Larynx Carcinoma

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Larynx Carcinoma

Cancer Larynx

Larynx Carcinoma

  • It is 10 times more common in males than in females (MCQ)
  • mostly seen in the age group of 40-70 years(MCQ)
  • Risk factors in laryngeal cancer.
    • Both tobacco and alcohol
      • Cigarette smoke contains benzopyrene– carcinogenic
      • Combination of alcohol and smoking increases the risk 15-folds compared to each factor alone (2-3 folds).
    • Previous radiation to neck for benign lesions or laryngeal papilloma may induce laryngeal carcinoma. (MCQ)
    • Occupational exposure to asbestos, mustard gas and petroleum products related to the genesis of laryngeal cancer
  • Anatomy
    • Supraglottis
      • Suprahyoid epiglottis (both lingual and laryngeal surfaces)
      • Infrahyoidepiglottis
      • Aryepiglottic folds (laryngeal aspect only)
      • Arytenoids
      • Ventricular bands (or false cords)
    • Glottis
      • True vocal cords including anterior and posterior commissure
    • Subglottis
      • Subglottis up to lower border of cricoid cartilage
  • TNM Classification and Staging
    • Tumor Size
      • Supraglottis
        • T1- Tumour limited to one subsite of supraglottis with normal vocal cord mobility
        • T2 -Tumour 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 – Tumour limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues, paraglottic space and/or minor thyroid cartilage invasion
        • T4a -Tumour invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of tongue, strap muscles, thyroid or oesophagus)
        • T4b -Tumour invades prevertebral space, encases carotid artery or invades mediastinal structures
      • Glottis
        • T1- Tumour limited to vocal cord(s) (may involve anterior or posterior commissures) with normal mobility
        • T1a -Tumour limited to one vocal cord
        • T1b -Tumour involves both vocal cords
        • T2- Tumour extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility
        • T3  Tumour limited to the larynx with vocal cord fixation and/or invades paraglottic space and/or minor thyroid cartilage erosion
        • T4a- Tumourinvades through thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or oesophagus)
        • T4b- Tumour invades prevertebral space, encases carotid artery or invades mediastinal structures
      • Subglottis
        • T1- Tumourlimited to the subglottis
        • T2 -Tumourextends to vocal cord(s) with normal or impaired mobility
        • T3 -Tumour limited to larynx with vocal cord fixation
        • T4a- Tumour invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of tongue, strap muscles, thyroid or oesophagus)
        • T4b -Tumour invades prevertebral space, encases carotid artery or invades mediastinal structures
    • Regional lymph nodes (N)
      • NX- Regional lymph nodes cannot be assessed
      • N0 –No regional lymph node metastasis
      • N1 -Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
      • N2 -Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.
      • N2a -Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension
      • N2b- Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
      • N2c- Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
      • N3 -Metastasis in a lymph node more than 6 cm in greatest dimension
    • Distant metastasis (M)
      • MX -Distant metastasis cannot be assessed
      • M0 –No distant metastasis
      • M1- Distant metastasis

 

  • Histopathology
    • About 90-95% of laryngeal malignancies are squamous cell carcinoma.(MCQ)
    • Cordal lesions are often well-differentiated while supraglottic ones are anaplastic.
  • Supraglottic Cancer
    • Majority of lesions are seen on epiglottis, false cords followed by aryepiglottic folds, in that order.
    • spread locally and invade the adjoining areas, i.e. vallecula, base of tongue and pyriform fossa.
    • Cancer of infrahyoid epiglottis and anterior ventricular band may extend into pre-epiglottic space and penetrate the thyroid cartilage.
    • Nodal metastasesoccur early.(MCQ)
    • Upper and middle jugular nodes are often involved.
    • Bilateral metastases may be seen in cases of epiglottic cancer.
    • Supraglottic growths are often silent.
    • Hoarseness is a late symptom.
    • Throat pain, dysphagia and referred pain in the ear or mass of lymph nodes in the neck may be the presenting features. (MCQ)
    • Weight loss, respiratory obstruction, halitosis are late features.
  • Glottic Cancer
    • In vast majority of cases, laryngeal cancer originates in the glottic region. (MCQ)
    • Free edge and upper surface of vocal cord in its anterior and middle third is the most frequent site (MCQ)
    • Fixation of vocal cord
      • indicates spread of disease to thyroarytenoidmuscle
      • is a bad prognostic sign.
    • There are few lymphatics in vocal cords and nodal metastasis are practically never seen in cordal lesions (MCQ)
    • Hoarseness of voice is an early sign because lesions of cord affect its vibratory capacity.(MCQ)
      • It is because of this that glottic cancer is detected early.
    • Increase in size of growths with accompanying oedema or cord fixation may cause stridor and laryngeal obstruction.
  • Subglottic Cancer (1-2%)
    • The earliest presentation of subglottic cancer may be stridor or laryngeal obstruction but this is often late
    • by this time disease has already spread sufficiently to encroach the airway.

 

  • Diagnosis of Laryngeal Cancer
    • Any patient in cancer age group having persistent or gradually increasing hoarseness of voice for 3 weeks must have laryngeal examination to exclude cancer

 

  • Supravital staining and biopsy
    • Toluidine blue is applied to the laryngeal lesion
    • Carcinoma-in-situ and superficial carcinomas take up the dye while leukoplakia does not. Thus, it helps to select the area for biopsy in a leukoplakic patch.

Treatment of Laryngeal Cancer( Very important MCQ area)

      • Treatment consists of:
        • Radiotherapy
        • Surgery
          • conservation laryngeal surgery
          • totallaryngectomy
        • Combined therapy.
      • Radiotherapy
        • Curative radiotherapy is reserved for early lesions whichneither impair cord mobility nor invade cartilage or cervical nodes. (MCQ)
        • Cancer of the vocal cord without impairment of its mobility gives a 90% cure rate after irradiation and has the advantage of preservation of voice. Superficial exophytic lesions, especially of the tip of epiglottis, and aryepiglottic folds give 70-90% cure rate.
        • Radiotherapy does not give good results in lesions with fixed cords, subglottic extension, cartilage invasion, and nodal metastases. These lesions require surgery.
      • Surgery
        • Conservation surgery
          • Conservation surgery includes:
            • Excision of vocal cord after splitting the larynx (cordectomy via laryngofissure),
            • Excision of vocal cord and anterior commissure region (partial frontolaterallaryngectomy),
            • Excision of supraglottis, i.e. epiglottis, aryepiglottic folds, false cords and ventricle
            • a sort of transverse section of larynx above the vocal cords (partial horizontal laryngectomy).
        • Total laryngectomy
          • The entire larynx including the hyoid bone, pre-epiglottic space, strap muscles, and one or more rings of trachea are removed.
          • Pharyngeal wall is repaired and lower tracheal stump sutured to the skin for breathing.
          • patient was left with no voice and a permanent tracheostome
          • Laryngectomy may be combined with block dissection for nodal metastasis.
          • Total laryngectomy is indicated in the following conditions:
            • T3 lesions (i.e. with cord fixed)
            • All T4 lesions
            • Invasion of thyroid or cricoid cartilage
            • Bilateral arytenoid cartilage involvement
            • Lesions of posterior commissure
            • Failure after radiotherapy or conservation surgery
            • Transglottic cancers, i.e. tumours involving supraglottis and glottis across the ventricle, causing fixation of the vocal cord.
        • It is contraindicated in patients with distant metastasis.
      • Combined therapy
        • Surgical ablation may be combined with pre- or post-operative radiation
          • decrease the incidence of recurrence.
          • Pre-operative radiation may also render fixed nodes resectable.
      • Glottic Carcinoma
          • Carcinoma-in-situ
            • It is best treated by transoral endoscopic CO2 laser.
            • If laser is not available, stripping of vocal cord is done under microscope and tissue subjected to biopsy.
            • If biopsy shows invasive carcinoma, give radiotherapy.
            • If biopsy confirms only carcinoma in situ, treatment is regular follow-up.
        • Invasive carcinoma
            • T1-carcinoma-
              • Radiotherapy is the treatment of choice.
              • If radiotherapy is refused or not available, excision of cord by endoscopic CO2 laser or laryngofissure is performed.
            • T1-carcinoma with extension to anterior commissure.
              • Radiotherapy is the best choice.
              • In the absence of this, frontolateral partial laryngectomy is done with regular follow-up.
              • If it fails, total laryngectomy is performed.
            • T1-carcinoma with extension to arytenoid.
              • Treatment is same as above but surgery is preferred.
            • T2N0
            • It implies tumour of the glottic region, i.e. vocal cord(s), anterior commissure and/or vocal process of the arytenoid with extension to supraglottic or subglottic regions but with no lymph node involvement.
            • Treatment depends on two factors
              • Is mobility of vocal cord normal or impaired?
              • Is there involvement of anterior commissure and/or arytenoid?
              • If cord is mobile and anterior commissure and arytenoid is not involved, radiotherapy gives good results.
              • If disease recurs, total laryngectomy is performed.
              • Some surgeons will still consider partial vertical laryngectomy to preserve voice in such radiation-failed cases.
              • If anterior commissure and/or arytenoid is involved or cord mobility is impaired
                • radiotherapy is not preferred
                • becauseradiotherapy leads toperichondritis which would entail total laryngectomy.
                • In such cases, some form of conservation surgery such as vertical hemilaryngectomy or frontolaterallaryngectomy is done to preserve the voice
              • In N0 neck, in T2 carcinoma, chances of occult nodal metastasis are less than 25%, therefore prophylactic neck dissection is not done.
              • However, if radiation is considered the mode of treatment, for the primary, upper neck nodes are included in the radiation field.
              • Cord mobility is important in determining the outcome of T2 lesions.
                • Normal cord mobility suggests growth is only limited to the surface.
                • Impaired mobility indicates deeper invasion into intrinsic laryngeal muscles or paraglottic space and thus poor response to radiation.
              • Invasion of paraglottic or subglottic space is also associated with undetected invasion of laryngeal cartilages and hence poor survival results.
              • With radiation, cure rate of T2 lesions,
                • with normal cord mobility, is 86%
                • it drops to 63% if cord mobility is impaired
          • T3 and T4 glottic carcinomas
              • best treated by total laryngectomy.
              • It is combined with neck dissection if nodes are palpable.
          • T4 lesions
              • treated by combined therapy, i.e. surgery with post-operative radiotherapy or only palliative treatment.

larnyx

          • Subglottic cancer
            • Early lesions T1 and T2 are treated by radiotherapy.
            • T3 and T4 lesions require total laryngectomy and post-operative radiation.
            • Radiation portal should also include superior mediastinum.
          • Supraglottic cancer
            • T1 lesions
              • respond well to radiation.
              • can also be excised with CO2 laser.
          • T2 lesions
            • if lung function is good.
              • treated by supraglotticlaryngectomy with or without neck dissection
            • If lung function is poor
              • radiotherapy can be given to the primary and the nodes.
          • T3 and T4 lesions
            • often require total laryngectomy with neck dissection and post-operative radiotherapy to neck
          • Vocal Rehabilitation After Total Laryngectomy
          • Oesophageal speech (MCQ)
          • Electrolarynx.
          • Transoral pneumatic device.
          • Tracheo-oesophageal speech
          • Blom-Singer or Panjeprosthesis are being used to shunt air from trachea to the oesophagus.

Endoscopy of Carcinoma of the Larynx
The etiology of oral epidermoide carcinoma is connected to the abusive use of tobacco and alcohol, having been in various studies demonstrated the effect synergetic of these
agents, the gastroesophageal reflux disease play role in pathogenesis of the Squamous cell carcinoma of the larynx.
Laryngeal cancer is the most common cancer of the upper aerodigestive tract. 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. Death from laryngeal cancer is 20 times more likely for the heaviest smokers than for nonsmokers.
It should be suspected in any patient with hoarseness of the voice for three weeks or longer until proven otherwise.
Men are affected more often than women but during the last decade, the number of cases in women has increased such that they now account for about 20% of cases. Most patients are elderly and almost always, are smokers.
Larynx Cancer with Orotracheal invasion
Laryngeal cancer is the most common cancer of the upper aerodigestive tract. 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. Death from laryngeal cancer is 20 times more likely for the heaviest smokers than for nonsmokers.
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