MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU „TVOŘÍME BUDOUCNOST MEDICÍNY“ Oncology in ENT II Clinic of Otorhinolaryngology and Head and Neck Surgery, Masaryk university, Faculty St. Ann Hospital Head: Ass. Prof. Gál Břetislav, MD, Ph.D. Pekařská 53 656 91 Brno, Czech Republic Tumors of larynx - epidemiology ▪ Incidence in Czech rep. 9,3 male and 1,1 female/100 000 inhabitants. ▪ Incidence without greater changes over last years in CR ▪ In man 1,59 % of all malignant tumors ▪ In female only 0,23 % Tumors of larynx – lymphatic drainage ▪ Deep lymphatic net – divided left and right side. ▪ Vocal cords – poor lymphatic drainage , border between supraand subglottis ▪ Supraglotis drained into jugulocarotic chain. ▪ Subglotis drained into mediastinum, paratracheal lymph node. Tumors of larynx – risk factors ▪ Tobacco use especially when start in young age and more than 20 cig/day. Associated with higher expression of protooncogene bcl-2 (participation in apoptotic inhibition) ▪ Alcohol abuse higher number of non- specific mutations of gene P53 ▪ Uranium, irradiation for benign lesion (papillomatosis). ▪ chromium ▪ Papillomavirus (HPV) Tumors of larynx – evaluation, grading, stagging • Clinical evaluation - character and extension of primary tumor, tributary lymph nodes = staging. Microlaryngoscopy sec. Kleinsasser • Histology – histopathologic grading • Sonography of lymph nodes and organs of stomach cavity • CT, MRI of primary tumor a tributary lymph nodes • X-ray evaluation of esophagus • Stomatology evaluation, prostate by men, gynecology by women Advanced supraglottic carcinoma (thyroid cartilage afflicted by tumor) Tumors of larynx - symptoms Depends on the extent and localization of primary tumor • hoarseness – Every man in risk group (smoker, more than 40 years old should be evaluated when hoarseness is present longer than 14 days • feeling of foreign body - early symptom in supraglottic cancer • cough • bleeding • swallowing problems, odynophagia, dysphagia – early symptom in supraglottic cancer • Dyspnea with stridor • perichondritis – pain, odynophagia, dysphagia, temperature • Cachexia tumorosa Tumors of larynx TNM classification Tumors of larynx (glottis) TNM classification T1 Tumor limited to vocal cord(s) (may involve anterior or posterior commissure) with normal mobility T1a Tumor limited to one vocal cord T1b Tumor involves both vocal cords T2 Tumour extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3 Tumour limited to larynx with vocal cord fixation and/or invades paraglottic space, and/or with minor thyroid cartilage erosion (e.g. inner cortex) Tumors of glottis TNM classification Tumors of glottis TNM classification T4a Tumor invades through the thyroid cartilage, or invades tissues beyond the larynx, e.g., trachea, soft tissues of neck including deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), strap muscles, thyroid, esophagus T4b Tumor invades prevertebral space, mediastinal structures, or encases carotid artery Cancer of right vocal cord Cancer of left vocal cord Laryngeal cancer stages Strategy of laryngeal cancer treatment • Safely tumor removal, safe QOL without sacrifice of overall survival • In last decades noticeable shift, emphasis on organ saving protocol – voice and swallowing • Transoral Laser Microsurgery (TLM) vs. Open (external) approaches and radiotherapy have comparable outcomes of local tumor control, overall survival, but difference in voice quality • Decision about treatment choice depends on localization, stage, tumor attributes, general status (incl. Vital pulmonary capacity – possibility of external approach) of patient and his preferences. • Tumor stage • early (T1-2) – surgery or RT • advanced (T3-4) – surgery + RT or chemoRT () Totální laryngektomie Rozšířená totální laryngektomie Surgery of laryngeal tumors Conservative Endoscopic transoral TLM – transoral laser micro surgery TORS –transoral robotic micro-surgery External approach – partial laryngectomies laryngophisura chordectomy Vertical partial laryngectomy Antero-frontal, Fronto-lateral Lateral hemilaryngectomy Horizontal partial laryngectomy (supra-glottic) Subtotal supracricoid laryngectomy Near total laryngectomy Radical Total laryngectomy/extended total laryngectomy Supraglottic cancer Cancer of right aryepiglottic fold Cancer of right ventricular fold Cancer of supraglottis (epiglottis) T2 Cancer of supraglottis (epiglottis) T2 in direct laryngoscopy Surgery of laryngeal tumors - indications Endoskopic methods (TLM, TORS) ▪ Tis or T1 Laryngophissura with chordectomy ▪ T1 Horizontal partial laryngectomy (supraglottic, Allonzo 1937) ▪ T1-2 tumors, supraglotic larynx incl. aryepiglotic and ventricular folds and preepiglottic space Partial frontolateral laryngectomy ▪ T2 tumors glottis Indications for transoral laser micro-surgery supra glottis • Ca supraglottic early stage inside borders of supraglotic larynx and preepiglottic space. • Small to middle advanced tumor; Tis,T1,T2 and selected cases T3 (limited spread into preepiglottic space). • age • Pulmonary functions • Comorbidities • Social relations, family, patient´s wish Ca spino plicae vocalis l.dx. cT2 6 months after RT Narrow Band Imaging (NBI) – better depiction of capillary net Surgery of advanced laryngeal tumors - indications Total laryngectomy ▪ T3-4 tumors, breathing is only possible via the tracheostomy Total laryngectomy with removal of the pharynx ▪ Extended about piriform sinus Organ saving protocols ▪ Combined not surgical treatment - Radiotherapy, chemotherapy, targeted („biologic“) treatment, monoclonal antibodies Total laryngectomy Ca spino laryngis glottic form pT4 pN0 M0 Subglottic carcinoma In the case, that it is find out in resectable stage, every time it is treated by surgery. Inoperable stage of all sites – palliative radiotherapy. Prognosis of laryngeal cancer Rehabilitation after laryngectomy Partial laryngectomy Hoarseness, aspiration – rehabilitation of swallowing Total laryngectomy ▪ Rehabilitation of smell ▪ Voice: – Esophageal speech – Electrolarynx – Voice prosthesis Voice prosthesis ▪ Introduction into tracheostoma – primary or secondary ▪ Complication – fungal infection, leak, granulations, displacement of prosthesis Voice rehabilitation Elektrolarynx, arteficial larynx - generator of vibration, produce mechanical sound, this sound is articulated by the tongue, lips and teeth as understandable speech Laryngeal cancer – local recurrens Ca spino oro- et hypopharyngis l.sin. cum meta colli Reccurentio (1 year after neck dissection) what we should do ✓Prevention ✓Early detection of tumors ✓Prognosis depends on general status of patient before treatment (alimentation) ✓Management – evaluation and treatment in the as short as possible time (ultrasound, stomatology evaluation) to remember Early detection of oncologic disease ✓ Not healing efflorescence on the skin ✓ One side nose blocking, recurrent epistaxis ✓ Asymmetry in the region of isthmus faucium ✓ Hoarseness in risk group of inhabitants lasting longer time as 14 days should be evaluated by otolaryngology physician ✓ Feeling of foreign body in the throat ✓ Neck mass