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LARYNGEAL CARCINOMA: BY-DR.SUDEEP K.C.

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Laryngeal Carcinoma :. BY-DR.SUDEEP K.C. Overview. Accounts for 25% of head and neck cancer and 1% of all cancers One-third of these patients eventually die of their disease Most prevalent in the 6 th and 7 th decades of life. Overview. 4:1 male predilection - PowerPoint PPT Presentation

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Laryngeal Carcinoma

Laryngeal Carcinoma:BY-DR.SUDEEP K.C.OverviewAccounts for 25% of head and neck cancer and 1% of all cancers

One-third of these patients eventually die of their disease

Most prevalent in the 6th and 7th decades of lifeOverview4:1 male predilection

Due to increasing public acceptance of female smoking

More prevalent among lower socioeconomic class, in which it is diagnosed at more advanced stagesSubtypesGlottic Cancer: 59%

Supraglottic Cancer: 40%

Subglottic Cancer: 1%

Most subglottic masses are extension from glottic carcinomasHistoryThe first laryngectomy for cancer of the larynx was performed in 1883 by Billroth

Patient was successfully fed by mouth and fitted with an artificial larynx

In 1886 the Crown Prince Frederick of Germany developed hoarseness as he was due to ascend the throne.HistoryWas evaluated by Sir Makenzie of London, the inventor of the direct laryngoscope

Fredericks lesion was biopsied and thought to be cancer

He refused laryngectomy and later died in 1888Risk FactorsProlonged use of tobacco and excessive EtOH use primary risk factors

The two substances together have a synergistic effect on laryngeal tissues

90% of patients with laryngeal cancer have a history of bothRisk FactorsHuman Papilloma Virus 16 &18

Chronic Gastric Reflux

Occupational exposures

Prior history of head and neck irradiationHistological Types85-95% of laryngeal tumors are squamous cell carcinomaHistologic type linked to tobacco and alcohol abuseCharacterized by epithelial nests surrounded by inflammatory stromaKeratin Pearls are pathognomonicHistological TypesVerrucous CarcinomaFibrosarcomaChondrosarcomaMinor salivary carcinomaAdenocarcinomaOat cell carcinomaGiant cell and Spindle cell carcinomaAnatomy

Anatomy

Anatomy

Anatomy

Anatomy

AnatomyNatural HistorySupraglottic tumors more aggressive:Direct extension into pre-epiglottic spaceLymph node metastasisDirect extension into lateral hypopharnyx, glossoepiglottic fold, and tongue base

Natural HistoryGlottic tumors grow slower and tend to metastasize late owing to a paucity of lymphatic drainageThey tend to metastasize after they have invaded adjacent structures with better drainageExtend superiorly into ventricular walls or inferiorly into subglottic spaceCan cause vocal cord fixation

Natural HistoryTrue subglottic tumors are uncommonGlottic spread to the subglottic space is a sign of poor prognosisIncreases chance of bilateral disease and mediastinal extensionInvasion of the subglottic space associated with high incidence of stomal reoccurrence following total laryngectomy (TL)PresentationHoarsenessMost common symptomSmall irregularities in the vocal fold result in voice changesChanges of voice in patients with chronic hoarseness from tobacco and alcohol can be difficult to appreciate

PresentationPatients presenting with hoarseness should undergo an indirect mirror exam and/or flexible laryngoscope evaluation

Malignant lesions can appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color

Videostrobe laryngoscopy may be needed to follow up these subtler lesionsPresentationGood neck exam looking for cervical lymphadenopathy and broadening of the laryngeal prominence is required

The base of the tongue should be palpated for masses as well.

Restricted laryngeal crepitus may be a sign of post cricoid or retropharyngeal invasionPresentationOther symptoms include:DysphagiaHemoptysisThroat painEar painAirway compromiseAspirationNeck massWork upBiopsy is required for diagnosisPerformed in OR with patient under anesthesiaOther benign possibilities for laryngeal lesions include: Vocal cord nodules or polyps, papillomatosis, granulomas, granular cell neoplasms, sarcoidosis, Wegners granulomatosisWork upOther potential modalities:Direct laryngoscopyBronchoscopyEsophagoscopyChest X-rayCT or MRILiver function tests with or without USPET ?TXMinimum requirements to assess primary tumor cannot be metT0No evidence of primary tumorTisCarcinoma in situStaging- Primary Tumor (T)Staging- SupraglottisT1Tumor limited to one subsite of supraglottis with normal vocal cord mobility T2Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis, or region outside the supraglottis (e.g. mucosa of base of the tongue, vallecula, medial wall of piriform sinus) without fixation T3Tumor limited to larynx with vocal cord fixation and or invades any of the following: postcricoid area, preepiglottic tissue, paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) T4aTumor invades through the thyroid cartilage and/or invades tissue beyond the larynx (e.g. trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) T4bTumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging- GlottisT1Tumor limited to the vocal cord (s) (may involve anterior or posterior commissure) with normal mobilty T1aTumor limited to one vocal cord T1bTumor involves both vocal cords T2Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) T4aTumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus T4bTumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging- SubglottisT1Tumor limited to the subglottis T2Tumor extends to vocal cord (s) with normal or impaired mobility T3Tumor limited the larynx with vocal cord fixation T4aTumor invades cricoid or thyroid cartilage and/or invades tissues beyond larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) T4bTumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging- NodesN0No cervical lymph nodes positive N1Single ipsilateral lymph node 3cm N2aSingle ipsilateral node > 3cm and 6cm N2bMultiple ipsilateral lymph nodes, each 6cmN2cBilateral or contralateral lymph nodes, each 6cm N3Single or multiple lymph nodes > 6cm Staging- MetastasisM0No distant metastasesM1Distant metastases presentStage Groupings0TisN0M0IT1N0M0IIT2N0M0IIIT3N0M0T1-3N1M0IVAT4aN0-2M0T1-4aN2M0IVBT4bAny NM0Any TN3M0IVCAny TAny NM1TreatmentPremalignant lesions or Carcinoma in situ can be treated by surgical stripping of the entire lesionCO2 laser can be used to accomplish this but makes accurate review of margins difficultTreatmentEarly stage (T1 and T2) can be treated with radiotherapy or surgery alone, both offer the 85-95% cure rate.Surgery has a shorter treatment period, saves radiation for recurrence, but may have worse voice outcomesRadiotherapy is given for 6-7 weeks, avoids surgical risks but has own complicationsTreatmentXRT complications include:MucositisOdynophagiaLaryngeal edemaXerostomiaStricture and fibrosisRadionecrosisHypothyroidism

TreatmentAdvanced stage lesions often receive surgery with adjuvant radiationMost T3 and T4 lesions require a total laryngectomySome small T3 and lesser sized tumors can be treated with partial larygectomyTreatmentAdjuvant radiation is started within 6 weeks of surgery and with once daily protocols lasts 6-7 weeksIndications for post-op radiation include: T4 primary, bone/cartilage invasion, extension into neck soft tissue, perineural invasion, vascular invasion, multiple positive nodes, nodal extracapsular extension, margins50%No tongue base disease past circumvallate papillaeApex of pyriform sinus not invlovedSupracricoid Laryngectomy

Resection of true vocal cords, supraglottis, thyroid cartilageLeave arytenoids and cricoid ring intactHalf of patients remain dependent on tracheostomyTotal LarygectomyIndications:T3 or T4 unfit for partialExtensive involvement of thyroid and cricoid cartilagesInvasion of neck soft tissuesTongue base involvement beyond circumvallate papillaeVoice RehabilitationTracheostomal prosthesis

Electrolarynx

Pure esophageal speech

ComplicationsInaccurate stagingInfectionVoice alterationsSwallowing difficultiesLoss of taste and smellFistulaTracheostomy dependenceInjury to cranial nerves: VII, IX, X, XI, XIIStroke or carotid blowoutHypothyroidismRadiation induced fibrosis

Prognosis5 year survivalStage I>95%Stage II85-90%Stage III70-80%Stage IV50-60%After initial treatment patients are followed at 4-6 week intervals. After first year decreases to every 2 months. Third and fourth year every three months, with annual visits after thatPrognosisPatients considered cured after being disease free for five yearsMost laryngeal cancers reoccur in the first two yearsDespite advances in detection and treatment options the five year survival has not improved much over the last thirty years