Carcinoma larynx

Includes brief info about epidemiology, etiology, TNM staging, types,symptoms and management of CA larynx/ larynx carcinoma.
glottic ,subglottic and supraglottic carcinoma of larynx is also discussed with the individual management.

1. CARCINOMA of larynx

2. EPIDEMIOLOGY 6th commonest cancer world wide. Cancer larynx constitutes 2.63% of all body cancers in India . Age group – 40 to 70 years. M ore common in males.

3. etiology TARGET - Mnemonic T obacco – Benzopyrene is a carcinogen. Less than 5% cancer occurs in non-smoker A lcohol – synergistic with tobacco R adiation G enetic E nvironmental exposure - Asbestos, mustard gas. T umors – solitary papilloma, leukoplakia, erythroplakia ..

4. CLASSIFICATION of site

5. HISTOPATHOLOGY 90-95% are squamous cell carcinoma with various grades of differentiation 5-10% lesion includes Verrucous carcinomas Spindle cell carcinomas Malignant salivary gland tumors Sarcomas

6. TNM Classification of cancer larynx (American joint committee on cancer) SUPRAGLOTTIS T1 Tumor confined to one subsite of larynx; normal mobility (i.e., ventricular bands; arytenoids; epiglottis) T2 Involving more than one subsite ( supraglottis or glottis; normal mobility) T3 Tumour limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre- epiglottic tissues T4 Tumor invasion of cartilage or tissue beyond larynx

7. TNM Classification of cancer larynx (American joint committee on cancer) GLOTTIS T1 Tumor limited to vocal cords, normal mobility T1a Tumour limited to one vocal cord T1b Tumour involves both vocal cords T2 Extension to supraglottis and/or subglottis ; may be impaired cord mobility T3 Limited to larynx with cord fixation T4 Extension beyond larynx or into cartilage

8. TNM Classification of cancer larynx (American joint committee on cancer) SUBGLOTTIS T1 Tumour limited to the subglottis T2 Tumour extends to vocal cord(s) with normal or impaired mobility T3 Tumour limited to larynx with vocal cord fixation T4 Extension beyond larynx or into cartilage

9. Regional Lymph Nodes (N) Nx Cannot be assessed N0 No regional metastasis N1 Single positive ipsilateral node, less than 3 cm N2 Nodes less than 6 cm N2a Single ipsilateral node 3-6 cm N2b Many ipsilateral nodes less than 6 cm N2c Bilateral and contralateral node less than 6 cm N3 Node(s) greater than 6 cm

10. Distant Metastasis (M) Mx Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis Stage Grouping Tis N0 M0 I T1 N0 M0 II T2 N0 M0 III T3 N0 M0 T1 N1 M0 T2 N1 M0 T3 N1 M0 IVA T4 N0 M0 Any T N2 M0 IVB Any T N3 M0 IVC Any T Any N M1 Histopathologic Grades Grade 1 : Well-differentiated Grade 2 : Moderately differentiated Grade 3 : Poorly differentiated

11. SUPRAGLOTTIC CANCER

12. SYMPTOMS Muffled voice ( hot potato speech) Hoarseness of voice Foreign body sensation Dysphagia Pain throat and referred otalgia(via vagus ) Neck swelling Aspiration Stridor

13. GLOTTIC CANCER Most commonly involved Free edge and upper surface of vocal cord is the most frequent site

14. SYMPTOMS Persistence Hoarseness – cardinal feature Cough due to aspiration Dyspnea Stridor Hemoptysis (rare)

15. SUBGLOTTIC CARCINOMA Rare ( 1-5%) Invades cricothyriod membrane, thyroid gland and strap muscles of neck Lymphatic metastasis Prelaryngeal Paratracheal Lower jugular nodes Symptoms Stridor or laryngeal obstruction Hoarseness (late feature)

16. DIAGNOSIS HISTORY - any patient in cancer age group having persistent or gradually increasing hoarseness for 3 weeks must have laryngeal examination to exclude cancer. Indirect Laryngoscopy Appearance of lesion Vocal cord mobility Extent of disease Lesions of suprahyoid epiglottis are usually exophytic & infrahyoid epiglottis lesions are ulcerative. Lesions of vocal cord may appear as raised nodule, ulcer or thickening. Lesions of anterior commissure may appear as granulation tissue. Lesions of subglottic region appear as a raised submucosal nodule .

17. 3. V ideo laryngoscopy . 4. Examination of neck. Extralaryngeal spread of disease nodal metastasis . Radiography X-RAY chest Soft tissue lateral view CT /MRI scan

18. 6. DIRECT LARYNGOSCOPY 7. MICROLARYNGOSCOPY 8. SUPRAVITAL STAIN AND BIOPSY

19. TREATMENT 1. Radiotherapy 2. Surgery (a) Conservation laryngeal surgery (b) Total laryngectomy 3. Combined therapy. Surgery with pre- or postoperative radiotherapy 4. Endoscopic CO2 laser excision 5. Organ preservation

20. TREATMENT PLAN For the first and second stages Radiation therapy and/or conservative surgery For the third and fourth stages Radical surgery Total laryngectomy Laryngopharyngectomy Combined with unilateral radical neck dissection with or without contralateral modified neck dissection Post operative radiotherapy

21. RADIOTHERAPY CURATIVE – 6500 grays/30 fraction for 6 weeks. 90% cure rate, if vocal mobility is not impaired. SURGERY INDICATIONS Fixed cords Subglottic extension Cartilage invasion Nodal metastases.

22. CONSERVATIVE SURGERY ADVANTAGES Preserves voice Avoids permanent tracheostome . INCLUSION UNDER CONSERVATIVE SURGERY ( i ) Excision of vocal cord after splitting the larynx ( cordectomy via laryngofissure ). (ii) Excision of vocal cord and anterior commissure region (partial frontolateral laryngectomy). (iii) Excision of supraglottis , i.e. epiglottis, aryepiglottic folds , false cords and ventricle (partial horizontal laryngectomy).

23. Total laryngectomy The entire larynx including the hyoid bone, pre- epiglottic space, strap muscles and one or more rings of trachea are removed. Pharyngeal wall is repaired and lower tracheal stump sutured to the skin for breathing . INDICATIONS ( i ) T3 lesions (i.e. with cord fixed) (ii) All T4 lesions (iii) Invasion of thyroid or cricoid cartilage (iv) Bilateral arytenoid cartilage involvement (v) Lesions of posterior commissure (vi) Failure after radiotherapy (vii) Transglottic cancers,

24. Combined therapy. Surgical ablation may be combine with pre- or postoperative radiation to decrease the incidence of recurrence. Endoscopic resection with CO2 laser T1 lesions of the supra- or infrahyoid epiglottis with or without neck nodes are treated with CO2 laser. Laser excision has the advantages of lower cost , lower duration of treatment and morbidity.

25. PROGNOSIS 5 YEAR SURVIVAL STAGE I >95% STAGE II 85-90% STAGE III 70-80% STAGE IV 50-60%

26. Vocal rehabilitation after total laryngectomy

27. ELECTROLARYNX Vibrating disc is held against the soft tissues of the neck and a low-pitched sound is produced in the hypopharynx which is further modulated into speech by tongue, lips, teeth and palate