Larglot et supraglot - UCLouvain · RxTh Partial laryngeal surgery (SCL + CHEP) EUA + biopsy T2 Dysplasia Cis Subligamental cordectomy Observe, Smoking cessation, ±Antireflux treatment

Larynx 1

Mar. 2006

Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme

Laryngeal carcinoma

Larynx 2

Mar. 2006


Laryngeal carcinoma

•• WorkWork--up procedureup procedure

•• TNM stagingTNM staging

•• Primary treatmentPrimary treatment

•• FollowFollow--upup

•• Treatment of recurrent and/or Treatment of recurrent and/or metastaticmetastatic diseasedisease

•• ReferencesReferences

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Mar. 2006


Clinical evaluation Evidence Option

l complete history of the diseasel weight and weight lossl performance status (Karnofsky / ECOG-WHO)l fiberoptic examination of H&N mucosal neck examinationl drawing of any lesions

Type CType CType CType CType CType C

Std.Std.Std.Std.Std.Std.

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Mar. 2006


Endoscopic evaluation Evidence Option

l endoscopy under general anesthesia with biopsiesof any suspicious site

Type C Std.

Larynx 5

Mar. 2006


Advanced clinical evaluation Evidence Option

l dental examination by oral surgeonl nutritional assessmentl others (if required)

Type CType CType C

Std.Std.Std.

Larynx 6

Mar. 2006


Laboratory tests Evidence Option

l hemogram, coagulation tests, liver enzymes, kidneyfunction

l thyroid function: TSH

Type C

Type C

Std.

Std.

Larynx 7

Mar. 2006


Imaging Evidence Option

l Loco-regional: CT scan (or MRI)1

l Metastatic work-up: chest X-ray, thoracic spiralCT scan

l Additional examination depending on previousfindings

l PET scan

Type CType C

Type C

Type 3

Std.Std.

Std.

Invest.1See guidelines for loco-regional imaging

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Mar. 2006


Pathologic examination Evidence Option

Standards of the British Royal College ofPathologists (endorsed by EORTC)1

Type C Std.

1See pathology guidelines

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Mar. 2006


Laryngeal carcinoma







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Mar. 2006


Staging Evidence Option

• TNM classification (6th ed., 2002) • WHO International Classification of Diseases for

Oncology (ICD-O 9 or ICD-O 10)

Type C Type C

Std. Std.

T4 divided into T4A (resectable) and T4B(unresectable) leading to the division

of stage IV into stage IVA, stageIVB and stage IVC

Stage IVA T4aN0M0, T4aN1M0, T1N2M0, T2N2M0, T3N2M0, T4aN2MO

Stage IVB T4b any N M0, any T N3 M0

any T N3 M0

Stage IVC any T any N M1

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Mar. 2006


TNM/AJCC TNM/AJCC 20022002 StagingStaging

Supraglottis:• Tx primary tumor cannot be assessed• T0 no evidence of primary tumor• T1 one subsite, normal mobility• T2 involving mucosa of more than one adjacent subsite of supraglottis or

glottis or adjacent region outside the supraglottis; without fixation• T3 limited to larynx with vocal cord fixation or invades postcricoid area,

pre-epiglottic tissues, base of tongue• T4a invades through thyroid cartilage, and/or extends into tissues beyond

the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, esophagus)

• T4b invades prevertebral space, encases carotid artery, or invades mediastinal structures

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Mar. 2006


TNM/AJCC TNM/AJCC 20022002 StagingStagingGlottis:

• T4a invades through thyroid cartilage, and/or extends into tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, esophagus)


• Subglottis:

• T4a invades through thyroid cartilage, and/or extends into tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, esophagus)


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Mar. 2006


TNM/AJCC 1997 StagingTNM/AJCC 1997 Staging

• N0: no regional node metastasis• Nx: regional nodes cannot be assessed• N1: single ipsilateral node, ≤ 3 cm• N2a: single ipsilateral node, > 3 cm and ≤ 6 cm• N2b: multiple ipsilateral nodes, ≤ 6 cm• N2c: controlateral or bilateral nodes, ≤ 6 cm• N3: node > 6 cm

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Mar. 2006


TNM/AJCC 1997 StagingTNM/AJCC 1997 Staging

•• Mx: Distant Mx: Distant metastasis cannot be assessedmetastasis cannot be assessed•• M0: No distant M0: No distant metastasismetastasis•• M1: Distant M1: Distant metastasismetastasis

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Mar. 2006


Laryngeal carcinoma







Larynx 16

Mar. 2006


Treatment of Glottic CancerTreatment of Glottic Cancer

Superficial lesion, T1Superficial lesion, T1

RxThRxTh PartialPartiallaryngeal laryngeal surgerysurgery

(SCL + CHEP)(SCL + CHEP)

EUA + biopsyEUA + biopsy

T2T2

DysplasiaDysplasia CisCis

Subligamental Subligamental cordectomycordectomy

Observe,Observe,Smoking cessation,Smoking cessation,

±±Antireflux treatmentAntireflux treatment

ReevaluateReevaluate22--3 months3 months TransmuscularTransmuscular

EndoscEndosc..cordectomycordectomy

PartialPartiallaryngeallaryngealsurgerysurgery

RxThRxTh

EUA + biopsy (excisional EUA + biopsy (excisional when possible)when possible)

Paraglottic spaceParaglottic spaceinvolvement ?involvement ?

YESYESNONO

NONO YESYESInvasion ?Invasion ?

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Mar. 2006


T3 T3 -- T4T4

No cartilage destructionNo cartilage destructionor cartilage or cartilage

minimaly invadedminimaly invaded

Thyroid cartilageThyroid cartilagemassively invadedmassively invadedTumor extending Tumor extending

beyond larynxbeyond larynx

++ PostopPostop RxThRxTh

Total laryngectomyTotal laryngectomy+ + PostopPostop

RxThRxTh

Supracricoid LSupracricoid L+ CHEP+ CHEP+ THEP+ THEP

Locally advanced RxThLocally advanced RxThprotocolprotocol

Surgical salvageSurgical salvage

RecurrenceRecurrence

Candidate for conservative surg ?Candidate for conservative surg ?YESYES

NONO

Treatment Treatment of of glottic glottic cancercancer

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Mar. 2006


Primary treatment: general strategy: glottic carcinoma Evidence Option

l T1, N0, M0-CO2 laser cordectomy ± RxTh (if positive margin)1

-T1a away from the ant. commissure and the arytenoid cartilage

-External RxTh:-T1a reaching or slightly invading the ant. commissure-T1b not originating from the ant. commissure-T1 invading the post. Commissure-T1a with unadequate exposure for laser cordectomy

-Partial laryngectomy-Tumor of the ant. commissure-Patients with poor compliance for follow-up

Type 3

Type 3

Type 3

Std.

Std.

Std.

1 see guidelines for post-operative radiotherapy

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Mar. 2006



l T2, N0-N1, M0-Partial laryngectomy (supracricoid laryngectomy) + bilateral ND ± RxTh1

-“Moderately advanced” RxTh protocol (T+N bilateral)2

± ND3

-tumor not suitable for conservative surgery-poor general health, poor pulmonary reserve-patient’s wish to preserve excellent voice

-CO2 laser “extended” cordectomy-only in very specific cases: T2a (normal V.C. mobility) easily exposed by endoscopy-surgeon’s feeling to obtain free margins

Type 3

Type 3

Type 3

Std.

Std.

Indiv.

1 see guidelines for post-operative radiotherapy2 see guidelines for RxTh regimen (slide 28)3 see guidelines for post radiotherapy ND (slide 30)

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Mar. 2006



l T2, ≥ N2a, M0-“Locally advanced” RxTh protocol (T+N bilateral)1 + ND2

- Partial laryngectomy (supracricoid laryngectomy) + bilateral ND + RxTh3

Type 3Type 3

Std.Std.

1 see guidelines for RxTh regimen (slide 28)2 see guidelines for post radiotherapy ND (slide 30)3 see guidelines for post-operative radiotherapy

Larynx 21

Mar. 2006



l T3-T4, any N, M0-“Locally advanced” RxTh protocol (T+N bilateral)1 ± ND2

-Conservative surgery (SCL+CHEP, SCL+CHP, SCL+THEP) + bilateral ND + RxTh3

-limited subglottic extension-no fixation of the arytenoid cartilage-no postcricoid extension or extension to the post.

commissure-no extralaryngeal extension-adequate general status and pulmonary reserve-permission for total laryngectomy, if needed

-Total laryngectomy + bilateral ND + RxTh3

-very advanced T4

Type 3Type 3

Type 3

Std.Std.

Std.


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Mar. 2006


Partial laryngeal surgeryPartial laryngeal surgery-- Supraglottic LSupraglottic L-- Supracricoid L (+ CHP)Supracricoid L (+ CHP)-- Endoscopic (limited T1 Endoscopic (limited T1

suprahyoid epiglottis)suprahyoid epiglottis)

Treatment of Supraglottic CancerTreatment of Supraglottic Cancer

Tis, T1, T2Tis, T1, T2

Good performance statusGood performance statusGood pulmonary function (VEMS Good pulmonary function (VEMS ≥≥ 1L)1L)

RxTh ± NDRxTh ± ND

Positive nodes ?Positive nodes ?Positive margins ?Positive margins ?

Complete responseComplete response

NONO NONO YESYESYESYES

ObservationObservation ObservationObservationPostopPostopRxThRxTh

Surgical Surgical salvagesalvage

YesYes NoNo

Larynx 23

Mar. 2006


Treatment of Supraglottic CancerTreatment of Supraglottic Cancer

T3 T3 -- T4T4

Thyroid cartilage intactThyroid cartilage intactor moderately invadedor moderately invaded

••Thyroid cartilage Thyroid cartilage massively invadedmassively invaded

••Tumor extending Tumor extending beyond larynxbeyond larynx

Supraglottic LSupraglottic LExtend SGLExtend SGLSupracricoid L + CHPSupracricoid L + CHP

Locally advanced RxThLocally advanced RxThprotocolprotocol

+ + postoppostopRxThRxTh

recurrencesrecurrences

Surgical Surgical salvagesalvage

Total laryngectomyTotal laryngectomy

+ + postoppostop RxThRxTh

Candidate for conservation surgery ?Candidate for conservation surgery ?YESYES NONO

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Mar. 2006


Primary treatment: general strategy: supraglottic carcinoma Evidence Option

l T1-T2, N0-N1, M0-External surgery: supraglottic laryngectomy or supracricoid laryngectomy (T2 invading glottis) + bilateral ND ± RxTh1

-adequate general health and pulmonary reserve-“Moderately advanced” RxTh2 ± ND3

-not suitable for conservative surgery based on medical or oncologic reason-Endoscopic laser supraglottic laryngectomy

-only for selected superficial and suprahyoid T1

Type 3

Type 3

Type 3

Std.

Std.

Std.

1 see guidelines for post-operative radiotherapy2 see guidelines for RxTh regimen (slide 28)3 see guidelines for post radiotherapy ND (slide 30)

Larynx 25

Mar. 2006



l T2, ≥ N2a, M0-“Locally advanced” RxTh protocol (T+N bilateral)1 + ND2

-External surgery: supraglottic laryngectomy or supracricoid laryngectomy (T2 invading glottis) + bilateral ND + RxTh3

-adequate general health and pulmonary reserve

Type 3Type 3

Std.Std.


Larynx 26

Mar. 2006



l T3-T4, any N, M0-“Locally advanced” RxTh protocol (T+N bilateral)1 + ND2

-Conservative surgery (SGL, ESGL, SCL,+CHP)+ bilateral ND + RxTh3

-no subglottic extension-no fixation of the arytenoid cartilage-no postcricoid extension or extension to the post. commissure-limited invasion of the thyroid cartilage-adequate pulmonary reserve-permission for total laryngectomy if needed

-Total laryngectomy + bilateral ND + RxTh3

-very advanced T4

Type 3Type 3

Type 3

Std.Std.

Std.


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Mar. 2006


Primary treatment: surgical procedure of the “N” site Evidence Option

l N site:- N0: bilateral selective ND (II-IV)1

- N1: homolateral MRND + controlateral selective ND- N2a-b: homolateral MRND + controlateral selective

ND (or RND)- N2c: bilateral MRND (or RND + MRND)- N3: homolateral RND + controlateral SND

Type CType CType C

Type CType C

Std.Std.Std.

Std.Std.

1see clinical target volume for the nodes (slide 29)

Larynx 28

Mar. 2006


Primary treatment: RxTh regimen Evidence Option

l Target volumesT: CTV = GTV + margin according to anatomical barriersN: see table on node levels according to T site

l Technique-conformal radiotherapy-IMRT radiotherapy

l Dose / fractionation / treatment timel Early stage:1

-prophylactic dose: 50 Gy,-therapeutic dose: 66-70 Gy, 2 Gy daily

l "moderately advanced"2 / "locally advanced"3 stage-on protocol: GORTEC 99-02 / IMCL CP02-9815-off protocol: moderately accelerated regimen (concomitant boost)

l post-operative RxTh-dose: 60-64 Gy, 2 Gy daily4

Type C

Type C

Type 3Type 3

Type CType C

-Type 1

Type 2

Std.

Std.

Std.Invest.

Std.Std.

Invest.Std.

Std.1T1 N0-N12T2 N0-N13any T N2a-N34See guidelines for post-operative radiotherapy

Larynx 29

Mar. 2006


Target Volumes: larynxTarget Volumes: larynxLevel of evidence : type 3 / option : standardLevel of evidence : type 3 / option : standard

Stage Ipsilateral neck Controlateral neck

N0-N1 II1-III-IV + VI for II1-III-IV + VI for trans- or sub-glottic ext. trans- or sub-glottic ext.

N2a-N2b II-III-IV-V + VI II-III-IV-V + VI trans- or sub-glottic ext. trans- or sub-glottic ext.

N2c According to N stage on According to N stage oneach side of the neck each side of the neck

N3 Ib-II-III-IV-V+VI (trans- or sub- II1-III-IV + VI for glottic ext.) ± adjacent structures trans- or sub-glottic ext.

according to clinical andradiological data

1level IIb could be omitted for N0 patients

Larynx 30

Mar. 2006


Std.Std.Type 3Type 3•• Planned ND (SND, RMND, RND or extended ND) 2Planned ND (SND, RMND, RND or extended ND) 2--3 3 monthsmonths afterafter completioncompletion ofof RxTh in patients with aRxTh in patients with acontrolledcontrolled primary site and in case of residual or suspected primary site and in case of residual or suspected

residual, resectable N diseaseresidual, resectable N disease irrespectiveirrespective ofof the initial N the initial N stagestage

OptionOptionEvidenceEvidencePrimary treatment: neck dissection following a primary radiotherapy

Larynx 31

Mar. 2006


Laryngeal carcinoma







Larynx 32

Mar. 2006


Follow-up Evidence Option

l Clinical examination-fiberoptic examination and neck palpation

every 2 months (first 2 years), every 6 months (3rd-5th year), then every year (> 5 years)

-dental examination every 6 monthsl Imaging

-chest X-ray every yearl Laboratory tests

-thyroid function (TSH) every yearl Evolution of late toxicity (EORTC/RTOG) scale

Type C

Type C

Type C

Type CType C

Std.

Std.

Std.

Std.Std.

Larynx 33

Mar. 2006


Laryngeal carcinoma







Larynx 34

Mar. 2006


Salvage treatment for recurrent disease: general principle

Treatment will depend on:l Site and extension (rTNM stage)l Previous treatment(s)l Performance statusl Patient wishes

Larynx 35

Mar. 2006


Salvage treatment for recurrent disease Evidence Option

l anyT-N0-M0-surgery ± RxTh1

-RxTh1

-chemotherapyl T0-anyN-M0

-ND ± RxTh1

-RxTh1

-chemotherapyl AnyT-anyN-M0

-surgery ± RxTh1

-chemotherapy-best supportive care

l Metastasis-chemotherapy-best supportive care

Type CType CType C

Type CType CType C

Type CType CType C

Type CType C

Std.Indiv.Indiv.

Std.Std.

Indiv.

Std.Indiv.Indiv.

Std.Std.

1depending on previous radiotherapy ; see guidelines for post-operative radiotherapy

Larynx 36

Mar. 2006


Laryngeal carcinoma







Larynx 37

Mar. 2006


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Laryngol. 1987;96(4):384-6.• Bocca E. Sixteenth Daniel C. Baker, Jr, memorial lecture. Surgical management of supraglottic cancer and its lymph node

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impaired motion of the true vocal cord: 5-year oncologic results with 112 patients. Ann Otol Rhinol Laryngol. 1997 106(5):364-9

• Chevalier D, Lejeune R, Fayoux P,Darras JA, Piquet JJ. Les laryngectomies subtotales dans les tumeurs étendues du larynx. In : Actualités de Carcinologie cervico-faciale. Les traitements conservateurs en cancérologie cervico-faciale. Masson eds.1998 ;23 :89-92

• Chevalier D, Piquet JJ. Subtotal laryngectomy with cricohyoidopexy for supraglottic carcinoma: review of 61 cases. Am J Surg. 1994;168(5):472-3.

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