorly and >5mm posteriorly  Inadequate pulmonary reserve
  42. 42. Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy  No local recurrence reported by Laccourreye et al  3.3% reported by chevalier  Nasogastric feeding is required for 30-365 days  Total laryngectomy may be required in 10% of cases
  43. 43. Transoral Endoscopic LASER Resection  Outpatient procedure possible  Shorter operating time  Less overtreatment  Better voice quality  Low morbidity  No feeding tube  No tracheostomy  Similar oncologic results
  44. 44. Transoral Endoscopic LASER Resection  As compared to radiotherapy it has similar oncologic and functional results, lower cost.  Radiotherapy is possible after endocopic laser if it fails
  45. 45. Hypopharynx
  46. 46. Conservation surgery for cancer of Hypopharynx  Cancer of hypopharynx includes  Cancer of pyriform sinus (70%)  Postcricoid (15%)  Posterior pharyngeal wall (15%)  Of all Head and Neck sites Hypopharyngeal Cancer has poorest prognosis – 5yr survival rate of <20%  Patients usually present with advanced diseaseAbout 66% of patients have nodal disease at presentation  Thus it requires treatment of primary and also of neck
  47. 47. Conservation surgery for cancer of Hypopharynx  T1 and small volume T2 without neck metastasis  Usually treated by radiation  Partial pharyngectomy and bilateral selective neck dissection can also be performed  T1 and small volume T2 with neck metastasis  Comprehensive neck dissection  Radiation to the primary
  48. 48. Conservation surgery for cancer of Hypopharynx  Large volume T2 / T3 / T4  Radical surgery  Excision of primary tumour  Reconstruction  Radiotherapy  Endoscopic laser  Excellent functional results  With synchronous or separate neck dissection
  49. 49. Oral cavity
  50. 50. Conservation surgery for cancer of the Oral cavity  Limited resection of oral cavity is to be condemned  However it is possible to perform conservative surgery to mandible  Careful assessment is carried out by bimanual palpation.  CT is helpful in assessing cortical invasion  MRI helps to find marrow invasion and inferior alveolar nerve
  51. 51.  Segmental mandibulectomy is carried out if  Gross invasion by cancer  Tumour close to mandible in irradiated patient  Invasion of inferior alveolar nerve or canal by tumour  Massive soft tissue disease adjacent to tumour  Marginal mandibulectomy is done if  Superficial aspect of cortical bone is involved
  52. 52.  Marginal mandibulectomy is done if  Superficial aspect of cortical bone is involved  Marginal mandibulectomy is contraindicated  Gross invasion into cancellous part  Irradiated mandible  Edentulous patient with pipestem mandible
  53. 53. Oropharynx
  54. 54. Conservation surgery for cancer of Oropharynx  Transoral laser resection is an alternatve to chemoradiation and radical surgery  With the use of appropriate retractors and distending pharyngoscopes adequate access is obtained  Temporary tracheostomy may be required  Postoperative radiotherapy is recommended  TORS
  55. 55. Nose and PNS
  56. 56. Conservation surgery for cancer of Nose and PNS  Certainly, endoscopic approach for benign disease has advantage over open surgical resection  Better function as well as cosmesis  Availability of  real time image guidance,  neuro-navigation and  intraoperative MRI has furthur improved the safety and accuracy of endoscopic resections  However, malignant disease management is still questionable
  57. 57. Conservation surgery for cancer of Nose and PNS  Indications  Midline lesions with limited lateral extension  Benign tumours – inverted papilloma and angiofibroma  Low grade malignant tumours  Palliation  Medical comorbidity limiting open approach
  58. 58. Conservation surgery for cancer of Nose and PNS  Contraindications  Lateral extension of tumour  Intracranial invasion  Intraorbital invasion  High grade malignant tumours
  59. 59. Parotid
  60. 60. Conservation surgery for Tumours of Parotid Gland  Warthin’s tumour excision without parotidectomy  Preservation of facial nerve unless they are adherent to or directly invaded by tumour  If major branches or the main trunk are involved, then immediate cable grafts should be done using branches of Cervical plexus or Sural nerve
  61. 61. NEXT  05.09.13 Dr Sonu Kumar Singh M.S.(ENT,PGY2) Benign tumours of mouth and jaw
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