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اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX...

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Page 1: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

یکتا ایزد نام به دفتر .... اول

Page 2: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

  MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX

Chapter 99Department of Oto-Rhino-Laryngolog of Isfahan Medical University

Page 3: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

INTRODUCTION

similarities between malignant tumors of the larynx and hypopharynx in relationship to etiology

Laryngeal carcinomas are more prevalent in heavy smokers, present earlie

hypopharyngeal carcinomas present late, have a high association with alcoholism and other disorders, and commonly present with cervical metastatic disease.

Page 4: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

INCIDENCE

m/f incidence from 15:1 5:1 in 2004 incidence of hypopharyngeal/larynx tumors :1/3 smoked 40 or more cigarettes daily had an age-

adjusted death rate of 15/100,000 0.6/100,000 : among nonsmokers.

Rolled cigarettes are also more dangerous than commercially packaged cigarettes

A recent French study showed a 13-fold increase in laryngeal cancer for smokers, and those consuming more than 1.5 L/day of wine had a 34-fold increased risk

Page 5: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

RF For larynx tumor

Cigarettes and alcohol Chemical carcinogens : asbestos, nickel compounds,

and certain mineral oils Genetics and susceptibility to:1-secondary primary

tumor.2-Aneuploidy dysplasia to head and neck cancer 3-Genetic alterations of chromosomal region 9p21.4-mutant p53 (suppressive gene )

HPV DNA?? gastroesophageal reflux

Page 6: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Risk Factors

Page 7: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

RF FOR HYPOPHARYNGEAL CANCER

postcricoid carcinoma, (F>M), all forms of hypopharyngeal malignancy M>>F AT: 55 to 70Y

. heavy alcohol ingestion, and heavy smoking Plummer-Vinson syndrome postcricoid

carcinoma Plummer-Vinson or Paterson-Brown-Kelly

Syndrome :dysphagia, hypopharyngeal and esophageal webs, weight loss, and iron deficiency anemia in women aged 30 to 50

Page 8: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Second Primary Malignancies

Patients with hypopharynx CA : significant risk of a second primary malignancy OR metachronous malignancy

. The likelihood of a second primary tumor developing for head and neck cancer is 12.8%

The likelihood of a second primary tumor developing increases with time and is 23% at 8 years

all patients with second primary tumor had a history of >50 pack-years of smoking.

The hypopharyngeal area was the third most common site for patients with floor of mouth cancers to have a second primary malignancy

Page 9: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

HX

laryngeal cancers are detected at an earlier Most patients with hypopharyngeal cancers (70%)

manifest stage III disease. Hypopharyngeal tumors can cause a chronic sore

throat, dysphagia, or referred otalgia and are thus managed with antibiotics, because the process is mistakenly attributed to infectious disease.

The rich lymphatic network in the submucosal tissue surrounding the hypopharynx allows early spread

Page 10: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

ANATOMY AND EMBRYOLOGY

hypopharynx tracheobronchial primordium (arch 4 or 5) in the midline Fusion

supraglottis buccopharyngeal primordium (arch 3 or 4) without a midline merger

The supraglottis superior laryngeal nerve as the nerve of the 3th arch and the superior thyroid artery as its vascular supply.

In contrast, arches 4 and 6 create the glottis and subglottis the theory : separate derivation explains why supraglottic

tumors of substantial bulk do not spread across the laryngeal ventricle to the vocal cord. This region was confirmed as a barrier to tumor spread

Transglottic tumors cross the ventricle and may initiate as supraglottic or glottic cancers. As they enlarge, these tumors fail the compartmentalization thesis by direct mucosal extension or through the paraglottic space.

Page 11: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

  Anatomic regions of the hypopharynx.

Page 12: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Diagnosis

educated the public to seek evaluation for hoarseness persisting longer than 4 weeks

Dysphagia& :common symptom of supraglottic or hypopharyngeal ca

refractory asthma without voice change common symptom of subglott ca

DX:Laryngoscopy(vc &biopsy)\CT MRI(LN)

Page 13: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Diagnosis of Hypopharyngeal Cancer

hX of heavy alcohol ingestion; heavy smoking; persistent dysphagia, persistent sore throat, or a foreign body

sensation. The average duration : 2 to 4 months. . A later symptom is referral otalgia , 20% : asymptomatic neck mass, (ipsilateral, a jugulodigastric or

midjugular lymph node ) Radiologic Assessment of the Larynx and

Hypopharynx :CT(1-preepiglottic space and paraglottic space involvement 2-Eeosion

Thyroid cartilage destruction :best by CT total laryngectomy (T4 stage)

MRI using T2-weighted images may be superior to highlight submucosal tumor extension into the preepiglottic and paraglottic spaces

Page 14: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Endoscopic Evaluation of the Larynx and Hypopharynx

Cord mobility is best assessed preoperatively. fixation of the cord is differentiated from

arytenoid fixation by palpation of the vocal process and can help stage the disease.

NO flexible esophagogastrostomy &N0 barium swallow

Endoscopy is also required to rule out the existence of a second or concurrent malignancy

Page 15: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Assessment of Precancerous Laryngeal Lesions

Biopsy is always needed to confirm the diagnosis, gross appearance of 1- fungal laryngitis, 2-

sarcoidosis,3- tuberculosis, or4- Wegener's granulomatosis can be mistaken for advanced carcinoma

Small suspicious lesions should be completely excised with a border of healthy laryngeal submucosa

large lesions should be adequately sampled with the laryngeal biopsy forceps to measure invasion below the basement membrane

Pseudoepitheliomatous hyperplasia (granular cell myoblastoma) of the supraglottic larynx may be misdiagnosed as carcinoma

Page 16: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Staging- Primary Tumor (T)

TX Minimum requirements to assess primary tumor cannot be met

T0 No evidence of primary tumor

Tis Carcinoma in situ

Page 17: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Staging- Supraglottis

T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility

T2 Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis, or region outside the supraglottis (e.g. mucosa of base of the tongue, vallecula, medial wall of piriform sinus) without fixation

T3 Tumor limited to larynx with vocal cord fixation and or invades any of the following: postcricoid area, preepiglottic tissue, paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex)

T4a Tumor invades through the thyroid cartilage and/or invades tissue beyond the larynx (e.g. trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus)

T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

Page 18: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Staging- Glottis

T1 Tumor limited to the vocal cord (s) (may involve anterior or posterior commissure) with normal mobilty

T1a Tumor limited to one vocal cord

T1b Tumor involves both vocal cords

T2 Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility

T3 Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex)

T4a Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus

T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

Page 19: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Staging- Subglottis

T1 Tumor limited to the subglottis

T2 Tumor extends to vocal cord (s) with normal or impaired mobility

T3 Tumor limited the larynx with vocal cord fixation

T4a Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus)

T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

Page 20: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

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

N2c Bilateral or contralateral lymph nodes, each ≤6cm

N3 Single or multiple lymph nodes > 6cm

Page 21: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Staging- Metastasis

M0 No distant metastases

M1 Distant metastases present

Page 22: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.
Page 23: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

MANAGEMENT OF PREMALIGNANT LESIONS AND CA IN SITU

five categories with 1-hyperkeratosis, 2-hyperkeratosis with atypia3- carcinoma in situ (CIS)4- superficially invasive carcinoma,5- invasive carcinoma

When :1-hyperkeratosis with atypia and often 2-CIS, TX conservative strip of cord is removed. :( microscopically removed). F/up and rebiopsy: 6 to 12 W later

Management of precancerous lesions is conservative surgery. : radiotherapy may fail (10%),

Many surgeons believe that unless the patient is unreliable, is a significant risk for repeat GA, or lives far away, radiation is a second choice for this disease

Page 24: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

MANAGEMENT OF LARYNGEAL CANCER

Glottic Cancer

for T1 lesions, surgery 90% to 95% cure rates --_>radiotherapy(cure rates of 75% to 90%.)

Partial surgery(no radiotherapy): 1)decreasing importance vocal cord mobility, 2) subglottic extension, 3) anterior commissure invasion, 4) arytenoid cartilage involvement. The middle third of vocal fold lesions

endoscopic, laser resection, or open cordectomy. (Cure rates =100% -with good margins _)&95% cure rate for radiotherapy.

Page 25: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

MANAGEMENT OF Glottic Cancer

50% of radiotherapy failures for T1 glottic cancer failed at the anterior commissure.

Hypomobility of the vocal fold reduces the cure rates and emphasizes the advantage of surgery over radiotherapy

T2 tumors managed by primary radiotherapy showed a 30% local failure rate, which, when surgically salvaged, improved to 94%

T2 lesions classification be divided into T2a and T2b on the basis of mobility. In this analysis, a 70% local control rate was noted for the former category vs 51% in the latter

T2 and early T3 lesions of the glottis have more recently been managed by supracricoid laryngectomy with cricohyoidoepiglottopexy.

cricohyoidoepiglottopexy.= resection of the entire thyroid cartilage and paraglottic spaceThe cricoid cartilage, the hyoid bone, much of the epiglottis and at least one arytenoid cartilage must be conserved.

cricohyoidoepiglottopexy. have satisfactory deglutition, phonation, and 100% decannulation with a 5% local recurrence rate.

Page 26: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

CRITERIA FOR HEMILARYNGECTOMY FOR

RECURRENT CANCER AFTER RADIOTHERAPY

Lesion limited to one cord (may involve the anterior commissure)

Body of arytenoid free of tumorSubglottic extension no >5 mmMobile cordNo cartilage invasionRecurrence correlating with initial tumor

Page 27: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Subglottic Cancer is unusual, with only 1% located 1 cm below the vocal cord =arise below the

conus elasticus The clinical presentation : airway obstruction; spread locally cricoid cartilage and thyroid gland with lymphatic spread lower deep jugular nodes, the

Delphian node (prelaryngeal), and the paratracheal nodes .

Management requires1) total laryngectomy+2)Ipsilateral thyroidectomy and3) paratracheal node dissection 4) positive nodes or deep invasion, postoperative radiotherapy to include the superior mediastinum is needed to prevent stomal recurrence.

stage T4 or T3 glottic carcinoma total laryngectomy ipsilateral nodes(in most cases ), =20% risk metastasis

Page 28: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Late-Stage Disease Obstructive laryngeal premanagement tracheostomy increased

local or stomal recurrence If a tracheostomy is necessary, surgery within 48 hours+bilateral

paratracheal node dissection+ postoperative mantle radiotherapy. Recurrence at the stoma after laryngectomy is grave extensive

penetration subglottic cancer is most associated with stomal recurrence

because the Delphian and paratracheal drainage ports are presumed to be the pathway to recurrence

even aggressive management of stomal recurrence is morbid and often unsuccessful, prevention of recurrence is paramount

risk of infiltration is high, the1) thyroid gland, at least ipsilateral, is removed and2) bilateral paratracheal node dissections are accomplished and3) postsurgical radiation used. includes the upper mediastinum and paratracheal beds.

Page 29: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Late-Stage Disease

Hemithyroidectomy or subtotal thyroidectomy is recommended

1- for cases of palpable abnormality, 2-subglottic tumors, 3- or glottic tumors with >1 cm of subglottic extension, 4-T4 glottic tumors, and T4 piriform sinus tumors. Thyroid function is reduced after larynx cancer

management that includes radiotherapy or extensive laryngeal and thyroid surgery depressed and lethargic months after management may be hypothyroid;

Follow-up : at 6 months, 1 year, and when clinically indicated thereafter

Page 30: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Supraglottic Cancer

Early supraglottic (epiglottic) tumors, which are suprahyoid, can be grossly excised endoscopically

but infrahyoid tumors do not fare so well with only laser resection endoscopic laser partial laryngectomy

preepiglottic space has been invaded in up to 50% of cases of infrahyoid carcinoma, which cannot be predicted even if CT and physical examination are used.

frequent postoperative x-ray therapy is used for indications at the primary site vs a rare need for this accompanying N0 supraglottic laryngectomy.

more central supraglottic lesions have less metastatic potential than aryepiglottic fold or lateral epiglottic sites

Page 31: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Supraglottic Cancer

Limited supraglottic tumors, which are defined as T1 to T3 supraglottic laryngectomy (if the vocal cord is mobile).

Arytenoid involvement allowed partial surgery +complications with swallowing,

Extended resections that removal of the vallecula and base of the tongue up to the level of the circumvallate papilla

Patient selection for supraglottic laryngectomy is important (Younger, and good pulmonary reserve..)to tolerate the mild-to-moderate aspiration

Page 32: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

Limitations to supraglottic laryngectomy

Include1) thyroid cartilage invasion or anterior commissure involvement,

2) Involvement of the glottis and vocal cord fixation paraglottic space invasion are relative contraindications to partial surgery,

3) Cricoid cartilage involvement clearly mandates against a supraglottic laryngectomy, because swallowing is severely impaired with laryngeal preservation and cricoid cartilage resection.

4) Bilateral arytenoid cartilage involvement is an absolute contraindication to supraglottic laryngectomy

Radiotherapy seems to offer less local control than supraglottic laryngectomy

73% 5-year survival after supraglottic surgery actuarial 4-year survival is 50%, and cancer-free survival is 74%

Page 33: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

EXTENSION OF SUPRAGLOTTIC LARYNGECTOMY

Subtotal laryngectomy with cricohyoidopexy ( a functional laryngectomy) for carcinoma extended to the 1)true vocal cord, the ventricle, 2)involving the thyroid cartilage and the paraglottic space.

The resection includes the entire thyroid cartilage, the paraglottic space, the epiglottis and the entire preepiglottic space. To be successful, the cricoid cartilage, hyoid bone, and at least one arytenoid cartilage must be spared.

Control of the neck is the most important aspect of managing supraglottic tumors,

Page 34: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

VARIANTS OF SQUAMOUS CELL CARCINOMA

Verrucous Carcinoma

Pseudosarcoma

Basaloid Squamous Cell Carcinoma

Page 35: اول دفتر به نام ایزد یکتا..... MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99 Department of Oto-Rhino-Laryngolog of Isfahan Medical University.

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