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Introduction
About 90-95% of laryngeal malignancies are squamous cell carcinoma with various grades of differentiation Squamous cell subtypes include keratinizing and nonkeratinizing and well-differentiated to poorly differentiated grade
The rest 5-10% of lesions include verrucous carcinoma, spindle cell carcinoma, malignant salivary gland tumor and sarcomas.
Glottic (59%)> Supraglottic (40%)> Subglottic (1%)..
Widely prevalent in the Indian Sub-continent in comparison to the west
Introduction
The larynx is divided into the following three anatomical regions:
The Supraglottic larynx includes the epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids.
The Glottis includes the true vocal cords and the anterior and posterior commissures.
The Subglottic region begins about 1 cm below the true vocal cords and extends to the lower border of the cricoid cartilage or the first tracheal ring.
Ref. American Cancer Society.: Cancer Facts and Figures 2012. Atlanta, Ga: American Cancer Society, 2012. Last accessed January 5, 2012
Glottic cancer
Most common- 59% Spread: Anteriorly- anterior commisure Posteriorly- vocal process and arytenoid
process Upward- ventricle and false cord Downward- Subglottic region
Symptoms: Hoarseness of voice is an early sign bcoz lesions
of cord affect its vibratory capacity, stridor when growth becomes larger in size.
There are few lymphatics in vocal cords and nodal metastasis are never seen unless the disease spreads beyond the region of membranous cords.
Good Prognosis : Bcoz of early presentation and late spread, it has good prognosis.
Picture of glottic squamous cell carcinoma of the larynx. The tumor involves the anterior half of the left vocal cord.
Supraglottic cancer Less frequent than glottic cancer Majority of lesion are seen on epiglottis,false
cord followed by aryepiglottic fold, in that order
May spread locally and invade the adjoining areas (vallecula, base of tounge and pyriform fossa)
Nodal metastases occur early(T1- 20%,T2-35%,T3-50%,T4-65%)
Upper and middle jugular nodes are often involved
Bilateral metastases may be seen in cases of epiglottic cancer.
Symptoms: Often silent, Hoarseness is a late symptom. May present with throat pain, dysphagia and referred pain in ear, mass of lymph node in the neck.
Bad Prognosis : Due to early spread and late presentation.
Preepiglottic space involvement through foramen in infrahyoid epiglottis.
Paraglottic space involvement through mucosa of the ventricle.
Subglottic cancer
Lesions rare( 1 - 2%) Spread: Anterior wall, to the opposite side
or downwards to the trachea May invade cricothyroid membrane,
thyroid gland and muscles of neck Paratracheal LN involved Symptoms: Stridor is the Earliest presentation.
Hoarseness is a late symptom as upward spread to the vocal cords is late.
Hoarseness of voice indicates :
Spread of disease to undersurface of vocal cords.
Infiltration of thyroarytenoid muscle. Involvement of recurrent laryngeal nerve.
Diagnosis Of Laryngeal Cancer
1. History : Symptomatology of glottic, subglottic, supraglottic is
different as explained earlier.
2. Indirect Laryngoscopy : It is done to see the- A) Appearance of lesion- which vary according to the
site of origin. B) Vocal Cord Mobility – Fixation of vocal cords
indicate deeper infiltration.
C) Extent of the disease.
3. Direct Laryngoscopy : It is done to see the- a) Hidden areas of larynx b) Extent of disease.
4. Examination Of Neck : It is done to find the- a) Extralaryngeal spread of the disease. b) Nodal metastasis.
5. Radiography : Chest X Ray – Essential for co-existent
lung diseases,pulmonary metastasis and mediastinal nodes.
CT Scan – Useful investigation to find the
extent of the tumour,invasion of pre and para epiglottic space,destruction of cartilage and lymph node involvement.
Laryngograms using dionosil are
obsolete.
6. Microlaryngoscopy: For smaller lesions, laryngoscopy is done
under microscope for better visualisation.
7. Supravital staining and biopsy: Toluidine blue is applied to the laryngeal
lesion and then washed and examined. CIS and superficial carcinomas take up dye while leukoplakia does not and thus helping in selecting the area for biopsy.
TNM STAGING
The staging system for laryngeal cancer is clinical and based on the best possible estimate of the extent of disease before treatment.
Staging of disease is very important it influences the choice of therapy and helps in predicting the overall prognosis, it provides confirmity amongst clinicians
thereby helping in comparing the efficacy of various forms of therapy.
Staging – Primary Tumour
Tx - Primary tumor cannot be assessed.T0 - No evidence of primary tumor.Tis - Carcinoma in situ.
Supraglottis
T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility.
T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.
T3 Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage.
T4a Moderately advanced local disease.Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
T4b Very advanced local disease.Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
GLOTTIS
T1 Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility.
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 invasion of paraglottic space and/or inner cortex of the thyroid cartilage.
T4a Moderately advanced local disease.Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
T4b Very advanced local disease.Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
• Subglottis– T1: limited to subglottis– T2: extends to vocal cord
with normal or impaired mobility
– T3: limited to larynx w/vocal cord fixation
– T4a: invades cricoid or thyroid cartilage, and/or invades tissues beyond the larynx
– T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures
Staging• Nodes
– Nx: regional LN can’t be assessed
– N0: no regional node mets– N1: single ipsilateral node, ≤
3 cm– N2a: single ipsilateral node,
> 3 cm, ≤ 6 cm– N2b: multiple ipsilateral
nodes, ≤ 6 cm– N2c: bilateral or
contralateral nodes, ≤ 6 cm– N3: node > 6 cm
• Mets– Mx: unknown– M0: no distant mets– M1: distant mets
Stage Grouping
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage IIIT3 N0 M0
T1-3 N1 M0
Stage IVAT4a N0-1 M0
T1-4a N2 M0
Stage IVBT4b any N M0
any T N3 M0
Stage IVC any T any N M1
Earlystage
Advanced stage
Glottic cancer
Carcinoma in situ(Tis):if b/l staged procedure /web formation
Diffuse lesion
• Complete mucosal cord stripping with co2 laser
• Quit smoking/no RT• Vigilant follow up
Localised lesion
•Excision of leukoplakia with microscissors/forceps•Quit smoking/ no RT•Vigilant f/u
T1 Glottic Carcinoma
T1 Carcinoma•RT or CO2 laser•Laryngofissure and cordectomy
T1 Carcinoma with ext. to anterior
commissure
•RT• Partial frontolateral laryngectomy
T1 with ext. to arytenoid
•Endoscopic laser resection•Laryngofissure & cordectomy (surgery preferred)•RT
Surgical optionsfor small T1 lesions
CO2 laser
Transoral endoscopic CO2 laser cordectomy
Cure rates are uniformly above 90% Quality of voice depents on extend of
resection
Laryngofissure and cordectomy..rarely used now
When endoscopic exposure is very poor
CO2 laser
Indications
Tumor limited to the glottis (T1/T2/early
T3)normal vocal cord mobility
localised residual /recurrent disease following failure of RT for early cancer
debulking of tumour for stridor
T2N0 Glottic cancer (freely mobile cords)
- Radiotherapy to the primary including radiation to upper neck nodes.
If failure occurs, Conservative laryngectomy
or Total laryngectomy +/- neck dissection is done.
T2N0 glottic cancer(Impaired cord mobility, Involvement of anterior
commissure or arytenoids)
RT is avoided bcoz of the possibility of developing perichondritis. Also impaired mobility indicates deeper invasion and thus poorer response to radiation.
- Conservative laryngectomy is done, if failure occurs Total laryngectomy is done.
T3 & T4 glottic carcinoma
Best treated by total laryngectomy combined with neck dissection if lymph nodes are palpable.
Can also be combined with post operative RT.
Subglottic carcinoma
T1 & T2 are treated by RT.
T3 & T4 require total laryngectomy and post-op. RT (radiation should also include superior mediastinum)
Supraglottic Carcinoma
T1 lesions are treated by Rt or CO2 Laser.
T2 lesions require consideration of pulmonary function.
If pulmonary function is good, supraglottic laryngectomy is done.If pulmonary function is poor, RT can be given with follow up.
T3 & T4 lesions require total laryngectomy with neck dissection and post-op RT.
Vocal Rehabilitation after TL
1. Oesophageal Speech : The patient is taught to swallow air in the oesophagus
and to release it slowlyfrom oesophagus to pharynx. Patient can speak upto 6-10 understandable words.
2. Artificial Larynx : a) Electrolarynx – It has a vibrating disc which is held against the soft tissues of the neck. b) Transoral Pneumatic Device – Here vibrations produced in a rubber diaphragm is carried
by a plastic tube into the back of oral cavity where sound is converted to speech by modulators.
Tracheo-oesophageal Speech
Here attempt is made to carry air from trachea to oesophagus or hypopharynx by the creation of skin lined fistula or nowdays, prosthesis (Blom-Singer or Panje) are used which prevent the risk of aspiration.
Thank You!!!