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Laryngeal Malignancy Dr. Vishal Sharma. Overview Most common head & neck malignancy in adults Accounts for 25% of head & neck cancer Accounts for 1% of.

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Presentation on theme: "Laryngeal Malignancy Dr. Vishal Sharma. Overview Most common head & neck malignancy in adults Accounts for 25% of head & neck cancer Accounts for 1% of."— 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 Undifferentiated carcinoma Adenocarcinoma Miscellaneous carcinoma Sarcoma Types

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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 Hemoptysis Stridor Neck swelling Referred otalgia Dysphagia History taking

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 tumorMicrolaryngoscopy & biopsy: glottic & subglottic tumorsPanendoscopy: for node metastasis of unknown originContact 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

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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 assessedT0: = no evidenceTis: carcinoma in situT1 = limited to one site, normal cord mobilityT2 = adjacent site OR impaired cord mobilityT3 = 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 assessedN0 = no evidence of regional lymph nodesN1 = ipsilateral, single, < 3 cmN2a = ipsilateral, single, > 3 to 6 cmN2b = ipsilateral, multiple, < 6 cmN2c = bilateral or contralateral, < 6 cmN3 = > 6 cmMX = regional lymph nodes cannot be assessedM0 = no evidence of regional lymph nodesM1 = presence of distant metastasis

26 Supraglottis: T1 = 1 subsite, normal cord mobilityT2 = > 1 adjacent subsites, no fixation of hemilarynx Glottis: 1a = 1 vocal cord only, normal cord mobility1b = both vocal cords, normal cord mobilityT2 = supraglottis / subglottis; OR impaired cord mobility Subglottis: T1 = limited to subglottis, normal cord mobilityT2 = extension to glottis OR impaired cord mobility

27 Stage 0 = Tis NO MO Stage I = T1 NO MOStage II = T2 NO MOStage III = presence of T3 or N1Stage IVA = presence of T4 or N2Stage IVB = presence of N3Stage 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

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43 Three-fourth Laryngectomy

44 Supra-cricoid Laryngectomy

45 Supra-cricoid Laryngectomy + Crico-hyoido-pexy

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47 Near-total Laryngectomy

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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 Radiotherapyor Radical Radiotherapy with salvage surgeryor Chemo-radiation

59 Glottis Tis (Ca in situ): Radiotherapy or Endoscopic excisionT1a: Radiotherapy or Vertical Partial LaryngectomyT1b tumor: Radiotherapy or Supracricoid LaryngectomyT2 supraglottis: Supracricoid Laryngectomy or RTT2 involving subglottis: Near-total or Total LaryngectomyT2 impaired cord mobility: Supracricoid Laryngectomy or RTT3 & 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 & 4 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 voiceB. Artificial larynx: Pneumatic, ElectricalC. Shunt technique 1. tracheo-hypopharyngeal shunt 2. esophago-tracheal shuntD. Valved devices for tracheo-esophageal puncture 1. Blom Singer prosthesis 2. Panje button device 3. Provox prosthesisE. 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 symptoms1. Debulking surgery (Laser-assisted)2. Radiotherapy (short-course)3. Chemotherapy4. Tracheostomy5. Counseling

66 Thank You


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