Download Laryngel Cancer

Laryngel Cancer
It is the most common
cancer of the upper
aerodigestive tract.
Subtypes
• Glottic Cancer: 59%
• Supraglottic Cancer: 40%
• Subglottic Cancer: 1%
• Most subglottic masses are extension from
glottic carcinomas
Risk Factors
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.
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.
Risk Factors<<<
• 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.
Risk Factors
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Human Papilloma Virus 16 &18
Chronic Gastric Reflux
Occupational exposures
Prior history of head and neck irradiation
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.
Sex & Age Incidence
• In the 1950s, the male-to-female ratio in patients
with laryngeal cancer was 15:1.
• This number had changed to 5:1 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.
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
Histological Types
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Verrucous Carcinoma
Fibrosarcoma
Chondrosarcoma
Minor salivary carcinoma
Adenocarcinoma
Oat cell carcinoma
Giant cell and Spindle cell carcinoma
Anatomy
The supraglottic larynx
• It consists of
epiglottis, false vocal
cords, ventricles,
aryepiglottic folds,
and arytenoids
The glottic larynx
• It consists of the true
vocal cords and
anterior commissure
and posterior
commissure
The subglottic larynx
• It consists of the
region between
the vocal cords
and the trachea.
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.
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.
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
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 .
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
Staging- Nodes
N0
No cervical lymph nodes positive
N1
Single ipsilateral lymph node ≤ 3cm
N2a
Single ipsilateral node > 3cm and ≤6cm
N2b
Multiple ipsilateral lymph nodes, each ≤
6cm
Bilateral or contralateral lymph nodes, each
≤6cm
Single or multiple lymph nodes > 6cm
N2c
N3
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.
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.
Glottic carcinomas
• The true vocal cords are the most
common site of laryngeal carcinomas; the
ratio of glottic carcinomas to supraglottic
carcinomas is approximately 3:1.
• 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.
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.
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.
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
Presentation
• Other symptoms include:
– Dysphagia
– Hemoptysis
– Throat pain
– Ear pain
– Airway compromise
– Aspiration
– Neck mass
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
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
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,
Wegner’s granulomatosis
Work up
• Other potential modalities:
– Direct laryngoscopy
– Bronchoscopy
– Esophagoscopy
– Chest X-ray
– CT or MRI
– Liver function tests with or without US
– PET ?
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
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
Treatment
• XRT complications include:
– Mucositis
– Odynophagia
– Laryngeal edema
– Xerostomia
– Stricture and fibrosis
– Radionecrosis
– Hypothyroidism
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
Treatment
• Chemotherapy can be used in addition to
irradiation in advanced stage cancers
• Two agents used are Cisplatinum and 5flourouracil
• Cisplatin thought to sensitize cancer cells
to XRT enhancing its effectiveness when
used concurrently.
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
Supraglottic laryngectomy
• T1,2, or 3 if only by
preepiglottic space
invasion
• Mobile cords
• No anterior commissure
involvement
• FEV1 >50%
• No tongue base disease
past circumvallate
papillae
• Apex of pyriform sinus
not invloved
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
Total Laryngectomy