Download Larynx - MD Anderson Cancer Center

This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
INITIAL EVALUATION
Confirm outside pathology
History:
● Chief complaint
● History of present illness and previous treatment
Past Medical History:
● Medical illnesses
● Surgeries
● Medication allergies
● Family history
● Social history (including tobacco and alcohol use)
● Medications
● Review of systems
● Previous Radiation Therapy – Head and Neck,
Thoracic, Breast (for previous primary or benign
diagnosis)
Physical Examination:
● Full head and neck exam
● Fiberoptic exam
● Videostroboscopy (optional)
General medical exam
Stage T and N (AJCC)
Imaging studies:
● CT scan H&N
● Consider PET scan for Stage III/IV
● Modified Barium Swallow / espophagoscopy
● Chest Imaging as clinically indicated.
Copyright 2015 The University of Texas MD Anderson Cancer Center
CONSULTATIONS
If no biopsy/pathology: consider
EUA, DL, Biopsy, esophagoscopy
● Radiation oncology
● Medical oncology for patients with
Stage III or IV
● Dental oncology for dentulous
patients except those receiving
narrow field radiation.
● Speech pathology for all patients
and videostroboscopy, if indicated
● Consider esophagoscopy or barium
swallow
1
● IMPAC (for surgical management)
● Plastic surgery for patients who
will require major reconstruction
(pharyngeal reconstruction)
● Nutritional assessment and follow
all patients
● Smoking cessation for active
smokers only
PRE-TREATMENT
EVALUATION
●
Glottic
Patient information
presented at
Multidisciplinary
Planning Conference
Supraglottic
● Node Negative
Supraglottic
● Node Positive
(based on clinical and/or
radiographic imaging)
See page 2
See page 3
See page 4
1
Conditions for pre-op internal medicine consult:
Hypertension
● Uncontrolled or newly diagnosed
● Poorly compliant patient
● Multi-drug regimen for control
Cardiac Disease
● History of MI or angina
● History of cardiac or vascular surgery
● Cardiac murmur or valvular heart disease
● CHF
Pulmonary Disease
● 20 or more pack per year smoking history
● Moderate to severe COPD with less than 2 flight
exercise tolerance
● Reactive airway disease
● Previous lung resection
● Multiple history of pneumonias
● History of TB
Cerebrovascular Disease
Diabetes
● Previous CVA
● Type I
● History of TIA
● Type II
● Carotid bruit or known stenosis
Hepatic Disease
● History of cirrhosis
● Laboratory of hepatic dysfunction
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
CLINICAL EVALUATION
ADJUVANT
TREATMENT
PRIMARY TREATMENT
Severe dysplasia /
carcinoma in situ
Endoscopic removal (stripping/laser)
Radiation to Primary
(greater than or equal to 66 Gy) or
● Endoscopic partial laryngectomy or
● Open partial laryngectomy
Is
nodal status
positive?
●
Primary Tumor:
Most T1-2, any N
Concurrent
chemoradiation
Glottic
Primary Tumor:
Most T3, N0-N1
Complete
response at
primary
site?
Total laryngectomy1,2 and neck
dissection(s), as indicated, and
ipsilateral thyroidectomy.
● Consider primary Tracheosophageal
Puncture (TEP)
Yes
No
1
2
Observe
Neck dissection(s)
No
Yes
Presence of
pathological risk
features3?
Total laryngectomy and neck dissection(s), as
clinically indicated, and ipsilateral thyroidectomy
● Consider primary Tracheosophageal Puncture (TEP)
●
No
Radiation therapy
4
● Consider chemoradiation
●
3
No
Observe
Radiation therapy
4
● Consider chemoradiation
●
Primary tumors requiring total laryngectomy not amenable to partial surgery.
Total Laryngectomy to be considered for patients with significant pretreatment laryngopharyngeal dysfunction or are medically unable to tolerate organ preservation therapy.
Copyright 2015 The University of Texas MD Anderson Cancer Center
Surveillance
(See page 6)
● Medical oncology
(optional) for
chemoprevention
trials
●
Observe
Total laryngectomy and neck dissection(s),
as clinically indicated
●
Primary Tumor:
T4 disease, Any N
Radiation therapy or
● Neck dissection(s)
●
Yes
Yes
Residual
nodal
disease?
SURVEILLANCE
Pathological Risk Features include:
Primary pathology:
● Any T1 or T2 with perineural invasion, OR
lymphovascular invasion
● Any T3 or T4
Regional pathology:
● Multiple lymph nodes (any N2, N3)
4
Pathological Risk Factors include:
● Positive margins (re-excision to clear
margins is preferred)
● Extracapsular extension
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
CLINICAL
EVALUATION
ADJUVANT TREATMENT
PRIMARY TREATMENT
Definitive Radiation
Primary Tumor:
Most T1-2, N0
Surgery:
● Endoscopic resection with
neck dissection(s) or
● Open partial laryngeal
surgery with neck
dissection(s)
Presence of
Pathological Risk
Features4 ?
Complete
response at primary
site?
Concurrent
chemoradiation
Primary Tumor:
● T3, N0
1
● Selected T4 , N0
Total laryngectomy2,3 and neck
dissection(s), as indicated, and
ipsilateral thyroidectomy.
● Consider primary Tracheosophageal
Puncture (TEP)
Radiation or Chemoradiation
Yes
Yes
No
Pathologic
N1?
No
No
Yes
Residual
nodal
disease?
Yes
Supraglottic
Node
Negative
SURVEILLANCE
Consider radiation therapy
Observe
Neck dissection(s)
No
Observe
Laryngectomy, neck dissection(s) as clinically indicated
●
Presence of
pathological risk
features4 ?
Yes
●
●
Radiation therapy
Consider chemoradiation5
Yes
No
Pathologic
N1?
No
Radiation Therapy
Observe
4
Total laryngectomy and neck
dissection(s), as indicated, and
ipsilateral thyroidectomy.
● Consider primary Tracheosophageal
Puncture (TEP)
●
Primary Tumor:
T4, N0
1
Copyright 2015 The University of Texas MD Anderson Cancer Center
See page 4
Surveillance
(page 6)
Low-volume base-of-tongue involvement
Primary tumors requiring total laryngectomy not amenable to partial surgery.
3
Total Laryngectomy to be considered for patients with significant pretreatment
laryngopharyngeal dysfunction or are medically unable to tolerate organ preservation therapy.
2
Node Positive
Radiation therapy
5
● Consider chemoradiation
●
Surveillance
(See page 6)
● Medical oncology
(optional) for
chemoprevention
trials
●
Pathological Risk Features include:
Primary pathology:
● Any T1 or T2 , with perineural invasion, OR
lymphovascular invasion
● Any T3 or T4
Regional pathology:
● Multiple lymph nodes (any N2, N3)
5
Pathological Risk Factors include:
● Positive margins (re-excision to clear
margins is preferred)
● Extracapsular extension
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
CLINICAL EVALUATION
Primary Tumor:
● T1-2, N+ and
● Selected T3
(Not requiring Total
Laryngectomy)
Concurrent
chemoradiation
Concurrent
chemoradiation
Copyright 2015 The University of Texas MD Anderson Cancer Center
Yes
Complete
response at
primary site?
Yes
No
Total laryngectomy2 and neck
dissection(s),79as indicated, and
ipsilateral thyroidectomy.
● Consider primary Tracheosophageal
Puncture (TEP)
Total laryngectomy and neck
dissection(s), as indicated and
ipsilateral thyroidectomy.
● Consider primary
Tracheosophageal Puncture (TEP)
N1
(initial stage)
Yes
Complete
response of nodal
disease?
No
Observe
Neck dissection
N2-3
Salvage surgery as clinically indicated
Complete
response of nodal
disease?
Yes
Observe
No
Neck dissection
Salvage surgery as clinically indicated
●
●
Primary Tumor:
T4, N+
Complete
response at
primary site?
No
Supraglottic
Node
Positive
Primary Tumor:
1
● Most T3, N+ or
1
● Selected T4
SURVEILLANCE
TREATMENT
Presence of
Pathological Risk
Features3?
Yes
No
Radiation therapy
4
● Consider chemoradiation
●
Surveillance
(See page 6)
● Medical oncology
(optional) for
chemoprevention
trials
●
Radiation therapy
3
Pathological Risk Features include:
Primary pathology:
● Any T1 or T2 with perineural invasion, OR
Surveillance
Radiation or
lymphovascular invasion
(See page 6)
chemoradiation
● Any T3 or T4
Regional pathology:
● Multiple lymph nodes (any N2, N3)
4
Pathological Risk Factors include:
1
● Positive margins (re-excision to clear
Low-volume base-of-tongue involvement
2
margins is preferred)
Total Laryngectomy to be considered for patients with significant pretreatment laryngopharyngeal
● Extracapsular extension
dysfunction or are medically unable to tolerate organ preservation therapy.
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
CLINICAL PRESENTATION
RECURRENT TREATMENT
●
●
Consider Systemic Therapy/Phase I Clinical Trial
Palliative Care as clinically indicated
Yes
Recurrent
disease
Restage
● CT head and neck
● CT chest or PET to
evaluate for distant
metastatic disease
Consider Salvage Surgery
as clinically indicated
Presence of
distant metastatic
disease?
Yes
Is recurrence
resectable?
No
Yes
No
●
Primary
treatment
chemoradiation?
●
Consider Systemic Therapy
Palliative Care as clinically
indicated/clinical trial
Surveillance
(See page 6)
Consider Salvage Surgery
as clinically indicated
● Consider postoperative
chemotherapy and
Radiation Therapy1
●
No
Yes
Is recurrence
resectable?
No
1
Consider Chemotherapy
and Radiation Therapy
Pathological Risk Factors should be taken into consideration when making concurrent treatment decisions
Copyright 2015 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
LARYNX CANCER SURVEILLANCE
Total Years for
Surveillance
Copyright 2015 The University of Texas MD Anderson Cancer Center
Yr
1
Yr
2
Yr
3
Yr
4
Yr
5
Frequency of
Surveillance
by month
3
6
9
12
16
20
24
36
48
60
Head and Neck
History and Physical
Exam
x
x
x
x
x
x
x
x
x
x
Baseline CT
x
x
x
x
x
x
x
x
x
x
CXR
(CT chest if smoker)
x
x
x
x
x
x
Thyroid function
x
x
x
x
x
x
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
SUGGESTED READINGS
Bradford C, Wolf GT, Carey TE, et al.(1999). Predictive markers for response to chemotherapy, organ preservation and survival in patients with advanced laryngeal carcinoma.
Otolaryngology Head Neck Surg, 121(5),534-538.
Forastiere AA, Geopfert H, Maor M, et al. (2003). Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med, 349(22),2091-2098.
Fu KK, Pajak TF, Trotti A, et al. (2000). A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated
fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinomas: first report of RTOG 2003. Int J Radiat Oncol Biol Phys, 48,7-16.
Fung K, Lyden TH, Lee J, et al. (2005). Voice and swallowing outcomes of an organ-preservation trial for advanced laryngeal cancer. Int J Rad Onc Bio Phys, 63(5), 1395-1399.
Hanna E, Alexiou M, Morgan J, et al. (2004). Intensive chemoradiotherapy as a primary treatment for organ preservation in patients with advanced cancer of the head and neck: efficacy, toxic
effects, and limiatations. Arch Otolaryngol Head Neck Surg,130(7),861-867.
Hanna E, Sherman A, Cash D, et al. (2004). Quality of life for patients following total laryngectomy vs chemoradiation for laryngeal preservation. Arch Otolaryngol Head Neck Surg,
130(7),875-879.
The Department of Veterans Affairs Laryngeal cancer Study Group.(1991). Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal
cancer. N Engl J Med, 324,1685-1690.
Weber RS, Berkey BA, Forastiere A, et al. (2003). Outcome of salvage total laryngectomy following organ-preservation therapy: the Radiation Therapy Oncology Group trial 91-11.
Arch Otolaryngol Head Neck Surg,129(1), 44-49.
Copyright 2015 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
Development Credits
This practice consensus algorithm is based on majority expert opinion of the Head and Neck Center faculty at the University of Texas, MD Anderson Cancer Center.
It was developed using a multidisciplinary approach that included input from the following medical, radiation and surgical oncologists:
Beth Beadle, MD, PhD
Lauren Byers, MD
Gregory Chronowski, MD
Gary L Clayman, DMD, MD, FACS
Renata Ferrarotto, MD
Steven J Frank, MD
Clifton Fuller, MD PHD
Adam S Garden, MD
Paul W Gidley, MD
Ann M Gillenwater, MD, FACS
Bonnie S Glisson, MD, FACP
Kathryn Gold, MD
Neil Gross, MD
Brandon Gunn, MD
Ehab Y Hanna, MD, FACS
Amy C Hessel, MD‡
Waun Ki Hong, MD
Merrill S Kies, MD
Michael E Kupferman, MD
Stephen Y. Lai, MD, PhD
Carol Lewis, MD
Charles Lu, MD
William H Morrison, MD
Jeffrey N Myers, MD, PhD, FACS
Vassiliki Papadimitrakopoulou, MD
Jack Phan, MD, PHD
Kristen B Pytynia, MD
David I Rosenthal, MD
Shalin Shah, MD
Shirley Y. Su, MBBS
Erich Madison Sturgis, MD, MPH,FACS
Randal S Weber, MD, FACS
Mark Zafereo, MD‡
‡Development Leads
Copyright 2015 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015