2 MALIGNANT TUMORS OF THE LARYNX AND HYPOPHARYNX Chapter 99Department of Oto-Rhino-Laryngolog of Isfahan Medical University
3 INTRODUCTIONsimilarities between malignant tumors of the larynx and hypopharynx in relationship to etiologyLaryngeal carcinomas are more prevalent in heavy smokers, present earliehypopharyngeal carcinomas present late, have a high association with alcoholism and other disorders, and commonly present with cervical metastatic disease.
4 INCIDENCE m/f incidence from 15:1 5:1 in 2004 incidence of hypopharyngeal/larynx tumors :1/3smoked 40 or more cigarettes daily had an age-adjusted death rate of 15/100,000 0.6/100,000 : among nonsmokers.Rolled cigarettes are also more dangerous than commercially packaged cigarettesA recent French study showed a 13-fold increase in laryngeal cancer for smokers, and those consuming more than 1.5 L/day of wine had a 34-fold increased risk
5 RF For larynx tumor Cigarettes and alcohol Chemical carcinogens : asbestos, nickel compounds, and certain mineral oilsGenetics and susceptibility to:1-secondary primary tumor.2-Aneuploidy dysplasia to head and neck cancer 3-Genetic alterations of chromosomal region 9p21.4-mutant p53 (suppressive gene )HPV DNA??gastroesophageal reflux
7 RF FOR HYPOPHARYNGEAL CANCER postcricoid carcinoma, (F>M), all forms of hypopharyngeal malignancy M>>F AT: 55 to 70Y. heavy alcohol ingestion, and heavy smokingPlummer-Vinson syndrome postcricoid carcinomaPlummer-Vinson or Paterson-Brown-Kelly Syndrome :dysphagia, hypopharyngeal and esophageal webs, weight loss, and iron deficiency anemia in women aged 30 to 50
8 Second Primary Malignancies Patients with hypopharynx CA : significant risk of a second primary malignancy OR metachronous malignancy. The likelihood of a second primary tumor developing for head and neck cancer is 12.8%The likelihood of a second primary tumor developing increases with time and is 23% at 8 yearsall patients with second primary tumor had a history of >50 pack-years of smoking.The hypopharyngeal area was the third most common site for patients with floor of mouth cancers to have a second primary malignancy
9 HX laryngeal cancers are detected at an earlier Most patients with hypopharyngeal cancers (70%) manifest stage III disease.Hypopharyngeal tumors can cause a chronic sore throat, dysphagia, or referred otalgia and are thus managed with antibiotics, because the process is mistakenly attributed to infectious disease.The rich lymphatic network in the submucosal tissue surrounding the hypopharynx allows early spread
10 ANATOMY AND EMBRYOLOGY hypopharynx tracheobronchial primordium (arch 4 or 5) in the midline Fusionsupraglottis buccopharyngeal primordium (arch 3 or 4) without a midline mergerThe supraglottis superior laryngeal nerve as the nerve of the 3th arch and the superior thyroid artery as its vascular supply.In contrast, arches 4 and 6 create the glottis and subglottisthe theory : separate derivation explains why supraglottic tumors of substantial bulk do not spread across the laryngeal ventricle to the vocal cord. This region was confirmed as a barrier to tumor spreadTransglottic tumors cross the ventricle and may initiate as supraglottic or glottic cancers. As they enlarge, these tumors fail the compartmentalization thesis by direct mucosal extension or through the paraglottic space.
12 Diagnosiseducated the public to seek evaluation for hoarseness persisting longer than 4 weeksDysphagia& :common symptom of supraglottic or hypopharyngeal carefractory asthma without voice change common symptom of subglott caDX:Laryngoscopy(vc &biopsy)\CT MRI(LN)
13 Diagnosis of Hypopharyngeal Cancer hX of heavy alcohol ingestion; heavy smoking;persistent dysphagia, persistent sore throat, or a foreign body sensation. The average duration : 2 to 4 months.. A later symptom is referral otalgia, 20% : asymptomatic neck mass, (ipsilateral, a jugulodigastric or midjugular lymph node )Radiologic Assessment of the Larynx and Hypopharynx :CT(1-preepiglottic space and paraglottic space involvement 2-EeosionThyroid cartilage destruction :best by CT total laryngectomy (T4 stage)MRI using T2-weighted images may be superior to highlight submucosal tumor extension into the preepiglottic and paraglottic spaces
14 Endoscopic Evaluation of the Larynx and Hypopharynx Cord mobility is best assessed preoperatively.fixation of the cord is differentiated from arytenoid fixation by palpation of the vocal process and can help stage the disease.NO flexible esophagogastrostomy &N0 barium swallowEndoscopy is also required to rule out the existence of a second or concurrent malignancy
15 Assessment of Precancerous Laryngeal Lesions Biopsy is always needed to confirm the diagnosis,gross appearance of 1- fungal laryngitis, 2-sarcoidosis,3- tuberculosis, or4- Wegener's granulomatosis can be mistaken for advanced carcinomaSmall suspicious lesions should be completely excised with a border of healthy laryngeal submucosalarge lesions should be adequately sampled with the laryngeal biopsy forceps to measure invasion below the basement membranePseudoepitheliomatous hyperplasia (granular cell myoblastoma) of the supraglottic larynx may be misdiagnosed as carcinoma
16 Staging- Primary Tumor (T) TXMinimum requirements to assess primary tumor cannot be metT0No evidence of primary tumorTisCarcinoma in situ
17 Staging- Supraglottis Tumor limited to one subsite of supraglottis with normal vocal cord mobilityT2Tumor 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 fixationT3Tumor 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)T4aTumor 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)T4bTumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
18 Staging- GlottisT1Tumor limited to the vocal cord (s) (may involve anterior or posterior commissure) with normal mobiltyT1aTumor limited to one vocal cordT1bTumor involves both vocal cordsT2Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobilityT3Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex)T4aTumor 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 esophagusT4bTumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
19 Staging- Subglottis T1 Tumor limited to the subglottis T2 Tumor extends to vocal cord (s) with normal or impaired mobilityT3Tumor limited the larynx with vocal cord fixationT4aTumor 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)T4bTumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
20 Staging- Nodes N0 No cervical lymph nodes positive N1 Single ipsilateral lymph node ≤ 3cmN2aSingle ipsilateral node > 3cm and ≤6cmN2bMultiple ipsilateral lymph nodes, each ≤ 6cmN2cBilateral or contralateral lymph nodes, each ≤6cmN3Single or multiple lymph nodes > 6cm
23 MANAGEMENT OF PREMALIGNANT LESIONS AND CA IN SITU five categories with 1-hyperkeratosis, 2-hyperkeratosis with atypia3- carcinoma in situ (CIS)4- superficially invasive carcinoma,5- invasive carcinomaWhen :1-hyperkeratosis with atypia and often 2-CIS, TX conservative strip of cord is removed. :( microscopically removed). F/up and rebiopsy: 6 to 12 W laterManagement of precancerous lesions is conservative surgery. : radiotherapy may fail (10%),Many surgeons believe that unless the patient is unreliable, is a significant risk for repeat GA, or lives far away, radiation is a second choice for this disease
24 MANAGEMENT OF LARYNGEAL CANCER Glottic Cancer for T1 lesions, surgery 90% to 95% cure rates --_>radiotherapy(cure rates of 75% to 90%.)Partial surgery(no radiotherapy):1)decreasing importance vocal cord mobility,2) subglottic extension,3) anterior commissure invasion,4) arytenoid cartilage involvement.The middle third of vocal fold lesions endoscopic, laser resection, or open cordectomy. (Cure rates =100% -with good margins _)&95% cure rate for radiotherapy.
25 MANAGEMENT OF Glottic Cancer 50% of radiotherapy failures for T1 glottic cancer failed at the anterior commissure.Hypomobility of the vocal fold reduces the cure rates and emphasizes the advantage of surgery over radiotherapyT2 tumors managed by primary radiotherapy showed a 30% local failure rate, which, when surgically salvaged, improved to 94%T2 lesions classification be divided into T2a and T2b on the basis of mobility. In this analysis, a 70% local control rate was noted for the former category vs 51% in the latterT2 and early T3 lesions of the glottis have more recently been managed by supracricoid laryngectomy with cricohyoidoepiglottopexy.cricohyoidoepiglottopexy.= resection of the entire thyroid cartilage and paraglottic spaceThe cricoid cartilage, the hyoid bone, much of the epiglottis and at least one arytenoid cartilage must be conserved.cricohyoidoepiglottopexy. have satisfactory deglutition, phonation, and 100% decannulation with a 5% local recurrence rate.
26 CRITERIA FOR HEMILARYNGECTOMY FOR RECURRENT CANCER AFTER RADIOTHERAPY Lesion limited to one cord (may involve the anterior commissure)Body of arytenoid free of tumorSubglottic extension no >5 mmMobile cordNo cartilage invasionRecurrence correlating with initial tumor
27 Subglottic Cancer is unusual, with only 1% located 1 cm below the vocal cord =arise below the conus elasticusThe clinical presentation : airway obstruction;spread locally cricoid cartilage and thyroid glandwith lymphatic spread lower deep jugular nodes, the Delphian node (prelaryngeal), and the paratracheal nodes .Management requires1) total laryngectomy+2)Ipsilateral thyroidectomy and3) paratracheal node dissection 4) positive nodes or deep invasion, postoperative radiotherapy to include the superior mediastinum is needed to prevent stomal recurrence.stage T4 or T3 glottic carcinoma total laryngectomy ipsilateral nodes(in most cases ), =20% risk metastasis
28 Late-Stage DiseaseObstructive laryngeal premanagement tracheostomy increased local or stomal recurrenceIf a tracheostomy is necessary, surgery within 48 hours+bilateral paratracheal node dissection+ postoperative mantle radiotherapy.Recurrence at the stoma after laryngectomy is grave extensive penetrationsubglottic cancer is most associated with stomal recurrence because the Delphian and paratracheal drainage ports are presumed to be the pathway to recurrenceeven aggressive management of stomal recurrence is morbid and often unsuccessful, prevention of recurrence is paramountrisk of infiltration is high, the1) thyroid gland, at least ipsilateral, is removed and2) bilateral paratracheal node dissections are accomplished and3) postsurgical radiation used. includes the upper mediastinum and paratracheal beds.
29 Late-Stage DiseaseHemithyroidectomy or subtotal thyroidectomy is recommended1- for cases of palpable abnormality,2-subglottic tumors,3- or glottic tumors with >1 cm of subglottic extension,4-T4 glottic tumors, and T4 piriform sinus tumors.Thyroid function is reduced after larynx cancer management that includes radiotherapy or extensive laryngeal and thyroid surgery depressed and lethargic months after management may be hypothyroid;Follow-up : at 6 months, 1 year, and when clinically indicated thereafter
30 Supraglottic CancerEarly supraglottic (epiglottic) tumors, which are suprahyoid, can be grossly excised endoscopicallybut infrahyoid tumors do not fare so well with only laser resection endoscopic laser partial laryngectomypreepiglottic space has been invaded in up to 50% of cases of infrahyoid carcinoma, which cannot be predicted even if CT and physical examination are used.frequent postoperative x-ray therapy is used for indications at the primary site vs a rare need for this accompanying N0 supraglottic laryngectomy.more central supraglottic lesions have less metastatic potential than aryepiglottic fold or lateral epiglottic sites
31 Supraglottic CancerLimited supraglottic tumors, which are defined as T1 to T3 supraglottic laryngectomy (if the vocal cord is mobile).Arytenoid involvement allowed partial surgery +complications with swallowing,Extended resections that removal of the vallecula and base of the tongue up to the level of the circumvallate papillaPatient selection for supraglottic laryngectomy is important (Younger, and good pulmonary reserve..)to tolerate the mild-to-moderate aspiration
32 Limitations to supraglottic laryngectomy Include1) thyroid cartilage invasion or anterior commissure involvement,2) Involvement of the glottis and vocal cord fixation paraglottic space invasion are relative contraindications to partial surgery,3) Cricoid cartilage involvement clearly mandates against a supraglottic laryngectomy, because swallowing is severely impaired with laryngeal preservation and cricoid cartilage resection.4) Bilateral arytenoid cartilage involvement is an absolute contraindication to supraglottic laryngectomyRadiotherapy seems to offer less local control than supraglottic laryngectomy73% 5-year survival after supraglottic surgery actuarial 4-year survival is 50%, and cancer-free survival is 74%
33 EXTENSION OF SUPRAGLOTTIC LARYNGECTOMY Subtotal laryngectomy with cricohyoidopexy ( a functional laryngectomy) for carcinoma extended to the 1)true vocal cord, the ventricle, 2)involving the thyroid cartilage and the paraglottic space.The resection includes the entire thyroid cartilage, the paraglottic space, the epiglottis and the entire preepiglottic space. To be successful, the cricoid cartilage, hyoid bone, and at least one arytenoid cartilage must be spared.Control of the neck is the most important aspect of managing supraglottic tumors,