8. TREATMENT OF T3 CANCER OF
LARYNX(INTERMEDIATE STAGE)
Includes cancer which has caused fixity of
cord or hemilarynx and invaded pre-
epiglottic and paraglottic space or post
cricoid, without any gross destruction of
framework.
Concomittent chemoradiation with partial
laryngectomy.
Surgery is decided:
•Site and extent of lesion
•Fixity of vocal cord
•Lateralized lesion
•Degree of airway obstruction
•age, general health and pulmonary status
9.
10. TREATMENT OPTIONS
• 66-70 Gy of radiation combined with cisplatin over
6-7 weeks.
• Mainly preferred in patients in whom voice
conservation surgery is not possible.
• Severe mucosal toxicity can occur.
• Combining cetuximab with radiation (bioradiation)
can be an option in those with poor renal functions.
1. CONCURRENT
CHEMORADIATION:
11.
12. • Two cycles of ICT with cisplatin + 5-fluorouracil
or with Docetaxel + Cisplatin + 5-fluorouracil
are given to judge the response to
chemotherapy.
• Good responders go on to receive
chemoradiation or radiation alone.
• Poor responders to chemotherapy generally
respond poorly to radiation also and are best
treated with surgery.
2. Induction
chemotherapy
(ICT) followed by
chemoradiation
in good
responders and
surgery in those
who respond
poorly to ICT:
13. • In those cases of T3 cancer, where voice conserving
surgical procedure is feasible but non-surgical organ
preservation is desirable.
• In T3, cancers with bulky but resectable nodal
disease (N2a/N3), If the primary responds well to
ICT but node mass doesn't, then a lymph node
dissection is performed before the commencement
of concurrent chemoradiation.
The treatment plan of ICT
is preferred over
concurrentchemoradiation
in two situations:
14.
15. • Radiotherapy reserved for those cases where
the patient is unfit for chemotherapy.
• Local failure rate may be as high as 40 or 50%.
• Vigilant follow-up is therefore needed to
detect failures early and perform a salvage
laryngectomy.
3.
Radiotherapy:
16. • In T3, glotto-supraglottic laryngeal cancers where subglottic
extension of disease is minimal or absent, both arytenoids
are freely mobile, and there is no extension of disease to
pyriform, the vallecula or to the retroarytenoid region.
• Reconstruction is with cricohyoidopexy (CHP) in cases with
significant supraglottic disease or with
cricohyoidoepiglottopexy (CHEP) in cases with predominantly
glottic disease.
4. Supracricoid
partial
laryngectomy(SCPL):
17. Voice following SCPL is very harsh, though local control of the disease is 90%.
SCPL is therefore reserved today for:
young patients, where one wants to avoid radiation therapy.
those who respond poorly to ICT.
those who have received radiotherapy to the neck previously
18.
19. • Feasible in T3 laryngeal cancer when the disease is
lateralized, the interarytenoid and the retroarytenoid
region has minimal involvement.
• A high rate of success is achieved for lung-powered
speech by creating a voice shunt from the patient's own
tissues.
• Nasal respiration is not preserved.
• Due to requirement of permanent tracheostome, the
procedure is very rarely used today, replaced largely by
chemoradiation.
• Only patients who are unfit for the chemoradiation or
those who fail to respond to ICT are now offered NTL
5. Near-total
laryngectomy:
20.
21. • T3 cancer of the larynx presenting with stridor (Fig 23) or
laryngeal dysfunction due to bilateral cord fixity and
aspiration are best treated with total laryngectomy.
• T3 cancer in patients who are unfit for chemotherapy due to
impaired renal, cardiac or hepatic functions or due to frail
health are also best treated with total laryngectomy, except
where tumor volume is small, in which case radiotherapy
alone is offered, reserving surgery for salvage of radiotherapy
failures.
6. Total
Laryngectomy:
22.
23. • Supraglottic cancer that is T3 because of pre-
epiglottic space invasion is amenable to a
horizontal partial laryngectomy, provided the
vocal cords and the arytenoids are freely
mobile.
• It should be the preferred option over chemo
radio patient if, fit for surgery.
7.
Conventional
open partial
laryngectomy:
24.
25. Glottic cancer classified as T3
because of paraglottic space
invasion is amenable to a vertical
partial laryngectomy provided
there is minimal or no subglottic
extension and both arytenoids
are freely mobile.
26. SUMMARY
Total laryngectomy used to be mainstay of treatment, focus has shifted to organ
preservation, either with one of the partial laryngectomy procedure or with non-surgical
method of chemotherapy with radiation therapy.
Chemo-radiation is most preferred option.
Surgery is preferred for who are unfit for chemotherapy (cardiac, renal, hepatic problems),
those who have received radiotherapy in the past and, those who are unlikely to respond
to chemo-radiation.
27. TREATMENT OF T4 CANCER OF LARYNX(ADVANCED
STAGE)
Cancer of larynx is considered to be T4, if the laryngeal framework is
invaded or the tumour has spread into paralaryngeal soft tissues either
through the thyrohyoid or crico-thyroid membranes or directly through the
thyroid cartilage.
Stage is further classified into T4a for advanced operable cancer and T4b
for advanced unresectable cancer.
28.
29. • Surgery followed by radiotherapy remains the
mainstay of treatment.
• This will mean total laryngectomy in majority of cases,
if well lateralized lesions, near -total laryngectomy.
• Laryngectomy for T4a cancer of larynx also entails
ipsilateral thyroid lobectomy and clearance of lymph
nodes at levels II, III and IV bilaterally if the neck is 'N'.
1. Moderately
Advanced
Laryngeal
Cancer
(Operable)
T4a:
30.
31. In case of N0 neck nodes, levels II - V
are cleared and if there is subglottic
disease paratracheal lymph nodes
(level VI) are also cleared.
Post-operative radiation therapy is the
standard adjuvant treatment following
surgery.
Chemo-radiotherapy as adjuvant
treatment may be indicated when the
surgical margins are unsatisfactory or
when there is nodal extra-capsular
extension of disease.
32. In some T4a cancer where a lesion anterior commissure and petiole of epiglottis is eroding thyroid
cartilage, is possible supracricoid partial laryngectomy provided most part of larynx is normal and
subglottic spread minimal.
Prolonged phase of aspiration in post op.
Chemo-radiation is unlikely to succeed in advanced lesions, particularly when cartilage is eroded.
If there is no erosion of cartilaginous framework, but the thyro-hyoid membrane is penetrated with
limited paralaryngeal soft tissue invasion, non-surgical treatment with chemo-radiation can be considered.
Start with induction or neo-adjuvant chemotherapy with a Taxane, Cisplatin and 5-Fluorouracil.
33. • This is advanced, unresectable cancer due to
extensive soft tissue invasion pre-vertebral
muscles posteriorly or carotids laterally.
• The mainstay of treatment is symptomatic and
supportive care.
• Chemotherapy may be considered for
palliation.
2. Very
Advanced
Cancer of the
Larynx
(Inoperable)
T4b:
34. LYMPH NODES- INCIDENCE AND PATTERN
Status of cervical lymph nodes is the most important prognostic factor that
influences survival in squamous cancers of the head and nec.
Higher clinical 'N' stage significantly increases the risk of distant metastasis
in squamous cell cancer of the larynx.
Most common sites of cervical lymph node metastases from cancer of the
larynx are the nodes along the internal jugular vein viz. levels II, III and IV.
35.
36. SUPRAGLOTTIS
The supraglottis has a rich lymphatic network and metastases to
the cervical nodes are frequent.
Between 23- 50% of all supraglottic cancers present with cervical
lymph node involvement.
Forty percent of patients may develop contralateral or bilateral
neck metastases.
37. GLOTTIS
The glottis has sparse lymphatics and early glottic lesions (T1,T2) rarely metastasize to cervical
nodes, incidence being 1- 4%.
The neck therefore need not be treated in early glottic cancers with a clinically N0 neck.
Nodal involvement in glottic cancer usually occurs when tumour has spread to the adjoining
supraglottis, subglottis or has invaded the paraglottic space or the thyroid cartilage.
The incidence of neck metastases in T3/T4, glottic cancers is 15-42%.
38. SUBGLOTTIC
Lymph nodes at level VI pre- laryngeal,
paralaryngeal and paratracheal cervical
lymph nodes are at risk in subglottic
cancers and glotto- subglottic cancers.
39. In lesions that are well lateralised, the risk to the contralateral
neck is very low if the ipsilateral neck is 'N'.
This is true even if the lesion has crossed the midline but the
lymph nodes on the dominant side are negative for metastases.
If, however, the ipsilateral lymph nodes are positive for
metastases, the risk to the contralateral neck nodes is significant.
40. EXTENT OF NECK DISSECTION
In patients with clinico-radiologically node-negative status, if primary is being treated surgically and a neck
sampling is done, then the ipsilateral level II, III and IV are cleared and sampled for frozen section.
If frozen section reveals a positive node, then level V is cleared on the same side.
Midline lesions may require the basis both sides of the neck to be addressed in such a manner.
Paratracheal nodal clearance (level VI) is advocated for patients with subglottic extension of the disease
41. The extent of neck dissection on the ipsilateral side of the palpable lymph node metastasis
varies with the size and number of lymph node metastases.
In most cases with N1 or N2 metastatic disease, it is possible to perform a selective infra-
digastric neck dissection sparing level I.
With N3 or N4 lymph node metastases, a comprehensive neck dissection is performed
including level 1.
The paratracheal lymph nodes are included in block dissection if disease at primary site is
advanced and necessitates a total or near-total laryngectomy.
42. MANAGEMENT OF CERVICAL LYMPH NODES PER
PRIMUM
Treatment of the neck in laryngeal cancers depends upon:
Site of the primary
T' stage of the primary
Clinical 'N' stage
Choice of treatment modality for the primary
43. • In a T1/T2 N0 glottic cancer neck is not treated.
• Even sampling of the lymph nodes is not done during
a partial laryngectomy procedure.
• When the primary is advanced (T3/T4), the neck is
treated depending upon the choice of treatment for
the primary.
• For a T3/T4 N0 glottic cancer, if the primary is treated
surgically, bilateral nodal clearance is performed.
• If a T3/T4 N0 glottic cancer is treated with radiation
therapy, both sides of neck are included in field of
radiotherapy.
N0
Neck in
glottic
cancer:
44. • The management of N+ neck in glottic cancer depends upon
choice of treatment for primary site.
• If the treatment plan is RT/CRT and the neck node disease is
N1, neck is included in field of radiation and surgery is
reserved only for salvage of RT failure.
• When the neck disease is (N2N3), in the organ preservation
treatment plan of involved side is cleared prior to RT, if there
is no significant regression in the node mass after induction
chemotherapy.
• When the treatment for the primary site is surgery, then the
ipsilateral neck is dissected comprehensively or at least from
levels II to V and the contralateral neck from levels II to IV.
N+
Neck in
glottic
cancer:
45. • Options for management of the N0 neck in
supraglottic cancer include, "elective" treatment vs.
"wait & watch" policy, undertaking neck dissection if
metastatic lymph nodes manifest clinically.
• In most N0 situations elective neck treatment is
preferred even though its impact on survival
remains controversial.
N0 neck in
Supraglottic and
Hypopharyngeal
Cancer:
46. • a. If the primary tumour is treated with
radiation, both sides of the neck are included
in the field of radiation, regardless of the
stage of the disease.
• b. If an early primary is resected
endoscopically with the CO2 laser, the N0
neck is not treated electively.
Management is
largely influenced
by the choice of
treatment for the
primary. The
following guidelines
are the suggested:
47. Instead, close follow up is maintained at regular intervals
for early detection and treatment of metastatic neck
nodes.
This approach is preferred because the neck has not been
entered into for resection of the primary.
48. c. When open partial laryngectomy is performed for an early
supraglottic cancer, the neck is entered and therefore, lymph node
sampling and frozen section examination is carried out.
d. If the sampled nodes do not show metastasis on frozen section, the
neck is observed. If, however, metastasis is revealed on subsequent
paraffin section, the neck is treated with adjuvant radiation therapy.
e. If a near-total or total laryngectomy is performed for a locally
advanced supraglottic cancer, the clinically N0 neck is dissected
bilaterally clearing levels II, III, IV, & VI.
49. • N1 Neck:
• Palpable metastatic lymph nodal disease is
preferably tackled surgically in most cases, since
control rates with radiotherapy alone are very low.
• If however, metastatic lymph nodes are small in
size (less than 3 cms), and choice of treatment for
primary RT or CRT then neck included in field of RT
and surgery is served for salvage of residual neck
disease.
N+ neck in
supraglottic
cancer:
50. • a. When chemo-radiotherapy is the treatment plan: It is
preferable to incorporate neck dissection as an integral part
of plan.
• Following induction chemotherapy, if the node mass
responds well and shrinks to a small size, neck dissection is
deferred and chemo-radiation is completed with both sides
neck included in the field of radiotherapy.
• Neck dissection is reserved only for salvage of residual
disease.
N2N3
neck:
51. If the primary is resected transorally
with the CO2 laser, neck dissection is
performed on side of palpable neck
disease, preferably 4-5 days later.
b. If primary is treated with an open
partial laryngectomy, then tipsilateral
neck is cleared and contralateral neck
is sampled.
•i. Either comprehensive neck dissection or level 1 sparing neck dissection on the side
of palpable disease.
•ii. Levels II, III, IV clearance on the contralateral side
•iii. Central compartment clearance, i.e clearance of paratracheal lymph nodes (level VI)
bilaterally, along with ipsilateral thyroid lobectomy.
c. If the surgical treatment for the
primary is laryngectomy with partial or
circumferential pharyngectomy, a wide
field dissection (vein to vein clearance)
is performed which includes:
