In depth head and neck cancer management

-Conservative surgery-

5-7 December 2016 - Kashiwa, Japan

www.excemed.org

IMPROVING THE PATIENT’S LIFE

THROUGH

MEDICAL EDUCATION

Larynx-preserving surgery for laryngeal carcinoma

Type of Cancer Organ-Preservation Strategy

Recommended Other Options Basis for Recommendation Quality of Evidence

T1 cancer of the glottis: Endoscopic resection Open organ-preservation High local control rates and quality Comparison of outcomes

T1—tumor limited to the vocal cord(s) (selected patients) OR surgery of voice after endoscopic from case series/

(may involve anterior or posterior radiation therapy resection compared with prospective single-arm

studies

commissure) with normal mobility radiation therapy; possible cost

T1a—tumor limited to one vocal cord savings; ability to reserve

T1b—tumor involves both vocal cords radiation for possible second

primary cancers of the upper

aerodigestive tract; however,

not suitable for all patients

T2 cancer of the glottis, Open organ-preservation Endoscopic resection Open organ-preservation surgery is Comparison of outcomes

favorable:T2—tumor surgery OR radiation (selected patients) associated with highest local from case series/

extends to supraglottis therapy control rates; however, leads to prospective single-arm

and/or subglottis, or with permanent hoarseness; local studies

Summary of Recommended Strategies for Treatment of the Primary Site for Larynx Preservation

and/or subglottis, or with permanent hoarseness; local studies

impaired vocal cord mobility control rates after radiation therapy

are also high, and functional

outcomes may be better

T2 cancer of the glottis, unfavorable Open organ-preservation Radiation therapy Higher local control rates after Comparison of outcomes

surgery OR concurrent Endoscopic surgery compared with radiation from case series/

chemoradiation therapy resection (selected therapy alone; quality of voice prospective single-arm

(selected patients with patients) after therapy of less concern if studies; randomized

node-positive disease) vocal cord function is controlled clinical trials

irreversibly compromised by comparing concurrent

tumor invasion; endoscopic chemoradiation therapy,

surgery requires careful patient and/or induction

selection chemotherapy followed

For patients with T2 N by radiation, and/or

disease, evidence from radiation therapy alone,

randomized trials supports and/or surgery followed

concurrent chemoradiation by radiation

therapy as an organ-preservation

option

Comparison of outcomes

DG. Pfister 2006

・ All patients with T1-T2 laryngeal cancer should be treated, at least initially, with

intent to preserve the larynx.

・ T1-T2 laryngeal cancer can be treated with radiation or larynx-preservation surgery

with similar survival outcomes. Selection of treatment depends on patient factors, local

expertise, and the availability of appropriate support and rehabilitative services.

・ Every effort should be made to avoid combining surgery with radiation therapy because

functional outcomes may be compromised by combined-modality therapy; single-

modality treatment is effective for limited-stage, invasive cancer of the larynx.

4

modality treatment is effective for limited-stage, invasive cancer of the larynx.

・ Surgical excision of the primary tumor with intent to preserve the larynx should be

undertaken with the aim of achieving tumor-free margins; so-called narrow-margin

excision followed by postoperative radiation therapy is not an acceptable treatment

approach.

・ Local tumor recurrence after radiation therapy may be amenable to salvage by organ-

preservation surgery, but total laryngectomy will be necessary for a substantial

proportion of patients, especially those with index T2 tumors.

DG. Pfister 2006

Transition of procedures for larynx-preserving

surgery for HPC in Japan

1981- Partial pharyngectomy with free free flap reconstruction

1990- Development of the NBI (Narrow Band Imaging) of endoscope and

detection of superficial pharyngeal cancer

2000- Endoscopic resection for pharyngeal cancer (EMR/ESD) 2000- Endoscopic resection for pharyngeal cancer (EMR/ESD)

Muto et al. 2004

Endoscopic Laryngo-Pharyngeal Surgery (ELPS)

Sato Y, Omori T et al. 2006

Tateya et al. 2015

Transoral Videolaryngoscopic Surgery (TOVS)

Shiotani et al. 2008

Larynx-preserving surgery

for hypopharyngeal carcinoma

with free flap reconstruction with free flap reconstruction

Indications of laryngeal preservation surgery

1981～～～～Tumors involve mainly piriform sinus (PS) or posterior wall (PW)

and resection can be successfully performed without resection of

a portion of the larynx

1997～～～～1997～～～～Tumors involve mainly piriform sinus (PS) or posterior wall (PW)

and resection can be successfully performed

with resection of the arytenoid and aryepiglottic

fold without resection of the arytenoid on

the other side

Male:Female 57:15

Mean age 61.2 yrs. (44-79)

Median follow-up duration 57 mos. (12-211)

Subsites PS 37

PW 33

PC 2

Without resection of the larynx 46

Patient Characteristics

Without resection of the larynx 46

With partial resection of the larynx 26

Previous treatment

None 62

recurrent cases 10

Treatment operation only 62

adjuvant RT 9

adjuvant CT 11982-2006 NCCH & NCCHE

T1

(n=11)

24%

T3

(n=7)

15%

T4

(n=3)

7%T2

(n=11)

42%

T3

(n=13)

T4

(n=2)

8%

Operative procedure according to the T stage

T2 (n=13)

50%

Without resection of the larynx

(n=46)

With partial resection of the larynx

(n=26)

T2

(n=25)

54%

67 M :

HPC(PW) T2N0M0 Partial

pharyngectomy with free

jejunum reconstruction

70M :

HPC(PS) T2N2ｂｂｂｂN0

Partial phryngo-laryngectomy

with forearm flap reconstruction

5 POY11 POY

Preservation of the larynx

・・・・Eating and conversation were possible

・・・・Decannulation was possible

・・・・No local recurrence was found during the follow up

No. of pts. successful (%) unsuccessful (%)

All patients 72 62 (86) 10(14)

Without resection 46 42 (91)* 4(9)

of the larynx

With partial resection 26 20 (77)* 6(23)

of the larynx

* : p=0.09

Survival curves

5-yr. survival rate (%)

All patients (n=72) 58

Without resection (n=46) 59

of the larynx.4

.6

.8

1100

50

(%)

of the larynx

With partial resection (n=26) 57

of the larynx0

.2

.4

0 12 24 36 48 60

50

0months

1982-2006 NCCH & NCCHE

Detection of superficial pharyngeal

squamous cell carcinoma and transoral

resection for early pharyngal cancerresection for early pharyngal cancer

1 Selection of a high risk group developing SCC in head

and neck

The presence of numerous irregular-shaped multiform Lugol-

voiding lesions was closely associated with second primary

esophageal SCC and SCC of the head and neck

Muto et al. 2002

Detection of superficial pharyngeal squamous cell

carcinoma (spscc)

Muto et al. 2002

2 Technology advancement of endoscope

1) Development of magnifying endoscope

2) Narrow Band Imaging (NBI) system

NBI filter

400 500 600 700 nm

Conventional RGB filter

Narrow Band Imaging System (NBI)

400 500 600 700 nm

We changed the spectral feature of the RGB optical filters

at the front of Xenon lighting source (CLV-U40, OLUMPUS Corp.).

Well-demarcated brownish area and

irregular microvascular pattern

CD34

Pathological findings

Squamous cell carcinoma in situ

Endoscopic Mucosal Resection using a Cap (EMR-C)

Endoscopic Submucosal Dissection (ESD)Endoscopic Submucosal Dissection (ESD)

Satake et. al. 2015

Head & Neck

Surgeon

Endoscopic Laryngo-Pharyngeal Surgery (ELPS)

Endoscopist

Subepithelial invasion

(n = 50)

SCC in situ

(n = 148)P value

Endoscopic resection method, n (%)

EMR-C 26 (52)  85 (57)

0.329ESD 17 (34)  53 (36)

ELPS  7 (14)  10 (7)

Endoscopic resection type, n (%)

En bloc resection 33 (66) 111 (75)0.218

Piecemeal resection 17 (34)  37 (25)

Clinical results of endoscopic resection procedures

(n = 198)

Piecemeal resection 17 (34)  37 (25)

No. of resected segments, median (range)  3 (2 – 9)   3 (2 – 9)

Major complications, n (%)  8 (16)   9 (6) 0.031

Delayed bleeding  2 (4)   0 (0)

Dysphasia  2(4)   3(2)

Laryngeal edema  1(2)   2(1)

Aspiration pneumonia  1 (2)   0 (0)

Subcutaneous emphysema  1 (2)   0 (0)

Trismus  1 (2)   0 (0)

Perforation  0 (0)   5(3)

Temporary tracheostomy, n (%) 10 (20)  21 (14) 0.330

Satake et. al. 2015

Clinical course No. of patients (%)

Local recurrence 6 (13)

Treatment

Salvage endoscopic resection 4

Partial resection 1

Chemoradiotherapy 1

Neck lymph node metastasis 1 (2)

Clinical course after endoscopic resection for superficial

pharyngeal squamous cell carcinoma invading the

subepithelial layer (n = 47).

Neck lymph node metastasis 1 (2)

Treatment

Neck lymph node dissection 1

Death 7 (15)

Cause of death

Esophageal squamous cell carcinoma 3

Colorectal cancer 1

Lung cancer 1

Cardiac disease 1

Unknown cause 1

Satake et. al. 2015

Endoscopic

resection

(n = 47)

Age, mean, years  64

TNM stage 1 – 2, %  98

5-year overall survival rate, %  84.5

Overall survival time after endoscopic resection for

superficial HNSCC invading the subepithelium.

5-year overall survival rate, %  84.5

5-year disease-specific survival rate, % 100

Failure patterns, %

Local  13

Nodal   2

Satake et. al. 2015

1500μm1500μm1500μm1500μm

ER casesER casesER casesER cases

V+V+V+V+

VVVV----

Th

ickne

ssT

hickn

ess

Th

ickne

ssT

hickn

ess

Relationship of LN metastasis(macroscopic findings, vascular invasion and tumor thickness)

●●●● 0. 0. 0. 0. Superficial Superficial Superficial Superficial

▲▲▲▲ 1. 1. 1. 1. PPPProtuberantrotuberantrotuberantrotuberant

▼▼▼▼ 2. 2. 2. 2. UUUUlcerativelcerativelcerativelcerative

VVVV----

0 1 2 3 4 5 6 7 8 12

Th

ickne

ssT

hickn

ess

Th

ickne

ssT

hickn

ess

No. of lymph node No. of lymph node No. of lymph node No. of lymph node involvementinvolvementinvolvementinvolvement

tumor

Superficial

HNSCC

Inv. Muscle layer or

other organ（（（（＋）＋）＋）＋）Inv. Muscle layer or

other organ（（（（-））））

Follow –up of the patients after transoral resection

HNSCC

High risk of lymph node meta. low risk of lymph node meta.

Thickness

≧≧≧≧1000μm

or

v(+)

Thickness

＜＜＜＜1000μm

and

V (-)

Handling issues for spscc (1)

Histological measurement of tumor depth

epithelium

Tumor thickness;

1875mm

Definition: Tumor thickness

From tumor surface to the deepest

point

Related factors to subepithelial invasion

Tumor thickness

Depth of subepthelial invasion

Tumor thick ness and depth of subepithelial

invasion

Related factors to subepithelial invasion

Thickness P<0.0001

Diameter P=0.0013

MVD P=0.0078

Related factors to vascular invasion

Thickness P<0.0001

Diameter P<0.0001

Staging of pT

4.5 cm 4.5 cm

Handling issues for spscc (2)

What is pT ?

T1? T2? T3?

1.5 cm 3.8 cm

Transoral surgery

(ER, ELPS TOVS, TORS)

Open Larynx-preserving

surgery

・・・・What are the indications for neck dissection for superficial

tumors?

Changing Paradigm Of Surgical Role In HPC

・・・・When there is an extensive superficial tumor, what extent of

resection results in an acceptable mucosal defect without

stenosis?

・・・・ How do we add the concept of tumor depth ensuring

consistencies with the international classification ?