Carcinoma of Larynx

CARCINOMA OF LARYNX
  • The larynx is the second most common site of occurence in the head and neck after the oral cavity.
  • It has a poor prognosis.
POTENTIAL RISK FACTORS TO THE DEVELOPMENT OF LARYNGEAL CARCINOMA
  • Tobacco/Smoking 
  • Excessive ethanol use
  • Male sex(Common in males:M:F-8:1)
  • Infection with human papillomavirus
  • Increasing age(usually occurs after the age of 40 years).
  • Diets low in green leafy vegetables
  • Diets rich in salt preserved meats and dietary fats
  • Exposure to paint/asbestos/radiation,diesel and gasoline fumes
  • Laryngopharyngeal reflux(Reflux laryngitis may produce Subglottic stenosis and Ca larynx)
GROSS PATHOLOGY OF LARYNGEAL CARCINOMA
Sites:
  • Supraglottis(35%)
  • Glottis(65%)(Most common site of Laryngeal carcinoma)
  • Subglottis(5%)
Microscopic Pathology:
  • Squamous cell carcinoma(most common)
  • Variations include verrucous carcinoma, spindle cell carcinoma, basaloid-squamous cell carcinoma, and papillary squamous cell carcinoma.
  • Other malignancies of the larynx are neuroendocrine carcinoma, lymphoepitheliomatous carcinoma, adenocarcinoma, and rare tumors (including sarcomas, lymphomas, adenocarcinomas, and metastases).
Macroscopic presentation:
  • Malignant ulcer/mass/warty growth
Predisposing leasions:
  • Leukoplakia,Papilloma,Keratosis of Larynx : managed by Laser vaporising or stripping of the lesion on vocal cord.
PRESENTATION IN A CASE OF LARNGEAL CARCINOMA
  • Hoarseness of voice(early symptom in Glottic cancer)
  • Dry irritating cough and foreign body sensation
  • Throat pain,Referred ear pain
  • Difficulty in swallowing(pyriform fossa involvement)
  • Hemoptysis
  • Respiratory distress.
  • The most common cause of laryngeal stridor in a 60-year ­old male is Carcinoma larynx.
  • Neck mass(lymph node involvement).
SPREAD OF LARYNGEAL CARCINOMA
  • Local:Base of Tongue,Thyroid,Pyriform Fossa
Lymphatic:
  • Supraglottic(Early nodal metastasis to upper and middle jugular nodes)
  • Glottic(rare,as lymphatics are very sparse)
  • Subglottic(lower cervical lymph nodes/mediastinal lymph nodes)
  • Glottic Carcinoma has the best prognosis as symptoms occur the earliest and lymph node metastasis last.
  • Systemic metastasis:Liver,Lung,Bone.
INVESTIGATIONS IN A CASE OF LARYNGEAL CARCINOMA
  • Biopsy of the ulcer or growth and lymph node.
Direct Larnygoscopy:
  1. Lesions of suprahyoid epiglottis – exophytic
  2. Lesions of infrahyoid epiglottis – ulcerative
  3. Lesion of subglottic region – raised submucosal nodule
  4. Chest X ray: may be indicated because the lungs are the most common site for metastases . 
  • CT scans and MRIs may demonstrate the extension of tumor into vital structures such as the surrounding soft tissue, the preepiglottic space.
  •  They may also show invasion though the thyrohyoid-ligament and cartilage invasion. 
STAGING OF LARYNGEAL CARCINOMA
  • Primary tumor (T)
  • T0: No evidence of primary tumor
  • T is is carcinoma in situ .
Supraglottis
  • T1: Tumor is limited to one subsite of supraglottis with normal vocal cord mobility.
  • T2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (eg, mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.
  • T3: Tumor is 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 erosion (eg, inner cortex).
  • T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
  • T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
Glottis
  • T1: Tumor is limited to the vocal cord or cords (may involve anterior or posterior commissure) with normal mobility.
  • T1a: Tumor is limited to one vocal cord.
  • T1b: Tumor involves both vocal cords.
  • T2: Tumor extends to the supraglottis and/or subglottis, and/or with impaired vocal cord mobility.
  • T3: Tumor is limited to the larynx with vocal cord fixation and/or invades paraglottic space, and or minor thyroid cartilage erosion (eg, inner cortex).
  • T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
  • T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
Subglottis

  • T1: Tumor is limited to the subglottis.
  • T2: Tumor extends to the vocal cord(s), with normal or impaired mobility.
  • T3: Tumor is limited to the larynx with vocal cord fixation.
  • T4a: Tumor invades the cricoid or thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus).
  • T4b: Tumor invades the prevertebral space, encases carotid artery, or invades mediastinal structures.
Regional lymph nodes (N)
  • N0: No regional lymph node metastasis exists.
  • N1: Metastasis is in a single ipsilateral lymph node, 3 cm or less in greatest dimension.
  • N2a: Metastasis is in a single ipsilateral lymph node, more than 3 cm but less than 6 cm in greatest dimension.
  • N2b: Metastasis is in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension.
  • N2c: Metastasis is in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.
  • N3: Metastasis is in a lymph node, more than 6 cm in greatest dimension.
Distant Metastasis (M)
  • M0: No distant metastasis.
  • M1: Distant metastasis.
  • Stage Grouping
  • Stage I :T1 N0 M0
  • Stage II: T2 N0 M0
Stage III
  1. :T3 N0 M0
  2. T1 N1 M0
  3. T2 N1 M0
  4. T3 N1 M0
  • Stage IVA :
  1. T4a N0 M0
  2. T4a N1 M0
  3. T1 N2 M0
  4. T2 N2 M0
  5. T3 N2 M0
  6. T4a N2 M0
  • Stage IV B:
  1. T4b Any N M0
  2. Any T N3 M0
  3. Stage IV C:
  4. Any T Any N M1
TREATMENT OF LARYNGEAL CARCINOMA
  • Early-stage laryngeal carcinomas (stage I-II) are ideally treated with either radiation or surgical techniques (either endoscopic or open) that preserve laryngeal function. Transoral laser microsurgery is ideal for the treatment of early-intermediate glottic and supraglottic cancer.
  • The preferred treatment of verrucous carcinoma of the larynx is Endoscopic removal.
  • Stage III(like T3N1Mo) lesions are treated by Surgery and Radiotherapy or Chemoradiation with organ preservation.
  • Open partial laryngectomy is useful for cancer involving the anterior commissure with or without spread onto the petiole of the epiglottis and for selected advanced tumors (T3 or early T4).
  • Treatment of choice in a patient presenting with carcinoma of the larynx involving the left false cords, left arytenoid and the left aryepiglottic folds with bilateral mobile true cords is Horizontal partial hemilaryngectomy.
  • Advanced-stage larynx cancer (Stages III and IV) is treated by dual-modality therapy with surgery and radiation. For most T3 and T4 tumors, where total laryngectomy is required for the complete removal of the tumor with amply clear margins, organ preservation treatment with combined chemotherapy and radiation therapy is preferred. 
  • Stage T4 lesions glottic cancer are managed by total laryngectomy with neck dissection for clinically positive nodes and post opera­tive radiotherapy if nodes are not palpable. Spinal Accessory nerve may get severed during neck dissection leading to difficulty in elevating thacheostomy:
  1. A patient of carcinoma larynx with stridor presents in casualty, immediate management is Te point of shoulder(Shrugging).Trracheostomy.
  2. Maintenance of airway during laryngectomy in a patient with carcinoma of larynx is best done by Tracheostomy.
  • Indication of Total laryngectomy in Ca larynx 
  1. T3 lesions (i.e. with cord fixed) not amenable to chemoradiation or partial laryngectomy procedures
  2. All T4 lesions
  3. Invasion of thyroid or cricoid cartilage
  4. Bilateral arytenoid cartilage involvement
  5. Lesions of posterior commissure
  6. Failure after radiotherapy or conservation surgery
  7. Transglottic cancers i.e. tumors involving supraglottis and glottis across the ventricle, causing fixation of the vocal cord.
  • Total laryngectomy is contraindicated in patients with distant metastasis.
  • Method of speech communications after laryngectomy include: Electrolarynx ,Oesophageal speech ,Tracheo-oesophageal speech.
Exam Question
  • Referred otalgia can be due to Carcinoma larynx.
  • Treatment of choice in a patient presenting with carcinoma of the larynx involving the left false cords, left arytenoid and the left aryepiglottic folds with bilateral mobile true cords is Horizontal partial hemilaryngectomy.
  • T3 N1 Mo stage of Carcinoma larynx is treated by Surgery and radiotherapy.
  • Smoking increase the risk of Larynx cancer.
  • Management in a 50 year old male chronic smoker complaining of hoarseness of voice for the past 4 months and Microlaryngoscopic biopsy showing it to be keratosis of the larynx is Stop smoking,Laser vaporizer or Stripping of vocal cord.
  • Ca Larynx has poor prognosis.
  • Ca Larynx is commonly seen in males.
  • Method of speech communications after laryngectomy include: Electrolarynx ,Oesophageal speech ,Tracheo-oesophageal speech.
  • Treatment of choice in a case of carcinoma larynx with the involvement of anterior commissure and right vocal cord and perichondritis of thyroid cartilage is laryngectomy and then post-operative radiotherapy.
  • Best treatment modality for a middle aged man diagnosed of having T3N1M0 stage of carcinoma of larynx is Organ preservation treatment with combined chemotherapy and radiation therapy .
  • Elevating the point of the shoulder (shrugging) would be the most likely difficulty in a patient with squamous cell carcinoma of the larynx who has undergone radical neck dissection to remove the tumor and regional lymph nodes and the spinal accessory nerve is severed.
  • Treatment for stage I of cancer larynx (glottic cancer) is either microlaryngoscopic surgery or Radiotherapy.
  • Laryngeal carcinoma is commonly seen after 40 years of age.
  • The most common cause of laryngeal stridor in a 60-year ­old male is Carcinoma larynx.
  • Reflux laryngitis produces Subglottic stenosis and Ca larynx.
  • Premalignant conditions for carcinoma larynx would include: Leukoplakia, Papillomas,Keratosis of larynx
  • Infraglottic carcinoma of larynx commonly spreads to mediastinal nodes.
  • Treatment of choice for carcinoma larynx in stage III is Radiotherapy and Surgery.
  • A patient of carcinoma larynx with stridor presents in casualty, immediate management is Tracheostomy.
  • Maintenance of airway during laryngectomy in a patient with carcinoma of larynx is best done by Tracheostomy.
  • Glottic Ca is the most common in Ca larynx. 
  • The preferred treatment of verrucous carcinoma of the larynx is Endoscopic removal.
  • Treatment of choice for laryngeal carcinoma of glottis extending to supraglottic region with vocal cord fixation with papable solitary ipsilateral lymph node is total laryngectomy with radical neck dissection.
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