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!!!