conservative surgery for head and neck cancer
DESCRIPTION
presented at Department of ENT, NMCH, Patna by Dr Zeeshan Ahmad, PGY2TRANSCRIPT
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Principles of Conservative Surgery in Head & Neck Oncology
Dr Zeeshan AhmadM.S.(ENT,PGY2)
Department of ENTNMCH, Patna.29-08-13
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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
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Neck
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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.
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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.
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Types of Selective Neck Dissection
SupraOmoHyoid Neck Dissection
Extended SupraOmoHyoid Neck Dissection
Anterolateral Neck Dissection
Posterolateral Neck Dissection
Central compartment Neck Dissection
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SupraOmoHyoid Neck Dissection
SCC of Oral Cavity
Lymph nodes of level I to III
Submandibular Gland
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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
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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
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Posterolateral Neck Dissection
Primary cutaneous malignancies of Posterior Scalp.
Lymph nodes of level II to IV and suboccipital LN.
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Central compartment Neck Dissection
Diferentiated Thyroid carcinoma.
Lymph nodes of level VI to VII and Delphian
Perithyroid
Tracheo-osophageal groove
Anterior-superior mediastinum
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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
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Structures removed in RND along with level I to V LN
RND SSG
IJV
SCM
Sp Acc N
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Structures removed in MRND along with level I to V LN
MRND type I – (Spinal Accessory spared) SSG
IJV
SCM
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Structures removed in MRND along with level I to V LN
MRND type II –( Spinal Accessory + SCM spared) SSG
IJV
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Structures removed in MRND along with level I to V LN
MRND type III – (Spinal Accessory + SCM + IJV spared) SSG
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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.
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Larynx
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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.
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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.
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Open Partial Laryngeal surgery
General principles Consent for Total Laryngectomy
Speech rehabilitation – patient and family active
Good pulmonary function
No medical problem
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Types
Glottic Vertical Partial Laryngectomy
Lateral
anterolateral
Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.
Supraglottic Horizontal SPL
Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.
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GLOTTIC
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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.
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Vertical Partial Laryngectomy
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
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Vertical Partial Laryngectomy
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%
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Vertical Partial Laryngectomy
Functional results
Some degree of hoarseness
Most impairment – if no reconstruction
Least – replacement of glottis with adjacent false cord flap
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Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
Resection of Both true cords and Both false cords
Entire thyroid cartilage and One arytenoid
Paraglottic spaces bialterally
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Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
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.
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Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
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
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SUPRAGLOTTIC
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Horizontal Supraglottic Partial Laryngectomy
Parts removed Epiglotis and Pre-epiglottic space
Hyoid bone
Thyrohyoid membrane
Upper half of thyroid cartilage
Supraglottic mucosa
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Horizontal Supraglottic Partial Laryngectomy
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
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Horizontal Supraglottic Partial Laryngectomy
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
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Horizontal Supraglottic Partial Laryngectomy
High local control for T1 and T2
75% for T3 and 67% for T4
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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
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Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
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
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Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
Operation involves resection of Both true cords and both false cords
Entire thyroid cartilage
Both paraglottic spaces
Maximum of one arytenoid
Thyrohyoid membrane
epiglottis
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Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
Reconstruction using Hyoid bone
Cricoid
tongue
Temporary tracheostomy tube and feeding tube is required.
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Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
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
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Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
Contraindications Bulky pre-epiglottic space involvement
Gross thyroid cartilage destruction
Interarytenoid involvement
Fixed arytenoids
Subglottic extension >10mm anteriorly and >5mm posteriorly
Inadequate pulmonary reserve
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Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy
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
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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
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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
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Hypopharynx
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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
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Conservation surgery for cancer of Hypopharynx
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
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Conservation surgery for cancer of Hypopharynx
Large volume T2 / T3 / T4
Radical surgery Excision of primary tumour
Reconstruction
Radiotherapy
Endoscopic laser Excellent functional results
With synchronous or separate neck dissection
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Oral cavity
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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
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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
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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
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Oropharynx
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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
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Nose and PNS
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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
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Conservation surgery for cancer of Nose and PNS
Indications Midline lesions with limited lateral extension
Benign tumours – inverted papilloma and angiofibroma
Low grade malignant tumours
Palliation
Medical comorbidity limiting open approach
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Conservation surgery for cancer of Nose and PNS
Contraindications Lateral extension of tumour
Intracranial invasion
Intraorbital invasion
High grade malignant tumours
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Parotid
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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
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Thank you
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05.09.13 Dr Sonu Kumar SinghM.S.(ENT,PGY2)
Benign tumours of mouth and jaw