Cancer of the larynx presentation

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}فلله الحمد رب السموات ورب األرض رب 36: الجاثية {العالمين

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. 39فصلت( – : قدير

Cancer of the larynx

By

Dr, IBRAHIM H. AHMEDM.D.

otorhinolaryngology

introductionIncidence : 10,000 cases per year in U S A.

Most frequent upper aerodigestive tract cancerThe integration of chemotherapy and radiation therapy has expanded organ preservation

options. The patient’s perspective , with emphasis on retention of speech , swallowing , & quality of life has affected the decision making process.

Anatomy of larynx

area extending from : tip of epiglottis to

lower border of cricoid cartilage .

divided into 3 anatomical subsites: Supraglottis

glottis, subglottis .

supraglottisLingual & laryngeal surfaces of the

epiglottis. Arytenoid fold .

Arytenoid cartilages. False vocal folds. Ventricle.

glottis

- true vocal cord. - Anterior commisure.

- post . Commisure.

Upper border : floor of ventricle. Lower border : 1 cm below apex of

ventricle

subglottis

• Upper border :• lower limit of glottis .

• Lower limit :• inferior rim of cricoid cartilage.

embryologySupraglottic

Buccopharyngeal anlagen of branchial

arches 3&4 .

Glottis &subglottis

Tracheobroncial anlagen of branchial arches 5&6 branchial arches

Histology of supraglottis• Ciliated columnar epithelium except

free edges of epiglottis & aryepiglottic fold ( stratified squamous mucosa ) .

• Mucous gland are abundant esp. ( saccule & periarytenoid areas ) .

• Rich vascularity & lymphatic .

Histology of glottisVocal cord : stratified squamous epithelium

(edges). peudostratified ciliated

epithelium ( sup. & inf. Aspect )Lamina propria : superficial ( Reink’s space ) intermediate & deep ( vocal lig. * blood vessels & lymphatics are almost absent in Reinke’s space. * no mucous glands on free edge

of vocal cord.

Blood supply of the larynx

Arterial supply of larynx

•1 -sup. Laryngeal a. ( branch of sup. Thyroid a. )

2 -inf. Laryngeal a. ( branch of inf. Thyroid a ) .

Venous drainage

1 -Sup. Thyroid v. , ends in I . J . V. 2 -inf. Thyroid v.

, ends in innominate v .

Nerve supply of the larynx

Motor supply : recurrent laryngeal nerve supplies all laryngeal muscles

except cricothyroid muscle which supplied by external laryngeal n. ( branch of sup. Laryngeal nerve ). Sensory supply :

internal laryngeal n. ( branch of sup. Laryngeal n ) . supply mucous membrane above the vocal cords .

Recurrent laryngeal n. supplies mucous membrane below the vocal cords.

Lymphatics of larynx1- The vocal cords & upper part of the larynx drain

into the upper deep cervical lymph nodes .

2- The lower part of the larynx drain into the lower deep cervical lymph nodes & prelaryngeal lymph nodes .

.

Cancer of the larynx

epidemiology

•10,000 new cases per year in U S A

etiology

Excessive tobacco use &

alcohol consumption.

Epidemiology of cancer larynx -1% of all cancer related deaths in U S A.

-10,000 new cases / year in U S A. -5 year survival is 65. %

-Male to female ratio : 9,2 : 1 for glottic ca .

3-5 : 1 for supraglottic. -Age : affect elderly . The peak incidence is 6th

& 7th decades. < 1% in < 30 years of age.

-No rational predominance in U S A .

Risk factors -tobacco.

- Synergistic effect with heavy alcohol intake in Smokers .

-occupational exposure Painter – metal working – plastic working –

diesel & gasoline fumes .wood dust & asbestos .

-G O R . -Infectious agents especially papilloma virus.

Clinical presentation

symptoms : 1 – hoarseness . 2 – dysnea & stridor . 3 – pain . 4 – dysphagia . 5 – swelling in the neck . 6 – cough & irritation in the throat . 7- hemoptysis . 8 – fetor & anorexia .

:

Clinical presentationHoarseness

Hot potato voiceHemoptysis

Weight loss & dysphagia

Referred otalgiaPalpable neck lumpDysnea & stridure

Vocal cord involvement . Progressive & unremitting. supraglottic ca .

Large fungating or ulcerated lesion (epiglottic lesion ) Malnutrition . (advanced lesion _pharyngeal involvement )

Cartilage invasion. Direct extension in soft tissue neck

1st presentation -subglottic or supraglottic ca2nd presentation in glottic ca.

Clinical evaluation -complete history of the disease

- weight and weight loss -performance status

- fiberoptic examination of H&N mucosa

-neck examination -drawing of any lesions

Complete examination of the head and neck Includes examination

• oral cavity,• pharynx, • indirect laryngoscopy.• fiberoptic examination of the larynx and pharynx - videostroboscopy

.

videostroposcopy -proper assessment of glottic lesion :

1 -Detailed vibrator behavior of vocal cord. - amplitude of vibration

- mucosal wave - non vibrating portion

2 -Outpatient procedure. 3 -Documentation.

4 -Selection of patient for biopsy.

The examination

status of the dentition,the status of the airway,

vocal cord mobility, laryngeal crepitus ,

tumor extension

Palpation of the neck bilaterally , Recording

1- the location (Group or Level II - IV), - size ,

- mobility , - relationship of the node(s) to adjacent

structures .2 -widening of thyroid angle.

3 -direct extention of the lesion. 4 -Fixation of the larynx.

5 -carotid pulsation.

Pattern of lymphatic spread

Supraglottic ca:

Primary glottic ca :

Subglottic ca :

Lymph node Metastases 44%

L. N. metastases 5%

L. N. metastases 6%

Mobility of larynx

Vocal cord mobility. Arytenoid mobility.

Hemilarynx mobility. Laryngeal mobility over prevertebral

fascia (More’s sign )

The staging of the primary and of the cervical lymph nodes must be documented

Radiological examination of cancer larynx

To reveal tumour invasion of laryngeal cartilages & extra laryngeal tissues.

With clinical / endoscopic examination result in proper staging accuracy.

Imaging Studies:

•Chest radiographs, PA and lateral

To rule out

(1) A synchronous pulmonary tumor,(2) Acute or chronic pulmonary

disease (3) Metastatic tumor.

imaging.

Thickness , invasion , Lymph node metastasis.

Under estimate cartilage invasion.

More accurate than C T scan. Soft tissue details & fat planes, Tissue edema & tumor extention. Over estimate cartilage invasion. Viability of a tumor.

Residual , recurrent tumor afterRadiotherapy & or chemotherapy.

Sensitive for detection of lymph node metastasis.

C T scan

Spiral C T scanM R I

P E T

a mass is seen eroding the thyroid cartilage and spreading into the

soft tissue of the neck.

the thyroid cartilage is seen to be eroded. The airway also appears

to be compromised.

The tumor appears to be eroding the anterior commissure area of the thyroid cartilage. The tumor appears large and predominately on the right side of the larynx. The airway also appears to be compromised.

Laboratory Tests: •C .B .C , B . T . , C . T . , serum calcium. • Pulmonary function and arterial blood gases in the patients with COPD or who are candidates for surgery . •Liver & kidney function tests (optional).

ENDOSCOPIC EXAMINATION & BIOPSY UNDER ANESTHESIA Direct laryngoscope :

1 - confirmation . 2 - site , size , extent of the tumour . 3 - vocal cord mobility . 4 - arytenoid mobility . 5 - type of lesion . 6 - neck is felt . 7 - biopsy . 8 - drawing in axial & sagittal plane .

Pan endoscopy to exclude 2nd primary .

Pathology of cancer larynx1 -keratosis :

2 -dysplasia :

Keratin layer in a normally non keratinized epithelium.

Involves true vocal cords &interarytenoid area.

Cellular atypia , loss of maturity , and loss of stratification in some

cases of keratosis. 1 -mild.

2 -moderate. 3 -severe.

Leukoplakia of right vocal cord

Pathology of cancer larynx3- carcinoma in situ Atypical changes throughout the

epithelium without evidence of surface maturation or invasion trough the basement

membrane.

Invasive squamous cell carcinoma Incidence

Grades:

Variants :

>90% of laryngeal carcinoma. -Well differentiated.

-moderately differentiated -poorly differentiated.

1 -papillary SCC. 2 -Sarcomatoid carcinoma.

3 -Basaloid SCC.

Verrucous carcinoma A slow – growing , locally aggressive tumor with an exophytic , fungating , warty , gray – white appearance and

well defined margins.

Non squamous tumors Mucous gland tumors.

Cartilaginous tumors. Neuroendocrine tumors

Adenocarcinoma. Adenoid cystic carcinoma.

Mucoepidermoid carcinoma.Chondrosarcoma. Paraganglioma. Large cell tumor. Atypical carcinoid. Small cell tumor.

Consultations

•Radiation therapy

In anticipation of possible need for post-operative radiation therapy or to use radiation therapy as a definitive primary modality of treatment in early stage tumors.

Consultations:

•Dental

To assess the status of the teeth and make recommendations considering that radiation therapy may be indicated. The evaluating dentist should be versed in the effects of radiotherapy on dentition. This evaluation should be done with knowledge of the treatment portals planned for the radiotherapy.

Consultations

•Speech pathology

For pre-operative counseling regarding possible post-operative speech and swallowing rehabilitation.

TMN / PRIMARY TUMOR ( T )TX : Primary tumor cannot be assessed. To : No evidence of primary tumor. Tis : Carcinoma in situ. Supraglottis .Glottis. Subglottis .

SUPRGLOTTIS ( T )T1 : Tumor limited to one subsite of supraglottis with normal

vocal cord mobility. T2 : Tumor invades mucosa of more than one subsite of supraglottis or region outside the supraglottis ( e.g., mucosa of base of tongue , vallecula , medial wall of pyriform sinus )

without fixation of the larynx. T3 : Tumor limited to the larynx with vocal cord fixation and/or invade any of the following : postcricoid area , pre-epiglottic

tissues. T4 : tumor invade through the thyroid cartilage and/or extends

into soft tissue of the neck , thyroid and/or esophagus.

supraglottic squamous cell carcinoma of the larynx

GLOTTIST1 : Tumor limited to the vocal cord(s) ( may involve

anterior or posterior commisure ) with normal mobility. T1a : Tumor limited to one vocal cord. T1b : Tumor involves both vocal cords.

T2 : Tumor extends to supraglottis and/or subglottis and/or occurs with impaired vocal cord mobility. T3 : Tumor limited to the larynx with vocal cord fixation.

T4 : Tumor invades through the thyroid cartilage and/or to other tissues beyond the larynx ( e.g., trachea , soft

tissue of neck , including thyroid and pharynx .

Cancer of the left vocal cord

Picture of

glottic squamous cell carcinoma of the larynx. The tumor involves the anterior half of the left

vocal cord.

SUBGLOTTIST1 : Tumor limited to the subglottis.

T2 : Tumor extended to vocal cord(s) with normal or impaired mobility.

T3 : Tumor limited to the larynx with vocal cord fixation.

T4 : Tumor invade through the cricoid or thyroid cartilage and/or to other tissues beyond the larynx ( e.g., trachea , soft tissues of neck , including the thyroid and pharynx )

Picture of an extensive squamous cell carcinoma of the larynx. The tumor involves the subglottic region,

the glottis and the supraglottic area .

TNM STAGING

No : no regional node metastasis .Nx : regional nodes cannot be assessed .

N1 : single ipsilateral node,≤3cm N2a : single ipsilateral nodes, > 3cm and ≤ 6cm

N2b : multiple ipsilateral nodes , ≤ 6cmN2c : controlateral or bilateral nodes , ≤ 6cm

N3 : node > 6cm

≤

TNM staging

Mx: Distant metastasis can’t be assessedM0: No distant metastasisM1: Distant metastasis

Treatment of glottic ca.

1 -carcinoma in situ.

2 - Stage 1.

3 – stage II..

Micro laryngeal surgery– Radiotherapy.

Radiotherapy. Partial surgery. Trans oral co2 laser.

Radiotherapy. Chemotherapy & radiotherapy. Partial surgery. Trans oral laser excision..

T1 squamous cell carcinoma of vocal cord

Immediate post operative , after biopsy & surgical removal of leukoplakia .This patient will be

treated with full course of radiotherapy.

Pre and post biopsy views of a patient with two T1 SCC of true vocal cords .

The patient was treated with vocal cord stripping and radiation therapy

Treatment of glottic ca

4 – stage III.

5 – stage IV.

1 – radiotherapy . or chemo&radiotherapy.

2 - trans oral co2 laser excision3 - surgery.

1 -total laryngectomy + Post operative radiotherapy.

Management of neck in glottic ca.1 -No.

2 – NI , NII.

3 – N III.

1 – radiotherapy. 2 – elective neck dissection.

1 – selective neck dissection.

1 – modified or radicalneck dissection + radiotherapy .

Treatment of supraglottic ca.

1 -TI.

2 -TII.

1 -radiotherapy. 2 -open epiglottictomy.

3 -co2 laser epiglottictomy1 -radiotherapy.

2 -supraglottic laryngectomy. 3 -trans oral co2 laser resection.

Treatment of supraglottic ca.3 -TIII.

4 -TIV.

1 -accelerated radiotherapy.

2 -co2 laser resection. 3 -near total laryngectomy

4 -cicohyoidopexy. 1 -1ry radiotherapy.

2- total laryngectomy & post . op . radiotherapy

Management of neck in supraglottic ca.

1 -No

2 -N1 , N2 , N3 ,

Ipsilateral selective neck dissection . IF +ve ----- contra lateral selective neck dissection level II

, III , IV. Radical neck dissection + post

operative radiotherapy .

Treatment of subglottic ca.

T1.

T2.

T3.

Radiotherapy.

Radiotherapy or total laryngectomy.

Radiotherapy or total laryngectomy.

Management of neck in subglottic ca.

Ipsilateral level VI dissection . If lymph node +ve , post

operative radiotherapy.

عليك .... } الله فضل وكان تعلم تكن لم ما وعلمك113النساء : { عظيما

DR , IBRAHIM HABIBThank you