Laryngeal Carcinoma

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 6th and 7th decades of life Overview 4:1 male predilection Due to increasing public acceptance of female smoking

More prevalent among lower socioeconomic class, in which it is diagnosed at more advanced stages Subtypes Glottic Cancer: 59% Supraglottic Cancer: 40% Subglottic Cancer: 1%

Most subglottic masses are extension from glottic carcinomas History The 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. History Was 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 1888 Risk Factors Prolonged 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 both Risk Factors Human Papilloma Virus 16 &18 Chronic Gastric Reflux

Occupational exposures Prior history of head and neck irradiation 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 Anatom y o at An y

m AN AT OM Y T A AN Y M O An

a to m y Anatomy Natural History Supraglottic tumors more aggressive: Direct extension into pre-epiglottic space Lymph node metastasis Direct extension into lateral hypopharnyx,

glossoepiglottic fold, and tongue base Natural History Glottic tumors grow slower and tend to metastasize late owing to a paucity of lymphatic drainage They tend to metastasize after they

have invaded adjacent structures with better drainage Extend superiorly into ventricular walls or inferiorly into subglottic space Can cause vocal cord fixation Natural History

True subglottic tumors are uncommon Glottic spread to the subglottic space is a sign of poor prognosis Increases chance of bilateral disease and mediastinal extension Invasion of the subglottic space associated with high incidence of stomal reoccurrence following total laryngectomy (TL) 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 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 Videostrobe laryngoscopy may be needed to follow up these subtler lesions 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 Presentation

Other symptoms include: Dysphagia Hemoptysis Throat pain Ear pain Airway compromise Aspiration Neck mass 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, Wegners granulomatosis Work up Other potential modalities: Direct laryngoscopy Bronchoscopy

Esophagoscopy Chest X-ray CT or MRI Liver function tests with or without US PET ? Staging- Primary Tumor (T) TX Minimum requirements to assess primary tumor cannot be met T0 No evidence of primary tumor

Tis Carcinoma in situ Staging- Supraglottis T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility T2 Tumor 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

T3 Tumor 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) T4a Tumor 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) T4 b Tumor invades prevertebral space, encases carotid artery, or

invades mediastinal structures Staging- Glottis T1 Tumor limited to the vocal cord (s) (may involve anterior or posterior commissure) with normal mobilty 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 invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) T4a Tumor 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 T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging- Subglottis T1 Tumor limited to the subglottis T2 Tumor extends to vocal cord (s) with normal or impaired mobility

T3 Tumor limited the larynx with vocal cord fixation T4a Tumor 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) T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

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 Staging- Metastasis M0 No distant metastases M1 Distant metastases present Stage Groupings 0 I II III IVA IVB

IVC Tis T1 T2 T3 T1-3 T4a T1-4a T4b Any T Any T N0 N0 N0

N0 N1 N0-2 N2 Any N N3 Any N M0 M0 M0 M0 M0 M0 M0 M0

M0 M1 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

Adjuvant radiation is started within 6 weeks of surgery and with once daily protocols lasts 6-7 weeks Indications 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, margins<5mm, positive margins, subglottic extension of primary tumor. 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

Induction chemotherapy with definitive radiation therapy for advanced stage cancer is another option Studies have shown similar survival rates as compared to total laryngectomy with adjuvant radiation but with voice preservation. Role in treatment still under investigation

HEMILARYNGECTOMY No more than 1cm subglottic extension anteriorly or 5mm posteriorly Mobile affected cord Minimal anterior contralateral cord involvement No cartilage invasion No neck soft tissue invasion 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 SUPRACRICOID LARYNGECTOMY

Resection of true vocal cords, supraglottis, thyroid cartilage Leave arytenoids and cricoid ring intact Half of patients remain dependent on tracheostomy 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 Voice Rehabilitation Tracheostomal prosthesis

Electrolarynx Pure esophageal speech Complications

Inaccurate staging Infection Voice alterations Swallowing difficulties Loss of taste and smell Fistula Tracheostomy dependence Injury to cranial nerves: VII, IX, X, XI, XII Stroke or carotid blowout Hypothyroidism Radiation induced fibrosis Prognosis

5 year survival Stage I Stage II Stage III Stage IV >95% 85-90% 70-80% 50-60% 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 that Prognosis Patients considered cured after being disease free for five years Most laryngeal cancers reoccur in the first two years Despite advances in detection and treatment options the five year survival has not improved much over

the last thirty years

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