Management of Laryngeal Cancer

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Management of Laryngeal Cancer

• Cees A. Meeuwis, MD, PhD
• Erasmus University Hospital Rotterdam, the
  Netherlands

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Cancer of the larynx

• 3.5 of all new malignancies diagnosed annually
  worldwide
• SCCA of the larynx most frequent malignant tumor
  of the upper aerodigestive tract in europe
• Worldwide distribution
• General incidence 2.5-17.2/100,000 per year
• Highest in Basque country, Spain (20.4) and
  lowest in Qidong, China (0.1)
• High incidence in Brazil, North Thailand, France
  and Poland
• (Parkin,1992Shah,2003)

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Laryngeal cancer in the Netherlands

• 600 new cases per year (?? 5 1)
• stage I-II 80
• stage III-IV 20

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• Head and neck division of the Erasmus Medical
  Center
• 750 new patients per year
• 125-150 patients with laryngeal cancer

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Introduction
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Early stage Larynx carcinoma
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T3 larynx carcinoma
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Late stage larynx carcinoma
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initial treatment options for cancer of the
larynx

• T1 radiotherapy / surgery (CO2 / partial
  laryngectomy)
• T2 radiotherapy / surgery (CO2 / partial
  laryngectomy)
• T3 radiotherapy /chemotherapy/ surgery /
  partial laryngectomy)
• T4 surgery(total) radiotherapy /
  chemoradiotherapy

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University Hospital Rotterdam treatment protocol

• T(cis) laser surgery
• T1 radiation
• T2 radiation
• T3 radiation (chemotherapy)
• T4 surgery (laryngectomy) radiation
• chemoradiation

66-70 Gy in 2 Gy fractions 5-6 x per week
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Radiotherapy for T1/T2 glottic carcinoma

• Local control rate approximating 90 for T1
• 
  70 to 80 for T2
• 5 year local control T1a 94
• T1b
  93
• T2a
  80
• T2b
  72
• (Spriano, 1997
  Fletcher 1994, Mendenhall, 2001)
• 
  
• Voice quality after radiotherapy tend to be less
  when compared to pre-radiotherapy but almost
  normal 2-3 years after treatment
  
  (Verdonck,1999Hirano,1994Heeneman,1994)

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Treatment of T1/T2 glottic carcinoma

• No randomised trials comparing laser with
  radiotherapy and surgery
• Retrospective studies comparing these modalities
  have shown to result to similar local control
  rates.

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Surgical optionsfor small T1 lesions
co2 laser
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CO2 laserIndications

• tumor limited to the glottis
• complete visualization of the tumor is possible
• normal vocal cord mobility
• no extension of tumor into the anterior
  commissure

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Endoscopic surgery(C02 laser) for T1/T2 glottic
carcinoma

• Early studies showed local control rate from 88
  to 96
• (Shapshay, 1990 Rudert, 1995 Mahieu 1999)
• 
  involved only T1a tumors
• 
  
• Recent studies show local control rates for
• T1a 100
• T1b 94
• T2 91
• 
  minimal supraglottic/subglottic extension
• (Gallo, 2002Pradhan, 2003)
• Voice quality in general is preserved but
  would depend largely on the site of the lesion
  and amount of tissue removed
• (
  MacGuirt, 1992 Rydell, 1995 Mahieu, 1999)

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Endoscopic surgery(C02 laser) for T1/T2 glottic
carcinoma

• Advantages of C02 laser over radiotherapy
• Possibility of using the same modality (C02
  laser) for a recurrence
• Radiotherapy can still be used as back-up
  treatment in cases of recurrence and second
  primaries
• Less morbidity and less treatment time for the
  patient
• Less cost

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Management of T3 larynx carcinoma

• Best therapeutic approach for T3N0 tumors is
  still uncertain
• Patients may considered for chemoradiotherapy
  while selected patients may do just as well with
  conservation surgery with or without chemo or
  radiotherapy alone

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Management of T3 glottic larynx carcinoma

• 200 patients with T3N0 glottic ca treated with
• Total laryngectomy with or without radiotherapy
• Conservation surgery with and without
  radiotherapy
• Radiotherapy alone
• 5 year disease specific survival 67
• 5 year overall survival 54
• Locoregional control 74
• Laryngeal preservation 70
• All did not significantly differ according to
  treatment
• 
  
  (Sessions, 2002)

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Management of locoregionally advanced larynx
carcinoma

• General principles
• Primary goal is curation
• Organ sparing strategies should be considered
  even in late stages
• Factors that would influence quality of life
  play an important role in the choice of treatment
• functions of the upper aerodigestive tract

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Surgical options

• T3 N
• T4
• Recurrent disease
• Total laryngectomy

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T4 glottisch carcinoom
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Laryngectomy
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Provox voice prosthesis
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  folder\tle\DSC00054.JPGC

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Billroth 1873first total laryngectomy for cancer
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Irving-Foulds artificial larynx (1875)
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Esophageal and electrolarynx voice
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Purely surgical (Staffieri) vs. prosthetic vocal
rehabilitation techniques
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Prosthetic voice rehabilitation after total
laryngectomy
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Experience with non-indwelling voice
prosthesesBlom-Singer (1980) and Panje (1980)
Original Blom-Singer duckbill prosthesis
Panje prosthesis
Blom-Singer low-resistance prosthesis (1982)
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Experience with indwelling voice
prosthesesGroningen (1980-88) and Provox
(1988-present)
Provox
Groningen
Blom-Singer (1992)
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Provox low-resistance, indwelling voice
prosthesis (retrograde insertion and replacement
system)
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Indwelling vs non-indwelling voice prostheses
advantages and disadvantages

• advantages
• no replacement required by patient
• shorter learning curve and little dexterity
  needed for daily care
• more robust design longer device life
• with increasing age (loss of dexterity/visual
  acuity) still applicable

• disadvantage
• patient stays dependent of clinician
• Due to leakage through or araund the prosthesis

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Comprehensive rehabilitation after total
laryngectomy is more than voice alone

• The larynx is more than just a voice box.Due
  to its central position in the respiratory tract,
  its removal requires rehabilitation of all three
  systems depending on respiratory airflow, i.e.
• vocal rehabilitation
• pulmonary rehabilitation
• olfactory rehabilitation
• Rehabilitation of laryngectomized patients
  requires a multidisciplinary team effort in order
  to achieve optimal results and quality of life

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Olfactory rehabilitationthe polite yawning
technique
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Pulmonary Rehabilitation After Total Laryngectomy

• Due to the disconnection of the upper and lower
  airways, conditioning (heating, moisturing,
  filtering) of the breathing air will not take
  place any longer
• The considerable decrease in breathing
  resistance, leads to a shift of the equal
  pressure point to more periferal in the
  pulmonary tract, which has a negative effect on
  pulmonary physiology

• Ackerstaff, Hilgers, Meeuwis, Knegt, Weenink.
  Clin Otolaryngol 199924491-4.

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Effets des HME (McRae et al. 199621366-368)
Température 28.8 C Humidité 65
Température 36 C Humidité 98
Température 20 C Humidité 42

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Pulmonary rehabilitationHeat and Moisture
Exchangers (HMEs)

• Ackerstaff, Hilgers, Aaronson, de Boer, Meeuwis,
  Knegt, Spoelstra, van Zandwijk, Balm.Clin
  Otolaryngol 1995 20 504-509

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Early postoperative application of the Provox HME
and Optiderm adhesive
Hydrocolloid adhesive is ideal for first
postop day application
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Additional benefits of Provox HME use

• Retention of approximately 60 of the daily water
  loss (500 ml excessive loss with stoma breathing
  instead of nasal breathing
• More hygienic handling of stoma
• More effective coughing andsputum clearance by
  deliberatelyclosing stoma and releasing
  thevalve while coughing
• Filtering of dust particles

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Factors for successful voice rehabilitation

• Anatomy and morphology of the neoglottis
• Motivation of the patient
• Motivation of the multidisciplinary team
  (Otolaryngologist, Speech Therapist, Oncology
  Nurse)
• Voice prosthesis any voice prosthesisis better
  than no voice prosthesis at all(our preference
  is Provox, becauseof its low resistance, easy
  replacement,reliable retention, and easy
  cleaning)

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through magnets supported adjustable speech
membrane,cough relief valve,and walk-talk
position
Ultimate goalhandsfree speech Latest
development is Provox FreeHands HME
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Voice rehabilitation in theErasmusmc Rotterdam

• Primary prosthetic voice rehabilitation is the
  method of choice our hospital since 1989
• Indwelling, low-resistance voice prostheses, such
  as Provox(2), are preferred, with a long term
  success rate of approx. 90

• Voice prostheses are also applicable after
  extensive pharyngeal resection and reconstruction
• Patients also are offered esophageal voice
  rehabilitation (success rate approx. 40)
• Electrolarynx speech is considered a valuable
  back-up method, but is too seldom used at present

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Rule of thumb

• 2/3 of the patients only require replacement of
  the prosthesis, mostly for mild leakage (median
  device life 3-4 months)
• 1/3 of the patients experience adverse events,
  which require special attention, but mostly are
  easily solvable
• these adverse events are seen in only 1 out of 9
  (10.7) replacements

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THANK YOU FOR YOUR ATTENTION