Laryngeal cancerLaryngeal cancerLIU Wei Wei, MDLIU Wei Wei, MD

Department of Head and Neck SurgerDepartment of Head and Neck Surgeryy

Email: drliuww@gmail.comEmail: drliuww@gmail.com

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

AnatomyAnatomy

HistologyHistology

Laryngeal EpitheliumLaryngeal Epithelium

Goblet Cells and Columnar Mucinous Cells

Squamous Epithelium

EpidemiologyEpidemiology

► Incidence rate increase recentlyIncidence rate increase recently►Region difference of laryngeal cancer inciRegion difference of laryngeal cancer inci

dencedence high in northeast of chinahigh in northeast of china►Presence more in 50-60sPresence more in 50-60s►Males>femalesMales>females►2020 ％ ％ of all head and neck cancersof all head and neck cancers

EtiologyEtiology

EtiologyEtiology

►Human Papilloma Virus 16 &18Human Papilloma Virus 16 &18►Chronic Gastric RefluxChronic Gastric Reflux►Occupational exposuresOccupational exposures►Prior history of head and neck irradiatioPrior history of head and neck irradiatio

nn

PathologyPathology

► 85-95% of laryngeal tumors are squamous cell c85-95% of laryngeal tumors are squamous cell carcinomaarcinoma

► Verrucous Carcinoma Verrucous Carcinoma ► Fibrosarcoma Fibrosarcoma ► Chondrosarcoma Chondrosarcoma ► Minor salivary carcinoma Minor salivary carcinoma ► Oat cell carcinomaOat cell carcinoma► AdenocarcinomaAdenocarcinoma► Giant cell and Spindle cell carcinomaGiant cell and Spindle cell carcinoma

In Situ Squamous Cell In Situ Squamous Cell CarcinomaCarcinoma

► Dysplastic process Dysplastic process involves the entire involves the entire thickness of the thickness of the epitheliumepithelium

► Loss of cellular maturation Loss of cellular maturation and polarityand polarity

► Increase of Increase of nuclear/cytoplaslic rationuclear/cytoplaslic ratio

► Normal and abnormal Normal and abnormal mitosesmitoses

► Keratosis and dyskeratosisKeratosis and dyskeratosis► Extension into adjacent Extension into adjacent

seromucinous glandsseromucinous glands

Microinvasive or Superficially Microinvasive or Superficially Invasive Squamous Cell CarcinomaInvasive Squamous Cell Carcinoma

► Nests of malignant cells Nests of malignant cells that have penetrated that have penetrated the basement the basement membrane and invaded membrane and invaded superficially into the superficially into the submucosasubmucosa

► Capable of Capable of metastasizingmetastasizing

► Development from Development from carcinoma in situ or carcinoma in situ or from epithelium with no from epithelium with no evidence of CISevidence of CIS

Invasive Squamous Cell CarcInvasive Squamous Cell Carcinomainoma

► 0.5% of all cancers in 0.5% of all cancers in womenwomen

► 95% of all laryngeal 95% of all laryngeal carcinomascarcinomas

► 2.5% of all cancers in 2.5% of all cancers in menmen

► Etiology: ETOH Etiology: ETOH (supraglottic), tobacco (supraglottic), tobacco (glottic), asbestos, nickel, (glottic), asbestos, nickel, wood, isopropyl alcohol, wood, isopropyl alcohol, radiationradiation

► DD: reactive epithelial DD: reactive epithelial changes, changes, pseudoepitheliomatous pseudoepitheliomatous hyperplasiahyperplasia

SymptomsSymptoms

► Sound hoarsenessSound hoarseness Most commonMost common Tiny lesion on vocal cord can cause sound cTiny lesion on vocal cord can cause sound c

hangehange

SymptomsSymptoms

►others:others: Swallowing difficultySwallowing difficulty Bloody sputumBloody sputum Sore throatSore throat otalgiaotalgia Breathing difficultyBreathing difficulty aspirationaspiration lymphadenopathylymphadenopathy

Clinical feature of different type Clinical feature of different type of Laryngeal cancerof Laryngeal cancer

►SupraglotticSupraglottic sound hoarseness not evident in early psound hoarseness not evident in early p

hasehase foreign body sensation present earlyforeign body sensation present early more common lymphadenopathymore common lymphadenopathy

► GlotticGlottic sound hoarseness present early, progressivesound hoarseness present early, progressive breathing difficulty presents more commonbreathing difficulty presents more common

► SubglotticSubglottic rare typerare type no evident symptoms in eary phaseno evident symptoms in eary phase easy to present breathing difficulty easy to present breathing difficulty

Clinical feature of different type Clinical feature of different type of Laryngeal cancerof Laryngeal cancer

supraglotticsupraglottic

glotticglottic

subglotticsubglottic

Clinical examinationClinical examination

►PEPE larynx shapelarynx shape cervical lymph nodescervical lymph nodes►Larynx and pharynx examinationLarynx and pharynx examination Indirect LaryngoscopyIndirect Laryngoscopy Flexible LaryngoscopyFlexible Laryngoscopy StroboscopyStroboscopy PanendoscopyPanendoscopy

Clinical examinationClinical examination

►Pathological biopsyPathological biopsy► ImagingImaging

plain X rayplain X ray

CTCT

MRIMRI

PETPET

VideoVideo

Laryngeal TBLaryngeal TB

病灶多位于杓状软骨间隙

表现为脓性分泌物覆盖的浅表溃疡

肺部大多有结核病灶存在

可有咳嗽、胸痛、午后潮热的症状

Vocal cord noduleVocal cord nodule

►Bilateral commonBilateral common►Located on anterior 1/3 of the cordLocated on anterior 1/3 of the cord►Any age can occureAny age can occure►Related to loudly speakingRelated to loudly speaking►Can present sound hoarsenessCan present sound hoarseness

Cord polypCord polyp

►epsilateralepsilateral►Located on anterior 1/3Located on anterior 1/3►Any age groupAny age group►Wide base, can have pedicleWide base, can have pedicle►Loud speaking, local infection and smokLoud speaking, local infection and smok

ing relateding related►Sound hoarsenessSound hoarseness

Laryngeal PapillomaLaryngeal Papilloma

► Benign, exophytic neoplastic growth Benign, exophytic neoplastic growth composed of branching fronds of composed of branching fronds of squamous epithelium with fibrovascular squamous epithelium with fibrovascular corescores

► The most common benign laryngeal The most common benign laryngeal neoplasmneoplasm

► No sex predilectionNo sex predilection► Changes in phonation, dyspnea, cough, Changes in phonation, dyspnea, cough,

dysphagia, stridordysphagia, stridor► HPV types 6 and 11HPV types 6 and 11

Laryngeal PapillomaLaryngeal Papilloma

►Juvenile type:Juvenile type: multiple lesions with extensive multiple lesions with extensive growth and rapid recurrence, may growth and rapid recurrence, may remit spontaneously or persist into remit spontaneously or persist into old ageold age

►Adult type:Adult type: more often single, recurs less often, more often single, recurs less often, less likely to spreadless likely to spread

► Exophytic, warty, friable, tan-white to red Exophytic, warty, friable, tan-white to red growthsgrowths

► Papillary fronds of multilayered benign squamous Papillary fronds of multilayered benign squamous epithelium containing fibrovascular coresepithelium containing fibrovascular cores

► Little or no keratin productionLittle or no keratin production

Laryngeal PapillomaLaryngeal Papilloma

► Absence of Absence of stromal invasionstromal invasion

► Certain degree Certain degree of cellular atypiaof cellular atypia

► Koilocytic Koilocytic changeschanges

KeratosisKeratosis

临床表现为声嘶、喉内不适

声带增厚，呈粉红色或白色斑块

病理上为不同程度的上皮增生和角质层

可伴有角化不全和乳头瘤样增生

Laryngeal LeukoplakiaLaryngeal Leukoplakia

Laryngeal AmyloidosisLaryngeal Amyloidosis

► Extracellular accumulation of fibrillar Extracellular accumulation of fibrillar proteinsproteins

► Systemic or localizedSystemic or localized► Primary or secondaryPrimary or secondary►Men > women, in the 5th and 6th Men > women, in the 5th and 6th

decades decades ► Polypoid mass (glottis and supraglottis) Polypoid mass (glottis and supraglottis)

or diffuse mucosal swelling (subglottis)or diffuse mucosal swelling (subglottis)►HoarsenessHoarseness

Laryngeal AmyloidosisLaryngeal Amyloidosis

► Extracellular, Extracellular, eosinophilic, eosinophilic, amorphous material amorphous material deposited randomly deposited randomly throughout throughout submucosa; submucosa; depositions around or depositions around or within the walls within the walls

► Disappearance of the Disappearance of the seromucous glands, seromucous glands,

► Mixed chronic Mixed chronic inflammatory infiltrateinflammatory infiltrate

Staging(supraglottic)Staging(supraglottic)T1T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobTumor limited to one subsite of supraglottis with normal vocal cord mob

ility ility

T2T2 Tumor involves mucosa of more than one adjacent subsite of supraglottiTumor involves mucosa of more than one adjacent subsite of supraglottis or glottis, or region outside the supraglottis (e.g. mucosa of base of the s or glottis, or region outside the supraglottis (e.g. mucosa of base of the tongue, vallecula, medial wall of piriform sinus) without fixation tongue, vallecula, medial wall of piriform sinus) without fixation

T3T3 Tumor limited to larynx with vocal cord fixation and or invades any of thTumor limited to larynx with vocal cord fixation and or invades any of the following: postcricoid area, preepiglottic tissue, paraglottic space, ande following: postcricoid area, preepiglottic tissue, paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) /or minor thyroid cartilage erosion (e.g. inner cortex)

T4aT4a Tumor invades through the thyroid cartilage and/or invades tissue Tumor invades through the thyroid cartilage and/or invades tissue beyond the larynx (e.g. trachea, soft tissues of neck including beyond the larynx (e.g. trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) esophagus)

T4bT4b Tumor invades prevertebral space, encases carotid artery, or invades mTumor invades prevertebral space, encases carotid artery, or invades mediastinal structures ediastinal structures

Staging(Glottic)Staging(Glottic)T1T1 Tumor limited to the vocal cord (s) (may involve anterior or posterior comTumor limited to the vocal cord (s) (may involve anterior or posterior com

missure) with normal mobilty missure) with normal mobilty T1aT1a Tumor limited to one vocal cord Tumor limited to one vocal cord

T1bT1b Tumor involves both vocal cords Tumor involves both vocal cords

T2T2 Tumor extends to supraglottis and/or subglottis, and/or with impaired vocTumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility al cord mobility

T3T3 Tumor limited to the larynx with vocal cord fixation and/or invades paraglTumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) ottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex)

T4aT4a Tumor invades through the thyroid cartilage, and/or invades Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g. trachea, soft tissues of the neck tissues beyond the larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus thyroid, or esophagus

T4bT4b Tumor invades prevertebral space, encases carotid artery, or invades mediTumor invades prevertebral space, encases carotid artery, or invades mediastinal structures astinal structures

Neck stagingNeck staging

N0N0 No cervical lymph nodes positive No cervical lymph nodes positive

N1N1 Single ipsilateral lymph node ≤ 3cm Single ipsilateral lymph node ≤ 3cm

N2aN2a Single ipsilateral node > 3cm and ≤6cm Single ipsilateral node > 3cm and ≤6cm

N2bN2b Multiple ipsilateral lymph nodes, each ≤ 6cMultiple ipsilateral lymph nodes, each ≤ 6cmm

N2cN2c Bilateral or contralateral lymph nodes, each Bilateral or contralateral lymph nodes, each ≤6cm ≤6cm

N3N3 Single or multiple lymph nodes > 6cm Single or multiple lymph nodes > 6cm

临床分期临床分期00 TisTis N0N0 M0M0

II T1T1 N0N0 M0M0

IIII T2T2 N0N0 M0M0

IIIIII T3T3 N0N0 M0M0

T1-3T1-3 N1N1 M0M0

IVAIVA T4aT4a N0-2N0-2 M0M0

T1-4aT1-4a N2N2 M0M0

IVBIVB T4bT4b Any NAny N M0M0

Any TAny T N3N3 M0M0

IVCIVC Any TAny T Any NAny N M1M1

TreatmentTreatment

►PrinciplePrinciple early lesion treated mainly by surgery and radiation, hearly lesion treated mainly by surgery and radiation, h

owever, advanced lesion treated by combined surgery wowever, advanced lesion treated by combined surgery with chemoradiation (combined therapy)ith chemoradiation (combined therapy)

T1/2 lesion: Rt or Surg.T1/2 lesion: Rt or Surg. For subglottic, total laryngectomy should be doneFor subglottic, total laryngectomy should be done Neck dissection for positive lymph nodesNeck dissection for positive lymph nodes Adenocarcinoma should be treated by surg.Adenocarcinoma should be treated by surg. For advanced lesion, laryngeal function preservation tFor advanced lesion, laryngeal function preservation t

herapy is another choiceherapy is another choice

SurgerySurgery

►Laser surgery under laryngoscopeLaser surgery under laryngoscope►Partial laryngectomyPartial laryngectomy►Total laryngectomyTotal laryngectomy►Neck dissectionNeck dissection

Laser surgeryLaser surgery

Laser surgeryLaser surgery

Vertical partial laryngectomyVertical partial laryngectomy

Supraglottic partial laryngectoSupraglottic partial laryngectomymy

Total laryngectomyTotal laryngectomy

Total laryngectomyTotal laryngectomy

Voice reconstructionVoice reconstruction

►Blom-singerBlom-singer

►Electrical larynxElectrical larynx

►Esophageal soundEsophageal sound

PrognosisPrognosis

5 year survival5 year survival

Stage IStage I >95%>95%

Stage IIStage II 85-90%85-90%

Stage IIIStage III 70-80%70-80%

Stage IVStage IV 50-60%50-60%

Thanks!Thanks!

Contact me:Contact me:LIU Wei WeiLIU Wei Wei

drliuww@gmail.comdrliuww@gmail.com