Laryngel Cancer

It is the most common cancer of the upper aerodigestive tract.

Subtypes

• Glottic Cancer: 59%

• Supraglottic Cancer: 40%

• Subglottic Cancer: 1%

• Most subglottic masses are extension from glottic carcinomas

Risk Factors

Etiology

• The incidence of laryngeal tumors is closely correlated with smoking, as head and neck tumors occur 6 times more often among cigarette smokers than among nonsmokers.

• The age-standardized risk of mortality from laryngeal cancer appears to have a linear relationship with increasing cigarette consumption.

Etiology

• Death from laryngeal cancer is 20 times more likely for the heaviest smokers than for nonsmokers.

• The use of unfiltered cigarettes or dark, air-cured tobacco is associated with further increases in risk.

Risk Factors<<<

• Although alcohol is a less potent carcinogen than tobacco, alcohol consumption is a risk factor for laryngeal tumors.

• In individuals who use both tobacco and alcohol, these risk factors appear to be synergistic, and they result in a multiplicative increase in the risk of developing laryngeal cancer.

Risk Factors

• Human Papilloma Virus 16 &18

• Chronic Gastric Reflux

• Occupational exposures

• Prior history of head and neck irradiation

Mortality/Morbidity

• The prognosis for small laryngeal cancers that do not have lymph node metastases is good, with cure rates of 75-95%, depending on the site, the size of the tumor, and the extent of infiltration.

• Advanced disease has a worse prognosis.

• Supraglottic cancers usually manifest late and have a poorer prognosis.

Sex & Age Incidence

• In the 1950s, the male-to-female ratio in patients with laryngeal cancer was 15:1.

• This number had changed to 5:1 by the year 2000, and the proportion of women afflicted by the disease is projected to increase in years to come.

• These changes are likely a reflection of shifts in smoking patterns, with women smoking more in recent years.

• Laryngeal cancer most commonly affects men middle-aged or older. The peak incidence is in those aged 50-60 years.

Histological Types

• 85-95% of laryngeal tumors are squamous cell carcinoma

• Histologic type linked to tobacco and alcohol abuse

• Characterized by epithelial nests surrounded by inflammatory stroma

• Keratin Pearls are pathognomonic

Histological Types

• Verrucous Carcinoma

• Fibrosarcoma

• Chondrosarcoma

• Minor salivary carcinoma

• Adenocarcinoma

• Oat cell carcinoma

• Giant cell and Spindle cell carcinoma

Anatomy

The supraglottic larynx

• It consists of epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids

The glottic larynx

• It consists of the true vocal cords and anterior commissure and posterior commissure

The subglottic larynx

• It consists of the region between the vocal cords and the trachea.

Pre-epiglottic fat space

• The pre-epiglottic fat is located in the anterior and lateral aspects of the larynx and is often invaded by advanced cancers.

Lymphatics • The first-echelon lymphatics for the supraglottic

larynx are the subdigastric nodes and the middle anterior cervical nodes and the second-echelon lymphatics are the lower anterior cervical nodes

• The first-echelon lymphatics for the subglottic larynx are the Delphian node, the lower anterior cervical nodes and paratracheal nodes, and the supraclavicular nodes, and the second-echelon lymphatics are the mediastinal nodes.

• Glottic and subglottic tumors metastasize to ipsilateral lymph nodes, but supraglottic tumors often spread to nodes on both sides of the neck.

In the supraglottis, the T stages are as follows

• T1: Tumor limited to 1 subsite of the supraglottis with normal vocal cord mobility

• T2: Tumor invasion of the mucosa of more than 1 adjacent subsite of the supraglottis or glottis or of a region outside the supraglottis , without fixation of the larynx

• T3: Tumor limited to the larynx with vocal cord fixation and/or invasion of any of the postcricoid area or pre-epiglottic tissues

• T4: Tumor invasion through the thyroid cartilage and/or extension into

In the glottis, the T stages are as follows:

• T1: Tumor limited to the vocal cord with normal mobility

• T2: Tumor extension to the supraglottis and/or subglottis and/or impaired vocal cord mobility

• T3: Tumor limited to the larynx with vocal cord fixation

• T4: Tumor invasion through the thyroid cartilage and/or other tissues beyond the larynx .

In the subglottis the T stages are as follows

• T1: Tumor limited to the subglottis• T2: Tumor extension to a vocal cord

with normal or impaired mobility• T3: Tumor limited to the larynx with

vocal cord fixation• T4: Tumor invasion through cricoid or

thyroid cartilage and/or extension to other tissues beyond the larynx

Staging- Nodes

N0 No cervical lymph nodes positive

N1 Single ipsilateral lymph node ≤ 3cm

N2a Single ipsilateral node > 3cm and ≤6cm

N2b Multiple ipsilateral lymph nodes, each ≤ 6cm

N2c Bilateral or contralateral lymph nodes, each ≤6cm

N3 Single or multiple lymph nodes > 6cm

Supraglottic carcinomas

• The epiglottis is the most frequent location for cancers that arise in the supraglottic larynx. These lesions are often exophytic and circumferential masses

• Tumors of the aryepiglottic fold are typically exophytic lesions that, when detected early, are confined laterally along the aryepiglottic fold.

• Advanced lesions may extend laterally to involve the adjacent wall of the pyriform sinus or medially to invade the epiglottis.

Supraglottic carcinomas

• Squamous cell cancers that arise from the false vocal cords and laryngeal ventricle tend to be ulcerative and infiltrative with a limited exophytic component. Deep invasion by such tumors results in their access to the paraglottic space, and this may lead to fixation of the supraglottic larynx.

• Because of their close proximity, these tumors may extend inferiorly to involve the true vocal cords.

Glottic carcinomas

• The true vocal cords are the most common site of laryngeal carcinomas; the ratio of glottic carcinomas to supraglottic carcinomas is approximately 3:1.

• The anterior portion of the true vocal cord is the most common location of squamous cell cancer, with most lesions occurring along the free margin of the vocal cord.

Glottic carcinomas

• Anteriorly, the tumor may extend to anterior commissure, where it may involve the contralateral true vocal cord.

• The likelihood of nodal involvement associated with glottic carcinomas depends on the stage of the tumor. The incidence of early T1 lesions has been reported to be as low as 2%. This figure increases to approximately 20% for T3 and T4 lesions.

Subglottic carcinomas

• Subglottic carcinomas are rare and account for only 5% of all laryngeal carcinomas.

• When present, these lesions are characteristically circumferential and often extend to involve the undersurface of the true vocal cords

• They have a tendency for early invasion of the cricoid cartilage and extension through the cricothyroid membrane.

Presentation

• Hoarseness– Most common symptom– Small irregularities in the vocal fold result in

voice changes– Changes of voice in patients with chronic

hoarseness from tobacco and alcohol can be difficult to appreciate

Presentation

• Other symptoms include:– Dysphagia– Hemoptysis– Throat pain– Ear pain– Airway compromise– Aspiration– Neck mass

Presentation

• Patients 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

Presentation

• Good 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 invasion

Work up

• Biopsy is required for diagnosis

• Performed in OR with patient under anesthesia

• Other benign possibilities for laryngeal lesions include: Vocal cord nodules or polyps, papillomatosis, granulomas, granular cell neoplasms, sarcoidosis, Wegner’s granulomatosis

Work up

• Other potential modalities:– Direct laryngoscopy– Bronchoscopy– Esophagoscopy– Chest X-ray– CT or MRI– Liver function tests with or without US– PET ?

Treatment

• Premalignant lesions or Carcinoma in situ can be treated by surgical stripping of the entire lesion

• CO2 laser can be used to accomplish this but makes accurate review of margins difficult

Treatment

• Early 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 outcomes

• Radiotherapy is given for 6-7 weeks, avoids surgical risks but has own complications

Treatment

• XRT complications include:– Mucositis– Odynophagia– Laryngeal edema– Xerostomia– Stricture and fibrosis– Radionecrosis– Hypothyroidism

Treatment

• Advanced stage lesions often receive surgery with adjuvant radiation

• Most T3 and T4 lesions require a total laryngectomy

• Some small T3 and lesser sized tumors can be treated with partial larygectomy

Treatment

• Chemotherapy can be used in addition to irradiation in advanced stage cancers

• Two agents used are Cisplatinum and 5-flourouracil

• Cisplatin thought to sensitize cancer cells to XRT enhancing its effectiveness when used concurrently.

Treatment

• Modified or radical neck dissections are indicated in the presence of nodal disease

• Neck dissections may be performed in patients with supra or subglottic T2 tumors even in the absence of nodal disease

• N0 necks can have a selective dissection sparing the SCM, IJ, and XI

• N1 necks usually have a modified dissection of levels II-IV

Supraglottic laryngectomy

• T1,2, or 3 if only by preepiglottic space invasion

• Mobile cords• No anterior commissure

involvement• FEV1 >50%• No tongue base disease

past circumvallate papillae

• Apex of pyriform sinus not invloved

Total Larygectomy

• Indications:– T3 or T4 unfit for partial– Extensive involvement of thyroid and cricoid

cartilages– Invasion of neck soft tissues– Tongue base involvement beyond

circumvallate papillae

Total Laryngectomy