Cancer Larync

8/12/2019 Cancer Larync

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Cancer Larynx


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Contents

1. Definition

2. Epidemiology

3. Etiology

4. Anatomical sites of larynx

5. Tumor, node, metastasis (TNM) system and Histologicgrading

6. Laryngeal carcinoma based on anatomical sitessupraglottic, glottic and subglottic cancer

7. Laryngeal carcinoma based on histologic classification8. Diagnosis

9. Principle of Treatment


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Definition

Laryngeal carcinoma is cancer of the larynx,

including the vocal cords (glottis), supraglottis,

and subglottis.(Ferri's Clinical Advisor 2014)


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Epidemiology

Laryngeal carcinoma is the most common

malignancy among head and neck

There are 12,000 new cases per year in the

U.S.

Male predominance, M:F (10:1)

4

th

to 7

th

decade, peak incidence at sixthdecade

Ferri's Clinical Advisor 2014


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Aetiology

Smoking

Alcohol

Previous radiation Genetic

Occupational exposure

Gastroesophageal reflux disease (GERD)

Human papillomavirus

Cummings Otolaryngology Head & Neck Surgery , Fifth Edition


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Larynx is divided into 3 regions:

1. Supraglottis

2. Glottis

3. Subglottis

This division reflects the embryologic structure ofthe larynx and the anatomic barriers to spread ofcancer.

Anatomical Sites of Larynx


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Classification of sites and various sub-

sites under each site in larynx

Site Sub-sites

Supraglottis Suprahyoid epiglottis

Infrahyoid epiglottis

Aryepiglottic folds

Arytenoids

Ventricular bands/ false cords

Glottis True vocal cord including anterior

and posterior commissure

Subglottis Subglottic up to the lower border

of cricoid cartilage

AJCC (American Joint Committee on Cancer) Classification 1997


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Anatomic regions and structures of the

larynx.

Leibel and Phillips Textbook of RadiationOncology , Third Edition


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Cummings Otolaryngology Head & NeckSurgery , Fifth Edition


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Structures of the larynx as seen from behind.

Leibel and Phillips Textbook of RadiationOncology , Third Edition


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TNM system

T: tumor and its extent

N: indicates regional lymph node enlargementand its size

M: distant metastasis


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Histologic Grading

(WHO 1987- Modified BrodersClassification)

Grade 1 : Well differentiated

- Excessive keratin pearl formation

Grade 2: Moderately differentiated- Moderate keratin formation

Grade 3: Poorly differentiated

- Keratin formation is only detected bycytokeratin immunohistochemical reaction or

electron miscroscopy


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Supraglottic Cancer

Extent:

The common sites: Epiglottis, false cord followedby aryepiglottic fold

Spread: For supraglottic cancer: Locally spread or invade the

adjoining areas like vallecula, base of tongue andpyriform form

Nodal metastasis: Occur early. Upper and middle jugular nodes are

often involved. Bilateral metastasis can be seen inepiglottic cancer


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Symptoms:

Always silent

Throat pain, dysphagia, referred pain to ear,painful neck swelling

Hoarseness of voicelate symptom

Weight loss, airway obstruction, halitosislate features

Supraglottic Cancer


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Glottic Cancer

Extent:

The most common site for laryngeal carcinoma, especiallyfree edge and upper surface of vocal cord in its anteriormiddle third

Spread: Locally may spread to Anteriorly: Anterior commissure

Posteriorly: Vocal process and arytenoid region

Superiorly: Ventricle and false cord

Inferiorly: Subglottic region

Early stage: Vocal cord is mobile Late stage: Fixation of cordspread to thyroarytenoid mucscle

bad prognosis

Nodal metastasis: Not common


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Glottic Cancer

Symptoms:

Hoarseness of voiceearly sign

Stridor Laryngeal obstruction


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Subglottic Cancer

Extent: From the glottic area to lower border of cricoidcartilage

Rare

Spread:

Spread around anterior wall to the opposite side Spread downward to the trachea

Upward spread to vocal cord is late symptomsno earlyhoarseness of voice

Invade cricothyroid membrane, thyroid gland

Nodal metastasis: Prelaryngeal nodes

Pretracheal nodes

Paratracheal nodes

Lower jugular nodes


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Subglottic Cancer

Symptoms:

Stridor and laryngeal obstruction

Hoarseness of voice


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Histologic Classification

Epithelial cancers:

Squamous cell carcinoma

Basaloid squmous carcinoma

Verrucous carcinoma

Adenocarcinoma

Pseudosarcoma

Anaplastic cancer

Transitional cell carcinoma

Neuroendocrine tumors, including small cell andcarcinoid

Sarcoma: Metastatic malignancies


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Squamous cell carcinoma

More than 95% of laryngeal tumours are

squamous cell carcinoma

Common site: Glottic regiontrue vocal cord


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Squamous Cell Carcinoma

Four subtypes:1. Glottic carcinoma

2. Supraglottic carcinoma

3. Subglottic carcinoma

4. Transglottic carcinoma: cross the ventricle from thesupraglottic area to involve the true and false vocal foldsor involve the glottis and extend subglottically more than10mm or both

Glottic carcinomas (50%-60%) Supraglottic carcinomas (30%-40%)

Subglottic carcinomas are uncommon (5% or less).


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Diagnosis

1. History

2. Indirect laryngoscopy

3. Neck examination4. Radiology

5. CT Scan

6. Direct laryngoscopy7. Microlaryngoscopy


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Persistent or gradually increasing hoarseness

of voice for 3 weeks

1.History


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2. Indirect laryngoscopy

Appearance of lesion

Vocal cord mobility

Extent of disease


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3. Examination of the Neck

Extralaryngeal spread of disease

Nodal metastasis


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4. Radiology

X-ray Chest

Soft tissue lateral view neck


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5. CT scan

Extent of tumour

Invasion

Destruction of cartilage Lymph node involvement


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6. Direct laryngoscopy

Hidden area of larynx

Extent of the disease


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7. Microlaryngoscopy

Small lesion of vocal lesion

For accurate biopsy specimens


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Treatment

Depends upon the site of lesion, extent of lesion,presence or absence of nodal and distantmetastases.

Radiotherapy

Surgery Conservative

Total laryngectomy

Combined therapy


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1. Radiotherapy

Early lesions which neither impair cord

mobility nor invade cartilage or cervical nodes

Not suitable for lesion with fixed cords,

subglottic extension, cartilage invasion, and

nodal metastasis


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2. Surgery

a. Conservative surgery

i. Preserve the voice

ii. Avoid a permanent tracheal opening

iii. Includes:

Excision of vocal cord after splitting the larynx

(cordectomy via laryngofissure)

Excision of vocal cord and anterior commissure(partial frontolateral laryngectomy)

Excision of the epiglottis


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2. Surgery

b. Total laryngectomy

Indications:i. T3 lesion with cord fixation

ii. All T4 lesion

iii. Invasion of thyroid and cricoid cartilage

iv. Bilateral arytenoid cartilage involvement

v. Posterior commissure lesion

vi. Failure after conservative surgery or radiotherapy

vii. Transglottic cancer

Contraindication: Patient with distant metastasis


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3. Combined Therapy

Surgery may be combined with pre-operative

or post-operative radiotherapy

To reduce the recurrence


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References (Draft)

Ferri's Clinical Advisor 2014, Fred F. Ferri, 643-643.e1

Diseases of ear, nose and throat, P.L Dhingra, 3rdedition

Cummings Otolaryngology Head & Neck Surgery , Fifth Edition, Paul W.

Flint, Bruce H. Haughey, Valerie J. Lund, John K. Niparko, Mark A.

Richardson, K. Thomas Robbins, and J. Regan Thomas CHAPTER 107, 1482-

1511

Leibel and Phillips Textbook of Radiation Oncology , Third Edition,

Richard T. Hoppe, Theodore Locke Phillips, and Mack Roach, Chapter 31,

642-665

Atlas of Head and Neck Pathology , Second Edition, Bruce M. WenigChapter 13, 439-532

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