Laryngeal Carcinoma - PowerPoint Presentation

Slide1

Laryngeal Carcinoma:

BY-DR.SUDEEP K.C.Slide2

OverviewAccounts for 25% of head and neck cancer and 1% of all cancersOne-third of these patients eventually die of their diseaseMost prevalent in the 6th and 7th decades of lifeSlide3

Overview4:1 male predilectionDue to increasing public acceptance of female smokingMore prevalent among lower socioeconomic class, in which it is diagnosed at more advanced stagesSlide4

SubtypesGlottic Cancer: 59%Supraglottic Cancer: 40%Subglottic Cancer: 1%Most subglottic masses are extension from glottic carcinomasSlide5

HistoryThe first laryngectomy for cancer of the larynx was performed in 1883 by BillrothPatient was successfully fed by mouth and fitted with an artificial larynxIn 1886 the Crown Prince Frederick of Germany developed hoarseness as he was due to ascend the throne.Slide6

HistoryWas evaluated by Sir Makenzie of London, the inventor of the direct laryngoscopeFrederick’s lesion was biopsied and thought to be cancerHe refused laryngectomy and later died in 1888Slide7

Risk FactorsProlonged use of tobacco and excessive EtOH use primary risk factorsThe two substances together have a synergistic effect on laryngeal tissues90% of patients with laryngeal cancer have a history of bothSlide8

Risk FactorsHuman Papilloma Virus 16 &18Chronic Gastric RefluxOccupational exposuresPrior history of head and neck irradiationSlide9

Histological Types85-95% of laryngeal tumors are squamous cell carcinomaHistologic type linked to tobacco and alcohol abuseCharacterized by epithelial nests surrounded by inflammatory stromaKeratin Pearls are pathognomonicSlide10

Histological TypesVerrucous CarcinomaFibrosarcomaChondrosarcomaMinor salivary carcinomaAdenocarcinomaOat cell carcinomaGiant cell and Spindle cell carcinomaSlide11

AnatomySlide12

AnatomySlide13

AnatomySlide14

AnatomySlide15

AnatomySlide16

AnatomySlide17

Natural HistorySupraglottic tumors more aggressive:Direct extension into pre-epiglottic spaceLymph node metastasisDirect extension into lateral hypopharnyx, glossoepiglottic fold, and tongue baseSlide18

Natural HistoryGlottic tumors grow slower and tend to metastasize late owing to a paucity of lymphatic drainageThey tend to metastasize after they have invaded adjacent structures with better drainageExtend superiorly into ventricular walls or inferiorly into subglottic spaceCan cause vocal cord fixationSlide19

Natural HistoryTrue subglottic tumors are uncommonGlottic spread to the subglottic space is a sign of poor prognosisIncreases chance of bilateral disease and mediastinal extensionInvasion of the subglottic space associated with high incidence of stomal reoccurrence following total laryngectomy (TL)Slide20

PresentationHoarsenessMost common symptomSmall irregularities in the vocal fold result in voice changesChanges of voice in patients with chronic hoarseness from tobacco and alcohol can be difficult to appreciateSlide21

PresentationPatients presenting with hoarseness should undergo an indirect mirror exam and/or flexible laryngoscope evaluationMalignant lesions can appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal colorVideostrobe laryngoscopy may be needed to follow up these subtler lesionsSlide22

PresentationGood neck exam looking for cervical lymphadenopathy and broadening of the laryngeal prominence is requiredThe base of the tongue should be palpated for masses as well.Restricted laryngeal crepitus may be a sign of post cricoid or retropharyngeal invasionSlide23

PresentationOther symptoms include:DysphagiaHemoptysisThroat painEar painAirway compromiseAspirationNeck massSlide24

Work upBiopsy is required for diagnosisPerformed in OR with patient under anesthesiaOther benign possibilities for laryngeal lesions include: Vocal cord nodules or polyps, papillomatosis, granulomas, granular cell neoplasms, sarcoidosis, Wegner’s granulomatosisSlide25

Work upOther potential modalities:Direct laryngoscopyBronchoscopyEsophagoscopyChest X-rayCT or MRILiver function tests with or without USPET ?Slide26

TXMinimum requirements to assess primary tumor cannot be met

T0

No evidence of primary tumor

Tis

Carcinoma in situ

Staging- Primary Tumor (T)Slide27

Staging- SupraglottisT1

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)

T4b

Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Slide28

Staging- GlottisT1

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 Slide29

Staging- SubglottisT1

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 Slide30

Staging- NodesN0

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 Slide31

Staging- MetastasisM0

No distant metastases

M1

Distant metastases presentSlide32

Stage Groupings0

Tis

N0

M0

I

T1

N0

M0

II

T2

N0

M0

III

T3

N0

M0

T1-3

N1

M0

IVA

T4a

N0-2

M0

T1-4a

N2

M0

IVB

T4b

Any N

M0

Any T

N3

M0

IVC

Any T

Any N

M1Slide33

TreatmentPremalignant lesions or Carcinoma in situ can be treated by surgical stripping of the entire lesionCO2 laser can be used to accomplish this but makes accurate review of margins difficultSlide34

TreatmentEarly 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 outcomesRadiotherapy is given for 6-7 weeks, avoids surgical risks but has own complicationsSlide35

TreatmentXRT complications include:MucositisOdynophagiaLaryngeal edemaXerostomiaStricture and fibrosisRadionecrosisHypothyroidismSlide36

TreatmentAdvanced stage lesions often receive surgery with adjuvant radiationMost T3 and T4 lesions require a total laryngectomySome small T3 and lesser sized tumors can be treated with partial larygectomySlide37

TreatmentAdjuvant radiation is started within 6 weeks of surgery and with once daily protocols lasts 6-7 weeksIndications 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.Slide38

TreatmentChemotherapy can be used in addition to irradiation in advanced stage cancersTwo agents used are Cisplatinum and 5-flourouracilCisplatin thought to sensitize cancer cells to XRT enhancing its effectiveness when used concurrently.Slide39

TreatmentInduction chemotherapy with definitive radiation therapy for advanced stage cancer is another optionStudies have shown similar survival rates as compared to total laryngectomy with adjuvant radiation but with voice preservation.Role in treatment still under investigationSlide40

HemilaryngectomyNo more than 1cm subglottic extension anteriorly or 5mm posteriorlyMobile affected cordMinimal anterior contralateral cord involvementNo cartilage invasionNo neck soft tissue invasionSlide41

Supraglottic laryngectomyT1,2, or 3 if only by preepiglottic space invasionMobile cordsNo anterior commissure involvementFEV1 >50%No tongue base disease past circumvallate papillaeApex of pyriform sinus not invlovedSlide42

Supracricoid LaryngectomyResection of true vocal cords, supraglottis, thyroid cartilageLeave arytenoids and cricoid ring intactHalf of patients remain dependent on tracheostomySlide43

Total LarygectomyIndications:T3 or T4 unfit for partialExtensive involvement of thyroid and cricoid cartilagesInvasion of neck soft tissuesTongue base involvement beyond circumvallate papillaeSlide44

Voice RehabilitationTracheostomal prosthesisElectrolarynxPure esophageal speechSlide45

ComplicationsInaccurate stagingInfectionVoice alterationsSwallowing difficultiesLoss of taste and smellFistulaTracheostomy dependenceInjury to cranial nerves: VII, IX, X, XI, XIIStroke or carotid “blowout”HypothyroidismRadiation induced fibrosisSlide46

Prognosis5 year survival

Stage I

>95%

Stage II

85-90%

Stage III

70-80%

Stage IV

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 thatSlide47

PrognosisPatients considered cured after being disease free for five yearsMost laryngeal cancers reoccur in the first two yearsDespite advances in detection and treatment options the five year survival has not improved much over the last thirty years