Conservative surgery for head and neck cancer

Principles of Conservative Surgery in Head & Neck Oncology

Dr Zeeshan AhmadM.S.(ENT,PGY2)

Department of ENTNMCH, Patna.29-08-13

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

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.

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.

Types of Selective Neck Dissection

SupraOmoHyoid Neck Dissection

Extended SupraOmoHyoid Neck Dissection

Anterolateral Neck Dissection

Posterolateral Neck Dissection

Central compartment Neck Dissection

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

Lymph nodes of level I to IV

Submandibular Gland

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

Posterolateral Neck Dissection

Primary cutaneous malignancies of Posterior Scalp.

Lymph nodes of level II to IV and suboccipital LN.

Central compartment Neck Dissection

Diferentiated Thyroid carcinoma.

Lymph nodes of level VI to VII and Delphian

Perithyroid

Tracheo-osophageal groove

Anterior-superior mediastinum

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

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


MRND type II –( Spinal Accessory + SCM spared) SSG

IJV


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.

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.

Larynx

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.

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.

Open Partial Laryngeal surgery

General principles Consent for Total Laryngectomy

Speech rehabilitation – patient and family active

Good pulmonary function

No medical problem

Types

Glottic Vertical Partial Laryngectomy

Lateral

anterolateral

Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.

Supraglottic Horizontal SPL

Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.

GLOTTIC

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.


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


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%


Functional results

Some degree of hoarseness

Most impairment – if no reconstruction

Least – replacement of glottis with adjacent false cord flap

Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy

Resection of Both true cords and Both false cords

Entire thyroid cartilage and One arytenoid

Paraglottic spaces bialterally


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.


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

SUPRAGLOTTIC

Horizontal Supraglottic Partial Laryngectomy

Parts removed Epiglotis and Pre-epiglottic space

Hyoid bone

Thyrohyoid membrane

Upper half of thyroid cartilage

Supraglottic mucosa


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


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


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

Near Total Laryngectomy =

this is a technically complex procedure to create a physiological voice shunt based around one mobile arytenoid.

Requires permanent stoma


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


Operation involves resection of Both true cords and both false cords

Entire thyroid cartilage

Both paraglottic spaces

Maximum of one arytenoid

Thyrohyoid membrane

epiglottis


Reconstruction using Hyoid bone

Cricoid

tongue

Temporary tracheostomy tube and feeding tube is required.


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


Contraindications Bulky pre-epiglottic space involvement

Gross thyroid cartilage destruction

Interarytenoid involvement

Fixed arytenoids

Subglottic extension >10mm anteriorly and >5mm posteriorly

Inadequate pulmonary reserve


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

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

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

Hypopharynx

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


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


Large volume T2 / T3 / T4

Radical surgery Excision of primary tumour

Reconstruction

Radiotherapy

Endoscopic laser Excellent functional results

With synchronous or separate neck dissection

Oral cavity

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

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

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

Oropharynx

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

Nose and PNS

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


Indications Midline lesions with limited lateral extension

Benign tumours – inverted papilloma and angiofibroma

Low grade malignant tumours

Palliation

Medical comorbidity limiting open approach


Contraindications Lateral extension of tumour

Intracranial invasion

Intraorbital invasion

High grade malignant tumours

Parotid

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

Thank you

NEXT

05.09.13 Dr Sonu Kumar SinghM.S.(ENT,PGY2)

Benign tumours of mouth and jaw

Conservative surgery for head and neck cancer

Health & Medicine

Transcript of Conservative surgery for head and neck cancer