carcinoma of larynx its spread and treatment .pptx

Brief about carcinoma larynx

1. MALIGNANCY OF LARYNX DEPARTMENT OF ENT IIMS&R PRESENTED BY – DR. MONIKA SACHAN PG RESIDENT JR 3 MODERATOR – DR. JAYA GUPTA ASSo. PROFF.

2. CLASSIFICATION OF SITE Transglottic tumors crossing ventricle in vertical axis supraglottic or glottic cancers Anatomy

3. Embryology Supraglottic - buccopharyngeal primordium - 3 rd & 4 th arch Glottis & subglottis - tracheobronchial primordium - 6 th arch

4. LYMPHATIC DRAINAGE SUBSITE DRAINAGE Supraglottis Subdigastric (level II)>> middle internal jugular chain (level III) Glottis No capillary lymphatics of the true vocal cords Subglottis Pretracheal (Delphian) lymph nodes Paratracheal (level VI) lymph nodes

5. E pidemiology 2.63% of all body cancers in India 40- 70 years M:F = 10:1

6. Risk factors tobacco- - only 1% of - in non smokers Alcohol - synergistic with tobacco Radiation Genetic Environmental/ Occupational exposure - Asbestos, mustard gas. Tumors – solitary papilloma, leukoplakia , erythroplakia .. Human Papilloma Virus Gastroesophageal reflux Diets

7. HISTOPATHOLOGY 90- 95% - squamous cell carcinoma 5- 10% lesion includes Verrucous carcinomas Sarcomas

8. Supraglottic cancer Majority - on epiglottis, false cord followed by aryepiglottic fold spread locally and invade – sup. vallecula , base of tongue and pyriform fossa (lat.) Preepiglottic space involve - through foramen in infrahyoid epiglottis . (ant.) Paraglottic space involve - through mucosa of ventricle. Bad Prognosis : early spread and late presentation

9. SYMPTOMS Pain throat (m/c) and referred otalgia(via vagus ) Foreign body sensation Dysphagia Neck mass LN Muffled voice ( hot potato speech) Hoarseness of voice Aspiration Stridor

10. Glottic cancer Spread - > confined vocal folds Anteriorly - anterior commisure Posteriorly - vocal process of arytenoid Upward- ventricle and false cord Downward- Subglottic region

11. Glottic Cancer Hoarseness of voice - early sign Progressive dyspnoea & stridor no lymphatics in vocal cords and nodal metastasis are rarely Good Prognosis : Early presentation and late spread,

12. Subglottic Cancer Rare( 1 - 2%) S pread : superficially/ submucosally - opposite side or downwards to trachea Anteriorly - cricothyroid membrane, thyroid gland and muscles of neck LN involve - 10- 34 % Symptoms: Stridor - earliest Hoarseness - late - upward spread to vocal cords is late. Hoarseness of voice indicates : Spread - undersurface of vocal cords. Infiltration - thyroarytenoid muscle. Involve - recurrent laryngeal nerve.

13. Diagnosis Of Laryngeal Cancer History Examination Of Head & Neck Chest X Ray , STN Indirect Laryngoscopy Direct Laryngoscopy : Gold standard Micro-laryngoscopy CT Scan MRI PET Supravital staining and biopsy Videostroboscopy

14. TNM STAGING choice of therapy overall prognosis efficacy of various forms of therapy. 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 .

15. STAGING : SUPRAGLOTTIC CANCER TX can not be assessed T i s Carcinoma in situ T1 one subsite with normal vocal cord mobility T2 more than one adjacent subsite - base of tongue , vallecula, medial wall of pyriform sinus) without fixation of larynx . T3 Limited to larynx with vocal cord fixation and/or invades any - postcricoid space, pre-epiglottic space, paraglottic space, and/or thyroid cartilage T4 Moderately advanced or very advanced disease

16. T4a invades - thyroid cartilage and/or trachea , soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) T4b invades prevertebral space, encases carotid artery, or invades mediastinal structures

17. STAGING : GLOTTIC CANCER TX cannot be assessed Tis Carcinoma in situ T1 vocal cord(s) (may involve - anterior or posterior commissure) with normal mobility T1a - one vocal cord T1b - both vocal cords. T2 supraglottis and/or subglottis with impaired vocal cord mobility.

18. T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage T4a invades - thyroid cartilage and/or trachea , cricoid cartilage, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus T4b prevertebral space, encases the carotid artery, or invades mediastinal structures

19. STAGING SUBGLOTTIC CANCER TX can not be assessed Tis Carcinoma in situ T1 Limited to subglottis T2 Extends to vocal cords with normal or impaired mobility

20. T3 Limited to larynx with vocal cord fixation and/or Invasion of paraglottic space and/or thyroid cartilage T4a Invades through thyroid cartilage outer cortex, trachea, soft tissues of neck, deep extrinsic muscles of tongue, strap muscles, thyroid, or esophagus. T4b Invades prevertebral space, encases carotid artery, or invades mediastinal structures.

21. CLINICAL NODAL STAGING NX cannot be assessed N0 No metastases N1 single ipsilateral , ≤3 cm N2 N2a: single ipsilateral > 3 cm, but ≤6 cm N2b : multiple ipsilateral , ≤6 cm N2c bilateral or contralateral ≤ 6 cm N3 N3a > 6 cm N3b any lymph node(s )

22. Distant metastasis (M) Mx: can’t be assessed M0: no distant metastasis M1: distant metastasis Regional Lymph Nodes

23. AJCC Stage Stage IVA T4a, N0, M0 T4a, N1, M0 T1, N2, M0 T2, N2, M0 T3, N2, M0 T4a, N2, M0 Stage IVB T4b, any N, M0 Any T, N3, M0 Stage IVC Any T, any N, M1 Stage Tis, N0, M0 Stage I T1, N0, M0 Stage II T2, N0, M0 Stage III T3, N0, M0 T1, N1, M0 T2, N1, M0 T3, N1, M0

24. Treatment

25. TREATMENT Radiotherapy Surgery Conservation laryngeal surgery Total laryngectomy Combined therapy. Surgery with pre- or postoperative radiotherapy Endoscopic CO2 laser excision Organ preservation

26. TREATMENT PLAN first and second stages Radiation therapy and/or conservative surgery 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

27. 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.

28. CONSERVATIVE SURGERY ADVANTAGES Preserves voice Avoids permanent tracheostome. INCLUSION UNDER CONSERVATIVE SURGERY (i) Excision of vocal cord after splitting 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).

29. TOTAL LARYNGECTOMY entire larynx - 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 ( v) Lesions of posterior commissure (vi) Failure after radiotherapy (vii) Transglottic cancers

30. Combined therapy. Surg ery combine with pre- or postoperative radiation to decrease incidence of recurrence. Endoscopic resection with CO2 laser T1 - supra- or infrahyoid epiglottis with or without neck nodes . A dvantages - lower cost, lower duration of treatment and morbidity.

31. T1 Glottic ca Mid cord RT Endoscopic laser resection Laryngofissure and cordectomy Ant commissure/ Cord + AC Frontal /frontolateral laryngectomy Endoscopic laser resection RT Posterior cord Endoscopic laser resection Laryngofissure & cordectomy RT

32. T1 Glottic Carcinoma Mid – cord Radiation therapy - best quality of voice Treatment of choice in professional voice users Surgery :- Young patients Veruccous cancer Pt desire short treatment time Willing voice compromise Transoral endoscopic CO2 laser cordectomy - > 90% cure rates Laryngofissure & Cordectomy - Rarely used now - when endoscopic exposure is poor

33. (Anterior commissure lesion /Cord lesion extending to ant commissure ) Vertical Partial laryngectomy – Frontal/ frontolateral > 90% cure rates Hospitalisation, temporary tracheostomy & NG tube feeding Transoral endoscopic CO2 laser resection Day-care procedure Higher recurrence - unsatisfactory exposure Radiation therapy higher failure rate – Difficulty in delivery of adequate dose - Undetected cartilage erosion- lack of inner perichondrium T1 Glottic ca

34. T1 Glottic ca ( Cord lesion extending posteriorly vocal process of arytenoid ) Transoral endoscopic CO2 laser resection - Surgical treatment of choice Laryngofissure & Cordectomy Radiation therapy -higher failure rate

35. Mid cord glotto - supraglotic RT Endoscopic laser resection VPL/SCPL- CHEP Anterior glotto supraglottic SCPL- CHEP Endoscopic laser resection RT Posterior glotto supraglottic Endoscopic laser resection Extended hemilaryngectomy SCPL- CHEP RT Glotto subglottic VPL/SCPL- CHEP Endoscopic laser resection RT T2 Glottic carcinoma (freely mobile cords)

36. T2 Glottic carcinoma (freely mobile cords) Surgery is TOC Vertical Partial laryngectomy – Frontal/ frontolateral /Extended hemilaryngectomy - better quality of voice than SCPL with CHEP - better tolerated by frail & COPD patients Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy superior cure rates poor quality of voice than VPL post operative aspiration best to reserve - fit pts

37. Transoral endoscopic CO2 laser resection - well tolerated by elderly & frail pts Radiation therapy preferred only in mid cord lesion with extention to supraglottis good voice results

38. VPL(hemilarynx) SCPL- CHEP Chemo RT RT Lateralised lesion SCPL- CHEP VPL( fronto lateral) CRT RT Lesion across ant commissure T2 Glottic carcinoma (impaired cord mobility)

39. T2 Glottic carcinoma (impaired cord mobility) Open partial laryngectomy - treatment of choice VPL ( Hemilaryngectomy ) - lateralised lesion (Frontolateral ) – lesion across ant comm. – safer in elderly individuals SCPL- CHEP – reserve for very fit pts Chemo radiation – TOC - unfit/unwilling for surgery Neoadjuvant CT +RT in responders Radiation alone – reserve for unfit/unwilling for surgery unlikely to able tolerate chemoradiation

40. T3 glottic ca (cord fixed arytenoid mobile) SCPL- CHEP Concurrent CTRT Performance status good VPL Neoadjuvant CTRT RT Performance status poor

41. T3 glottic ca ( Fixed hemilarynx) Concurrent CTRT Near total laryngectomy(lat disease) Total laryngectomy Performance status good Total laryngectomy Neo adjuvant CT RT Performance status poor

42. T4 Glottic Carcinoma ( T4a resectable lesion ) total laryngectomy combined with neck dissection if lymph nodes are palpable followed by post operative RT. Near total laryngectomy > in well lateralised lesion with uninvolved arytenoid region and2/3 of contralateral cord

43. Supraglottic Carcinoma T1- T2 Supraglottic Carcinoma Transoral endoscopic CO2 laser resection - treatment of choice If endoscopic laser resection is not feasible Radiotherapy -lesion at marginal zone T1 & small T2 lesions smaller lesion < 6cm –response rate – 80% minimal neck disease poor pulmonary reserve

44. T3 Supraglottic Carcinoma Chemo – radiotherapy Endoscopic CO2 laser resection - pre epiglottic space invasion is limited Supraglottic partial laryngectomy (for small volume disease) and SCPL— CHEP - growth is bulky or encroaching glottis - in patients who are fit and have no significant chest problems. Near- total laryngectomy - lateralised lesion. Total Laryngectomy as a last resort - if none of the above is feasible

45. Neoadjuvant chemotherapy 2 cycles of Cisplatin(80- 120mg/m2) + 5- FU(10- 15mg/m2) given within 3 weeks interval Only those with > 50% tumour regression will receive radiation therapy

46. T4 Supraglottic Carcinoma Total laryngectomy + post op RT Near- total laryngectomy + post op RT ( for lateralised disease )

47. Subglottic carcinoma T1 & T2 Subglottic carcinoma Radiotherapy alone - treatment of choice with preservation of voice Surgery - failure of radiation therapy or who cannot be easily assessed for radiation therapy . T3 & T4 Subglottic carcinoma Total laryngectomy and post- op. RT (radiation should also include superior mediastinum) Radiotherapy alone ( who are unfit for surgery )

48. Main predictor of survival - presence , number and extracapsular spread of lymph node metastases Management of neck Depends on site of primary T stage of primary Clinical N stage Choice of treatment modality for the primary Management of neck

49. N0

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

51. REFERENCES 1. Sultan pradhan 2. Scott brown 3. M ohan bansal 4. S tell maran