Unformatted text preview: Laryngeal Carcinoma:
Ryan Eric Neilan
For the Dept of Otolaryngology
University of Texas Medical Branch
July 20, 2007 Overview
Overview 11,000 new cases of laryngeal cancer per year in the U.S. Accounts for 25% of head and neck cancer and 1% of all cancers Onethird of these patients eventually die of their disease Most prevalent in the 6th and 7th decades of life Overview
Overview 4:1 male predilection Downward shift from 15:1 post WWII Due to increasing public acceptance of female smoking More prevalent among lower socioeconomic class, in which it is diagnosed at more advanced stages Subtypes
Subtypes Glottic Cancer: 59% Supraglottic Cancer: 40% Subglottic Cancer: 1% Most subglottic masses are extension from glottic carcinomas History
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. Crown Prince Frederick of Germany History
History Was evaluated by Sir Makenzie of London, the inventor of the direct laryngoscope Frederick’s lesion was biopsied and thought to be cancer He refused laryngectomy and later died in 1888 History
History Frederick was succeeded by Kaiser Wilhelm II, who along with Otto von Bismark militarized the German Empire and led them into WW I Could an Otolaryngologist have prevented WW I? Risk Factors
Risk Factors Risk Factors
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
Risk Factors Human Papilloma Virus 16 &18 Chronic Gastric Reflux Occupational exposures Prior history of head and neck irradiation Histological Types
Histological Types 8595% 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
Histological Types Verrucous Carcinoma Fibrosarcoma Chondrosarcoma Minor salivary carcinoma Adenocarcinoma Oat cell carcinoma Giant cell and Spindle cell carcinoma Anatomy
Anatomy Natural History
Natural History Supraglottic tumors more aggressive: – Direct extension into preepiglottic space
– Lymph node metastasis
– Direct extension into lateral hypopharnyx, glossoepiglottic fold, and tongue base Natural History
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
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
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
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
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
Presentation Other symptoms include: – Dysphagia
– Throat pain
– Ear pain
– Airway compromise
– Neck mass Work up
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
Work up Other potential modalities: – Direct laryngoscopy
– Chest Xray
– CT or MRI
– Liver function tests with or without US
– PET ? Staging Primary Tumor (T)
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
T2 Tumor limited to one subsite of supraglottis with normal vocal cord mobility 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) T4b 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) Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures T4b 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
Bilateral or contralateral lymph nodes, each ≤6cm Single or multiple lymph nodes > 6cm N2c
N3 Staging Metastasis
M0 No distant metastases
M1 Distant metastases present Stage Groupings
Any T N0
Any N M0
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
Treatment Early stage (T1 and T2) can be treated with radiotherapy or surgery alone, both offer the 8595% cure rate. Surgery has a shorter treatment period, saves radiation for recurrence, but may have worse voice outcomes Radiotherapy is given for 67 weeks, avoids surgical risks but has own complications Treatment
Treatment XRT complications include: – Mucositis
– Laryngeal edema
– Stricture and fibrosis
– Hypothyroidism Treatment
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
Treatment Adjuvant radiation is started within 6 weeks of surgery and with once daily protocols lasts 67 weeks
Indications for postop 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, CIS margins, subglottic extension of primary tumor. Treatment
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
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 Treatment
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 IIIV Surgical Options
Surgical Options Hemilaryngectomy
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
Supraglottic laryngectomy T1,2, or 3 if only by preepiglottic space invasion
No anterior commissure involvement
No tongue base disease past circumvallate papillae
Apex of pyriformsinus not invloved Supracricoid Laryngectomy
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
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
Total Laryngectomy Total Laryngectomy
Total Laryngectomy Total Laryngectomy
Total Laryngectomy Total Laryngectomy
Total Laryngectomy Voice Rehabilitation
Voice Rehabilitation Tracheostomal prosthesis Electrolarynx Pure esophageal speech Complications
Complications Inaccurate staging
Loss of taste and smell
Injury to cranial nerves: VII, IX, X, XI, XII
Stroke or carotid “blowout”
Radiation induced fibrosis Prognosis
5 year survival
Stage IV >95%
5060% After initial treatment patients are followed at 46 week intervals. After first year decreases to every 2 months. Third and fourth year every three months, with annual visits after that Prognosis
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 References
References Malignant Tumors of the Larynx and Hypopharynx . Cummings Otolaryngology Head and Neck Surgery. 4th ed., Mosby, 2005.
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Wolf, GT. The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction Chemotherapy Plus Radiation Compared with Surgery Plus Radiation in Patients with Advanced Laryngeal Cancer. New England Journal of Medicine. 1991; 324: 168590.
Lefebre J, Chevalier D, Luboinski B, Kirkpatrick A, Collette L, Sahmoud T. Larynx Preservation in Pyriform Sinus Cancer: Preliminary Results of a European Organization for Research and Treatment of Cancer Phase III Trial. Journal of the National Cancer Institute. Jul 1996. 88(13): 890899.
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- Fall '11
- Johannesburg, M1 motorway, total laryngectomy, vocal cord, vocal cord fixation