Laryngel Cancer

1
Laryngel Cancer

• It is the most common cancer of the upper
  aerodigestive tract.

2
Subtypes

• Glottic Cancer 59
• Supraglottic Cancer 40
• Subglottic Cancer 1
• Most subglottic masses are extension from glottic
  carcinomas

3
Risk Factors
4
Etiology

• The incidence of laryngeal tumors is closely
  correlated with smoking, as head and neck tumors
  occur 6 times more often among cigarette smokers
  than among nonsmokers.
• The age-standardized risk of mortality from
  laryngeal cancer appears to have a linear
  relationship with increasing cigarette
  consumption.

5
Etiology

• Death from laryngeal cancer is 20 times more
  likely for the heaviest smokers than for
  nonsmokers.
• The use of unfiltered cigarettes or dark,
  air-cured tobacco is associated with further
  increases in risk.

6
Risk Factorsltltlt

• Although alcohol is a less potent carcinogen than
  tobacco, alcohol consumption is a risk factor for
  laryngeal tumors.
• In individuals who use both tobacco and alcohol,
  these risk factors appear to be synergistic, and
  they result in a multiplicative increase in the
  risk of developing laryngeal cancer.

7
Risk Factors

• Human Papilloma Virus 16 18
• Chronic Gastric Reflux
• Occupational exposures
• Prior history of head and neck irradiation

8
Mortality/Morbidity

• The prognosis for small laryngeal cancers that do
  not have lymph node metastases is good, with cure
  rates of 75-95, depending on the site, the size
  of the tumor, and the extent of infiltration.
• Advanced disease has a worse prognosis.
• Supraglottic cancers usually manifest late and
  have a poorer prognosis.

9
Sex Age Incidence

• In the 1950s, the male-to-female ratio in
  patients with laryngeal cancer was 151.
• This number had changed to 51 by the year 2000,
  and the proportion of women afflicted by the
  disease is projected to increase in years to
  come.
• These changes are likely a reflection of shifts
  in smoking patterns, with women smoking more in
  recent years.
• Laryngeal cancer most commonly affects men
  middle-aged or older. The peak incidence is in
  those aged 50-60 years.

10
Histological Types

• 85-95 of laryngeal tumors are squamous cell
  carcinoma
• Histologic type linked to tobacco and alcohol
  abuse
• Characterized by epithelial nests surrounded by
  inflammatory stroma
• Keratin Pearls are pathognomonic

11
Histological Types

• Verrucous Carcinoma
• Fibrosarcoma
• Chondrosarcoma
• Minor salivary carcinoma
• Adenocarcinoma
• Oat cell carcinoma
• Giant cell and Spindle cell carcinoma

12
Anatomy
13
The supraglottic larynx

• It consists of epiglottis, false vocal cords,
  ventricles, aryepiglottic folds, and arytenoids

14
The glottic larynx

• It consists of the true vocal cords and anterior
  commissure and posterior commissure

15
The subglottic larynx

• It consists of the region between the vocal cords
  and the trachea.

16
Pre-epiglottic fat space

• The pre-epiglottic fat is located in the anterior
  and lateral aspects of the larynx and is often
  invaded by advanced cancers.

17
Lymphatics

• The first-echelon lymphatics for the supraglottic
  larynx are the subdigastric nodes and the middle
  anterior cervical nodes and the second-echelon
  lymphatics are the lower anterior cervical nodes
• The first-echelon lymphatics for the subglottic
  larynx are the Delphian node, the lower anterior
  cervical nodes and paratracheal nodes, and the
  supraclavicular nodes, and the second-echelon
  lymphatics are the mediastinal nodes.
• Glottic and subglottic tumors metastasize to
  ipsilateral lymph nodes, but supraglottic tumors
  often spread to nodes on both sides of the neck.

18
In the supraglottis, the T stages are as follows

• T1 Tumor limited to 1 subsite of the
  supraglottis with normal vocal cord mobility
• T2 Tumor invasion of the mucosa of more than 1
  adjacent subsite of the supraglottis or glottis
  or of a region outside the supraglottis , without
  fixation of the larynx
• T3 Tumor limited to the larynx with vocal cord
  fixation and/or invasion of any of the
  postcricoid area or pre-epiglottic tissues
• T4 Tumor invasion through the thyroid cartilage
  and/or extension into

19
In the glottis, the T stages are as follows

• T1 Tumor limited to the vocal cord with normal
  mobility
• T2 Tumor extension to the supraglottis and/or
  subglottis and/or impaired vocal cord mobility
• T3 Tumor limited to the larynx with vocal cord
  fixation
• T4 Tumor invasion through the thyroid cartilage
  and/or other tissues beyond the larynx .

20
In the subglottis the T stages are as follows

• T1 Tumor limited to the subglottis
• T2 Tumor extension to a vocal cord with normal
  or impaired mobility
• T3 Tumor limited to the larynx with vocal cord
  fixation
• T4 Tumor invasion through cricoid or thyroid
  cartilage and/or extension to other tissues
  beyond the larynx

21
Staging- Nodes
N0 No cervical lymph nodes positive
N1 Single ipsilateral lymph node 3cm
N2a Single ipsilateral node gt 3cm and 6cm
N2b Multiple ipsilateral lymph nodes, each 6cm
N2c Bilateral or contralateral lymph nodes, each 6cm
N3 Single or multiple lymph nodes gt 6cm
22
Supraglottic carcinomas

• The epiglottis is the most frequent location for
  cancers that arise in the supraglottic larynx.
  These lesions are often exophytic and
  circumferential masses
• Tumors of the aryepiglottic fold are typically
  exophytic lesions that, when detected early, are
  confined laterally along the aryepiglottic fold.
• Advanced lesions may extend laterally to involve
  the adjacent wall of the pyriform sinus or
  medially to invade the epiglottis.

23
Supraglottic carcinomas

• Squamous cell cancers that arise from the false
  vocal cords and laryngeal ventricle tend to be
  ulcerative and infiltrative with a limited
  exophytic component. Deep invasion by such tumors
  results in their access to the paraglottic space,
  and this may lead to fixation of the supraglottic
  larynx.
• Because of their close proximity, these tumors
  may extend inferiorly to involve the true vocal
  cords.

24
Glottic carcinomas

• The true vocal cords are the most common site of
  laryngeal carcinomas the ratio of glottic
  carcinomas to supraglottic carcinomas is
  approximately 31.
• The anterior portion of the true vocal cord is
  the most common location of squamous cell cancer,
  with most lesions occurring along the free margin
  of the vocal cord.

25
Glottic carcinomas

• Anteriorly, the tumor may extend to anterior
  commissure, where it may involve the
  contralateral true vocal cord.
• The likelihood of nodal involvement associated
  with glottic carcinomas depends on the stage of
  the tumor. The incidence of early T1 lesions has
  been reported to be as low as 2. This figure
  increases to approximately 20 for T3 and T4
  lesions.

26
Subglottic carcinomas

• Subglottic carcinomas are rare and account for
  only 5 of all laryngeal carcinomas.
• When present, these lesions are
  characteristically circumferential and often
  extend to involve the undersurface of the true
  vocal cords
• They have a tendency for early invasion of the
  cricoid cartilage and extension through the
  cricothyroid membrane.

27
Presentation

• Hoarseness
• Most common symptom
• Small irregularities in the vocal fold result in
  voice changes
• Changes of voice in patients with chronic
  hoarseness from tobacco and alcohol can be
  difficult to appreciate

28
Presentation

• Other symptoms include
• Dysphagia
• Hemoptysis
• Throat pain
• Ear pain
• Airway compromise
• Aspiration
• Neck mass

29
Presentation

• Patients presenting with hoarseness should
  undergo an indirect mirror exam and/or flexible
  laryngoscope evaluation
• Malignant lesions can appear as friable,
  fungating, ulcerative masses or be as subtle as
  changes in mucosal color

30
Presentation

• Good neck exam looking for cervical
  lymphadenopathy and broadening of the laryngeal
  prominence is required
• The base of the tongue should be palpated for
  masses as well
• Restricted laryngeal crepitus may be a sign of
  post cricoid or retropharyngeal invasion

31
Work up

• Biopsy is required for diagnosis
• Performed in OR with patient under anesthesia
• Other benign possibilities for laryngeal lesions
  include Vocal cord nodules or polyps,
  papillomatosis, granulomas, granular cell
  neoplasms, sarcoidosis, Wegners granulomatosis

32
Work up

• Other potential modalities
• Direct laryngoscopy
• Bronchoscopy
• Esophagoscopy
• Chest X-ray
• CT or MRI
• Liver function tests with or without US
• PET ?

33
(No Transcript)
34
Treatment

• Premalignant lesions or Carcinoma in situ can be
  treated by surgical stripping of the entire
  lesion
• CO2 laser can be used to accomplish this but
  makes accurate review of margins difficult

35
Treatment

• Early stage (T1 and T2) can be treated with
  radiotherapy or surgery alone, both offer the
  85-95 cure rate.
• Surgery has a shorter treatment period, saves
  radiation for recurrence, but may have worse
  voice outcomes
• Radiotherapy is given for 6-7 weeks, avoids
  surgical risks but has own complications

36
Treatment

• XRT complications include
• Mucositis
• Odynophagia
• Laryngeal edema
• Xerostomia
• Stricture and fibrosis
• Radionecrosis
• Hypothyroidism

37
Treatment

• Advanced stage lesions often receive surgery with
  adjuvant radiation
• Most T3 and T4 lesions require a total
  laryngectomy
• Some small T3 and lesser sized tumors can be
  treated with partial larygectomy

38
Treatment

• Chemotherapy can be used in addition to
  irradiation in advanced stage cancers
• Two agents used are Cisplatinum and
  5-flourouracil
• Cisplatin thought to sensitize cancer cells to
  XRT enhancing its effectiveness when used
  concurrently.

39
Treatment

• Modified or radical neck dissections are
  indicated in the presence of nodal disease
• Neck dissections may be performed in patients
  with supra or subglottic T2 tumors even in the
  absence of nodal disease
• N0 necks can have a selective dissection sparing
  the SCM, IJ, and XI
• N1 necks usually have a modified dissection of
  levels II-IV

40
Supraglottic laryngectomy

• T1,2, or 3 if only by preepiglottic space
  invasion
• Mobile cords
• No anterior commissure involvement
• FEV1 gt50
• No tongue base disease past circumvallate
  papillae
• Apex of pyriform sinus not invloved

41
Total Larygectomy

• Indications
• T3 or T4 unfit for partial
• Extensive involvement of thyroid and cricoid
  cartilages
• Invasion of neck soft tissues
• Tongue base involvement beyond circumvallate
  papillae

42
Total Laryngectomy
43
(No Transcript)