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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