Transcript laryngeal malignancy

Laryngeal
Malignancy
Dr. Vishal Sharma
Overview
• Most common head & neck malignancy in adults
• Accounts for 25% of head & neck cancer
• Accounts for 1% of all cancers
• Peak incidence between 55 - 65 years of age
• 10 :1 male predilection
Sites &
subsites
of larynx
Glottis
• Vocal cords
• Anterior commissure
• Posterior commissure
Supraglottis
• Suprahyoid epiglottis
• Aryepiglottic fold
• Arytenoid
• Infrahyoid epiglottis
• Ventricular bands
Subglottis
Incidence
Glottic: 60-75%
Supraglottic: 20-30%
Subglottis: 5-10%
• Squamous cell carcinoma (85%)
• Carcinoma in situ
• Verrucous carcinoma
Types
• Undifferentiated carcinoma
• Adenocarcinoma
• Miscellaneous carcinoma
• Sarcoma
Risk factors
• Tobacco
• Alcohol
• Industrial exposure
• Radiation exposure
• Laryngeal keratosis
• Laryngeal papilloma (HPV 16 & 18)
• Gastro-esophageal reflux disease
• Genetic
Natural
History
Supraglottic
tumors
• More aggressive,
early lymph node
metastasis
Subglottic
tumors
• B/L disease &
mediastinal
extension
Glottic
tumors
• Grow slower &
metastasize late
History taking
Progressive
& continuous
hoarseness
Dysphagia
Hemoptysis
Referred
otalgia
Stridor
Neck
swelling
Examination
Indirect
Laryngoscopy
& Flexible
Laryngoscopy
to look for
malignancy
Examination
of neck: for
lymph node
enlargement
Laryngeal
crepitus:
absent in
post-cricoid
involvement
Laryngeal
cartilage
splaying &
tenderness:
for cartilage
involvement
Investigations
Direct Laryngoscopy & biopsy: for supraglottic tumor
Microlaryngoscopy & biopsy: glottic & subglottic tumors
Panendoscopy: for node metastasis of unknown origin
Contact endoscopy using Toluidine blue: early detection
CT scan: pre-epiglottic & paraglottic extension, cartilage
involvement, extra-laryngeal spread
Positron Emission Tomography: recurrent or residual
tumour detection
Epiglottis malignancy
Ventricular band malignancy
Glottic malignancy
Glottic malignancy
Subglottic malignancy
CT scan: Rt vocal cord tumor
CT scan: cartilage invasion
PET scan: neck node metastasis
PET CT scan: laryngeal malignancy
TNM Classification
UICC (1997)
TX = cannot be assessed
T0: = no evidence
Tis: carcinoma in situ
T1 = limited to one site, normal cord mobility
T2 = adjacent site OR impaired cord mobility
T3 = limited to larynx with hemilarynx fixation
T4a = thyroid / cricoid cartilage, thyroid gland, soft
tissue neck, trachea, esophagus
T4b: Prevertebral space, carotid artery, mediastinum
NX = regional lymph nodes cannot be assessed
N0 = no evidence of regional lymph nodes
N1 = ipsilateral, single, < 3 cm
N2a = ipsilateral, single, > 3 to 6 cm
N2b = ipsilateral, multiple, < 6 cm
N2c = bilateral or contralateral, < 6 cm
N3 = > 6 cm
MX = regional lymph nodes cannot be assessed
M0 = no evidence of regional lymph nodes
M1 = presence of distant metastasis
Supraglottis:
T1 = 1 subsite, normal cord mobility
T2 = > 1 adjacent subsites, no fixation of hemilarynx
Glottis:
1a = 1 vocal cord only, normal cord mobility
1b = both vocal cords, normal cord mobility
T2 = supraglottis / subglottis; OR impaired cord mobility
Subglottis:
T1 = limited to subglottis, normal cord mobility
T2 = extension to glottis OR impaired cord mobility
Stage 0 = Tis NO MO
Stage I = T1 NO MO
Stage II = T2 NO MO
Stage III = presence of T3 or N1
Stage IVA = presence of T4 or N2
Stage IVB = presence of N3
Stage IVC = presence of M1
Treatment of
Laryngeal Malignancy
Definitive Treatment
• Radical Surgery
• Radical Radiotherapy (6000 cGray over 6 weeks)
• Chemotherapy: 5 Fluorouracil & Cisplatin
• Surgery with post-op Radiotherapy
• Radical Radiotherapy with salvage surgery
• Chemo-radiation (organ preservation)
Surgical Treatment
Glottic malignancy

Cordectomy

Frontal vertical partial laryngectomy

Lateral vertical partial laryngectomy

Fronto-lateral vertical partial laryngectomy

Extended fronto-lateral partial laryngectomy

Conventional VPL (hemi-laryngectomy)
Cordectomy
Frontal VPL
Lateral VPL
Fronto-lateral VPL
Subtotal bifrontal
laryngectomy
Conventional VPL:
hemi-laryngectomy
Extended hemi-laryngectomy
Supraglottic malignancy

Epiglottectomy

Supraglottic (horizontal partial) laryngectomy

Extended supraglottic laryngectomy
Trans-glottic malignancy

Subtotal laryngectomy (supra-cricoid laryngectomy
with crico-hyoido-pexy)

Three-fourth laryngectomy

Near-total laryngectomy
Supraglottic Laryngectomy
Supraglottic Laryngectomy
Supraglottic Laryngectomy
Three-fourth Laryngectomy
Supra-cricoid Laryngectomy
Supra-cricoid Laryngectomy
+ Crico-hyoido-pexy
Near-total Laryngectomy
Near-total Laryngectomy
Near-total Laryngectomy
Advanced malignancy
1. Total Laryngectomy

Narrow field: removal of entire larynx only

Wide field: removal of entire larynx, hyoid bone,
partial pharynx, strap muscles & I/L thyroid lobe
2. Extended (widespread ) total laryngectomy: wide
field total laryngectomy + resection of surrounding
structures (base of tongue, pharynx, thyroid gland)
Narrow field total laryngectomy
Total Laryngectomy
Repair of hypopharynx
Inferior constrictor approximated
Permanent tracheostome
Laryngectomy specimens
Treatment planning
Supraglottis
T1 & T2 tumor limited to supraglottis: Radiotherapy or
Supraglottic laryngectomy
T2 tumor involving glottis: Supracricoid Laryngectomy
or Radiotherapy
T3 & T4 tumor:
Total laryngectomy + post-operative Radiotherapy
or Radical Radiotherapy with salvage surgery
or Chemo-radiation
Glottis
Tis (Ca in situ): Radiotherapy or Endoscopic excision
T1a: Radiotherapy or Vertical Partial Laryngectomy
T1b tumor: Radiotherapy or Supracricoid Laryngectomy
T2 supraglottis: Supracricoid Laryngectomy or RT
T2 involving subglottis: Near-total or Total Laryngectomy
T2 impaired cord mobility: Supracricoid Laryngectomy or RT
T3 & T4 tumor: Total laryngectomy + post-operative RT
or Radical Radiotherapy with salvage surgery
or Chemo-radiation
Subglottis
T1: Total Laryngectomy + hemithyroidectomy or RT (?)
T2: Total Laryngectomy + hemithyroidectomy
T3 & T4: Total Laryngectomy + hemithyroidectomy
+ post-operative Radiotherapy
Neck nodes
N0: B/L selective dissection of levels 2, 3 & 4
or B/L Radiotherapy
N1: B/L modified radical neck dissection
N2 & N3: B/L modified radical neck dissection
+ post-operative Radiotherapy
Voice Rehabilitation
A. Esophageal voice
B. Artificial larynx: Pneumatic, Electrical
C. Shunt technique
1. tracheo-hypopharyngeal shunt
2. esophago-tracheal shunt
D. Valved devices for tracheo-esophageal puncture
1. Blom Singer prosthesis
2. Panje button device
3. Provox prosthesis
E. Surgical reconstruction of larynx
1. Laryngeal replacement (Teflon, Dacron)
2. Laryngeal transplant
Electronic Larynx
Tracheo-esophageal prosthesis
Palliative Care
Used in later stages to ameliorate symptoms
1. Debulking surgery (Laser-assisted)
2. Radiotherapy (short-course)
3. Chemotherapy
4. Tracheostomy
5. Counseling
Thank You