MCO 2011 - Slide 16 - A. Dietz - Prognostic factors and surgical approach
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(1) This document discusses prognostic factors and surgical approaches in head and neck cancer. (2) Key prognostic factors discussed include TNM stage, tumor volume, resection margin status, and HPV 16 status. (3) The document also discusses the importance of surgical approach and extent of resection in head and neck cancer treatment. Organ preservation is prioritized when possible with adjuvant radiation or chemoradiation therapy.
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MCO 2011 - Slide 16 - A. Dietz - Prognostic factors and surgical approach
- 1. Prognostic factors and surgical approach in Head and Neck Cancer Andreas Dietz Klinik und Poliklinik für Hals-, Nasen-, Ohrenheilkunde/Plastische Operationen Universitätsklinikum Leipzig Direktor: Univ.-Prof. Dr. med. Andreas Dietz 9th ESO-ESMO MASTERCLASS IN CLINICAL ONCOLOGY 03-04. April, 2011 Ermatingen (Lake Constance), Switzerland
- 2. To protect the lower airway from aspiration, respiration ceases and the larynx is closed at three levels: tongue aryepiglottic folds ventricular folds true vocal folds Andreas Dietz
- 3. Head & neck (49,569 cases) 5-year relative survival 42% •Women better than men 51% versus 39% •Young (15-44) better than old (75+) 54% versus 37% Andreas Dietz
- 4. Prognostic factors • TNM • Tumor volume • Degree of resection margin (R0 versus R+) • HPV 16 M HPV16 G0 E6 E6 p53 p53 Abbau G2 T O SE MI E I p16 S N N N N A T pRB S E H P Aktivierung R P G1 P P Transkription E2F Übergang in die S-Phase G1-Arrest Cyclin D CDK 4/6 pRB Inhibition von pRb p53 E7 Apoptose Repression p21 pRB keine Transkription E2F DNA-Schäden E7 Inhibition des G1/S-Übergang HPV16 Andreas Dietz
- 5. HPV16 +/- K. Kian Ang et al. N Engl J Med 2010;363:24-35. Andreas Dietz
- 6. R0= 5 mm Andreas Dietz
- 7. Prognostic factors UICC (2010) TNM-Classification: 7. Edition Cancer Staging Andreas Dietz 7
- 8. Extended definitions of R-Classification R0 >1mm No residual tumor, minimal distance between tumor and resection margin more than 1 mm R1< 1mm No residual tumor, minimal distance between tumor and resection margin 1 mm or less R1-dir Microscopic residual tumor, tumor directly within resection margin (tumor transsected) ------------------------------------------------------------------------------------------------ R0 > 5 mm No residual tumor, minimal distance between tumor and resection margin more than 5 mm ------------------------------------------------------------------------------------------------------------------------- Wittekind et al. A uniform residual tumor classification. Cancer 115, 3483-3488, 2009 Andreas Dietz 8
- 9. Exceptions in surgical treatment of the larynx - - Glottis: closed oncological unit - Slowly growing tumors - Margin of 1mm in glottis sufficient - Late metastasis via lymph drainage - En block resection tumor + neck nodes not necessarry Ogura 1976, Kirchner 1989, Kleinsasser 1989 , Glanz 1989, Meyer-Breiting 1994, Werner 1992 Andreas Dietz
- 10. Growing pattern of hypopharyngeal carcinomas William Wei Typ 1 Typ 2 Typ 3 Andreas Dietz
- 11. Andreas Dietz Dietz Andreas
- 12. Molecular field cancerisation Roesch-Ely et al. J.Pathology 2010 Andreas Dietz Dietz Andreas
- 13. principles in therapy HNSCC resectable Organ Adjuvant preserving radio- surgery , radiochemo- therapy … Ablativ Adjuvant surgery radio- , radiochemo- Palliativ Squamous cell therapy chemotherapy carcinoma head and neck First line Organ Salvage Second line preserving surgery chemo- radiation Non Chemo- Salvage resectable radiation surgery Andreas Dietz
- 14. principles in therapy resectable Organ Adjuvant preserving radio- surgery , radiochemo- therapy … Ablativ Adjuvant surgery radio- , radiochemo- Palliativ Squamous cell therapy chemotherapy carcinoma head and neck First line Organ Salvage Second line preserving surgery chemo- radiation Non Chemo- Salvage resectable radiation surgery Andreas Dietz
- 15. Andreas Dietz
- 16. Malignoma of the scullbase surgery radio chemo therapy therapy Andreas Dietz
- 17. Carcinoma of the external auditory canal Andreas Dietz
- 18. Orbitaboden Kieferhöhlenhinterwand Kieferhöhlenhinterwand Andreas Dietz
- 19. 2 years later (surgery + adj. Rad) Prof. Dr. Thomas Kahn Diagnostische Radiologie Universität Leipzig Andreas Dietz
- 20. Andreas Dietz
- 21. girl* 14.10.2002 swelling of medial orbit angle 20.10.2006, superior biopsy Andreas Dietz
- 22. girl* 14.10.2002 swelling of medial orbit angle 20.10.2006, superior biopsy Bildgebung: Prof. Dr. Thomas Kahn Zentrum für Radiologie Universitätsklinikum Leipzig Andreas Dietz
- 23. Andreas Dietz
- 24. After chemo and radiation no need for surgery Bildgebung: Prof. Dr. Thomas Kahn Zentrum für Radiologie Universitätsklinikum Leipzig Andreas Dietz
- 25. Andreas Dietz
- 26. principles in therapy resectable Organ Adjuvant preserving radio-, surgery radiochemo- therapy … Ablativ Adjuvant surgery radio- , radiochemo- Palliativ Squamous cell therapy chemotherapy carcinoma head and neck First line Organ Salvage Second line preserving surgery chemo- radiation Non Chemo- Salvage resectable radiation surgery Andreas Dietz
- 27. Andreas Dietz
- 28. Complete laryngectomy versus partial laryngectomy "satisfaction paradox―. Speech understanding – parallelised groups objektiv gemessen (mit PLTT*, hohe subjektiv vom Patienten eingeschätzt Werte = gute Sprachverständlichkeit) (Frage: „Wie bewerten Sie Ihre *Postlaryngektomie-Telefon-Verständlichkeits- Sprachverständlichkeit?“) Test nach Zenner Bindewald J. et al. Laryngoscope. 2007 Bindewald J. et al. Laryngorhinootologie 2007 Andreas Dietz
- 29. Andreas Dietz
- 30. Voice Prothesis: PROVOX I/II Andreas Dietz
- 31. Andreas Dietz
- 33. Lappenoberfläche Oberschenkel rechts Lappen entnommen mit M. vastus lateralis und Gefäß- stiel Oberschenkel rechts Resektat Zungengrund und Kehlkopfeingangs- Plattenepithelkarzinom T4 Lappen zur Rekonstruktion der Rachenvorderwand Rachenhinterwand Tumorresektion Verschlossener Oberschenkel Einblick in der Rekonstruierten Rachen, wobei der Oberschenkel- Lappen unter dem Haken zur Darstellung kommt. Andreas Dietz
- 35. Malignoma salivary glands Tumor Andreas Dietz
- 36. Malignoma salivary glands Prognostic relevance of „high grade― and „low grade― Andreas Dietz
- 37. Hypoglossus-Jump- graft (interpositional jump graft; May, 1991) âbgesetzte Facialisäste ACC Hypoglossus- Facialis-Jump- Anastomose Andreas Dietz
- 38. Reconstruction using N. hypoglossus Andreas Dietz
- 39. … 2 years later Andreas Dietz
- 40. Facial nerve paresis Illig 1958 Barclay & Roberts 1969 Seiff 1989 (prätarsale Fixierung) Andreas Dietz
- 42. Neck dissection: Classification of Robbins Robbins KT et al. Arch Otolaryngol Head Neck Surg. 2002; 128: 751-758 Andreas Dietz
- 43. Neck Dissection • radical Neck Dissektion (RND) Resection Level I-V incl. Resection of VJI, M.SCCM and N.accessorius • modified radical Neck Dissektion (mRND) = functional ND Resection of Level I-V; preservation of 1 or more non-lymphatic structures of RND • selektive Neck Dissektion (SND) Preservation of 1 or more LK-levels of RND; preservation of VJI, M.SCM and N.accessorius new: SND I-III old: supraomohyoidal SND • extended Neck Dissektion Andreas Dietz
- 44. principles in therapy resectable Organ Adjuvant preserving radio- surgery , radiochemo- therapy … Ablativ Adjuvant surgery radio- , radiochemo- Palliativ Squamous cell therapy chemotherapy carcinoma head and neck First line Organ Salvage Second line preserving surgery chemo- radiation Non Chemo- Salvage resectable radiation surgery Andreas Dietz
- 45. „laryngo- esophageal dysfunction- free survival“ Lefebvre JLJL, Ang KK. HEAD & NECK 2009 Andreas Dietz
- 46. Late toxicity platin based RTOG 91-11 simultaneous RCHT VA DeLOS-I PF-Induction TPF-Induction EORTC 24891 RT GETTEC TP-Induction + RT + RT RTOG 91-11 + RTTPE-Induction TAX 324 Argiris, ASCO 2008 + RT TAX 323 DeLOS-II GORTEC 2000-01 DeLOS-II 50% 100% „laryngo-esophageal dysfunction-free survival― after 5 years Andreas Dietz
- 47. Salvage Surgery resectable Organ Adjuvant preserving radio- surgery , radiochemo- therapy … Ablativ Adjuvant surgery radio- , radiochemo- Palliativ Squamous cell therapy chemotherapy carcinoma head and neck First line Organ Salvage Second line preserving surgery chemo- radiation Non Chemo- Salvage resectable radiation surgery Andreas Dietz
- 48. Results salvage surgery Meta-analysis of 1080 patients with recurrent Head & Neck Cancer Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the means? Goodwin WJ Jr. Laryngoscope. 2000 Mar;110(3 Pt 2 Suppl 93):1-18. Andreas Dietz
- 49. Failure after chemo radiation Andreas Dietz
- 50. Zbären et al. Otolaryngology –Head and Neck Surgery, 2007 Andreas Dietz Dietz et al. Eur.Arch Otor. 2008
- 51. Salvage surgery Andreas Dietz
- 52. Time line for salvage Increasing late Decreasing toxicity Tumor cell load Best time gab for salvage surgery 4 months Best time for End of therapy re-Staging 6 weeks time Chemo radiation 2 months post therapy efficacy Andreas Dietz
- 53. principles in therapy Prädiktive Response-Evaluation desirable resectable Organ Adjuvant preserving radio- surgery , radiochemo- therapy … Ablativ Adjuvant surgery radio- , radiochemo- Palliativ Squamous cell therapy chemotherapy carcinoma head and neck First line Organ Salvage Second line preserving surgery chemo- radiation Non Chemo- Salvage resectable radiation surgery Andreas Dietz
- 54. HEAD & NECK—DOI 10.1002/hed January 2010 …what is clear to me is that response to neoadjuvant chemotherapy is the strongest and most reliable biomarker that we have in advanced laryngeal cancer, Andreas Dietz
- 55. Andreas Dietz
- 56. FLAVINO-Assay and response prediction in DeLOS-II Colony formation: Colony formation: IC50 of docetaxel [nM] IC50 of cisplatin [nM] 1100 13333 After one cycle of induction chemotherapy 550 6667 (TPF + cetuximab) 0 0 Reduction in Reduction in Reduction in Reduction in tumor surface tumor surface tumor surface tumor surface <30%=clinical >30%=clinical <30%=clinical >30%=clinical nonresponder responder nonresponder responder Dietz et al. ASCO 2010 Andreas Dietz