ENDOSCOPIC SURGERY FOR LARYNGEAL CANCER

Mahmoud Ahmed Mahmoud | 846

Table of Contents

Endoscopic Surgery for Laryngeal Cancer

TABLE OF CONTENTS
Introduction: ................................................................................................................................... 2 Staging:............................................................................................................................................ 3 Primary Tumor: ........................................................................................................................... 3 Nodes: ......................................................................................................................................... 5 Metastasis: .................................................................................................................................. 5 Stage Groupings: ......................................................................................................................... 5 Indication: ....................................................................................................................................... 6 Carcinoma in Situ, Microinvasive Carcinoma and Small T1a Carcinomas: ................................. 6 Large T1a and T1b Glottic Carcinomas:....................................................................................... 6 T2 Carcinomas: ............................................................................................................................ 6 T3 Carcinomas: ............................................................................................................................ 6 Infrahyoid Epiglottis: ................................................................................................................... 7 Suprahyoid Epiglottis and False Cord Area: ................................................................................ 7 Supraglottic Carcinomas: ............................................................................................................ 8 Surgical Procedure: ......................................................................................................................... 8 Endoscopic Laser Cordectomy: ................................................................................................... 8 Endoscopic Laser Supraglottic Laryngectomy: .......................................................................... 10 Surgery for Carcinoma of the Epiglottic Border: ....................................................................... 11 Surgery for Vestibular fold Carcinoma: ..................................................................................... 11 Advantages and Disadvantages: ................................................................................................... 11 Advantages: ............................................................................................................................... 11 Disadvantages: .......................................................................................................................... 11 References: ................................................................................................................................... 12

Endoscopic Surgery for Laryngeal Cancer

Introduction

INTRODUCTION
The surgical, oncologic, and functional principles are the same for minimally invasive surgery as for more conventional resections. The primary objective is the complete resection of the tumour while preserving as much function as possible. The principle is to minimize surgical morbidity while adhering to long-standing oncologic standards. During transoral laser microsurgery, decisions are made in accordance with the local spread of the tumour. The tumour extension is often clearly apparent under the microscope, and the lesion is resected until healthy tissue is found and appropriate safety margins can be maintained. The goal of complete resection is achieved by variations in the surgical approach and dissection instrument. In general, a transoral approach is the primary choice, and the CO2 laser under microscopic control is used as a dissecting instrument. All tumour surgery should adhere to the principle of complete resection with clear surgical margins that are histologically documented. This involves the cooperation of both the surgeon and the pathologist. Using a small focal diameter of the laser beam results in minimal carbonization and is particularly suitable for this application. The histologic assessment of the resection margins is facilitated by this technique, despite relatively close margins. The unconventional surgical technique of dissecting through larger tumours during the resection and removing the tumour in parts allows the surgeon to inspect the surface of the tissue under microscopic control. There are no indications that the incidence of late regional or distant metastases increases due to laser incisions through a tumour; this may be explained by the sealing effect of the lymph vessels, which has been observed in previous investigations.

Endoscopic Surgery for Laryngeal Cancer

Staging

STAGING
Staging for laryngeal cancer is based on the TNM classification of the American Joint Committee on Cancer:

Primary Tumor:
TX T0 Tis Minimum requirements to assess primary tumor cannot be met No evidence of primary tumor Carcinoma in situ

Supraglottis: T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis, or region outside the supraglottis (e.g. mucosa of base of the tongue, vallecula, medial wall of pyriform sinus) without fixation Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, preepiglottic tissue, paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) Tumor invades through the thyroid cartilage and/or invades tissue beyond the larynx (e.g. trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

T2

T3

T4a

T4b

Endoscopic Surgery for Laryngeal Cancer

Staging Glottis: T1 T1a T1b T2 Tumor limited to the vocal cord (s) (may involve anterior or posterior commissure) with normal mobility Tumor limited to one vocal cord Tumor involves both vocal cords Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

T3

T4a

T4b

Subglottis: T1 T2 T3 Tumor limited to the subglottis Tumor extends to vocal cord (s) with normal or impaired mobility Tumor limited the larynx with vocal cord fixation Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

T4a

T4b

Endoscopic Surgery for Laryngeal Cancer

Staging

Nodes:
N0 N1 N2a N2b N2c N3 No cervical lymph nodes positive Single ipsilateral lymph node 3cm Single ipsilateral node > 3cm and 6cm Multiple ipsilateral lymph nodes, each 6cm Bilateral or contralateral lymph nodes, each 6cm Single or multiple lymph nodes > 6cm

Metastasis:
M0 M1 No distant metastases Distant metastases present

Stage Groupings:
Stage 0 I II III Tis T1 T2 T3 T1-3 IVA T4a T1-4a IVB T4b Any T IVC Any T N0 N0 N0 N0 N1 N0-2 N2 Any N N3 Any N M0 M0 M0 M0 M0 M0 M0 M0 M0 M1

Endoscopic Surgery for Laryngeal Cancer

Indication

INDICATION
Carcinoma in Situ, Microinvasive Carcinoma and Small T1a Carcinomas:
In cases of a biopsy-proven small carcinomas or carcinoma in situ, the entire lesion is excised with an appropriate resection margin. When tumour invades is found in the resection margin, two treatment strategies are possible: laser surgery or radiotherapy. Its recommended to repeat laser or conventional surgery because, in most cases where tissue is re-resected from the tumour margin, this tissue is tumour-free on histopathologic investigation, and radiotherapy would have been unnecessary. Most experiences indicate that, in general, vocal function is almost normal following such limited-excision biopsies.

Large T1a and T1b Glottic Carcinomas:

When a clearly superficial lesion infiltrates to a depth of only approximately 2 mm and does not cover the entire cord (i.e., microcarcinoma), the carcinoma is excised en bloc. When the depth of infiltration is in doubt, a single incision through the center of the tumour may help to estimate the depth. The subsequent laser surgical treatment is the same as for small, well circumscribed lesions. In cases of marginal involvement of the anterior commissure without subglottic extension, the anterior commissure is resected along with the bilateral cord lesion. The dissection is carried out along the thyroid cartilage under high magnification of the operating microscope. Laser surgical resections of carcinomas of the anterior commissure require a surgeon experienced in this technique because the risk of developing recurrent disease is more likely in the anterior commissure than in any other localization of the glottis.

T2 Carcinomas:
For all T2 carcinomas of the glottis, primary laser surgery is advocated regardless of the pattern of tumour spread. A surgeon with wide experience in laser surgery is essential. Superficially spreading carcinomas are ideally suited for laser surgery. Even if they cover vast areas of the endolarynx, they can be resected completely with a partial mucosectomy of the larynx if the carcinoma can be exposed adequately. The excision can be performed in several pieces, and the basal surfaces should be stained with blue ink for better orientation of the pathologist. Exact topographic descriptions on the pathology request form are important and should be copied onto patient charts. Additionally, the exact origin of the individual specimen must be noted in a schematic drawing of the larynx.

T3 Carcinomas:
Currently, the majority of resectable carcinomas are treated with conventional surgery. However, laser surgical resection is possible even for large tumours if they can be exposed adequately and if the surgeon has the required training in laser surgery. For these advanced

Endoscopic Surgery for Laryngeal Cancer

Indication

tumours of the glottis, incisions are placed through the bulk of the tumour to divide it into smaller portions, laterally onto the thyroid cartilage and inferiorly onto the superior surface of the cricoid cartilage. Incisions follow the extensions of the tumour and are placed deeply into the musculature until a tissue layer is encountered that reacts normally to the laser light under the microscope. If the musculature is invaded up to the perichondrium, the tumour can be resected by dissecting along the inner table of the thyroid cartilage. Suspected infiltration of the thyroid cartilage or definite penetration through parts of the cartilage is included in the resection. A specimen resected from the neighboring prelaryngeal soft tissues can be used to verify the completeness of the resection. The resection of extended carcinomas should be performed by a surgeon experienced in laser surgery to avoid an incomplete resection that would adversely affect the patient's prognosis. Conventional surgery is preferred where an experienced surgeon is unavailable.

Infrahyoid Epiglottis:
The depth of tumour infiltration in the area around the petiole is difficult to assess preoperatively. There may be considerable difficulty in distinguishing between a T1 tumour and a T3 lesion (infiltration of the pre-epiglottic space). To determine the extent of the carcinoma to the preepiglottic space, we usually split the suprahyoid epiglottis sagitally. The bivalved laryngoscope is subsequently advanced, thus revealing the surface of the dissection plane through the epiglottic cartilage as well as the pre-epiglottic fat and the laryngeal surface of the infrahyoid epiglottis with the tumour. The tumour is then dissected in a sagittal plane. The dissection proceeds in an inferior direction. Depending on the extent of the tumour, horizontal cuts are placed through the bulk of the lesion. If the thyroid cartilage or one of the arytenoid cartilages is infiltrated by tumour, it is included in the resection. During the resection of parts of the thyroid cartilage, care is taken to avoid damage to the extralaryngeal vessels. If the tumour has broken through the thyrohyoid membrane, it is followed as far into the neck as possible. The resection can reach all the way into the subcutaneous tissue of the neck. Persistent functional impairments are not anticipated with this surgery. Resection of advanced carcinomas requires attention to postoperative function. Resection of one arytenoid cartilage is not associated with long-lasting functional impairment; however, if both arytenoids are resected, deglutition without aspiration is usually not possible. Additional difficulties may occur if further resections in the area of the base of the tongue are required. As already noted, the resection of extended carcinomas is reserved for surgeons with extensive experience with laser surgery.

Suprahyoid Epiglottis and False Cord Area:

Technically, tumours in this location can be easily excised. Wide resection margins can be achieved without functional implications as in the case of glottic lesions.

Endoscopic Surgery for Laryngeal Cancer

Surgical Procedure

Supraglottic Carcinomas:
Small, well-circumscribed tumours of the supraglottis can be resected in one piece, similar to small lesions on the vocal cord.

SURGICAL PROCEDURE
Endoscopic Laser Cordectomy:
The procedure begins with the orotracheal intubation with a laser-safe endotracheal tube. The patients eyes are then taped and padded and a head drape and upper tooth guard is applied. When the patient is fully relaxed and sufficiently anaesthetized, a largest possible laryngoscope is introduced to get a good view of larynx. Before introducing the laryngoscope, the patients head is fully extended, and the laryngoscope is introduced between the endotracheal tube behind and lower jaw in front. Under visualization, laryngoscope is gently pushed forwards following the endotracheal tube between the epiglottis and the tube until the point reaches the petiole of epiglottis. If laryngoscope is passed too deeply into the larynx, both the vestibular fold and vocal folds are displaced laterally, whereas if the scope is not passed deeply enough the vestibular folds obscure the vocal cords. Once the laryngoscope is correct position, the chest holder is put in place to fix the scope in position. After exact adjustment of the scope, both vocal cords can be seen as far as the apex of vocal process. Once the laryngoscope is in the desired position, the light carrier is removed and an operating microscope is used. The patients head and face are protected with moist towels and the operating microscope, which is fitted with a microspot carbon dioxide laser and 400 mm lens is brought into position. To protect the endotracheal tube cuff, a moist cottonoid sponge is placed in the subglottis. Dissection is begun posteriorly and laterally. Medial retraction of the edge of the lesion shows the plane of dissection as the surgeon dissects anteriorly and inferior edge is resected at the end. A curved trajectory that parallels the contour of the normal vocal fold is used, and the depth of the excision is tailored to the lesion. The 30 or 70 angle telescope introduced through laryngoscope can be used with the advantage of examining the laryngeal surface of epiglottis, lateral wall of larynx, and subglottic space.

Endoscopic Surgery for Laryngeal Cancer

Surgical Procedure Different Types of Cordectomy: Type I: Subepithelial Cordectomy: This involves the resection of vocal fold epithelium, passing through the superficial layer of the lamina propria. It is performed for premalignant lesions and lesions that show malignant transformation. Usually entire vocal cord epithelium is resected and in rare cases, clinically normal epithelium may be preserved. Since subepithelial cordectomy ensures histopathological examination of entire vocal cord, the main role of this surgical procedure is diagnostic. This procedure can also be therapeutic if histological results confirm hyperplasia, dysplasia, or carcinoma in situ without signs of microinvasion. Type II: Subligamental Cordectomy: This is indicated for cases of microinvasive carcinoma or severe carcinoma in situ with possible microinvasion. In this procedure vocal cord epithelium, Reinke space, vocal ligament are resected by cutting between the vocal ligament and vocalis muscle. The resection may extend from the vocal process to the anterior commissure and vocalis muscle is preserved as much as possible. Type III: Transmuscular Cordectomy: This procedure is indicated for small superficial lesions of the mobile vocal folds that reaches the vocalis muscle and without deeply infiltrating it. This involves the resection of epithelium, lamina propria and the part of vocalis muscle. The resection may extend from the vocal process to the anterior commissure. In some cases, partial resection of the ventricular fold may be required for adequate visualization of the vocal fold Type IV: Total or Complete Cordectomy: This procedure is indicated for T1a lesions infiltrating the vocalis muscle. The resection extends from the vocal process to the anterior commissure and attachment of vocal ligament to the thyroid cartilage should be cut. The depth of the surgical margins reaches the internal perichondrium of the thyroid cartilage and sometimes perichondrium is included with resection. Type V: Extended Cordectomy Type Va: Extended Cordectomy encompassing the contralateral vocal fold: This surgical approach was meant to include the anterior commissure and, depending on the extent of tumor, either a segment or the entire contralateral vocal fold. This procedure is now replaced by type VI cordectomy.

Endoscopic Surgery for Laryngeal Cancer

Surgical Procedure Type Vb: Extended Cordectomy encompassing the arytenoids: This procedure is indicated for vocal fold carcinoma involving vocal process or arytenoid cartilage posteriorly. For this type of resection, arytenoid cartilage should be mobile, and the cartilage is partially or fully resected. Type Vc: Extended Cordectomy encompassing the ventricular fold: This procedure is indicated for ventricular cancers or trans glottis cancers that spread from vocal fold to the ventricle. This involves the resection of ventricular fold and Morganis ventricle. Type Vd: Extended cordectomy encompassing the subglottis: This procedure can be used for selected cases of T2 carcinoma with limited subglottic extension without cartilage invasion. Type VI cordectomy: This procedure is indicated for cancer originating in the anterior commissure involving one or both the vocal cords, without infiltrating the thyroid cartilage. The surgery comprises anterior commissurectomy with bilateral anterior cordectomy. If the tumor is in contact with cartilage, resection can encompass anterior part of thyroid cartilage. Resection of the anterior commissure may include the subglottis mucosa and cricothyroid membrane, because cancers of anterior commissure tend to spread toward the lymphatic vessels of the subglottis. The pharynx and teeth should be checked for damage before extubating from anesthesia.

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Endoscopic Laser Supraglottic Laryngectomy:

The technique of transoral laser resection of supraglottic cancer contradicts the classic rules of oncological surgery because in many cases tumors are sectioned and removed piecemeal. It is possible to do so because the hemostatic effect of the CO2 laser and the operating microscope allow the surgeon to detect the boundary between tumor and healthy tissue. Optimal exposure and visualization of the supraglottic region is critical for safe tumor resection. Ordinary tubular laryngoscopes are not suitable for procedures in this area. Bivalved laryngoscopes with spreadable blades are necessary. The blades may be separated by angulation or parallel distraction, thus providing flexibility in exposing various sites. Numerous adjustments of the position of the laryngoscope during surgery are usually necessary to achieve good visualization of the tumor and of the surrounding healthy tissue. Smaller tumors along the free margin of the epiglottis and of the aryepiglottic fold can be excised in one piece as an excisional biopsy. Larger tumors require piecemeal resection, with consequent sectioning of the neoplasm. Specimens are labeled as to location and sent for frozen section, with particular attention to the resection margins. Several techniques have been described to improve access and visibility. The epiglottis may be initially divided sagitally or horizontally and then retracted into a plane

Endoscopic Surgery for Laryngeal Cancer

Advantages and Disadvantages

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tangential to the laser beam. When infra-hyoid tumor extension is present, the pre-epiglottic space must be completely removed. The resection may be extended to include the false vocal cords and the paraglottic space. If cancer approaches the arytenoid cartilage, the arytenoid itself can be transected or resected completely. Consequently, the mucosal and endolaryngeal area that can be extirpated is comparable to that of the classic transcervical HSL, without resection of thyroid cartilage.

Surgery for Carcinoma of the Epiglottic Border:

Small T1 epiglottic carcinoma can be excised by CO2 laser much like a vocal cord lesion. This technique provides an en bloe removal with a safety margin of several millimeters. The patient has no functional deficits (swallowing, respiration) and can be released from hospital the gay after surgery.

Surgery for Vestibular fold Carcinoma:

A safe resection is performed using the same technique for epiglottic carcinoma. The incision may continue in the pre-epiglottic space down to the hyoid and the upper rim of the thyroid cartilage.

ADVANTAGES AND DISADVANTAGES

Advantages:
o o o o o o o May be extended to include tumors involving hypopharynx/oropharynx. Typically does not require tracheotomy. Reduced incidence of aspiration pneumonia. Preservation of superior laryngeal neurovascular bundle, preserving sensation to larynx. Lower incidence of pharyngocutaneous fistulas. Faster rehabilitation of swallowing. Shorter hospital stays.

Disadvantages:
o Large tumors that result in limited exposure via laryngoscope may be better addressed via an open approach. o More extensive endoscopic resections result in a higher risk of postoperative aspiration.

Endoscopic Surgery for Laryngeal Cancer

References

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REFERENCES
Malignant Tumors of the Larynx and Hypopharynx. Cummings- Otolaryngology- Head and Neck Surgery. 4th ed., Mosby, 2005. Malignant Laryngeal Lesions. Lawani- Current Diagnosis and Treatment in Otolaryngology- Head and Neck Surgery. McGraw-Hill and Lange, 2004. Surgery for Supraglottic Cancer. Myers- Operative Otolaryngology Head and Neck Surgery Vol. 1. 1st ed., Saunders, 1997. Surgery for Glottic Carcinoma. Myers- Operative Otolaryngology Head and Neck Surgery Vol. 1. 1st ed., Saunders, 1997. The Larynx. Lore and Medina- An Atlas of Head and Neck Surgery. 4th ed., Elsevier, 2005. Lefebre J, Chevalier D, Luboinski B, Kirkpatrick A, Collette L, Sahmoud T. Larynx Preservation in Pyriform Sinus Cancer: Preliminary Results of a European Organization for Research and Treatment of Cancer Phase III Trial. Journal of the National Cancer Institute. Jul 1996. 88(13): 890-899.

Endoscopic Surgery for Laryngeal Cancer