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Laryngeal Malignancy Dr. Vishal Sharma.

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Presentation on theme: "Laryngeal Malignancy Dr. Vishal Sharma."— Presentation transcript:

1 Laryngeal Malignancy Dr. Vishal Sharma

2 Overview Most common head & neck malignancy in adults
Accounts for 25% of head & neck cancer Accounts for 1% of all cancers Peak incidence between years of age 10 :1 male predilection

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4 Sites & subsites of larynx
Supraglottis Suprahyoid epiglottis Aryepiglottic fold Arytenoid Infrahyoid epiglottis Ventricular bands Glottis Vocal cords Anterior commissure Posterior commissure Subglottis

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6 Glottic: 60-75% Supraglottic: 20-30% Subglottis: 5-10% Incidence

7 Squamous cell carcinoma (85%) Carcinoma in situ Verrucous carcinoma
Types Squamous cell carcinoma (85%) Carcinoma in situ Verrucous carcinoma Undifferentiated carcinoma Adenocarcinoma Miscellaneous carcinoma Sarcoma

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9 Risk factors Tobacco Alcohol Industrial exposure Radiation exposure
Laryngeal keratosis Laryngeal papilloma (HPV 16 & 18) Gastro-esophageal reflux disease Genetic

10 Supraglottic tumors More aggressive, early lymph node metastasis Glottic tumors Grow slower & metastasize late Subglottic tumors B/L disease & mediastinal extension Natural History

11 Progressive & continuous hoarseness
History taking Progressive & continuous hoarseness Hemoptysis Stridor Neck swelling Referred otalgia Dysphagia

12 Examination Indirect Laryngoscopy & Flexible Laryngoscopy to look for malignancy Examination of neck: for lymph node enlargement Laryngeal crepitus: absent in post-cricoid involvement Laryngeal cartilage splaying & tenderness: for cartilage involvement

13 Investigations Direct Laryngoscopy & biopsy: for supraglottic tumor
Microlaryngoscopy & biopsy: glottic & subglottic tumors Panendoscopy: for node metastasis of unknown origin Contact endoscopy using Toluidine blue: early detection CT scan: pre-epiglottic & paraglottic extension, cartilage involvement, extra-laryngeal spread Positron Emission Tomography: recurrent or residual tumour detection

14 Epiglottis malignancy

15 Ventricular band malignancy

16 Glottic malignancy

17 Glottic malignancy

18 Subglottic malignancy

19 CT scan: Rt vocal cord tumor

20 CT scan: cartilage invasion

21 PET scan: neck node metastasis

22 PET CT scan: laryngeal malignancy

23 TNM Classification UICC (1997)

24 TX = cannot be assessed T0: = no evidence Tis: carcinoma in situ T1 = limited to one site, normal cord mobility T2 = adjacent site OR impaired cord mobility T3 = limited to larynx with hemilarynx fixation T4a = thyroid / cricoid cartilage, thyroid gland, soft tissue neck, trachea, esophagus T4b: Prevertebral space, carotid artery, mediastinum 

25 NX = regional lymph nodes cannot be assessed
N0 = no evidence of regional lymph nodes N1 = ipsilateral, single, < 3 cm N2a = ipsilateral, single, > 3 to 6 cm N2b = ipsilateral, multiple, < 6 cm N2c = bilateral or contralateral, < 6 cm N3 = > 6 cm MX = regional lymph nodes cannot be assessed M0 = no evidence of regional lymph nodes M1 = presence of distant metastasis

26 Supraglottis: Glottis: Subglottis:
T1 = 1 subsite, normal cord mobility T2 = > 1 adjacent subsites, no fixation of hemilarynx Glottis: 1a = 1 vocal cord only, normal cord mobility 1b = both vocal cords, normal cord mobility T2 = supraglottis / subglottis; OR impaired cord mobility Subglottis: T1 = limited to subglottis, normal cord mobility T2 = extension to glottis OR impaired cord mobility

27 Stage III = presence of T3 or N1 Stage IVA = presence of T4 or N2
Stage 0 = Tis NO MO Stage I = T1 NO MO Stage II = T2 NO MO Stage III = presence of T3 or N1 Stage IVA = presence of T4 or N2 Stage IVB = presence of N3 Stage IVC = presence of M1

28 Treatment of Laryngeal Malignancy

29 Definitive Treatment Radical Surgery
Radical Radiotherapy (6000 cGray over 6 weeks) Chemotherapy: 5 Fluorouracil & Cisplatin Surgery with post-op Radiotherapy Radical Radiotherapy with salvage surgery Chemo-radiation (organ preservation)

30 Surgical Treatment

31 Glottic malignancy Cordectomy Frontal vertical partial laryngectomy
Lateral vertical partial laryngectomy Fronto-lateral vertical partial laryngectomy Extended fronto-lateral partial laryngectomy Conventional VPL (hemi-laryngectomy)

32 Cordectomy

33 Frontal VPL

34 Lateral VPL

35 Fronto-lateral VPL

36 Subtotal bifrontal laryngectomy

37 Conventional VPL: hemi-laryngectomy

38 Extended hemi-laryngectomy

39 Supraglottic malignancy
Epiglottectomy Supraglottic (horizontal partial) laryngectomy Extended supraglottic laryngectomy Trans-glottic malignancy Subtotal laryngectomy (supra-cricoid laryngectomy with crico-hyoido-pexy) Three-fourth laryngectomy Near-total laryngectomy

40 Supraglottic Laryngectomy

41 Supraglottic Laryngectomy

42 Supraglottic Laryngectomy

43 Three-fourth Laryngectomy

44 Supra-cricoid Laryngectomy

45 Supra-cricoid Laryngectomy + Crico-hyoido-pexy

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47 Near-total Laryngectomy

48 Near-total Laryngectomy

49 Near-total Laryngectomy

50 Advanced malignancy 1. Total Laryngectomy
Narrow field: removal of entire larynx only Wide field: removal of entire larynx, hyoid bone, partial pharynx, strap muscles & I/L thyroid lobe 2. Extended (widespread ) total laryngectomy: wide field total laryngectomy + resection of surrounding structures (base of tongue, pharynx, thyroid gland)

51 Narrow field total laryngectomy

52 Total Laryngectomy

53 Repair of hypopharynx

54 Inferior constrictor approximated

55 Permanent tracheostome

56 Laryngectomy specimens

57 Treatment planning

58 Supraglottis T1 & T2 tumor limited to supraglottis: Radiotherapy or Supraglottic laryngectomy T2 tumor involving glottis: Supracricoid Laryngectomy or Radiotherapy T3 & T4 tumor: Total laryngectomy + post-operative Radiotherapy or Radical Radiotherapy with salvage surgery or Chemo-radiation

59 Glottis Tis (Ca in situ): Radiotherapy or Endoscopic excision
T1a: Radiotherapy or Vertical Partial Laryngectomy T1b tumor: Radiotherapy or Supracricoid Laryngectomy T2 supraglottis: Supracricoid Laryngectomy or RT T2 involving subglottis: Near-total or Total Laryngectomy T2 impaired cord mobility: Supracricoid Laryngectomy or RT T3 & T4 tumor: Total laryngectomy + post-operative RT or Radical Radiotherapy with salvage surgery or Chemo-radiation

60 Subglottis T1: Total Laryngectomy + hemithyroidectomy or RT (?) T2: Total Laryngectomy + hemithyroidectomy T3 & T4: Total Laryngectomy + hemithyroidectomy post-operative Radiotherapy Neck nodes N0: B/L selective dissection of levels 2, 3 & or B/L Radiotherapy N1: B/L modified radical neck dissection N2 & N3: B/L modified radical neck dissection post-operative Radiotherapy

61 Voice Rehabilitation

62 A. Esophageal voice B. Artificial larynx: Pneumatic, Electrical C. Shunt technique 1. tracheo-hypopharyngeal shunt 2. esophago-tracheal shunt D. Valved devices for tracheo-esophageal puncture 1. Blom Singer prosthesis 2. Panje button device 3. Provox prosthesis E. Surgical reconstruction of larynx 1. Laryngeal replacement (Teflon, Dacron) 2. Laryngeal transplant

63 Electronic Larynx

64 Tracheo-esophageal prosthesis

65 Palliative Care Used in later stages to ameliorate symptoms
1. Debulking surgery (Laser-assisted) 2. Radiotherapy (short-course) 3. Chemotherapy 4. Tracheostomy 5. Counseling

66 Thank You


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