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Laryngeal Cancer - Treatment
Last reviewed: 19.11.2021
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Treatment goals for laryngeal cancer
The peculiarity of planning the treatment of laryngeal cancer is that it is necessary not only to cure the patient, but also to restore the vocal, respiratory and protective functions of the larynx. In the early stages of the disease, complete recovery can be achieved with the help of radiation therapy, organ-preserving operations or a combination of these methods.
There is no need to dogmatically approach the implementation of the initial treatment plan. During radiation therapy, one of the most significant characteristics of the tumor is revealed - radiosensitivity. Depending on its severity, the initial treatment plan is adjusted.
Treatment planning should be carried out at consultations of surgeons, radiation therapists, and chemotherapists. If necessary, endoscopists, radiologists, and pathologists are invited to participate in the consultation. To discuss the treatment plan, it is necessary to have information about the tumor location in the larynx, its boundaries, spread to adjacent sections, the preepiglottic and periglottic space, the growth form, the features of the histological structure, and morphological differentiation. During the treatment, information about the radiosensitivity of the tumor is added to these criteria, assessing the degree of tumor reduction during radiation therapy. During a biopsy after preoperative radiation therapy or a microscopic examination after surgery, the correctness of the assessment of this criterion can be checked when determining the degree of radiation pathomorphosis of the tumor.
Non-drug treatment of laryngeal cancer
Middle laryngeal cancer T1-T2 has high radiosensitivity, so treatment begins with radiation therapy. Radiation therapy in the preoperative period (radiation dose of 35-40 Gy) does not impair tissue healing if surgery is performed after it. In cases where the degree of tumor reduction is more than 50% of its initial volume, and the remainder is small, radiation therapy is continued after 2 weeks until the therapeutic dose is reached (60-65 Gy). Morphological studies have shown that 3-4 weeks after the preoperative dose of radiation therapy, the tumor begins to recover due to radioresistant cells: thereby leveling out the preoperative effect of radiation therapy. In this regard, the interval between treatment stages should not exceed 2 weeks.
It should be noted that surgical intervention performed after a full dose of radiation therapy is fraught with the risk of developing postoperative complications leading to the formation of fistulas, erosion of the main vessels, significantly prolonging the postoperative period and complicating its management.
In the treatment of vocal fold cancer T1-T2, radiation therapy is performed from two opposing fields at an angle of 90°: the height of the field is 8 cm, the width is 6 cm. In the presence of regional metastases, fields directed from back to front at an angle of 110° can be recommended.
Instead of classical dose fractionation techniques (2 Gy 5 times a week)
Currently, a more effective method of splitting the dose into 3.3 Gy (1.65 Gy from each field) 3 times a week is used. Using this method, it is possible to deliver a dose of 33 Gy to the tumor in 10 treatment sessions over 22 days, equivalent in effectiveness to 40 Gy. When continuing radiation therapy according to the radical program, another 25 Gy is delivered to the tumor at the 2nd stage. In this case, the classical fractionation of the dose by 2 Gy 5 times a week is used as a more gentle one. This helps to avoid damage to cartilage and the development of chondroperichondritis.
In addition to radiation therapy performed under normal conditions (in the air), a method of radiation therapy under hyperbaric oxygenation conditions has been developed. The advantages of this method during preoperative irradiation are considered to be an increase in radiation damage to the tumor, a decrease in radiation damage to normal tissues included in the irradiation volume, and a decrease in the incidence of radiation epitheliitis.
The use of hyperbaric oxygenation allowed to reduce the total focal dose to 23.1 Gy (7 sessions of 3.3 Gy) during preoperative irradiation, which is equivalent to 30 Gy with classical fractionation in cases where combined treatment with laryngeal resection is initially planned. Morphological study of radiation pathomorphosis showed that the III degree of pathomorphosis in these patients was 2 times higher than after 33 Gy in the air. Such observations served as the basis for expanding the indications for independent radiation therapy under hyperbaric oxygenation conditions according to the radical program.
In case of vestibular laryngeal cancer T1-T2, treatment should begin with radiation therapy. The upper boundary of the radiation field is raised above the horizontal branch of the lower jaw by 1.5-2 cm. The dose fractionation technique and the level of total focal doses during preoperative radiation therapy and irradiation according to the radical program for all parts of the larynx are identical. If after radiation therapy at the preoperative dose (40 Gy) the tumor decreases insignificantly (less than 50%), then horizontal resection of the larynx is performed.
Treatment of vestibular laryngeal cancer T3-T4 begins with chemotherapy. After 2 courses of chemotherapy, radiation therapy is administered at a preoperative dose.
The final treatment tactics are determined after the tumor has been irradiated with a dose of 40 Gy. The patient undergoes laryngeal resection if the residual tumor is small, and laryngectomy if the tumor is large; tumors located in the anterior commissure, subcommissural region, laryngeal ventricle, and arytenoid cartilage are usually radioresistant. Detection of damage to these parts of the larynx is considered a compelling argument and benefit of surgery.
In case of subglottic larynx cancer TT-T2, treatment also begins with radiation therapy. Its results are assessed after a preoperative radiation dose of 40 Gy. If the tumor decreases by less than 50%, surgical intervention is performed.
Areas of regional metastasis are included in the radiation field during pre- or postoperative radiation therapy for laryngeal cancer.
The presence of a tracheostomy is not an obstacle to radiation therapy: it is included in the radiation field.
Drug treatment of laryngeal cancer
Chemotherapy is administered to patients with widespread cancer of the supraglottic part of the larynx (lesions of the root of the tongue, laryngopharynx, soft tissues of the neck). In case of cancer of the subglottic and vocal parts of the larynx, chemotherapy is ineffective.
Neoadjuvant chemotherapy consists of 2 identical courses with 1 day breaks between them. Each block includes:
- Day 1. Cisplatin at a dose of 75 mg/m2 against the background of hyperhydration and forced diuresis.
- on days 2-5, fluorouracil at a dose of 750 mg/ m2.
Surgical treatment of laryngeal cancer
If radioresistance of the middle T1-T2 section cancer is detected at the 2nd stage of treatment after preoperative radiation therapy at a dose of 40 Gy (in the air), organ-preserving surgery is performed. In case of cancer of the vocal part of the larynx, if the tumor does not extend to the anterior commissure and arytenoid cartilage, lateral resection of the larynx is performed. If the tumor extends to the anterior commissure, anterolateral resection is performed. It should be noted that the surgical method (laryngeal resection) as an independent method gives comparable results. However, in this case, the possibility of curing the patient without surgery using radiation therapy, which can preserve good voice quality, is excluded.
In case of cancer of the middle part of the larynx T3-T4, chemoradiation or radiation therapy is performed at the first stage, and laryngectomy is performed at the final stage. In recent years, methods of organ-preserving operations for cancer of the T3 have been developed, but they are performed according to strict indications. Cure of cancer of the T3 with the help of radiation therapy is possible only in 5-20% of patients.
A technique for laryngeal resection in TG with endoprosthetics has been developed.
Indications for surgery:
- damage on one side with transition to the anterior commissure and the other side by more than 1/3 while preserving the arytenoid cartilages;
- lesion of three sections of the larynx on one side with infiltration of the subglottic region, requiring resection of the cricoid cartilage.
To avoid cicatricial narrowing of the larynx, its lumen is formed on a tubular prosthesis made on the basis of vinylpyrrolidone and acrylate, impregnated with an antiseptic, or from medical silicone. Three to four weeks after the formation of the framework of the lumen of the resected larynx, the prosthesis is removed through the mouth.
In case of cancer of the subglottic larynx T3-T4, preoperative radiation therapy is not performed, because patients have pronounced stenosis of the laryngeal lumen before the start of treatment or there is a high risk of its development during radiation therapy. Treatment begins with laryngectomy with 5-6 tracheal rings. Radiation therapy is performed in the postoperative period.
The main method of treating recurrent laryngeal cancer is considered to be surgical intervention. Depending on the extent of tumor spread, growth form, morphological differentiation, the volume of the operation is planned (from resection to laryngectomy).
Preventive operations (in the absence of palpable and ultrasound-detectable metastases) are performed in the case of deep endophytic tumor growth with destruction of the laryngeal cartilage, and in the case of tumor spread to the laryngopharynx, thyroid gland, and trachea.
In the presence of regional metastases, fascial-case excision of the lymph nodes and neck tissue is performed. If the tumor grows into the internal jugular vein or sternocleidomastoid muscle, these anatomical structures are resected (Krail's operation). If single metastases are detected in the lungs and liver of a patient with laryngeal cancer, the question of their possible removal is decided.
Further management
After conservative and surgical treatment, patients need careful regular and long-term monitoring. The monitoring regimen is monthly during the first six months, every 1.5-2 months during the second six months; every 3-4 months during the second year and every 4-6 months during the third to fifth years.
Loss of voice function after laryngectomy is one of the common reasons why patients refuse this operation. Currently, the speech therapy method of voice function restoration has become widespread.
However, the method has a number of disadvantages: difficulties in mastering the technique of swallowing air into the esophagus and pushing it out during phonation, a small esophagus (180-200 ml) as a reservoir for air, hypertension or spasm of the pharyngeal constrictors. When using this method, good voice quality can be achieved in 44-60% of patients.
A significantly improved surgical method of voice rehabilitation after laryngectomy is free of these shortcomings. It is based on the principles of the collapse of the shunt between the trachea and esophagus, through which a powerful air flow from the lungs penetrates into the esophagus and pharynx. The air flow pushes out the vibrational activity of the pharyngeal-esophageal segment, which is the voice generator. The voice prosthesis, placed in the lumen of the shunt, passes air from the lungs into the esophagus and prevents the ingress of liquid and food in the opposite direction.
The acoustic analysis revealed significant advantages of the tracheoesophageal voice (using voice prostheses) over the esophageal voice. With this method, good voice quality was achieved in 93.3% of patients.
Thus, after operations for laryngeal cancer, restoration of vocal function is necessary.