Cancers of the larynx
1. PLAN INTRODUCTION reminders:. Anatomy. Physiology. Histology ETIOPATHOGENIE:. Epidemiology. Causal factors histopathology Clinical Study: TDD: EPIDERMOÏDE carcinoma of the CORDEVOCALE clinical forms CLASSIFICATIONTNM positive Diagnosis Differential Diagnosis Treatment: Goals – means – Complications due to treatment – Indications support for LOCAL or LOCOREGIONAL failure Rehabilitation LARYNGEE POSTTHERAPEUTIQUE EVOLUTION/COMPLICATIONS SURVEILLANCE Prognosis CONCLUSION 2
2. INTRODUCTION intimately linked to chronic smoking, laryngeal cancer occupies the first place in terms of incidence in human ENT cancers; it is in sharp increase in women as a change in female smoking; the most common histopathological form is squamous carcinoma (95%) and its overall prognosis is one of the best in the upper aerodigestive pathways;
3. INTRODUCTION There are multiple endoscopic or cervical, conservative or radical surgical techniques for treating it, classically associated with radiation therapy; chemotherapy has gained an undeniable place with its association with radiation therapy in laryngeal preservation protocols; The therapeutic strategy is personalized and depends on the locoregional and distance extension, the co-morbidities and the patient's wishes; It is decided in a multidisciplinary consultation meeting (RCP) associating throat doctor, radiologist, pathologist, medical oncologist, radiotherapist, anaesthetist, speech therapist, psychologist...
4. Anatomical reminders The larynx is an odd and median organ that occupies the upper part of the sub-Hyoïdienne region of the neck; • Made of a cartilaginous skeleton joined by joints, membranes, ligaments and muscles;
5. as well on the embryology, anatomical and surgical, it is important to distinguish in the larynx: 2 parts: • The tube laryngeal: cartilaginous which extends the trachea in the pharynx and plays the role of sphincter thanks to the aryténoïdes and their Muscular apparatus; • The device thyroid-omohyoid: Consisting of the hyoid bone, the thyroid-hyoïdienne membrane and the thyroid cartilage; It supports and protects the laryngeal tube.
6. and 3 floors: • Subglottic floor: Between the free edges of the 2 CV: glottis, anterior and posterior corners; • SUS-subglottic floor: Above CV: epiglottis, ventricular strips, morgani ventricle, ary-épiglottiques folds; • Subglottic floor: Starts at 10 mm below the free edge of the CV and extends to the lower edge of the cricoid.
7. Endolaryngés spaces important for the understanding of the extension of laryngeal carcinomas and the principles of surgery: The pre épiglottique area of Boyer or Loge hyo-thyroid-épiglottique (HTE): In a funnel with lower top, between the epiglottis in Back and the upper part of the thyroid cartilage and the thyroid-hyoïdienne membrane forward; the Space para subglottic: Limited forward and laterally by the thyroid cartilage and the Jacko-thyroid Junn, the 3 stages of the larynx are communicated; the previous commissal: Meeting Angle of CVS.
8. Anatomical reminders Intra-parietal spaces of the larynx
9. Areas of resistance to tumor extension: barrier to extra laryngeal extension: • Thyroid Cartilage (not ossified); • Cricoid Cartilage (not ossified); • thyroid-hyoïdienne Membrane; • And the Hyo-épiglottique membrane. barrier to Intra laryngeal extension: • The jack-vocal membrane or elastic cone: opposes the tumor propagation of the SUS subglottic and the para-subglottic space on the upstairs under Subglottic; • the vocal ligament; • The elastic layer under mucous membrane.
10. Areas of weakness for extra laryngeal extension: the jack-thyroid membrane: perforated by neurovascular-nervous elements; the previous commissal: at its level the thyroid cartilage is without internal perichondrium, frequently presents bone metaplasia, and is weakened by the penetration of lgt thyroid-épiglottique; a ossified cartilage.
11. Areas of weakness for intra laryngeal extension: the epiglottis: With its cribriformes apertures towards the HTE lodge; the thyroid-épiglottique ligament: towards the HTE Lodge; the HTE Lodge: from the glottis to the SUS glottis or conversely; the ventricle especially in the presence of a laryngocèle: towards the vestibule laryngeal; The Paraglottique space: communicates the 3 stages of the larynx and offers relationships with the bone metaplasia of the thyroid cartilages, cricoid and cricoarytenoid.
12. Lymphatic Drainage: floor SUS subglottic: Rich network; Drainage to the internal jugular chain, including sub-digastric and Omo-omohyoid; There is a cross to the contralateral network; floor subglottic: poor in lymphatics; The free edges of the CVs are lacking; Qqs VX at the CA and CP level; floor under subglottic: • Anterior pedicle (GGs jugular and pre-tracheal); • Pedicles post: (Jug inf, Récurentielle (cervical to the right and Cervico-mediastinal to the left). independence of the superficial networks SUS and under subglottic except at the level of CP; independence of the deep networks of the 2 hemi-larynx at the level of the SUS floor Subglottic.
13. Physiological reminders The larynx provides 3 functions: 1. Respiration: Prolongs the trachea at the top and opens PDT breathing. 2. Phonation: Emits the basic sounds that will then be modulated by the resonance cavities, the tongue and lip movements. 3. Protection during swallowing: the closure of the glottis, the ascent of the larynx and the folding of the epiglottis back protect against false roads.
14. histological reminders pharyngeal lining of the larynx: the pharyngeal mucosa lining the entire part of the larynx protruding into the hypopharynx; It is a stratified squamous epithelium; on the ant side of the epiglottis, the mucosa is easily peeled off, so that this area can be the seat of 1 considerable edema; the Épiglottique and the post face of the aryténoïdes are easily distended; elsewhere the mucosa is adherent.
15. Coating of Endolarynx: respiratory-type mucosal with a ciliate prismatic epithelium; a metaplasia squamous gradually occupies the areas of wear, installing a stratified squamous epithelium (epiglottis sus Hyoïdienne, free edge of the ventricular bands and vocal chords, fallback ary-épiglottique); The chorion contains numerous enclosed follicles (sub-subglottic region and ventricles); it is in continuity with the tracheal mucosa and pharyngeal; it is doubled by a fiber-elastic membrane strained from the ary-épiglotique ligament to the Cricoïdien arc.
16. in adult smokers, the cylindrical mucosa of the larynx is almost completely replaced by a carcinoma coating.17. ETIOPATHOGENIE of laryngeal cancers Epidemiology: • Incidence: 2.5 to 17.2 pour100000 ha/yr; France: 15.6; Italy: 10.1; United Kingdom: 4.4; • 3.5% of malignant tumours diagnosed annually in the world; 4.4% in Algeria (HCA/Pr Saunders and Col.); • 20000 deaths corresponding to 1% of deaths from cancer; • 25% of desVADS cancers; • Age: 45 to 70 years; Rare before 40 years; Exceptional in children (these are mainly embryonic tumours); • Sex ratio H/F: Classically 9:1 but evolving with female smoking, currently 5:1; Balanced among the under-35 in Europe; • 12th position of causes of death from cancer in men, 17th in women; • subglottic Cancer: 60%; Subglottic rare Cancer: <12% ;="" •="" le="" cancer="" supraglottique="" serait="" plus="" fréquent="" chez="" la="" femme="" (75%)="" que="" chez="" l’homme="" (46%).="" 18.="" facteurs="" étiologiques:="" ="" le="" tabac:="" •="" c’est="" le="" facteur="" de="" risque="" essentiel="" des="" carcinomes="" du="" larynx,="" il="" multiplierait="" 10="" à="" 30="" fois="" le="" risque="" de="" cancer="" du="" larynx;="" •="" plus="" de="" 4000="" substances="" chimiques="" dans="" la="" fumée="" de="" tabac="" dont="" au="" moins="" 250="" sont="" dangereuses="" et="" plus="" de="" 30="" sont="" cancérigènes="" comme="" les="" hydrocarbures="" aromatiques="" polycycliques="" et="" les="" nitrosamines;="" •="" le="" risque="" lié="" à="" la="" fumée="" de="" cigarette="">pipe > cigar; • Tobacco carcinogens alter cellular DNA and cause a mutation in the P53 protein gene (inhibitory cell multiplication); • Risk is dependent dose: a smoker of 20 Cigarettes/J has 9 times more chance of developing a carcinoma and one who smokes 40 cigarettes/J is 13 times more likely to die of cancer of the larynx! A patient who continues to smoke after controlling his laryngeal cancer at 3 years, has 7 times more risk of developing a 2nd carcinoma! • The risk of passive smoking is also certain!
19. Alcohol: • Alcoholism is an independent risk factor for smoking, but potentialiserait also affects the effects of tobacco; • Carcinogens identified in alcoholic beverages: phorbol esters in anise alcohol, polycyclic aromatic hydrocarbons in certain whiskies and nitrosamines in certain beers; • Alcohol has other deleterious effects such as: ˗ a chronic local irritation; ˗ a solvent effect of tobacco carcinogens; ˗ and a degradation of the organization's defences. • Alcohol-induced laryngeal carcinomas are readily developed at the SUS glottis (direct Contact) level; Food factors: • A multicentre study showed that consumption of fruit and vegetables, vegetable oil, fish and the restriction of butter and canned goods were linked to reduced risk; The taking of Vit C, of Vit E, of Vit B2, of iron, of zinc, of selenium, would have a protective effect; • Vitamin deficiencies would multiply the risk.
20. Professional factors: • Their role remains difficult to identify because of the quasi-systematic presence of smoking, or even chronic alcoholism associated with it; • But workers exposed to microparticles of asbestos, metals, diesel combustion products, sulphuric acid smoke, tar, textiles, wood and various organic and inorganic agents would have an increased risk of laryngeal cancer; • Cancer of the larynx by exposure to asbestos is recognised as an occupational disease in Germany; • Tobacco-related vocal fatigue would also be a risk factor. Genetic factors: • Some enzymes such as glutathione S-transferase (SGT) are involved in detoxification of tobacco carcinogens; • The GR deficiency of genetic origin would increase the risk of laryngeal carcinoma of tobacco origin; • A predisposition to laryngeal carcinomas has been observed in some families and in some patients with Lynch or Bloom syndrome.
21. gastroesophageal reflux disease (GERD): • It is a chronic laryngitis that exposes itself to the occurrence of laryngeal carcinoma, including the anterior 2/3 of the glottis; • In multi-variate study, Gerd would multiply the risk of cancer of the larynx by two; Virus: • The association of HPV with carcinoma of the larynx has been known for 30 years; • Types 16, 18, 31 and 33 are the most encountered, but are shown in varying ways according to the detection method (8 to 60% of cases); • Types 16 and 33 are detected in tumor cell DNA by PCR of 40% of cases; • HPV 11 is detected in 25% of normal human larynx; • The risk of laryngeal cancer is multiplied by 16 in patients carrying papillomatosis laryngeal treated with radiation therapy. other factors mentioned: adverse socio-economic Situation, hormonal factors, anterior cervical irradiation;
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22. Histopathology of laryngeal cancers pre-cancerous states: fall within the framework of chronic laryngitis, which have causal factors in common with laryngeal cancer: • Tobacco, • GERD, • Dragging Infections of the ENT sphere, • Voice, • Alcohol... macroscopically: These are non-specific chronic laryngitis that are artificially classified into 2 varieties: • Red laryngitis, • and white or keratotic laryngitis;
23. Red laryngitis: • Bluetongue: Is characterized by a hyperemia of the whole larynx with mucosal hypersecretion. Variable color of pinkish grey to bright red. No relief lesions are visible and capillaries are dilated but parallel to the free edge of the CV. • Red or hypertrophic pachydermique laryngitis: thickened and hyperhémiée mucosa with 2 main forms: ˗ the single rope: Dark red rope, flanged, cylindrical throughout its length, with capillaries at the anarchic disposal; ˗ the rope into islets: red protrusions, Ovalaires, scattered on the free edge and the upper side of the CV; This is an evolution of the previous rope, observed especially in women.
24. • hypertrophic laryngitis pseudo-myxomateuse (Reinke edema): edema, often bilaterally and symmetrically, extends along the entire length of the CV to its upper surface. Smooth, whitish and translucent mucosa with visible capillary networks, or red and angiomatous appearance. Its consistency is soft and the incision leaves a characteristic citrin liquid deaf. • "Posterior" laryngitis: secondary to GERD, they are of 2 types: ˗ the posterior pachydermique cord (Jackson contact ulcer), a bilateral SVT, limits a cup depression in the vocal processes; ˗ laryngitis Pachydermique Interaryténoïdienne achieves a thickening of the post commissal which may hinder the conduction of the CV in phonation.
25. White laryngitis: hyperkeratosis or Keratosis is responsible for the whitish appearance of the mucosa. Three aspects are usually described. • Leukoplakia (or leucokératose): flat lesion, induration, poorly demarcated, in "Candle spot"; Its greyish or pearly white color characteristic contrasts with the normal adjacent mucosa or, most often, inflammatory. Can be unique or multiple, and interest the subglottic plan and/or the laryngeal vestibule. • White Pachydermie: A well-delineated, grey or chalky growth, protruding in the laryngeal light. Its consistency is hard and the lining of the CV can be rigid, hardcover. Its irregular surface can make it difficult to distinguish from the corneal papilloma. It usually occupies the anterior half of one or both CV's and can extend to BV or even the whole larynx.
26. • Corneal papilloma: It has a more or less voluminous, hard, exophytique tumor aspect, characterized by spicules, and a wide and well-limited implantation base. It is grey or whitish in colour, depending on its degree of keratinization. Often unique and limited to the anterior part of the glottis, it can invade it in its entirety and extend to the laryngeal vestibule and the glottis, making an extensive papillomatosis.
27. • Histologically: Alteration of the epithelium and cellular atypies without rupture of the basal membrane. 3 grades are classically distinguished: ˗ grade I: Hyperplasia and hyperkeratosis with at most mild dysplasia (Image a); ˗ Grade II: Moderate dysplasias (Image B); ˗ Grade III: Severe dysplasia and carcinoma in situ (Image C). • The onset of cancer is not necessarily preceded by a pre-cancerous state and the transition from a pre-cancerous to a formed cancer is unpredictable, but it is estimated that: ˗ the carcinomatous transformation of a dyskeratosis varies from 1 to 40% depending on the degree of Dysplasia ˗ a dyskeratosis associated with mild, medium, or severe dysplasia evolves to 5-year-old carcinoma, respectively, in 5.5, 22.5, and 28% of cases.
28. Carcinomas squamous: 85 to 90% of the K of the larynx: • Mostly well or moderately differentiated carcinomas: 68% Survival at 5 years • Warty carcinoma: Highly differentiated variant: 1-4%; Little metastatic; Good prognosis: 95% survival at 5 years; • K fusiform cells: biphasic Pseudosarcomateuse variant; Prognosis equivalent to classic K: 68% survival at 5 years; • Basaloïde carcinoma: Aggressive biphasic variant, high propensity for meta-recurrence and distance; Mediocre Pc: 17.5% Survival; neuroendocrine carcinomas: • Atypical carcinoid tumor: the most common; Meta Ggaire cerv and Remote > 40%, SC > 20%; Pc: 48% survival at 5 years; • Small cell neuroendocrine tumor: rare, very aggressive; Meta Ggaire cerv: 50%, Remote: 75%; Pc: 5% survival at 5 years;
29. Primary mucosal melanomas of the larynx: exceptional; Few metastases ggaires but poor Pc: 20% survival at 5 years; chondrosarcoma laryngeal: most common conjunctive tumor; Slow evolution; Little Meta Ggaire cerv but remotely possible; PC: 90% survival at 5 years; adenocarcinomas: 1% of the tumours of the larynx; Most frequent: cystic adenoid carcinoma and mucoépidermoïde carcinoma; lymphomas: Less than 1% of malignant tumours of the larynx; are mostly B-cell lymphomas; Intra-laryngeal metastasis of a tumor at a distance: rare; Most often malignant melanoma cutaneous or renal adenocarcinomas, exceptionally pulmonary, mammary or ovarian tumor.
30. Methods of EXTENSION supraglottiques carcinomas: There is no anatomical barrier between glottis and SUS glottis; the extension pathways have been studied through the injection of isotopes: • From the ventricular band: first propagates to the Paraglottique space, then the HTE Lodge and the Aryépiglottique region; • Epiglottis Infrahyoïdienne: Towards the HTE Lodge through the pores of the épiglottique cartilage; Thus a tumor of the laryngeal face of the epiglottis under Hyoïdienne apparently T1 in endoscopy may have massively invaded the HTE Lodge and be classéT3; • Curbstone laryngeal: Rapid extension to the piriformis sinus, vallécule, language base and hyoid bone; • Of the ventricle: extension up to the ventricular strips, down to the Paraglottique space with possibility of destruction of the elastic cone, forward towards the foot of the epiglottis and the HTE Lodge with possibility of crossing the median line, lateral to the thyroid cartilage especially in the case of bone metaplasia, and back to the aryténoïdes. Often unknown at an initial stage carcinoma of the ventricle easily achieves a hit of the 3 stages!
31. Ganglionic Extension of sus glottiques carcinomas: • The existence of cross-lymphatic drainage means that a vestibule carcinoma can give ganglion metastases on both sides; Bilateral impairment is present in 25% of cases; • The existence of occult ganglionic metastasis is a function of the tumor stage: 5 to 25% for T1, 30 to 70% for T2 and T3, 65 to 80% for T4; • Preferentially affected groups are II, III and IV; • Carcinoma of the laryngeal curbstone more often ganglion metastasis than an infra-omohyoid carcinoma; Ganglionic impairment is identical to that of piriformis sinus carcinoma; The groups most often affected are the II and the III. Glottiques carcinomas: • The free edge carcinomas of the vocal fold: initially confined by the vocal ligament, they propagate forward and backward throughout the length of the vocal fold; Once the ligament is crossed, the vocal muscle is invaded and the chordal mobility is altered with the possibility of aryténoïdienne mobility being preserved.
32. • The carcinomas of the anterior commissal: must be formally distinguished from the glottiques carcinomas proper because their extension is easily made in the 3 planes of the space; Indeed they are in contact with the thyroid cartilage by the absence of internal perichondrium at the level of insertion of the thyroépiglottique ligament, with the lower part of the HTE Lodge, with the sub glottis and with the anterior cricothyroïdienne space hence a Strong extralaryngée extension potential; So a tumor that appears T1 in endoscopy can be classéeT4 by breaking laryngeal! Metastases ganglion glottiques carcinomas: • Due to the poverty of lymphatic drainage, glottiques carcinomas give less metastasis than glottiques carcinomas: < 5% for T1, 5-10% for T2, 10 to 20% for T3 and 25 to 40% for T 4 • Preferentially reached groups are II, III and IV, much more rarely I and LeV; • Anterior topographic tumours can propagate to the pretracheal ganglia in less than 10% of cases.
33. Glottiques carcinomas: • Upward: progression under mucous membrane through the elastic cone with paraglottique infiltration and fixation of the vocal fold; • Downward: Through the jack-thyroid membrane and the cricoid; • Back: Towards the piriformis sinus and esophagus. Metastases ganglion carcinomas under Glottiques: • Cervical metastases ganglion do not appear to exceed 20% overall; • However, the higher impairment of the paratracheal ganglia, in 50 to 65%, and the higher mediastinal ganglia, in 46% of cases, explains the poor prognosis of these tumors and the importance of the support of Paratracheal adenopathies!
34. Remote metastases and second locations: • The lungs are most often affected, followed by mediastinum, bone and liver; • Good locoregional control does not preclude the occurrence of a remote metastasis: In the absence of local failure, 11 to 15% of patients with supraglottic carcinoma will have a remote metastasis within 2 years after diagnosis, compared with 3 to 7% for Glottiques carcinomas; • Laryngeal carcinomas can also be associated with a 2nd VADS or lung cancer: 11 to 19% of patients develop a 2nd cancer within 5 years and 30% within 10 years; • The 2nd tumor is called synchronous when diagnosed at the same time as the laryngeal and Métachrone tumor when diagnosed during surveillance; • The value of an annual surveillance Telethorax is controversial and the completion of a thoracic injected scanner is discussed; The whole PET-Scan body is currently the best suited.
35. TDD: Squamous carcinoma of the vocal cord clinical study
36. Circumstances of discovery: It is classically a dysphonia, evolving in an alcoholic-smoking subject, whose persistence leads him to consult; any dysphonia that persists for more than 3 weeks in a smoking subject is a laryngeal endoscopic examination! Interrogation: Researches the pathological history, the history of cervical irradiation, the profession and alcoholic smoking habits; Specifies the date, the start mode and the evolution of the symptoms; looks for functional signs: ˗ Dysphonia, precocious, present in 95% of cases, allows diagnosis at a stage where the tumor still has a limited volume; ˗ the dysphagia or a simple pharyngeal discomfort translates the extension to the SUS-subglottic stage; ˗ dyspnea, sometimes associated with a stridor, translates obstruction or subglottic fixation and reveals an evolved tumor; ˗ a hemoptysis can be found in relation to ulceration or bleeding of a exophytique tumor; ˗ a persistent irritative cough can be found; ˗ The reflex earache is rarer.37. Physical Examination: Inspection: Mobility of the larynx to swallowing, deviation, cervical mass, dyspnea, circulation; palpation: ˗ of the laryngeal tube in search of a decrease in mobility and/or the disappearance of laryngeal crackles; ˗ of hyoid bone, thyroid cartilage, thyroid-hyoïdienne and jack-thyroid membranes, cricoid and trachea in search of a strain or sore point; ˗ of ganglion areas in search of ADP, mostly from areas II to IV and VI; Less revealing than for other ENT locations such as hypopharynx or oral cavity; Glottiques Cancers T1-T2 give exceptionally ganglion metastasis. laryngoscopy Indirect Mirror: Requires a minimum of material, but depends on the general condition and compliance of the patient; It is increasingly abandoned in favour of the Nasofibroscopie, the practice of which is becoming commonplace;
38. Nasofibroscopie: Analyzes the larynx in physiological conditions and allows to assess: ˗ The macroscopic aspect of the tumor: burgeoning, ulcerative or infiltration; The form; ˗ the seat and extensions: BV, epiglottis, vallécules, sinus pyriform, retrocricoïdiennes regions, Amygdaliennes lodges; ˗ the mobility of laryngeal elements: vocal chords and aryténoïdes; endoscopy with rigid optics 90 ° or 70 ° orally: ˗ best image quality; ˗ allows a good examination of the surface of the lining of the vocal chords; ˗ with Fiberscope, allows the strobe examination: useful for early diagnosis of subglottic cancer by showing the disappearance of the vibration of the mucosa, sign of the invasion by the tumor of the space of Reinke, or even the vocal ligament. Complete and General ENT examination: Looks for signs of metastasis and evaluates the general condition of the patient and the co-morbidities.
39. Diagnostic Traps: Two great classic pitfalls are to be avoided: ˗ Morgagni ventricle Cancer: Early diagnosis is very difficult because the clinical signs of onset, when present, are limited to a feeling of laryngeal discomfort and a Intermittent dysphonia; The main trap lies in a clinical examination laryngoscopic often normal at this stage and thus falsely reassuring. ˗ Cancers Sub-glottiques: Again, clinical signs appear late. When dyspnea or dysphonia attract attention, the examination does not always evoke the presence of a tumor under the subglottic plane; in these situations, in front of a patient over 50 years and with risk factors, it is necessary to repeat the clinical examination and if necessary do not hesitate to push the paraclinical investigations and perform an endoscopy under general anesthesia.
40. Additional Examinations: Imaging: • It has become indispensable for diagnosis and therapeutic decision; • Clinical and endoscopic examinations are insufficient on their own to clarify the importance of the locoregional extension. • The use of endoscopic data alone leads to a diagnostic sub-evaluation in 40 to 55% of cases! • It is recommended before the biopsy (inflammatory phenomena due to biopsies modify the radiological signal); • Neck x-rays and CT scans are no longer performed;
41. TDM: The scanner is currently the most commonly used test for evaluating the initial extension of laryngeal cancers; the Valsalva and phonation plates allow a better analysis of the ventricles, and a possible pharyngeal extension; thanks to the injection of contrast products, the TDM specifies the site and the tumor volume and the local extension in depth (Loge HTE, Espace Paraglottique, under Glottis). It also studies ganglionic extension in all territories, some of which are clinically inaccessible to palpation (rétropharyngés ganglia, under the base of the skull or in the mediastinum); The TDM also appreciates cartilaginous lysis which is an essential element for ClassificationTNM; 4 stages are described: ˗ condensation or cartilaginous sclerosis: it translates a degree of invasion that is variable according to the cartilage reached: 40% for thyroid cartilage, 76% for cricoid and 79% for aryténoïdes; ˗ minimal lysis or Erosi
On cartilaginous; ˗ lysis with interruption of a cortical (does classify T3); ˗ lysis transfixiante (actually classify T4); sensitivity of LaTDM: 82%, specificity: 79%, VPN: 85%.
42. Chondrosarcoma: calcification Flaky starting aryténoïdes with intrusion of vocal cords, ventricular bands and fat Para laryngeal
43. MRI: EtT1 T2 cuts after gadolinium injection: is more sensitive to detect minimal extensions, especially to cartilage, but the scanner seems more specific; There is a better spatial resolution of the MRI to show the details of soft tissues (language base, oral floor); Nonetheless, mobility-related artifacts (swallowing) are more frequent and make this examination more complex to practice and therefore its use is not systematic.
44. Pet/TDM or PET/scan: The whole PET/scan body plays an increasingly important role in the pre-therapeutic checkup and surveillance of DesVADS carcinomas; is a functional imaging of positron emission tomography with fusion of CT images; 18-FDG (Fluoro-deoxy-Glucose) is the most used tracer with a sensitivity of 85 to 95% and a specificity of 80 to 90% for the detection of tumours carcinoma DesVADS; It also has an interest in the detection of infracentimétriques cervical ADP or unusual seat (rétropharyngée), second tumor locations, remote metastases and synchronous tumors of other organs; Its realization must be done before the endoscopic balance to guide the biopsy gestures towards suspicious hypermetabolic zones; It is also useful for early detection of recurrences after treatment with chemotherapy and/or radiotherapy, with better performance than the classical examinations of imaging; other tracers, based on amino acids, such as 11c-Thymidine and 11c-methionine, would focus more specifically on tumor tissue than on inflammatory tissue.
45. Endoscopic examination under AG: LDS/Pan Endoscopy • Essential to the assessment of VADS cancers, its objectives are to specify the local extension of the tumor, to do the biopsy and to examine the whole mucosa of the VADS in search of another synchronous localization; • Includes a laryngoscopy, a bronchoscopy and a œsophagoscopie; • Examination of the larynx is done using optics of different angulations: 0, 30, 70 and 120 ° or under a microscope; • The micro instrumentation allows palpation of the vocal fold and the ventricular band and the unfolding of the ventricle in search of tumor infiltration; • In front of a lesion of the middle 1/3 of the vocal cord, an infiltration of the space of Reinke to the physiological serum which causes a Muco-ligamentous hydrodissection: A complete swelling of the space of Reinke indicates a superficial lesion, When incomplete there is a deep infiltration; • For very early lesions, new techniques have been developed: ˗ the autoflorescence using the natural fluorophore of the tissues activated by a light of narrowband wavelength; Normal cells emit a green fluorescence that disappears for cancerous tumor cells; False negatives: Actinic very exophytic; False positives: Moderate dysplasias or scarring and inflammatory areas; ˗ Contact Endoscopy that studies the area of mucous membranes previously stained with methylene blue; Despite all these techniques, the use of only endoscopic data leads to a diagnostic under diagnosis in 40 to 55% of cases!
46. Anatomopathologic Study: Raises the diagnosis of certainty by determining the histological type: Carcinoma carcinoma well or moderately differentiated. Metastatic extension balance: Tele-Thorax and abdominal ultrasound are increasingly being replaced by cervico-thoraco-pelvic CT or even pet/CT, especially in the presence of cervical ADP; Bone Scan. Pre-anesthetic Balance: • Its composition is a function of the patient's age and general condition, as well as associated co-morbidities; • It is oriented towards the diagnosis of patient's operability but also its ability to withstand heavy therapy (Radio-chemotherapy).
47. Clinical forms Topographic forms: Cancer of the stage SUS-subglottic: cancer of the vestibule laryngeal: • SF: late; dysphagia, moderate Dysphonia, +/-earache; • ADP: In 65% of cases; • Endoscopy: Lesion in the laryngeal face of the epiglottis, rarely at the level of the ventricular bands or the inter-aryténoïdienne indentation; • Extension: Towards the foot of the epiglottis, the anterior commissary and the HTE Lodge; • TDM: Study of the space HTE Cancer of the Curbstone laryngeal (or épilarynx): • SF: Odynophagia more frequent, dysphagia earlier, earache reflexes; • ADP: Present in 78% of cases, lymphatic diffusion similar to that of piriformis sinus carcinoma; • Endoscopy: Lesion of the free edge of the epiglottis or aryépiglottiques folds; • Extension: Towards the lingual face of the epiglottis, the region of the 3 folds, the vallécules, the language base and the pyriform sinuses; • TDM: Analysis of pyriform sinuses, the language base and even amygdaliennes boxes.
48. Ventricle Cancer: • SF: Late: Dysphonia, dyspnea if highly evolved tumor; • Cervical ADP in 30%; • Endoscopy: Difficult diagnosis and biopsy, fixity or decreased mobility of a vocal cord; Unfold and refoule the BV using a spreader; • Extension: To the Subglottic space and the SUS and under Glottiques. Cancer of the subglottic floor: Cancers at starting point under Glottiques are rare, 3% according to our experience (HCA/Pr and Col.); SF: Late, dominated by dyspnea which is progressive; ADP: About 20%, but frequent interference with the upper Paratracheal and mediastinal ganglia giving them a poor prognosis; Endoscopy: Difficult diagnosis, usually requiring general anesthesia and the use of high angulation endoscopes (90 and 120 °); Infiltration or ulcerative-infiltration tumor most often; Possible decrease in the mobility of the Hémilarynx; extension: Long contained by the elastic cone, once it is crossed, extension to the Paraglotique space, the vocal fold, the piriformis sinus and the esophagus.
49. Cancer extended to the 3 stages: occurs in case of late diagnosis, 9% in our experience (HCA/Pr and Col.); SF: Present for several months made of Dysphonia, dysphagia and dyspnea sometimes important requiring a tracheostomy; Cervical ADP in 40% of cases; Endoscopy: Ulcerative-infiltration or budding tumor extended with fixity or decreased CV mobility; Extension: Lateral wall of the hypopharynx, Sinus piriformis, vallécules, language base; TDM/MRI: space para subglottic, Loge HTE, language base, Hypopharynx, esophagus... Specific histological forms: Warty carcinoma: highly differentiated form of squamous carcinoma, is considered to be a broad-based papilloma. if the endoscopic appearance, Hyperkératosique, seems suspicious, the microscopic diagnosis is on the other hand difficult, requiring deep biopsies (superficial biopsy falsely reassuring); important local Extension but no remote metastases; Good prognosis: 95% survival at 5 years.
50. Fusiform cell carcinoma: squamous carcinoma associated with malignant epithelial cells and mesenchymal-type cells; arises in a polypoid aspect and is glad to be born at the level of the previous commissary; prognosis is equivalent to that of classical squamous carcinomas, or 68% survival at 5 years. Carcinoma developed on Laryngocèle: It is a particular Anatomo-clinical entity, which poses diagnostic problems between laryngocèle and cancer especially since a carcinoma of the ventricle can be manifested by an internal laryngocèle. Clinical and radiological diagnoses are difficult at an early stage; Chondrosarcoma laryngeal: most common laryngeal conjunctival tumor, mainly affecting the Cricoïdienne blade, more rarely thyroid cartilage, aryténoïdes or epiglottis; low grade chondrosarcoma is difficult to differentiate from chondroma to histological analysis; slow evolution over several years with strong local recidivism potential; few metastases ganglion cervical but possible remote metastasis; Good prognosis: 90% survival at 5 years;
51. CLASSIFICATIONTNM (UICC 2002)
52. SUS-subglottic Stage: • T2: Tumor invading more than one sublocation of the SUS-subglottic or subglottic or extraglottique (mucosa of the language base, Vallécule, inner wall of the sinus piriformis) without fixity of the larynx. • T1: Tumor limited to Sublocation of the SUS subglottic stage with normal mobility of vocal cords.
53. • T3: Tumor limited to the larynx with fixity subglottic and/or invasion of the Rétrocricoïdienne region, the Préépiglottique Lodge, the Paraglottique space and/or minimal erosion (internal perichondrium) of the thyroid cartilage. • T4A: tumor through thyroid cartilage and/or invasive extralaryngées structures: trachea, soft neck tissues (including the deep/extrinsic musculature of the tongue (Génioglosse, Hyoglosse, Palatoglosse, and styloglosse), muscles Hyoïdiens, the thyroid gland, the esophagus. • T4B: Tumor Invading the prevertebral space, structures mediastinal or reaching the internal carotid.
54. Subglottic Floor: T1: Tumor limited to 1 or 2 vocal cords (capable of invading anterior or posterior corners) with normal mobility: T2: Tumor extended to the cavity supraglottic and/or sub-subglottic, and/or with decreased mobility of the Vocal chord; ˗ T1A: Tm Limited has 1 vocal chord; ˗ T1b: Tm invading the 2 vocal chords;
55. T3: Tumor limited to the larynx with fixation of a vocal cord and/or invasion of the Paraglottique space and/or minimal erosion of the thyroid cartilage (e.g. internal cortex); T4a: tumor through the thyroid cartilage or invading other tissues beyond the larynx (trachea, soft parts of the neck including the deep/extrinsic muscles of the tongue (Génioglosse, Hyoglosse, Palatoglosse and Pen-gloss), the muscles of the neck, the thyroid, the esophagus; T4B: Tumors Invading the prevertebral space, the structures mediastinal or encompassing the carotid artery.
56. Floor sub-subglottic: • T1: Tumor limited to sub-glottis. • T2: Tumor extended to the subglottic plane with normal or decreased mobility. • T3: Tumor limited to the larynx with subglottic fixation.
57. • T4A: tumor through the thyroid or cricoid cartilage and/or invasive extralaryngées structures: trachea, soft neck tissues (including the deep/extrinsic musculature of the tongue, Génioglosse, Hyoglosse, Palatoglosse and Styloglosse), Hyoïdiens muscles, the thyroid gland, the esophagus. • T4B: Tumor Invading the prevertebral space, structures mediastinal or reaching the internal carotid.
58. Adenopathies: • N0: No signs of reaching the regional lymph nodes. ˗ N2a: Metastasis in a single lymph node > 3 cm but ≤ 6 cm. • N1: Metastasis in a single lymph node ipsilateral ≤ 3 cm in its largest diameter. • N2: Unique metastasis in a single lymph node ipsilateral > 3 cm and ≤ 6 cm in its largest diameter or metastases ganglion multiple homolatérales all ≤ 6 cm. ˗ N2b: Multiple homolatérales metastasis all ≤ 6 cm. -N2C: bilaterally metastases or contralateral ≤ 6 cm. • N3: Metastasis in a lymph node > 6 cm in large diameter. The median ganglia are considered to be ipsilateral.
59. M Classification: • MX: Insufficient information. • M0: No signs of remote metastasis; • M1: presence of remote metastases; Grouping by stages: • Stage 0: Tis n0 M0 • Stage I: T1 n0 M0 • Stage II: T2 n0 M0 • Stage III: T3 n0 M0-T1T2T3 N1 M0 • Stade IVa: T1T2T3 N2 M0-T4a n0 N1 N2 M0 • IVb Stadium: All T N3 M0-T4b all N M0 • Stage IVc : All All N M1
60. Positive Diagnosis Examination: Searches for signs of call and favourable factors (persistent dysphonia for more than 3 weeks in a smoker aged 40 years or older); indirect laryngoscopy and/or consultation endoscopy: highlight the tumor, its seat, its extension, the mobility of vocal cords; The LDS: Specifies the siege and local flooding and allows the biopsy to be performed for the anatomopathologic examination; TDM + MRI: Specify the limits of the tumor and its recurrence extensions. The histopathological examination of the biopsy parts: confirms the diagnosis by specifying the histological type and the degree of differentiation.
61. Diagnosis differential in front of chronic laryngitis: • Corneal papilloma: is a premalignant lesion that has a whitish warty aspect. The indication is surgical; the Laryngocèles: the holes in the thickness of the ventricular band. The Association Laryngocèle-cancer is classical; • Mostly white hypertrophic laryngitis, premalignant lesion par excellence; Difficult to detect malignant transformation, which is why a repeated coat biopsy (stripping) of vocal cords is necessary if the histological response reveals foci of moderate or severe dysplasia; • Red Pachydermies.
62. Diagnosis differential in front of a laryngeal papillomatosis: • Difficult differential diagnosis with warty carcinoma; • It is the histological examination that will diagnose, but requires deep and often repeated biopsies.
63. Diagnosis Differential granulomatosis of Wegener and tuberculosis laryngeal: sometimes make very neighboring and deceptive forms, hence the imperative need to biopsy before starting the treatment of cancer; Syphilis: Diffuse and symmetrical lesions, mobility retained; Serology confirms the DG but does not eliminate associated cancer; in front of a fixed vocal chord: Récurentielle paralysis (tapered and shortened CV);
64. Treatment purposes means Indications
65. Goals Eradicate the tumor; Restore the 3 functions of the larynx if possible; to prolong survival.
66. Means small medical means (adjuvant treatment): antibiotics for overinfection; Corticotherapy as a provisional treatment for laryngeal dyspnea; Aerosol Therapy; Oxygen Therapy; nutritional Support and PEC of electrolyte disorders.
67. Chemotherapy and targeted therapies • Once regarded as a palliative treatment, chemotherapy has acquired an undeniable place within the therapeutic arsenal with curative aim with the appearance in the years 70-80 of the association salts of Platinum/5-Florouracil and the more recent discovery of taxanes and targeted therapies; • It has thus opened the field of research in laryngeal preservation. Main cytotoxic molecules currently used: • Antipyrimidiques: 5-fluorouracil (5FU); • Platinum Salts (CDDP): the most used; Cisplatin is administered at a dose of 100 mg/m2 on the first day associated with 5-FLUOROURACIL 1 000 mg/m2 from the 1st to the 5th day; This cycle is renewed every 3 weeks under the guise of hematologic, renal and auditory surveillance; • Taxanes: One of the most promising protocols combines cisplatin (75 mg/m2 on day 1) with 5-fluorouracil (750 mg/m2 from 1st to 5th day) and docetaxel (75 mg/m2 on day 1); • Mitomycin C: Less used but interesting for tumors and ADP very necrotic because of its activity in hypoxic medium. It is administered at a dose of 10 to 15 mg/m2 under the guise of hematologic and renal surveillance.
68. Targeted therapies: The principal agent used is the cetuximab, which is a monoclonal antibody, of IgG type, exclusively directed against the Epidermal Growth Factor Receptor (EGFR); EGFR is a transmembrane receptor of thyrosine kinase that intervenes in cell survival and proliferation and in angiogenesis; Its level of expression, promoted by HPV virus E5, is about 90% in squamous carcinomas of VADS; Its overexpression is a factor of poor prognosis in glottiques carcinomas beginners because it promotes recurrences recurrence after radiotherapy; in vitro and in vivo studies showed synergy between radiotherapy and cetuximab; treatment with cetuximab entrains a varying degree of acneïforme skin rash in more than 80% of cases; patients treated with the radiotherapy-cetuximab association with a grade II to IV Rash have a better overall survival than those with a 0 to I rash!
69. Modes of chemotherapy: treatment of advanced or moderately advanced tumours: ˗ neoadjuvant or induction chemotherapy: delivered before any other treatment; Currently allows for the selection of good answering patients for concomitant radio-chemotherapy protocols; ˗ adjuvant chemotherapy: Delivered at the end of a radiosurgical sequence; currently has little interest; ˗ chemotherapy-concomitant radiotherapy: association with radiotherapy simultaneously or alternately; Is the pillar of laryngeal preservation protocols; chemotherapy of recurrent and/or metastatic forms or palliative chemotherapy: ˗ It remains quite disappointing with survival medians that do not exceed 7 to 8 months; ˗ It must, however, be considered in parallel with the support treatments (analgesics in particular) both by the temporary physical and psychic improvement that can be made by tumor stabilisations and regressions, even if these are Ephemeral.
70. Radiotherapy Types of irradiation: • External irradiation: ˗ It uses the photons of cobalt 60, X-rays or electrons of linear accelerators; ˗ Modern imaging techniques, three-dimensional dosimetry and possible changes in fractionation have improved the ballistic precision of irradiations and their biological efficacy; ˗ the perfect definition of tumour volumes and healthy tissues in space (definition in 3d) for obtaining an optimal therapeutic index (conformation radiotherapy); ˗ The new intensity modulation irradiation techniques (RTMI or IMRT in English) allow an ideal dose distribution. • Brachytherapy: ˗ It uses the technique of plastic tubes with iridium 192 wire, in association with external radiation therapy; ˗ exceptionally indicated in laryngeal cancers, it finds its indication in tumors extended to the language base.
71. Modes of irradiation: Exclusive irradiation: • Tumours of the SUS-subglottic and Curbstone: ˗ due to the important lymphophilie of these lesions, a bilateral tumor and ganglionic irradiation is carried out in principle; ˗ Doses: 65 to 70 Gy at a rate of 1.8 to 2 Gy/d, 5 days/week (FR Classic) ˗ node target Volume: medullary tolerance dose, i.e. 45 Gy; ˗ if Curbstone laryngeal: Irradiation extended to vallécules and the language base (Curbstone ant) and/or Hypopharynx (Curbstone lat). • Subglottic stage tumours: ˗ irradiation only concerns the tumor target volume because of the very low lymphophilie of these lesions; ˗ only a CA location or extension in addition or under-glottis justifies extending irradiation to ganglion areas. • Subsubglottical stage tumours: ˗ exclusive irradiation is exceptional due to remote submucosal infiltration that leads to underestimation of tumor volume; ˗ the ganglion target volume will be extended to the upper mediastinum to include the ganglion récurrentielles strings.
72. Postoperative irradiation: • After partial laryngectomy: ˗ The indication is based on the histological study of the margins of resection and lymph node invasion; ˗ schematically, four clinical situations can be distinguished: the cuts are healthy, the lymph nodes are not invaded: no postoperative irradiation; The cuts are healthy, the lymph nodes are invaded: only the ganglion areas are irradiated and we will ensure that the larynx is best protected by using electron beams; Radiotherapy is potentiated (Association with cisplatin or cetuximab) in case of capsular rupture; The overlappings are doubtful, the lymph nodes invaded: only the ganglion areas are irradiated and we will ensure that the larynx is protected as best as possible through electron beams; Intensive surveillance (endoscopy and TDM) of the larynx will be carried out and a reintervention will be proposed in case of local evolution; The overlappings are invaded, the lymph nodes are invaded or not: the Conservative surgical indication must be rediscussed because the best solution is to reintervene surgically; Irradiation will only be carried out in case of a formal rejection of the patient from a totalization, and bring a dose of 55 to 65 Gy.
73. • After total laryngectomy: ˗ Complete scarring must be obtained before irradiation; ˗ the indication depends on the quality of the cross-section, the Ganglionic invasion, the seat of the primitive lesion and its extensions, and the age and general condition of the subject; ˗ the delivered dose is 55 to 65 Gy over the entire target volume; ˗ the upper limit of the field must sufficiently include the base of the skull to cover the high ganglionic extension; ˗ two specific cases deserve to be noted: there was an extension to the language base: an irradiation delivering 55 Gy on the previously defined volume, supplemented by an overdose (possibly by brachytherapy) on the basis of language; This was a sub-subglottic lesion where there were adenopathies sus-supraclavicular or Récurrentielles: The irradiated volume was extended to the upper mediastinum.
74. Concept and protocols for laryngeal preservation • Total laryngectomy was for a long time the only recommended treatment for laryngeal tumours classified as T3 or T4; • It allows locoregional control in more than 80% of cases at the cost of a mutilation of the voice and the wearing of a definitive tracheostoma; • For nearly a quarter of a century, therapeutic trials have been conducted in the United States and Europe to try to achieve the same therapeutic efficacy with a conservative chemotherapy-radiotherapy treatment while avoiding mutilation Laryngeal is the concept of laryngeal preservation; • This research was initiated in the United States in 1991 by the study of veterans; • Since then, several trials and protocols have emerged and are currently being referred to as 3rd generation trials.
75. First generation of laryngeal preservation tests: sequential chemotherapy and radiotherapy (induction chemotherapy) principle: Induction chemotherapy based on cisplatin (CDDP) and 5-fluoro-uracil (5-FU), followed by Radiotherapy in good responders and total laryngectomy in others; Three randomized trials were conducted on this model: ˗ The study of the Veterans in the United States, on cancers of the larynx; ˗ the European Organization for Research and treatment of cancer (EORTC), hypopharynx and lateral curbstone cancers; ˗ and the study Group on tumours of the head and neck (GETTEC), on cancers of the larynx, in France. The veterans study included 332 patients with stage III and IV laryngeal carcinoma (T1N1 excluded), rendomisés in 2 arms: ˗ Total laryngectomy followed by radiotherapy from 50 to 74 Gy; ˗ Versus CDDP-5FU Induction chemotherapy (2 cycles) followed by a 3rd cycle in case of correct response and radiotherapy from 66 to 76 Gy; ˗ the RCC allowed laryngeal preservation from 64% to 2 years, with no difference in overall survival between the 2 arms (68%); Total catch-up laryngectomy was required in 56% of patients classésT4.82
76. Second generation of laryngeal preservation tests: Concomitant Radio-chemotherapy (RCC) principle: combination of radiotherapy with chemotherapy simultaneously and immediately without induction chemotherapy with total laryngectomy In non-responders; an update of the broad meta-analysis carried out at the Institut Gustave Rousse (MACH-NC) including tests of RCC in non-pretreated patients including 1565 carriers of a tumor laryngeal or hypopharyngée, showed that the patients included in the arm " Compared with those included in the arm "exclusive radiotherapy", a relative reduction of the risk to 5 years of 16 to 22%, which corresponded to an absolute survival benefit at 5 years of 8 to 10%; the second wave of randomized trials of laryngeal preservation has therefore explored the place of this therapeutic strategy; Thus, the RTOG (Radiation Therapy Oncology Group) in the United States published in 2003 the preliminary results of a three-arm study comparing induction chemotherapy (experimental arm of the study of the veterans) to radio-chemotherapy Concomitant (cisplatin 100 mg/m² at J1, J22 and J43) and exclusive radiotherapy; The "concomitant" arm had a significantly higher toxicity and the survival was not significantly different between the 3 arms but in the "concomitant" arm the laryngeal preservation rate was considerably greater: 88 to 95% versus 75 % for the arm "induction" and 70% for the arm "exclusive radiotherapy". 83
77. Third generation of laryngeal preservation tests: concomitant and sequential radiochemotherapy in the 1st generation trials, induction chemotherapy has the advantage of being able to quickly change strategy to operate the Patient in case of inadequate response, with appropriate post-operative radiotherapy; in the 2nd generation trials, RCC leads to more mucositis and requires the protocol to decide whether or not to make remedial surgery, but it seems to give higher levels of preservation; the principle of 3rd generation testing is therefore to combine the benefits of 2 generations by associating induction chemotherapy followed by an RCC in the correct responders or a surgery followed by radiotherapy (possibly associated with chemo) In the wrong answering machine; This strategy has been explored in the USA in phase II/III studies; Induction chemotherapy featured 1 to 6 cycles of variable associations: cis-or carboplatin + 5-fluorouracil + paclitaxel or docetaxel; The most classical association, cisplatin + 5-FU + docetaxel, is called "TPF protocol"; Radiotherapy has been associated with either cisplatin, carboplatin or paclitaxel; These studies concluded the feasibility of these programs and reported survival at 3 years up to 60 to 80%. 84
78. Lessons learned from the 3 generations of laryngeal preservation tests: The general consensus on the selection of patients is that they must have a laryngeal carcinoma classified as T2 not accessible to partial laryngectomy or T3 Without prior laryngeal dysfunction requiring tracheostomy and/or enteral feeding; Concomitant Radio-chemotherapy has become a laryngeal preservation standard; The contribution of Taxanes has allowed to boost induction chemotherapy while reducing its toxicity through the reduction of doses of cisplatin and 5-FU; No randomized laryngeal preservation study has shown a non-surgical treatment that results in better survival than that obtained through radical surgery, which is therefore not to be abandoned in all cases. In particular, it remains the best treatment for highly invasive tumours transglottiques and in case of manifest damage of cartilage; This approach should not exclude non-mutilating surgical possibilities (partial laryngectomies supracricoïdiennes in particular), for selected cases of T3 (minor invasion of the Préépiglottique Lodge, immobility of the rope Fixity without cricoarytenoid) and some T4 (minor thyroid cartilage damage on the scanner); 85
79. Ongoing trials and prospects: The evolution of laryngeal preservation protocols seems to be done towards: ˗ Association of Taxanes (TPF protocol) which improves induction chemotherapy without aggravating its toxicity; ˗ and the use of targeted therapies (cetuximab) in combination with radiotherapy in the RCC protocols. 86 The GORTEC (Group of Oncology radiation Therapy Head and neck) initiated, in France in June 2005, a randomized trial called Springboard, using the protocol TPF in induction chemotherapy and comparing in 2 arms the radiotherapy associated with cisplatin at the Radiotherapy associated with the cetuximab.
80. Surgery • This is the pillar of the management of tumours of the larynx; • It can be partial, subtotal or total and combines the management of ganglion areas; • It is at the larynx level that the greatest number of surgical techniques has been described; • After the development of partial surgery by external means, the most recent techniques are endoscopic; • In all cases, the objective is to propose a resection of the tumor in healthy tissue, not forgetting the need to treat ganglion areas.
81. Conservative partial surgery: the partial surgery of the larynx is aimed at the tumors classified T1, T2 and certainsT3 selected. Objectives: While avoiding a total laryngectomy, ensure a local eradication of the tumor by a resection of healthy tissue; preserve the functions of phonation and respiration without permanent tracheostomy; assure a swallowing without a permanent feeding probe and without false roads or pneumonia inhalation.
82. Contraindications to partial surgery of the larynx: bad cardio-pulmonary condition; Age > 70ans; Non-Accessibility or poor compliance with monitoring; tumor Extension to the sub-glottis; Extension Paraglottique Massive; massive infiltration of the HTE Lodge; fixity Aryténoïdienne (attainment of cricoid); A chordal fixity without fixity Aryténoïdienne is not a formal contraindication! intrusion of thyroid cartilage; inability to maintain a functional Jacko-Aryténoïdienne unit; NB: The patient must accept the possibility of conversion into total laryngectomy if the lesion balance sheet in per-op or the evolution of post-op lesions indicate this;
83. Transoral or Endoscopic surgery: It is essentially based on the CO2 laser and has developed through several important discoveries and innovations: ˗ discovery of the direct laryngoscopy by Kilian (1898) and Knight Jackson (1907); ˗ Description of laryngoscopy in suspension by Kleinssaser (1968); ˗ appearance of magnifying optics coupled with video; ˗ discovery of the laser by Maiman in 1960; ˗ precision provided by the imagery to evaluate the depth extension. en 1970: Strong and Jako Report The first cases of laryngeal microsurgery with Laser C02 and publish in 1975 the first series of laryngeal cancers treated by laser endoscopic pathway; without being a monoblock resection, the treatment of malignant tumours of the larynx with the laser does not consist of a simple vaporization, it is an "on-board" surgery which must be cancer (obtain healthy resection margins) while striving to Preserve the healthy fabric as much as possible in order to achieve a good functional result! It is done with a laser coupled to the carbon dioxide and requires a perfect exposure of the larynx and the use of laryngopharyngoscopes of different sizes whose position is modified throughout the procedure; The proper exposure of the operating field may require the resection of certain structures even when they are healthy (ventricular bands, foot of the epiglottis); it applies primarily to limited stage glottiques and Supraglottiques carcinomas (T1 and T2); 90
84. Endoscopic surgery of the subglottic plan: It was codified by a classification of the European Society of Throats in 2000, revised in 2007; 91 Cordectomie Type I or under epithelial: the epithelium is resected and the vocal ligament preserved.
85. Cordectomie type II or under ligament: the epithelium and the vocal ligament are resected and the vocal muscle preserved. 92 Cordectomie Type III or trans muscular:
86. Cordectomie type IV or exomusculaire: Full resection of the vocal chord to the internal perichondrium of the thyroid wing, the amount of resected tissue is identical to that of an external Cordectomie. 93 Cordectomie Type Va: Full resection of the extended vocal chord to the previous commissary and CV contralateral.
87. Cordectomie TypeVb: Cordectomie extended to Cricoarytenoid. 94 Cordectomie Type Vc: Cordectomie extended to the Sousglottique region.
88. Cordectomie type Vd: Cordectomie extended to the ventricle. 95 Cordectomie Type VI: Applies to carcinomas of the previous commissary; carries the anterior and anterior parts of the 2 vocal chords.
89. Endoscopic surgery supraglottic: The European Society of Throating has proposed in 2009 a classification of the laryngectomies Supra Glottiques endoscopic (LSGE); It is little practiced because complex and more delicate realization; It is also controversial in its indications as to the need to take charge of ganglion areas; it is reserved for small tumors of epiglottis or BV. 96 Type I LSGE: Resection of a limited part of the Supraglotte; LSGE type IIa: Resection of the epiglottis Suprahyoïdienne; LSGE type IIb: Covers all Epiglottis (supra and Infrahyoïdienne); LSGE of type IIIa: resection of the epiglottis and the HTE Lodge; LSGE of type IIIb: extension of the resection to the ventricular band; LSGE of type IVa: resection of the region of 3 folds and of the ventricular band if necessary; LSGE of type IVb: extension of the resection to the cricoarytenoid.
90. Transoral Robotic Surgery: The first case of surgery assisted by the DA Vinci robot was carried out in 1997, it was a cholecystectomy by laparoscopic way; Transoral Robot assisted surgery has developed late by report Ecuador to its applications in digestive, pediatric, gynecological, thoracic and urology surgery. This delay is explained by the fact the robot was created to perform interventions by a first laparoscopic; 97
91. The disadvantages of robot assisted transoral surgery: ˗ purchase price of the robot, maintenance and limited use instruments; ˗ need for specific training of the surgical team and the operating room team; ˗ lack of tactile recognition on the current model, requiring an assistant surgeon to palpate certain anatomical structures to allow their identification; ˗ need for the presence of a surgeon at the patient's head to perform hemostasis using microclips in case of hemorrhage; ˗ the conflict between the three arms of the robot placed in a space of reduced volume as the oral cavity can lead to the abandonment of the technique; ˗ the electro-coagulation and the ultracision generate a thermal effect in depth, not allowing the use at the level of the vocal cords; ˗ the improper exposure of the operating field that should always lead to the conversion to another technique, endoscopic or external. 98
92. Benefits of Transoral Robot assisted surgery: ˗ Robot assisted Surgery provides an exceptional vision quality in three dimensions and high definition with magnification that is multiplied by a factor of ten, and a vision Stable, with the optics attached to one of the robot's articulated arms; ˗ more precise and finer gestures, eliminating physiological tremor with greater freedom in the three axes of space; ˗ Best ergonomics for the surgeon who sits at the console; ˗ reduction in hospital duration, simplified operating procedures and better quality of life. the future of the technique lies in the miniaturization of the system and the coupling of the CO2 laser, transmitted by fiber, to one of the robot's arms. 99
93. History: la Thyrotomie or Laryngofissure, is the oldest form of laryngectomy, and it is the French surgeon Philippe Jean Pandit that is awarded the first Thyrotomie practiced in 1778 to remove a piece of meat inadvertently impacted in the larynx; in 1833, in Leuven, Belgium, Brauers, for the first time, uses this approach to successfully cauterize warty endolaryngées formations, with various preparations and a red-covered iron; Solis-Cohen (1860), Sand and Bowes (1863) were the first to attempt to treat laryngeal cancer by partial surgery by Thyrotomie; The first total laryngectomy was carried out by Theodore Billroth in Vienna in December 1873. Technique later taken over by Gluck and perish; 1874: Billroth reports the first Hémilaryngectomie; 1876: Isambert publishes a series of 5 patients treated with partial laryngectomy; The conservative surgery of the larynx by external means:
94. During the twentieth century several important developments have improved the surgical treatment of laryngeal cancers: • Development of anesthesia-resuscitation and antibiotic therapy; • Knowledge of anatomical locations and pathways for the extension of cancers of the larynx and refinement of diagnosis and indications and techniques of conservative surgery thanks to the work of Rouvière, Leroux-Robert, Bekeys, Lederman and Kirchner; • At the same time, enhancement of the visualization of the larynx by the discovery of the laryngeal mirror (Manuel Garcia, 1854) and more recently, the examination laryngeal using rigid optics and Nasofibroscope (Sawashima & Hirose, 1968).
95. During the twentieth century, partial surgery of the larynx underwent the following successive developments: the vertical partial surgery of the subglottic plan: Developed in Europe and the United States from the beginning of the twentieth century. Includes: Thyrotomie with Cordectomie, vertical partial laryngectomies: laryngectomy fronto-lateral described by Leroux Robert, anterior frontal laryngectomy and hémilaryngectomie; the Laryngectomies supraglottiques Typical and extended: appeared a little later from the anatomical works of Rouvière (1932), Leroux-Robert (1935), and Radiological (1939). Introduced in Europe, the United States and South America under the impetus of Huet with the Hyothyroépiglottectomie in 1938, Alonso who described the laryngectomy supraglottic in 1947, followed by Leroux-Robert (1955), Ogura and Som who returns the description of the Laryngectomy Supraglottic in a Time (1958).
96. the horizontal partial surgery of the subglottic stage: Developed in the years 1970, it has reduced the local failure rate of certain glottiques tumors treated by vertical partial laryngectomy. This is the horizontal glottectomie described by Calléaro (1978), Glottectomie translaryngée (Traissac 1984), and anterior frontal laryngectomy with Épiglottoplastie (Kambic-Tucker). partial laryngectomies Supracricoïdiennes (CSSA): With the total resection of the thyroid cartilage are divided into: partial laryngectomies supracricoïdiennes with reconstruction by Jacko-Hyoïdo-Épiglottopexie (CHEP), described in 1959 by Majer And Riedel, codified by Piquet in 1974 and indicated in extended glottiques cancers, and partial laryngectomies supracricoïdiennes with reconstruction by Crico-Hyoïdo-Pexie (CHP), described by Bayle (1971) and indicated in cancers Supraglottiques extended. These supracricoïdiennes partial laryngectomies techniques were disseminated in Europe and the United States by Laccourreye, Brasnu and Piquet in the years 1990. They are an alternative to total laryngectomy in selected cases of laryngeal cancers.
97. In summary, currently, 3 groups of partial laryngectomies by external channel are described classically: partial vertical laryngectomies; the horizontal partial laryngectomies; the partial laryngectomies supra cricoïdiennes.
98. Vertical partial Laryngectomies: Cordectomie; laryngectomy fronto-lateral; Anterior frontal laryngectomy reconstructive with Épiglottoplastie; Hémiglottectomie.
99. Cordectomie or Thyrotomie median or laryngofissure is intended for tumours strictly limited to the middle third of the perfectly mobile rope; It does not require a prior tracheostomy and is not associated with a ganglionic clearing; the skin incision is, either vertical, median, from the upper edge of the thyroid cartilage to the lower edge of the thyroid isthmus, or horizontally projected to the lower edge of the thyroid cartilage; the cartilage must be severed strictly on the median line in order not to reach the contralateral vocal chord to the tumor; On the tumor side, the CV is resected from the previous commissal to the vocal apophysis of the cricoarytenoid by carrying the internal perichondrium; closure is done by approximation of the two thyroid wings; The foot of the epiglottis is previously moored forward and the cricothyroïdienne membrane is sutured before the skin is closed; the operating suites are simple with a power recovery between J1 and J3, not requiring the installation of a nasogastric probe; It is significantly less realized since the development of endoscopic surgery.
100. Laryngectomy fronto-Lateral Its indications also become rarer and concern the superficially extended glottiques tumors to the anterior commissary (T1a etT1b); The tracheostomy made beforehand is not always indispensable; she realizes the resection of the anterior commissary of the anterior angle of the thyroid cartilage; On the tumor side, the vocal chord is removed to the cricoarytenoid and on the opposite side, the vocal chord is cut to a more or less posterior level depending on the tumor extension of the previous commissary; the operating procedures are simple and the oral feeding can be repeated within 48 hours after the procedure, without requiring any feeding by nasogastric probe.
101. Anterior frontal laryngectomy with épiglottoplastie It is intended for superficial tumors of the two vocal chords respecting at least one of the aryténoïdes and not reaching the thyroid cartilage; the "U" skin incision is centered on the cricotrachéale membrane; the principle of intervention is to remove the two vocal cords, the two ventricular bands and the anterior half of the two thyroid wings; The reconstruction is ensured by the epiglottis, lowered in a frontal plane; The feed is provided by a nasogastric probe up to J10, then begins by orally allowing the patient to tracheostomy decannulation process.
102. Hémiglottectomie It is aimed at a tumor of the entire vocal chord respecting the previous commissal but reaching the vocal apophysis without invading the cricoarytenoid; The sub-glottis must be free and the rope movable; It is very little used and is replaced by surgery laryngeal Supracricoïdienne; it conducts itself as a laryngectomy frontolatérale until the time of tumor resection then the resection carries the anterior commissary, the rope and the cricoarytenoid; the tracheostomy is left for about 10 days, an esophageal probe will be put in place because the resection of a cricoarytenoid causes false roads for about 15 days.
103. Horizontal partial Laryngectomies: laryngectomies Horizontal supraglottiques by anterior route: • Horizontal laryngectomy supraglottic; • Hyo-thyroid-épiglottectomie. Lateral laryngectomy Horizontal supraglottic; Hémilaryngopharyngectomie Supracricoïdienne; Hémilaryngopharyngectomie supraglottic.
104. Horizontal laryngectomy supraglottic It is intended for tumours of the laryngeal face of epiglottis, ventricular bands and anterior curbstone at the level of epiglottis sus-Hyoïdienne The procedure is performed under general anesthesia Under cover of a tracheostomy; the skin incision in "U" is the most suitable because it allows a bilateral first of the ganglion areas; It achieves the resection of the two ventricular bands, from the Epiglottis, from the hyoid bone to the vallécules at the top and bottom of the ventricles at the bottom. The resection can be driven from top to bottom or more rarely from bottom to top. This second option, if it allows to limit the upper resection, however, exposes the risk of injury of the subglottic plane when opening the larynx.
105. Hyo-thyroid-épiglottectomie It produces a laryngectomy supraglottic a minima and is indicated for very limited lesions of the laryngeal face of Epiglottis without lymphadenopathy; the operating technique is the same as that of the horizontal laryngectomy supraglottic but the resection differs. It concerns only epiglottis, and the section of aryépiglottiques folds and ventricular bands is more anterior. The HTE Lodge is completely removed. its indications are rare and when practicable, it is made most often by endoscopic way.
106. Horizontal laryngectomy supraglottic Lateral It is intended for tumours of lateral curbstone and is to remove epiglottis, one or two ventricular strips by entering the pharyngolarynx by lateral means; The procedure is conducted under general anesthesia under the guise of a tracheostomy; the "L" incision is adapted by allowing the creation of a ganglionic recess before the laryngeal gesture; it realizes the resection of the whole epiglottis, a ventricular band and the region of the three folds; reconstruction is ensured by the closure of the mucosa up and down through the coverage by the thyroid perichondrium and the hyoïdiens muscles.
107. Hémilaryngopharyngectomie Supracricoïdienne principle: To achieve the bulk resection of the hémilarynx with the adjoining piriformis sinus; Indications: Tumours of the lateral curbstone and the membranous portion of the piriformis sinus; it is performed under general anesthesia under the guise of a tracheostomy; the skin incision is in "L". The intervention begins with the creation of a ganglionic recess and then realizes the resection of the Hémiépiglotte, the ventricular band, the vocal chord with the cricoarytenoid and the upper part of the medial wall of the piriformis sinus; the closure is ensured by a mucosal suture upwards and a sub-omohyoid flap downwards; The feed is provided by a nasogastric probe during the postoperative period, and the cannula is gradually closed from day 6.
108. Hémilaryngopharyngectomie Supraglottic This intervention is done on the same principle as the Supracricoïdienne but retains the subglottic plan; Indications: Essentially the tumors of the lateral curbstone (three folds, folded Aryépiglottique Limited) and there should be no extension to the piriformis sinus or to the cricoarytenoid; the operating suites are simpler and the risk of false roads when swallowing is reduced.
109. The partial laryngectomies supra Cricoïdiennes: These interventions have in common the resection of the thyroid cartilage, the preservation of the cricoid, the hyoid bone, and at least a functional Aryténoïdienne unit. Depending on the intervention, the epiglottis is left in place; This surgery proposes to restore the three essential functions of the larynx that are phonation, swallowing, breathing; one distinguishes mainly 2 interventions which are different both by their indications and by their resection: • Partial laryngectomy Supracricoïdienne with Cricohyoïdopexie (CSSA-CHP); • Partial laryngectomy Supracricoïdienne with Jacko-Hyoïdo-Épiglottopexie (CSSA-CHEP).
110. Partial laryngectomy Supracricoïdienne with Cricohyoïdopexie (CSSA-CHP) principle: Achieves a true subtotal laryngectomy with conservation of cricoid and at least one cricoarytenoid; Indications: supraglottiques tumors with subglottic extension, preserving the mobility of aryténoïdes, ventricle tumours and those of the anterior commissary; the "U" incision allows to make a bilateral node recess, the tracheostomy is made low in anticipation of the ascent of the cricoid and the trachea during the closure; the resection carries the thyroid cartilage, the epiglottis in full, the 2 BV and the 2 CV keeping at least one of the 2 aryténoïdes; The Pexie made between the cricoid and the hyoid bone with the language base; The SNG feed is continued until the 10th-12th post op; The cannula begins to be plugged into the 5th Day post op. Tracheostomy decannulation process occurs when swallowing and breathing are satisfactory but can be achieved prior to food recovery.
111. Laryngectomy subtotality with CHP previous resection resection healthy side resection sick side closure largely taking the language base Neo larynx CHP
112. Partial laryngectomy Supracricoïdienne with Jacko-Hyoïdo-Épiglottopexie (CSSA-CHEP) It differs from the CSSA-CHP by the preservation of the upper part of the epiglottis; Indications: subglottic cancer with fixed cord and mobile cricoarytenoid, bilateral subglottic cancer and subglottic cancer with superficial extension to the anterior or ventricle floor; the skin incision and the first larynx are identical to those of Cssa-CHP; it carries the lower half of the epiglottis, the two ventricular bands and the two vocal chords keeping at least one of the two aryténoïdes; The Pexie is carried out by approximation of the cricoid of the hyoid bone and the language base, and by including the remaining epiglottis which can be used to shrink the néolarynx; the sequence of the suites is the same as for the CSSA-CHP with a little earlier delays due to the conservation of the epiglottis.
113. Laryngectomy subtotal with CHEP. A. Incision of the thyroid cartilage and the foot of the epiglottis. B. Resection on the sick side amputating the cricoarytenoid and part of the sub-glottis. C. Resection of the healthy side passing over the ventricular band. D. Closure by suture Jacko-hyoïdo-épiglottique, requiring the language base to be widely taken.
114. Radical surgery of the larynx principle: The total or subtotal ablation of the 3 stages of the larynx which can be extended to the neighbourhood structures according to the extension (Hypopharynx, language base, thyroid gland, prélaryngés muscles, skin); Indications: Tumours whose localization or extensions do not allow the completion of a cancer conservative partial surgery; it requires the completion of a definitive tracheostomy and a phonatory shunt or postoperative speech rehabilitation; It is increasingly being replaced in some of its indications by concomitant radio-chemotherapy (RCC) within the framework of the concept of laryngeal preservation; The main interventions are: • Subtotal laryngectomy with phonatory shunt; • Total laryngectomy with narrow field; • Total laryngectomy enlarged.
115. Subtotal laryngectomy with shunt phonatory it finds its place between the partial laryngectomies supracricoïdiennes and the total laryngectomy; It may be proposed for the treatment of T3 tumors of the subglottic and/or SUS-subglottic stages without the subsequent commissal; It achieves a true total laryngectomy but with a phonatory shunt that communicates the trachea and the remaining pharynx; on the non-tumor side are preserved 1 cricoarytenoid, one ½ cricoid and the nerves laryngeal superior and inféfieur; The stump is tubulisé on itself from the trachea to the healthy piriformis sinus, thus achieving the phonatory shunt providing better voice rehabilitation; but, as after Total laryngectomy, the Tracheostoma is definitive.
116. Total laryngectomy with narrow field it realizes the complete resection of the larynx and is indicated when the local extension of the primitive tumor against indicates the realization of a functional partial laryngectomy: fixity of the cricoarytenoid and/or Subglottic flooding; contraindications: Massive extension to the HTE Lodge or beyond the limits of the larynx (in these cases an enlarged total laryngectomy is indicated); the bilateral "U" skin incision is the most suitable for making a node recess at the same time; the resection extends from vallécules to the upper tracheal region; The closing of the pharyngostome must be made careful with the realization of separate points to the absorbable wire; The tracheostomy is made by mooring the trachea to the skin; often simple operating Suites. The sealing of the pharynx is controlled on the 10th day by the completion of a blue test or a pharyngeal transit to the water-soluble. Oral feeding can then be resumed. possible post-op incidents include salivary fistula requiring local care by compressive dressing and the crustal trachea that warrants the systematic use of humidifier aerosols.
117. Total enlarged laryngectomy depending on the local tumor extension, it may be necessary to extend the laryngectomy to neighbouring structures: to Hypopharynx (total laryngectomy with partial pharyngectomie) for extended cancers of Piriformis sinus or for curbstone tumors extended to the larynx; to the language base (total Subglossolaryngectomie) for tumours exceeding epiglottis sus-hyoïdienne or infiltrating vallécules; (laryngectomy Square) for tumors extended to prélaryngés tissues with subcutaneous tissue or skin. reconstruction is done at the same time by a myocutané flap of large pectoral or large dorsal.
118. Lymph node cleaning traditional radical Cleaning: resection of the celluloganglionnaire tissue of the àV levels; Sacrifice of SCM muscle, XI and LaVJI. Enlarged Radical Cleaning: traditional Radical cleaning + resections of other structures (cranial nerves, muscles, skin...). Modified Radical Cleaning: Type I: Radical bleeding with the preservation of the spinal nerve (XI); Type II: Radical cleaning with preservation of XI and SCM; Type III or functional: Radical cleaning with preservation of XI, SCM and LaVJI; Selective cleaning: is practised in the N0; the levels usually concerned are: II, III and IV (lateral or jugular); in case of interference under subglottic it is extended AuVI (central).
119. Complications due AUTRAITEMENT postoperative complications: • Cervical hematoma; • Lymphangitis by injury of the left thoracic canal or the large right lymph vein; • Cervical pain or even painful shoulder séquellaire; • Surgical Bed Infections and pharyngeal fistulas; • Vocal mutilation. post-chemotherapy Complications: • Infectious; • Toxic (hematologic, digestive, otological...)
120. Complications Post-radiotherapy: • Fibrosis at the level of the initial lesion seat; • Edema of Curbstone and glottis; Radial larynx; • Radio-Mucositis; • Radiation dermatitis of the cervical region, or even necrosis of the soft parts with risk of vascular rupture; • Carotid stenosis: variable onset times, from a few months to more than 20 years; Osteoradionecrosis • Hyposialie; • Hypothyroidism: Maximum risk especially for the first 2 years; • Limitation of mouth Opening: appears 3 to 6 months after treatment; • Vocal mutilation.
121. INDICATIONS Management of premalignant lesions: Red laryngitis laryngitis keratotic white presence of individual macroscopic lesions monthly to quarterly monitoring the first 2 years microsurgery laryngeal with Histopathological examination of cold or CO2 laser microinstruments (Cordectomie type I or type II) cessation of toxic substances (alcohol, tobacco) treatment of a possible GERD aerosol therapy A: 1 tablet per day, 10 days per month each month (no Systematic) reeducation speech no individualized macroscopic lesions monthly to quarterly Surveillance the first 2 years cessation of toxic substances (alcohol, tobacco) treatment of a possible GERD aerosol therapy A: 1 Tablet per day, 10 days per month each month (non-routine) reeducation speech persistent mucosal lesions microsurgery laryngeal with histopathological examination
122. Glottiques carcinoma: T1a transoral resection: • Cordectomie type I, II, III, IV or Vb if no CA is reached; • Cordectomie TypeVa if reached by CA. Exclusive radiotherapy rarely partial surgery by external means: • Cordectomie if no CA is reached; • laryngectomy frontal-lateral if superficially affected by CA; • If the starting point is CA, the risk of underestimation may result in an external surgery supracricoïdienne to 1 Rxpie or 1 TypeVI laser. Or or T1b transoral resection: • Cordectomie type Va If the achievement of the CV contralateral is very minimal and ant; • Cordectomie type VI if reached ant +/-Important CV contralateral. Exclusive radiotherapy rarely partial external surgery: • Anterior frontal laryngectomy with épiglottoplastie if superficial damage of CA; • If the starting point is CA, the risk of underestimation may result in an external surgery supracricoïdienne to 1 Rxpie or 1 TypeVI laser. Or or management of formed carcinomas:
123. T2 subglottic Mobility chordal normal radiotherapy laryngectomy Supracricoïdienne or or Laser typeVc ouVd mobility chordal altered laryngectomy Supracricoïdienne Best
124. T3 subglottic Protocol of Preservation laryngeal laryngectomy Total laryngectomy partial supracricoïdienne possible in patients selected without extension under subglottic or Paraglottique major and if the cricoarytenoid is not fixed. Or T4a subglottic a total laryngectomy with post op radiotherapy is preferable radiochemotherapy concomitant radiotherapy exclusive depending on the patient's condition or or T4b subglottic a total enlarged laryngectomy (which may not be Cancer!) Concomitant radiochemotherapy exclusive radiotherapy or or symptomatic palliative treatment or
125. Supraglottiques carcinomas: T1 oral resection laser type I radiotherapy exclusive or T2 supraglottic pure transoral resection laser type II or III radiotherapy exclusive radiochemotherapy concomitant or or laryngectomy horizontal Supraglottic or T2 extended beyond the Supraglotte radiotherapy exclusive radiochemotherapy concomitant or laryngectomy horizontal supraglottic extended or
126. T4a supraglottic (same floor subglottic) a total laryngectomy with post op radiotherapy is preferable radiochemotherapy concomitant radiotherapy exclusive depending on the condition of the patient or or T4b supraglottic (same floor subglottic) a Extended Total laryngectomy (which may not be cancer!) Concomitant radiochemotherapy radiotherapy exclusive OR or palliative treatment symptomatic or T3 supra subglottic protocol of Preservation laryngeal laryngectomy Total Cssa-CHP possible in selected patients without major impairment of The Préépiglottique space, neither fixity Aryténoïdienne nor major comorbidity. Or a transoral laser is not contraindicated if the infiltration of the réépiglottiques and paraglottiques spaces is minimal.
127. Glottiques carcinomas: • Superficial carcinomas limited to sub-glottis have an evolution similar to that of tracheal carcinoma. They are not accessible to a transoral laser resection but may be associated with concomitant radiochemotherapy; • For ulcerative-infiltration carcinomas, the indications are similar to those of glottiques carcinomas T3 or T4, however the total laryngectomy is the only surgical indication and must be extended to at least 4 tracheal rings with examination Extemporaneous of the lower resection margins.
128. Indications of treatment of ganglion areas: subglottic carcinoma T1 No treatment of areas ganglion carcinomas glottiques T2, T3 and T4 N0 or N1 bilateral functional scrubbing N2 or N3 radical ipsilateral and functional cleaning contralateral Supraglottic carcinoma and Curbstone N0 or N1 bilateral functional scrubbing N2 or N3 radical ipsilateral and functional bleeding contralateral carcinoma subglottic n0 or n1 bilateral functional scrubbing + Bilateral central clearing + Lobo-Isthmectomie or Total thyroidectomy N2 or N3 radical ipsilateral and functional cleaning contralateral + bilateral central cleaning + Lobo-Isthmectomie or total thyroidectomy if pn-→ no radiotherapy if pn + without capsular rupture → exclusive radiotherapy if PN + with Capsular rupture → radiotherapy + concomitant chemotherapy
129. Unlike a de novo carcinoma, which is more or less limited, laryngeal recurrent carcinoma is made of carcinomatous foci scattered within a fibrous stroma, hence the difficulties of management; It is further under-evaluated at endoscopy and imaging in 52% of cases. Local failure support or locoregional local failure after radiotherapy: • T1/T2 glottiques in failure of radiotherapy receive partial laryngectomy in 49% and total in 51%; local failure after partial surgery Supracricoïdienne: • In a cohort of 103 patients in local recurrence after partial laryngectomy Supracricoïdienne, a total catch-up laryngectomy was possible at 95%, allowing local control in 87% of cases, at the cost of severe complications in 11%; • 44.6% of patients died from their initial illness, compared to only 6.3% in the control group including patients operated in the same manner without recurrence; • Ganglionic relapse and remote metastases are statistically more frequent in local recidivism patients.
130. local failure after RCC: • Induction chemotherapy performed prior to RCC allows selection of good answering patients, thus avoiding difficult or impossible remedial surgery; • For 86 patients with recurred laryngeal carcinoma, 30% had serious scar complications (necrosis, pharyngostome) after a catch-up laryngectomy carried out after RCC, tale 11% if the remedial surgery is performed without Prior irradiation; • In the face of a scar complication after RCC, additional reconstructive surgery is required in 63% of cases. what to do in front of pathological resection margins after a transoral laser surgery: • A laser surgery must be carried out in bulk with extemporaneous study of the margins of resection; • A local recurrence is observed in 37.5% of patients with pathological margins at definitive histology, compared to 0% if the margins are healthy; • If extemporaneous is not possible, close monitoring or "second look" 4 to 6 weeks after initial action should be performed in patients with pathological margins.
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