Lysbilde 1

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Laryngeal Cancer Diagnosis and treatment
Jan Olofsson Professor Head Department of
Otolaryngology/Head Neck Surgery Haukeland
University Hospital Bergen, Norway



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Premalignant Laryngeal Lesions

• Introduction
• Increased interest
• Improved clinical diagnosis
• More strict histopathological classification
• Objective morphological parameters
• More selective management
• Laser Surgery

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Premalignant Laryngeal Lesions

• Clinical picture
• Chronic laryngitis
• Keratosis leukoplakia
• Erytroplasia
• Localized lesions
• Diffuse lesions
• Location mainly on the vocal folds
• 
  
  

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Premalignant Laryngeal Lesions

• Clinical examinations
• Mirror laryngoscopy
• Telescopes
• Fiber laryngoscopy
• Videolaryngostroboscopy
• Microlaryngoscopy
• Contact endoscopy
• Fluorescence endoscopy

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Premalignant Laryngeal Lesions

• Epidemiology and risk factors
• Tobacco
• Alcohol
• Toxic extrinsic agents
  e.g. asbestos and certain mineral oils
• Exposure to viral agents
  not to same degree as for
  cervical precancerous lesions

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Premalignant Laryngeal Lesions

• Histopathology and classification
• The WHO classification (Shanmugaratnam et al.
  1991)
• Most commonly used world wide
• Based on degree and extent of dysplasia rather
  than extent of atypical cells

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Premalignant Laryngeal Lesions

• Histopathology and classification
• The WHO classification contd
• Mild dysplasia
• Moderate
• Severe dysplasia including CiS

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Premalignant Laryngeal Lesions

• Histopathology and classification
• The WHO classification contd
• This classification was used in a series of 276
  patients with long-term follow-up (mean 10
  years).
• Invasive carcinoma developed
• in mild dysplasia 2.5
• in moderate dysplasia 13.5
• in severe dysplasia/cis 28.8
• Lundgren et al. 1999

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Premalignant Laryngeal Lesions

• Histopathological diagnosis
• Histo- and cytological examination
• Histopathological classification
• Morphometry
• DNA measurements
• Occurrence of hypertetraploid cell nuclei
  (cytologic smear)
• Low molecular weight cytokeratin proteins
• PCNA
• EGFR
• AgNOR
• Molecular biology

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Premalignant Laryngeal Lesions

• Independent malignant tumours in
• 268 patients with precancerous
• lesions
• Group HN Lung Gi Others
• I (154) 9 8 4 6
• II (39) 5 1 3
  2
• III (75) 10 3 1
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Premalignant Laryngeal Lesions

• Chevalier Jackson (1923)
• Chronic laryngitis and keratosis should be
  considered precancerous in the sense that they
  may be contributary factors in the etiology of
  cancer. We should not only eradicate these
  lesions but also contribute to their early
  recognition.
• Ann Surg, 771, 1923

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CANCER
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HISTOLOGY
Squamous cell carcinoma
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EPIDEMIOLOGY
1 - 2 OF ALL CANCER IN MALES
lt 0.5 OF ALL CANCER IN FEMALES
MAINLY 50 - 70 YEARS
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INCIDENCE
SWEDEN . NORWAY . FINLAND
3 / 100. 000
DENMARK
5 / 100. 000
BRAZIL
10 / 100. 000
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MALES FEMALES
CANADA . USA
6 1
SCANDINAVIA
10 1
ITALY (earlier)
32 1
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Risk factors
SMOKING
ALCOHOL
AIR POLLUTION
ASBEST
WOOD DUST
SOLVENTS
THERAPEUTIC IRRADIATION
HPV
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TREATMENT MODALITITES

• Radiotherapy
• Chemoradiotherapy
• Induction chemotherapy
• Concomitant chemotherapy
• Surgery

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Endoscopic procedures

• Classification of surgical procedures
• Preferably!
• Ref. Eur Arch Otorhinolaryngol (2000)
• 257227-231

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MULTIPLE PRIMARIES WITHIN THE RESPIRATORY TRACT.
GLOTTIC CARCINOMA 6.5 SUPRAGLOTTIC
CARCINOMA 12.3
Wagenfeld 1980, 1981
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MULTIPLE PRIMARIESAll sites

• 3 - 4 per year in all survivors

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Summation

• Glottic tumours 70
• Supraglottic tumours 25
• Subglottic tumours lt5

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Summation contd.

• Males Females 8-101
• Scandinavia
• Urban gt Rural
• Small glottic carcinomas gt90
• 5 year survival

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Summation contd.

• Smoking and alcohol most important risk factors.

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Cancer laryngis

• Results
• Absolute 5 and 10 years survival for glottic
  cancer is around 82 and 77 in a major Danish
  series.
• For supraglottic cancer the corresponding figures
  are 49 to 45 respectively.
• Hanne Sand Hansen, 1994

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Cancer laryngis

• 5-year crude survival was 61 and 35 for
  patients with glottic and supraglottic laryngeal
  cancers respectively.
• The number of laryngectomies have sucessively
  diminsihed.
• Hanne Sand Hansen, 1994

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Cancer laryngis

• National Norwegian Recommendations
• (guidelines) for Treatment of Laryngeal Cancer
  (2000)
• Glottic cancer
• T1a Treatment endoscopically with laser surgery
• or external irradiation to 64 Gy.
• T1b og T2 Irradiation to 64-70 Gy. Operation if
  
• verified rest tumour or recurrence.
• T3 Irradiation to neck fields 50 Gy and
  booster towards the tumour field to 70 Gy.

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Cancer laryngis

• National Norwegian Recommendations
• (guidelines) for Treatment of Laryngeal Cancer
  (2000)
• Supraglottic cancer
• T1 and T2 Small cancers are evaluated for
  endoscopic surgery with postoperative irradiation
  to 50 Gy. Alternatively curative irradiation to
  50 Gy covering upper and mid third of the neck to
  50 Gy followed by a boost against the tumour to
  64-70 Gy.
• T3 and T4 The same principles as for glottic
  tumours.

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Cancer laryngis

• National Norwegian Recommendations
• (guidelines) for Treatment of Laryngeal Cancer
  (2000)
• Subglottic cancer
• Subglottic cancers or glottic cancer with marked
  subglottic extension have a tendency to grow down
  in trachea and may metastasize to the upper
  mediastinum. The whole neck may be considered as
  a risk area. It may be most practical to give
  irradiation with a neck field both anteriorly and
  posteriorly without block. The upper margin is
  placed 1 cm above the lower border of the
  mandible, the lower border 3 5 cm below
  jugulum.
• After 50 Gy the tumour is re-evaluated.
• If there is a bad response operation is
  considered within 2 3 weeks.

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Cancer laryngis

• National Norwegian Recommendations
• (guidelines) for Treatment of Laryngeal Cancer
  (2000)
• Subglottic cancer contd
• As an alternative irradiation is continued up to
  64 70 Gy with operation if remaining tumour or
  recurrence. This part of the treatment is given
  with two opposite side fields that may be angled
  10 15 degrees to avoid the shoulders. When
  subglottic tumours or tumours with a marked
  subglottic extension, it may be an indication for
  operative treatment even for T2 and T3 tumours.
• Careful follow-up as the subglottic area may be
  difficult to control and a recurrence may be
  advanced before being diagnosed.

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Cancer laryngis

• National Norwegian Recommendations
• (guidelines) for Treatment of Laryngeal Cancer
  (2000)
• Irradiation treatment of T4, all localizations
• These tumours in principle have a combined
  treatment if pre- or postoperative irradiation is
  considered it may depend on the clinical status
  and operability. It is possible to irradiate
  centrally and posteriorly to 50 Gy with an upper
  margin 1 cm above the lower border of the
  mandible and the lower border below jugulum, 3
  5 cm below or more when treating a subglottic
  cancer.
• Alternative treatment may be two opposite side
  fields towards the upper and middle third of the
  neck irradiation from the front. (The posterior
  field may be added towards the lower part.)
• Irradiation doses above this is continuously
  evaluated for the individual patient.

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Cancer laryngis

• New national guidelines (recommendations) are
  under preparation

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Cancer laryngis

• Follow-up of patients treated for laryngeal
  cancer
• Every 2nd - 3rd months for 2 years
• After this every 4th months ? 5 years
• After this every 6th months
• Note! Especially a great risk for secondary
  primary malignancies.

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Cancer laryngis

• Thank you for your attention!