1. Clerk 2: 吳柏宣 陳昱潔 Supervisor: 李家和醫師
Laryngeal Cancer
Clerk 2: 吳柏宣 陳昱潔 Supervisor: 李家和醫師

2. Anatomy

3. Anatomy
Vaezi, MF . Nature Clinical Practice Gastroenterology & Hepatology (2005) 2,

4. Anatomy– Supraglottic larynx
It consists of epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids

5. Anatomy– Glottic larynx
It consists of the true vocal cords and anterior commissure and posterior commissure

6. Anatomy– Subglottic larynx
It consists of the region between the vocal cords and the trachea.

7. Epidemiology Male : Female = 4 : 1 Age: 50~60 y/o
> 90% squamous cell cancer
位置分類
Glottic cancer 80%
Supraglottic cancer 20%
Subglottic cancer 1%

8. Risk Factors Smoking(最主要危險因子)。 Alcohol(有加成作用)。 HPV type16 and 18 GERD。
長期暴露於石棉、芥子氣
、石化氣體

9. Clinical Presentation
Mass effect: hoarseness, dysphagia, hemoptysis, neck mass, airway compromise (difficulty breathing), aspiration
Throat pain, ear pain (referred through CN X branch)
Suggests advanced stage
Hoarseness = allow for early detection of glottic cancer
Weight loss
(auricular nerve of Arnold, CN X branch)

10. Clinical Presentation – cont’
Physical Exam
Complete head and neck exam
Palpation for nodes; restricted laryngeal crepitus.
Quality of voice
Breathy voice = cord paralysis
Muffled voice = supraglottic lesion
Laryngoscopy
Stroboscopic video laryngoscopy
Restricted laryngeal crepitus (the "clicking" movement from side to side across the pharynx and prevertebral fascia) can reveal postcricoid or even retropharyngeal invasion.

11. Staging Supraglottis Glottis Subglottis
T1: limited to subsite of supraglots w/normal cord mobility
T2: invade mucosa of > 1 subsite of supraglottis, glottis, or outside of supraglottis w/out fixation of the larynx
T3: limited to larynx w/vocal cord fixation and/or invades postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion
T4a: invades thyroid cartilage and/or tissues beyond larynx
T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures
Glottis
Tis: CA in-situ
T1: limited to cord;
T1a: one cord; T1b: two cords
T2: extends to supraglottis, and/or subglottis, and/or w/impaired cord mobility
T3: limited to larynx w/vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion
T4a: invades thyroid cartilage and/or tissues beyond larynx
T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures
Subglottis
T1: limited to subglottis
T2: extends to vocal cord with normal or impaired mobility
T3: limited to larynx w/vocal cord fixation
T4a: invades cricoid or thyroid cartilage, and/or invades tissues beyond the larynx
T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures

12. Staging Subglottis Nodes Mets Tis: CA in-situ
T1: limited to subglottis
T2: extends to vocal cord with normal or impaired mobility
T3: limited to larynx w/vocal cord fixation
T4a: invades cricoid or thyroid cartilage, and/or invades tissues beyond the larynx
T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures
Nodes
N0: no regional node mets
N1: single ipsilateral node, ≤ 3 cm
N2a: single ipsilateral node, > 3 cm, ≤ 6 cm
N2b: multiple ipsilateral nodes, ≤ 6 cm
N2c: bilateral or contralateral nodes, ≤ 6 cm
N3: node > 6 cm
Mets
Mx: unknown
M0: no distant mets
M1: distant mets

13. Stage Grouping Stage 0 Tis N0 M0 Stage I T1 Stage II T2 Stage III T3
Stage IVA
T4a
N0-1
T1-4a N2
Stage IVB
T4b
any N
any T N3
Stage IVC M1
Early
stage
Advanced stage

14. Treatment – Early Stage (I/II)
Early stage (T1 and T2) can be treated with radiotherapy or surgery (endoscopic resection or open organ-preservation surgery) alone, both offer the 85-95% cure rate.
Surgery has a shorter treatment period, saves radiation for recurrence, but may have worse voice outcomes
Radiotherapy is given for 6-7 weeks, avoids surgical risks but has own complications
Most influential factor to cure is overall treatment time.

15. Treatment – Early stage (I/II)
XRT complications include:
Mucositis
Odynophagia
Laryngeal edema
Xerostomia
Stricture and fibrosis
Radionecrosis
Hypothyroidism

16. Treatment – Advanced Stage (III/IV)
Advanced stage lesions often receive surgery with adjuvant radiation
Most T3 and T4 lesions require a total laryngectomy
Some small T3 and lesser sized tumors can be treated with partial larygectomy

17. Treatment – Advanced Stage (III/IV)
Chemotherapy can be used in addition to irradiation in advanced stage cancers
Two agents used are Cisplatinum and 5-flourouracil (5-FU)
Cisplatin thought to sensitize cancer cells to XRT enhancing its effectiveness when used concurrently.

18. Treatment – Advanced Stage (III/IV)
Modified or radical neck dissections are indicated in the presence of nodal disease
Neck dissections may be performed in patients with supra or subglottic T2 tumors even in the absence of nodal disease
N0 necks can have a selective dissection sparing the SCM, IJ, and XI
N1 necks usually have a modified dissection of levels II-IV