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Laryngeal cancer: treatment
Last reviewed: 19.11.2021
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Objectives of treatment of larynx cancer
The peculiarity of planning the treatment of laryngeal cancer is that it is necessary not only to heal the patient, but also to restore the voice, 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-saving operations, or a combination of these methods.
Do not dogmatically approach the implementation of the initial treatment plan. In the process of radiotherapy, one of the most significant characteristics of the tumor is identified - radiosensitivity. Depending on its severity, the initial treatment plan is adjusted.
Planning treatment should be conducted at the consultation of surgeons, radiation therapists, chemotherapists. If necessary, endoscopists, roentgenologists and pathomorphologists are invited to participate in the consultation. To discuss the treatment plan, it is necessary to have information about the localization of the tumor in the larynx, its boundaries, spreading to neighboring departments, prednadgortannikovoe and near-confluence space, the form of growth, features of the histological structure and morphological differentiation. In the process of treatment, these criteria are supplemented with information on the radiosensitivity of the tumor, assessing the extent to which the tumor is reduced in the course of radiotherapy. In biopsy after preoperative radiotherapy or microscopic examination after surgery, the correctness of the evaluation of this criterion can be monitored in determining the degree of radiation pathomorphism of the tumor.
Non-drug treatment of laryngeal cancer
The cancer of the middle larynx T1-T2 has a high radiosensitivity, so treatment is started with radiation therapy. Radiation treatment in the preoperative period (irradiation dose 35-40 Gy) does not worsen the healing of tissues if an operation is performed after it. In cases where the degree of tumor reduction is more than 50% of its original volume and the remainder is small, after 2 weeks, radiation therapy continues until a therapeutic dose (60-65 Gy) is reached. With the help of morphological studies, it was shown that 3-4 weeks after the preoperative dose of radiation therapy, the tumor begins to recover due to radioresistant cells: thereby pre-operative effect of radiotherapy is leveled. In this regard, the interval between the stages of treatment should not exceed 2 weeks.
It should be noted that surgical intervention performed after the full dose of radiation therapy is fraught with the danger of development of postoperative complications leading to the formation of fistulas, arthrosis of the main vessels that significantly prolong the postoperative period and make it difficult to maintain.
In the treatment of cancer of the T1-T2 vocal folds, radiation therapy is carried out from two opposing fields at an angle of 90 °: the height of the field is 8 cm and the width is 6 cm. In the presence of regional metastases, it is possible to recommend fields directed posteriorly at an angle of 110 °.
Instead of methods of classical dose fractionation (2 Gy 5 times a week)
Currently, a more effective method of dose splitting is used at 3.3 Gy (1.65 Gy from each field) 3 times a week. Using this technique, it is possible to bring a dose of 33 Gy, equivalent in efficiency to 40 Gy for 10 treatment sessions within 22 days. With the continuation of radiotherapy for the radical program, the second stage leads to a tumor of 25 Gy. At the same time, classical fractionation of a dose of 2 Gy is used 5 times a week as more sparing. This prevents cartilage damage and the development of chondroperichondritis.
In addition to radiotherapy, which is carried out under normal conditions (in the air), a method of radiotherapy in hyperbaric oxygenation has been developed. Advantages of this method in pre-operative irradiation include strengthening radiation damage to the tumor, reducing the radiation damage of normal tissues included in the volume of irradiation, and reducing the frequency of radiation epitheliae.
The use of hyperbaric oxygenation made it possible to reduce the total focal dose to 23.1 Gy in preoperative irradiation (7 sessions at 3.3 Gy}, which is equivalent to 30 Gy with classical fractionation in those cases when initially a combined treatment with laryngeal resection is planned. Pathomorphosis showed that the third degree of pathomorphosis in these patients was 2 times higher than after the addition of 33 Gy in air Such observations served as a basis for expanding the indications for an independent lu Eva therapy in hyperbaric oxygen therapy with curative intent.
With cancer of the vestibular larynx T1-T2 treatment should start with radiation therapy. The upper limit of the irradiation field is raised above the horizontal branch of the lower jaw by 1.5-2 cm. The method of dose fractionation and the level of total focal doses for preoperative radiotherapy and radical irradiation for all parts of the larynx are identical. If after the radiotherapy in a preoperative dose (40 Gy) the tumor decreases insignificantly (less than 50%), then a horizontal resection of the larynx is performed.
Treatment of cancer of the vestibular larynx of T3-T4 begins with chemotherapy. After 2 courses of chemotherapy, radiotherapy is performed in a preoperative dose.
The final treatment tactics are determined after a 40 Gy dose of irradiation has been applied to the tumor. The patient is resected by the larynx, if the residual tumor is small, and a laryngectomy with large tumor sizes localized in the area of the anterior commissure, subcompassural area, laryngeal ventricle, arytenoid cartilage is usually radioresistant. Detection of the lesion of these parts of the larynx is considered a weighty argument and favor operation.
With cancer of the podgolosal department of the larynx TT-T2, treatment is also started with radiotherapy. Her results are evaluated after a preoperative dose of 40 Gy. When the tumor is reduced by less than 50%, surgical intervention is performed.
Zones of regional metastasis include in the field of irradiation with pre- or postoperative radiotherapy for laryngeal cancer.
The presence of a tracheostomy is not an obstacle to radiation therapy: it is included in the field of irradiation.
Medicamentous treatment of larynx cancer
Chemotherapy is performed by a patient with a common cancer of the nadgosal part of the larynx (a lesion of the root of the tongue, laryngopharynx, soft tissues of the neck). With cancer of the podvolosovogo and voice departments of the larynx, chemotherapy is ineffective.
Neoadjuvant chemotherapy consists of 2 identical courses with 1-day breaks between them. Each block includes:
- The 1 st day. Cisplastin in a dose of 75 mg / m 2 on the background of hyperhydration and forced diuresis.
- for 2-5th day fluorouracil in a dose of 750 mg / m 2.
Surgical treatment of laryngeal cancer
In detecting the radio-resistance of the middle T1-T2 cancer at the 2nd stage of treatment after preoperative radiotherapy at a dose of 40 Gy (in air), perform an organ-preserving operation. In cancer of the voice part of the larynx, if the tumor does not spread to the anterior commissure and the arytenoid cartilage, perform lateral resection of the larynx. If the tumor extends to the anterior commissure, anterolateral resection is performed. It should be noted that the surgical method (resection of the larynx) as an independent one gives comparable results. However, in this case, the possibility of curing a patient without surgery with the help of radiation therapy, in which one can maintain a good voice quality, is excluded.
At a cancer of an average department of a larynx TZ-T4 at 1-st stage conduct chemoradiation or radial treatment, on final-laringintomy. In recent years, methods of organ-preserving surgery operations have been developed for TK cancer, but they are performed according to strict indications. TK cancer can be cured with radiation therapy only in 5-20% of patients.
A technique for resection of the larynx with TK with endoprosthetics was developed.
Indication for the operation:
- defeat on the one hand with the transition to the front commissure and the other side by more than 1/3 while maintaining the arytenoid cartilages;
- defeat of the three parts of the larynx on the one hand with infiltration of the podogolosovogo department, requiring resection of the cricoid cartilage.
To avoid cicatricial narrowing of the larynx, its lumen is formed on a tubular prosthesis made of vinylpyrrolidone and acrylaton impregnated with an antiseptic or from a medical silicone. 3-4 weeks after the formation of the skeleton of the luminal of the resected throat, the prosthesis is removed through the mouth.
With cancer of the podgolosal department of the larynx TZ-T4, preoperative radiotherapy is not performed, t. Patients have stenosis of the laryngeal lumen prior to the beginning of treatment or the danger of its development in the process of radiotherapy is beginning Treatment begins with laryngectomy with 5-6 rings of the trachea. Radiation therapy is performed in the postoperative period.
The main method of treating recurrences of laryngeal cancer is considered surgical intervention. Depending on the degree of spread of the tumor, the form of growth, morphological differentiation, the volume of the operation is planned (from resection to laryngectomy).
Preventive operations (in the absence of palpable and ultrasound-determined metastases) are performed with deep endophytic growth of the tumor with destruction of the larynx cartilage, with the spread of tumors to the laryngopharynx, thyroid gland and trachea.
In the presence of regional metastases perform fasial-cervical excision of lymph nodes and neck tissue. When the tumor grows into the inner ligament vein or the sternocleidomastoid muscle, these anatomical structures are resected (the Krajl operation). If a patient has cancer of the larynx, single metastases in the lungs and the liver are solved by the possibility of their removal.
Further management
After conservative and surgical treatment, patients need careful, regular and long-term follow-up. Observation mode and the first half a year - monthly, in the second half a year - in 1,5-2 months; for the 2nd year - in 3-4 months, for 3-5 years - after 4-6 months.
The loss of voice function after laryngectomy is one of the frequent reasons for patients' refusal from this operation. At present, the logopedic method for restoring the voice function has been widely used.
However, the method has a number of drawbacks: difficulties with mastering the technique of ingesting air into the esophagus and expelling it during phonation, a small esophagus (180-200 ml) as a reservoir for air, hypertension or spasm of pharynge compressors. Using this method, good quality of voice can be achieved in 44-60% of patients.
These defects are devoid of a significantly improved surgical method of voice rehabilitation after laryngectomy. It is based on the principles of a drop in the shunt between the trachea and the esophagus, through which a powerful flow of air from the lungs penetrates the esophagus and pharynx. The flow of water vytykaet vibratory activity of the pharyngeal esophagus segment, which is the generator of the voice. The voice prosthesis, placed in the lumen of the shunt, lets air from the lungs into the esophagus and prevents liquid and poor in the opposite direction.
The conducted acoustic analysis revealed great advantages of a tracheo-esophageal voice (with the use of vocal prostheses) in front of the esophageal. With this method, good voice quality was achieved in 93.3% of patients.
Thus, after surgery for laryngeal cancer, restoration of the voice function is necessary.