4EtiologyThe incidence of laryngeal tumors is closely correlated with smoking, as head and neck tumors occur 6 times more often among cigarette smokers than among nonsmokers.The age-standardized risk of mortality from laryngeal cancer appears to have a linear relationship with increasing cigarette consumption.
5EtiologyDeath from laryngeal cancer is 20 times more likely for the heaviest smokers than for nonsmokers.The use of unfiltered cigarettes or dark, air-cured tobacco is associated with further increases in risk.
6Risk Factors<<< Although alcohol is a less potent carcinogen than tobacco, alcohol consumption is a risk factor for laryngeal tumors.In individuals who use both tobacco and alcohol, these risk factors appear to be synergistic, and they result in a multiplicative increase in the risk of developing laryngeal cancer.
7Risk Factors Human Papilloma Virus 16 &18 Chronic Gastric Reflux Occupational exposuresPrior history of head and neck irradiation
8Mortality/MorbidityThe prognosis for small laryngeal cancers that do not have lymph node metastases is good, with cure rates of 75-95%, depending on the site, the size of the tumor, and the extent of infiltration.Advanced disease has a worse prognosis.Supraglottic cancers usually manifest late and have a poorer prognosis.
9Sex & Age IncidenceIn the 1950s, the male-to-female ratio in patients with laryngeal cancer was 15:1.This number had changed to 5:1 by the year 2000, and the proportion of women afflicted by the disease is projected to increase in years to come.These changes are likely a reflection of shifts in smoking patterns, with women smoking more in recent years.Laryngeal cancer most commonly affects men middle-aged or older. The peak incidence is in those aged years.
10Histological 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 pathognomonic
11Histological Types Verrucous Carcinoma Fibrosarcoma Chondrosarcoma Minor salivary carcinomaAdenocarcinomaOat cell carcinomaGiant cell and Spindle cell carcinoma
13The supraglottic larynx It consists of epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids
14The glottic larynxIt consists of the true vocal cords and anterior commissure and posterior commissure
15The subglottic larynxIt consists of the region between the vocal cords and the trachea.
16Pre-epiglottic fat space The pre-epiglottic fat is located in the anterior and lateral aspects of the larynx and is often invaded by advanced cancers.
17LymphaticsThe first-echelon lymphatics for the supraglottic larynx are the subdigastric nodes and the middle anterior cervical nodes and the second-echelon lymphatics are the lower anterior cervical nodesThe first-echelon lymphatics for the subglottic larynx are the Delphian node, the lower anterior cervical nodes and paratracheal nodes, and the supraclavicular nodes, and the second-echelon lymphatics are the mediastinal nodes.Glottic and subglottic tumors metastasize to ipsilateral lymph nodes, but supraglottic tumors often spread to nodes on both sides of the neck.
18In the supraglottis, the T stages are as follows T1: Tumor limited to 1 subsite of the supraglottis with normal vocal cord mobilityT2: Tumor invasion of the mucosa of more than 1 adjacent subsite of the supraglottis or glottis or of a region outside the supraglottis , without fixation of the larynxT3: Tumor limited to the larynx with vocal cord fixation and/or invasion of any of the postcricoid area or pre-epiglottic tissuesT4: Tumor invasion through the thyroid cartilage and/or extension into
19In the glottis, the T stages are as follows: T1: Tumor limited to the vocal cord with normal mobilityT2: Tumor extension to the supraglottis and/or subglottis and/or impaired vocal cord mobilityT3: Tumor limited to the larynx with vocal cord fixationT4: Tumor invasion through the thyroid cartilage and/or other tissues beyond the larynx .
20In the subglottis the T stages are as follows T1: Tumor limited to the subglottisT2: Tumor extension to a vocal cord with normal or impaired mobilityT3: Tumor limited to the larynx with vocal cord fixationT4: Tumor invasion through cricoid or thyroid cartilage and/or extension to other tissues beyond the larynx
21Staging- 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
22Supraglottic carcinomas The epiglottis is the most frequent location for cancers that arise in the supraglottic larynx. These lesions are often exophytic and circumferential massesTumors of the aryepiglottic fold are typically exophytic lesions that, when detected early, are confined laterally along the aryepiglottic fold.Advanced lesions may extend laterally to involve the adjacent wall of the pyriform sinus or medially to invade the epiglottis.
23Supraglottic carcinomas Squamous cell cancers that arise from the false vocal cords and laryngeal ventricle tend to be ulcerative and infiltrative with a limited exophytic component. Deep invasion by such tumors results in their access to the paraglottic space, and this may lead to fixation of the supraglottic larynx.Because of their close proximity, these tumors may extend inferiorly to involve the true vocal cords.
24Glottic carcinomasThe true vocal cords are the most common site of laryngeal carcinomas; the ratio of glottic carcinomas to supraglottic carcinomas is approximately 3:1.The anterior portion of the true vocal cord is the most common location of squamous cell cancer, with most lesions occurring along the free margin of the vocal cord.
25Glottic carcinomasAnteriorly, the tumor may extend to anterior commissure, where it may involve the contralateral true vocal cord.The likelihood of nodal involvement associated with glottic carcinomas depends on the stage of the tumor. The incidence of early T1 lesions has been reported to be as low as 2%. This figure increases to approximately 20% for T3 and T4 lesions.
26Subglottic carcinomas Subglottic carcinomas are rare and account for only 5% of all laryngeal carcinomas.When present, these lesions are characteristically circumferential and often extend to involve the undersurface of the true vocal cordsThey have a tendency for early invasion of the cricoid cartilage and extension through the cricothyroid membrane.
27Presentation Hoarseness Most common symptom Small irregularities in the vocal fold result in voice changesChanges of voice in patients with chronic hoarseness from tobacco and alcohol can be difficult to appreciate
28Presentation Other symptoms include: Dysphagia Hemoptysis Throat pain Ear painAirway compromiseAspirationNeck mass
29PresentationPatients 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 color
30PresentationGood neck exam looking for cervical lymphadenopathy and broadening of the laryngeal prominence is requiredThe base of the tongue should be palpated for masses as wellRestricted laryngeal crepitus may be a sign of post cricoid or retropharyngeal invasion
31Work up Biopsy is required for diagnosis Performed 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 granulomatosis
32Work up Other potential modalities: Direct laryngoscopy Bronchoscopy EsophagoscopyChest X-rayCT or MRILiver function tests with or without USPET ?
34TreatmentPremalignant 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 difficult
35TreatmentEarly 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 complications
36Treatment XRT complications include: Mucositis Odynophagia Laryngeal edemaXerostomiaStricture and fibrosisRadionecrosisHypothyroidism
37TreatmentAdvanced 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 larygectomy
38TreatmentChemotherapy 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.
39TreatmentModified or radical neck dissections are indicated in the presence of nodal diseaseNeck dissections may be performed in patients with supra or subglottic T2 tumors even in the absence of nodal diseaseN0 necks can have a selective dissection sparing the SCM, IJ, and XIN1 necks usually have a modified dissection of levels II-IV
40Supraglottic laryngectomy T1,2, or 3 if only by preepiglottic space invasionMobile cordsNo anterior commissure involvementFEV1 >50%No tongue base disease past circumvallate papillaeApex of pyriform sinus not invloved
41Total Larygectomy Indications: T3 or T4 unfit for partial Extensive involvement of thyroid and cricoid cartilagesInvasion of neck soft tissuesTongue base involvement beyond circumvallate papillae