Laryngeal CA Slides 070720

7/28/2019 Laryngeal CA Slides 070720

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Laryngeal Carcinoma:Laryngeal Carcinoma:An OverviewAn Overview

Ryan EricRyan Eric NeilanNeilan

MS IVMS IV

For the Dept of OtolaryngologyFor the Dept of Otolaryngology

University of Texas Medical BranchUniversity of Texas Medical Branch

JulyJuly 20, 200720, 2007


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OverviewOverview

11,000 new cases of laryngeal cancer per11,000 new cases of laryngeal cancer per

year in the U.S.year in the U.S.Accounts for 25% of head and neckAccounts for 25% of head and neck

cancer and 1% of all cancerscancer and 1% of all cancers OneOne--third of these patients eventually diethird of these patients eventually die

of their diseaseof their disease

Most prevalent in the 6Most prevalent in the 6thth and 7and 7thth decadesdecades

of lifeof life


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OverviewOverview

4:1 male predilection4:1 male predilection

Downward shift from 15:1 post WWIIDownward shift from 15:1 post WWII

Due to increasing public acceptance ofDue to increasing public acceptance of

female smokingfemale smoking More prevalent among lowerMore prevalent among lower

socioeconomic class, in which it issocioeconomic class, in which it isdiagnosed at more advanced stagesdiagnosed at more advanced stages


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SubtypesSubtypes

GlotticGlottic Cancer: 59%Cancer: 59%

SupraglotticSupraglottic Cancer: 40%Cancer: 40%

SubglotticSubglottic Cancer: 1%Cancer: 1%

MostMost subglotticsubglottic masses are extension frommasses are extension fromglotticglottic carcinomascarcinomas


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HistoryHistory

The firstThe first laryngectomylaryngectomy for cancer of thefor cancer of the

larynx was performed in 1883 bylarynx was performed in 1883 by BillrothBillroth Patient was successfully fed by mouth andPatient was successfully fed by mouth and

fitted with an artificial larynxfitted with an artificial larynx In 1886 the Crown Prince Frederick ofIn 1886 the Crown Prince Frederick of

Germany developed hoarseness as he wasGermany developed hoarseness as he was

due to ascend the throne.due to ascend the throne.


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Crown Prince Frederick of GermanyCrown Prince Frederick of Germany


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HistoryHistory

Was evaluated by SirWas evaluated by Sir MakenzieMakenzie of London,of London,

the inventor of the direct laryngoscopethe inventor of the direct laryngoscope FrederickFredericks lesion wass lesion was biopsiedbiopsied andand

thought to be cancerthought to be cancer He refusedHe refused laryngectomylaryngectomy and later died inand later died in

18881888


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HistoryHistory

Frederick wasFrederick was

succeeded by Kaisersucceeded by KaiserWilhelm II, who alongWilhelm II, who alongwith Otto vonwith Otto von BismarkBismarkmilitarized themilitarized theGerman Empire andGerman Empire andled them into WW Iled them into WW I

Could anCould anOtolaryngologistOtolaryngologist havehave

prevented WW I?prevented WW I?


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Risk FactorsRisk Factors


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Prolonged use of tobacco and excessiveProlonged use of tobacco and excessive

EtOHEtOH use primary risk factorsuse primary risk factors The two substances together have aThe two substances together have a

synergistic effect on laryngeal tissuessynergistic effect on laryngeal tissues 90% of patients with laryngeal cancer90% of patients with laryngeal cancer

have a history of bothhave a history of both


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HumanHuman PapillomaPapillomaVirus 16 &18Virus 16 &18

Chronic Gastric RefluxChronic Gastric Reflux Occupational exposuresOccupational exposures

Prior history of head and neck irradiationPrior history of head and neck irradiation


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Histological TypesHistological Types

VerrucousVerrucous CarcinomaCarcinoma

FibrosarcomaFibrosarcoma ChondrosarcomaChondrosarcoma

Minor salivary carcinomaMinor salivary carcinomaAdenocarcinomaAdenocarcinoma

Oat cell carcinomaOat cell carcinoma Giant cell and Spindle cell carcinomaGiant cell and Spindle cell carcinoma


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AnatomyAnatomy


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AnatomyAnatomy


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AnatomyAnatomy


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AnatomyAnatomy


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AnatomyAnatomy


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AnatomyAnatomy


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AnatomyAnatomy


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AnatomyAnatomy


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Natural HistoryNatural History

SupraglotticSupraglottic tumors more aggressive:tumors more aggressive:

Direct extension into preDirect extension into pre--epiglotticepiglottic spacespace Lymph node metastasisLymph node metastasis

Direct extension into lateralDirect extension into lateral

hypopharnyxhypopharnyx

,,

glossoepiglotticglossoepiglottic fold, and tongue basefold, and tongue base


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GlotticGlottic tumors grow slower and tend totumors grow slower and tend to

metastasize late owing to a paucity ofmetastasize late owing to a paucity oflymphatic drainagelymphatic drainage

They tend to metastasize after they haveThey tend to metastasize after they have

invaded adjacent structures with betterinvaded adjacent structures with betterdrainagedrainage

Extend superiorly into ventricular walls orExtend superiorly into ventricular walls orinferiorly intoinferiorly into subglotticsubglottic spacespace

Can cause vocal cord fixationCan cause vocal cord fixation


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TrueTrue subglotticsubglottic tumors are uncommontumors are uncommon

GlotticGlottic spread to thespread to the subglotticsubglottic space is aspace is asign of poor prognosissign of poor prognosis

Increases chance of bilateral disease andIncreases chance of bilateral disease andmediastinalmediastinal extensionextension

Invasion of theInvasion of the subglotticsubglottic space associatedspace associated

with high incidence ofwith high incidence ofstomalstomal reoccurrencereoccurrence

following totalfollowing total laryngectomylaryngectomy (TL)(TL)


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PresentationPresentation

HoarsenessHoarseness

Most common symptomMost common symptom Small irregularities in the vocal fold result inSmall irregularities in the vocal fold result in

voice changesvoice changes

Changes of voice in patients with chronicChanges of voice in patients with chronic

hoarseness from tobacco and alcohol can behoarseness from tobacco and alcohol can be

difficult to appreciatedifficult to appreciate


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Patients presenting with hoarsenessPatients presenting with hoarseness

should undergo an indirect mirror examshould undergo an indirect mirror examand/or flexible laryngoscope evaluationand/or flexible laryngoscope evaluation

Malignant lesions can appear as friable,Malignant lesions can appear as friable,fungatingfungating, ulcerative masses or be as, ulcerative masses or be as

subtle as changes in mucosal colorsubtle as changes in mucosal color

VideostrobeVideostrobe laryngoscopylaryngoscopy may be neededmay be neededto follow up these subtler lesionsto follow up these subtler lesions


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Good neck exam looking for cervicalGood neck exam looking for cervical

lymphadenopathylymphadenopathy and broadening of theand broadening of thelaryngeal prominence is requiredlaryngeal prominence is required

The base of the tongue should beThe base of the tongue should bepalpated for masses as wellpalpated for masses as well

Restricted laryngealRestricted laryngeal crepituscrepitus may be amay be a

sign of postsign of post cricoidcricoid or retropharyngealor retropharyngealinvasioninvasion


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Other symptoms include:Other symptoms include:

DysphagiaDysphagia HemoptysisHemoptysis

Throat painThroat pain

Ear painEar pain

Airway compromiseAirway compromise

AspirationAspiration

Neck massNeck mass


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Work upWork up

Biopsy is required for diagnosisBiopsy is required for diagnosis

Performed in OR with patient underPerformed in OR with patient underanesthesiaanesthesia

Other benign possibilities for laryngealOther benign possibilities for laryngeallesions include: Vocal cord nodules orlesions include: Vocal cord nodules or

polyps,polyps, papillomatosispapillomatosis,, granulomasgranulomas,,

granular cellgranular cell neoplasmsneoplasms,, sarcoidosissarcoidosis,,WegnerWegnerss granulomatosisgranulomatosis


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Work upWork up

Other potential modalities:Other potential modalities:

DirectDirect laryngoscopylaryngoscopy BronchoscopyBronchoscopy

EsophagoscopyEsophagoscopy

Chest XChest X--rayray

CT or MRICT or MRI

Liver function tests with or without USLiver function tests with or without US

PET ?PET ?


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StagingStaging-- Primary Tumor (T)Primary Tumor (T)

TXTX Minimum requirements to assess primaryMinimum requirements to assess primarytumor cannot be mettumor cannot be met

T0T0 No evidence of primary tumorNo evidence of primary tumor

TisTis Carcinoma in situCarcinoma in situ


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StagingStaging-- SupraglottisSupraglottis

T1T1 Tumor limited to oneTumor limited to one subsitesubsite ofofsupraglottissupraglottis with normal vocal cordwith normal vocal cord

mobilitymobility

T2T2 Tumor involves mucosa of more than one adjacentTumor involves mucosa of more than one adjacent subsitesubsite ofofsupraglottissupraglottis

or glottis, or region outside theor glottis, or region outside the supraglottissupraglottis (e.g. mucosa of base of the(e.g. mucosa of base of the

tongue,tongue, valleculavallecula, medial wall of, medial wall ofpiriformpiriform sinus) without fixationsinus) without fixation

T3T3 Tumor limited to larynx with vocal cord fixation and or invadesTumor limited to larynx with vocal cord fixation and or invades any of theany of thefollowing:following: postcricoidpostcricoid area,area, preepiglotticpreepiglottic tissue,tissue, paraglotticparaglottic space, and/orspace, and/or

minor thyroid cartilage erosion (e.g. inner cortex)minor thyroid cartilage erosion (e.g. inner cortex)

T4aT4a Tumor invades through the thyroid cartilage and/or invades tissuTumor invades through the thyroid cartilage and/or invades tissuee

beyond the larynx (e.g. trachea, soft tissues of neck includingbeyond the larynx (e.g. trachea, soft tissues of neck including deepdeepextrinsic muscles of the tongue, strap muscles, thyroid, or esopextrinsic muscles of the tongue, strap muscles, thyroid, or esophagus)hagus)

T4bT4b Tumor invadesTumor invades prevertebralprevertebral space, encases carotid artery, or invadesspace, encases carotid artery, or invades

mediastinalmediastinal structuresstructures


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StagingStaging-- GlottisGlottis

T1T1 Tumor limited to the vocal cord (s) (may involve anterior or posTumor limited to the vocal cord (s) (may involve anterior or posteriorterior

commissurecommissure) with normal) with normal mobiltymobilty

T1aT1a Tumor limited to one vocal cordTumor limited to one vocal cord

T1bT1b Tumor involves both vocal cordsTumor involves both vocal cords

T2T2 Tumor extends toTumor extends to supraglottissupraglottis and/orand/or subglottissubglottis, and/or with, and/or withimpaired vocal cord mobilityimpaired vocal cord mobility

T3T3 Tumor limited to the larynx with vocal cord fixation and/or invaTumor limited to the larynx with vocal cord fixation and/or invadesdes

paraglotticparaglottic space, and/or minor thyroid cartilage erosion (e.g. innerspace, and/or minor thyroid cartilage erosion (e.g. inner

cortex)cortex)T4aT4a Tumor invades through the thyroid cartilage, and/or invades tissTumor invades through the thyroid cartilage, and/or invades tissuesues

beyond the larynx (e.g. trachea, soft tissues of the neck includbeyond the larynx (e.g. trachea, soft tissues of the neck includinging

deep extrinsic muscles of the tongue, strap muscles, thyroid, ordeep extrinsic muscles of the tongue, strap muscles, thyroid, or

esophagusesophagus

T4bT4b Tumor invadesTumor invades prevertebralprevertebral space, encases carotid artery, or invadesspace, encases carotid artery, or invades

mediastinalmediastinal structuresstructures


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StagingStaging-- SubglottisSubglottis

T1T1 Tumor limited to theTumor limited to the subglottissubglottis

T2T2 Tumor extends to vocal cord (s) with normal or impairedTumor extends to vocal cord (s) with normal or impaired

mobilitymobility

T3T3 Tumor limited the larynx with vocal cord fixationTumor limited the larynx with vocal cord fixation

T4aT4a Tumor invadesTumor invades cricoidcricoid or thyroid cartilage and/or invadesor thyroid cartilage and/or invades

tissues beyond larynx (e.g. trachea, soft tissues of the necktissues beyond larynx (e.g. trachea, soft tissues of the neckincluding deep extrinsic muscles of the tongue, strap muscles,including deep extrinsic muscles of the tongue, strap muscles,

thyroid, or esophagus)thyroid, or esophagus)

T4bT4b Tumor invadesTumor invades prevertebralprevertebral space, encases carotid artery, orspace, encases carotid artery, or

invadesinvades mediastinalmediastinal structuresstructures


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StagingStaging-- NodesNodes

N0N0 No cervical lymph nodes positiveNo cervical lymph nodes positive

N1N1 SingleSingle ipsilateralipsilateral lymph nodelymph node 3cm3cm

N2aN2a SingleSingle ipsilateralipsilateral node > 3cm andnode > 3cm and 6cm6cm

N2bN2b MultipleMultiple ipsilateralipsilateral lymph nodes, eachlymph nodes, each

6cm6cm

N2cN2c Bilateral orBilateral or contralateralcontralateral lymph nodes, eachlymph nodes, each

6cm6cm

N3N3 Single or multiple lymph nodes > 6cmSingle or multiple lymph nodes > 6cm


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StagingStaging-- MetastasisMetastasis

M0M0 No distant metastasesNo distant metastases

M1M1 Distant metastases presentDistant metastases present


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Stage GroupingsStage Groupings

00 TisTis N0N0 M0M0

II T1T1 N0N0 M0M0IIII T2T2 N0N0 M0M0

IIIIII T3T3 N0N0 M0M0

T1T1--33 N1N1 M0M0

IVAIVA T4aT4a N0N0--22 M0M0

T1T1--4a4a N2N2 M0M0

IVBIVB T4bT4b Any NAny N M0M0

Any TAny T N3N3 M0M0IVCIVC Any TAny T Any NAny N M1M1


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TreatmentTreatment

PremalignantPremalignant lesions or Carcinoma in situlesions or Carcinoma in situ

can be treated by surgical stripping of thecan be treated by surgical stripping of theentire lesionentire lesion

CO2 laser can be used to accomplish thisCO2 laser can be used to accomplish this

but makes accurate review of marginsbut makes accurate review of margins

difficultdifficult

T


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TreatmentTreatment

Early stage (T1 and T2) can be treatedEarly stage (T1 and T2) can be treated

with radiotherapy or surgery alone, bothwith radiotherapy or surgery alone, bothoffer the 85offer the 85--95% cure rate.95% cure rate.

Surgery has a shorter treatment period,Surgery has a shorter treatment period,

saves radiation for recurrence, but maysaves radiation for recurrence, but mayhave worse voice outcomeshave worse voice outcomes

Radiotherapy is given for 6Radiotherapy is given for 6

--7 weeks,7 weeks,

avoids surgical risks but has ownavoids surgical risks but has owncomplicationscomplications

TT t t


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TreatmentTreatment

XRT complications include:XRT complications include:

MucositisMucositis OdynophagiaOdynophagia

Laryngeal edemaLaryngeal edema

XerostomiaXerostomia

Stricture and fibrosisStricture and fibrosis

RadionecrosisRadionecrosis

HypothyroidismHypothyroidism

T t tT t t


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TreatmentTreatment

Advanced stage lesions often receiveAdvanced stage lesions often receive

surgery with adjuvant radiationsurgery with adjuvant radiation Most T3 and T4 lesions require a totalMost T3 and T4 lesions require a total

laryngectomylaryngectomy

Some small T3 and lesser sized tumorsSome small T3 and lesser sized tumors

can be treated with partialcan be treated with partial larygectomylarygectomy

T t tT t t


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TreatmentTreatment

Adjuvant radiation is started within 6 weeks ofAdjuvant radiation is started within 6 weeks of

surgery and with once daily protocols lasts 6surgery and with once daily protocols lasts 6--77

weeksweeks

Indications for postIndications for post--op radiation include: T4op radiation include: T4

primary, bone/cartilage invasion, extension intoprimary, bone/cartilage invasion, extension intoneck soft tissue,neck soft tissue, perineuralperineural invasion, vascularinvasion, vascular

invasion, multiple positive nodes, nodalinvasion, multiple positive nodes, nodal

extracapsularextracapsular extension, margins


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TreatmentTreatment

Chemotherapy can be used in addition toChemotherapy can be used in addition to

irradiation in advanced stage cancersirradiation in advanced stage cancers Two agents used areTwo agents used are CisplatinumCisplatinum and 5and 5--

flourouracilflourouracil

CisplatinCisplatin thought to sensitize cancer cellsthought to sensitize cancer cells

to XRT enhancing its effectiveness whento XRT enhancing its effectiveness when

used concurrently.used concurrently.

T t tT eatment


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TreatmentTreatment

Induction chemotherapy with definitiveInduction chemotherapy with definitive

radiation therapy for advanced stageradiation therapy for advanced stagecancer is another optioncancer is another option

Studies have shown similar survival ratesStudies have shown similar survival rates

as compared to totalas compared to total laryngectomylaryngectomy withwith

adjuvant radiation but with voiceadjuvant radiation but with voice

preservation.preservation. Role in treatment still under investigationRole in treatment still under investigation

T t tTreatment


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TreatmentTreatment

Modified or radical neck dissections are indicatedModified or radical neck dissections are indicated

in the presence of nodal diseasein the presence of nodal disease

Neck dissections may be performed in patientsNeck dissections may be performed in patients

with supra orwith supra or subglotticsubglottic T2 tumors even in theT2 tumors even in the

absence of nodal diseaseabsence of nodal disease N0 necks can have a selective dissection sparingN0 necks can have a selective dissection sparing

the SCM, IJ, and XIthe SCM, IJ, and XI

N1 necks usually have a modified dissection ofN1 necks usually have a modified dissection of

levels IIlevels II--IVIV

Surgical OptionsSurgical Options


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Surgical OptionsSurgical Options

HemilaryngectomyHemilaryngectomy


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HemilaryngectomyHemilaryngectomy

No more than 1cmNo more than 1cm

subglotticsubglottic extensionextension

anteriorlyanteriorly or 5mmor 5mmposteriorlyposteriorly

Mobile affected cordMobile affected cord

Minimal anteriorMinimal anteriorcontralateralcontralateral cordcord

involvementinvolvement

No cartilage invasionNo cartilage invasion No neck soft tissueNo neck soft tissue

invasioninvasion

SupraglotticSupraglottic laryngectomylaryngectomy


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SupraglotticSupraglottic laryngectomylaryngectomy

T1,2, or 3 if only byT1,2, or 3 if only bypreepiglotticpreepiglottic spacespace

invasioninvasion Mobile cordsMobile cords

No anteriorNo anterior commissurecommissure

involvementinvolvement FEV1 >50%FEV1 >50%

No tongue base diseaseNo tongue base diseasepastpast circumvallatecircumvallatepapillaepapillae

Apex ofApex ofpyriformpyriform sinussinusnotnot invlovedinvloved

SupracricoidSupracricoid LaryngectomyLaryngectomy


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SupracricoidSupracricoid LaryngectomyLaryngectomy

Resection of trueResection of true

vocal cords,vocal cords,

supraglottissupraglottis, thyroid, thyroid

cartilagecartilage

Leave arytenoids andLeave arytenoids andcricoidcricoid ring intactring intact

Half of patientsHalf of patients

remain dependent onremain dependent ontracheostomytracheostomy

TotalTotal LarygectomyLarygectomy


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TotalTotal LarygectomyLarygectomy

Indications:Indications:

T3 or T4 unfit for partialT3 or T4 unfit for partial Extensive involvement of thyroid andExtensive involvement of thyroid and cricoidcricoid

cartilagescartilages

Invasion of neck soft tissuesInvasion of neck soft tissues

Tongue base involvement beyondTongue base involvement beyond

circumvallatecircumvallate papillaepapillae

TotalTotal LaryngectomyLaryngectomy


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Voice RehabilitationVoice Rehabilitation


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Voice RehabilitationVoice Rehabilitation

TracheostomalTracheostomal prosthesisprosthesis

ElectrolarynxElectrolarynx

Pure esophageal speechPure esophageal speech

ComplicationsComplications


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ComplicationsComplications

Inaccurate stagingInaccurate staging

InfectionInfection

Voice alterationsVoice alterations Swallowing difficultiesSwallowing difficulties

Loss of taste and smellLoss of taste and smell

FistulaFistula TracheostomyTracheostomy dependencedependence

Injury to cranial nerves: VII, IX, X, XI, XIIInjury to cranial nerves: VII, IX, X, XI, XII

Stroke or carotidStroke or carotidblowoutblowout HypothyroidismHypothyroidism

Radiation induced fibrosisRadiation induced fibrosis

PrognosisPrognosis


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PrognosisPrognosis

After initial treatment patients are followed at 4After initial treatment patients are followed at 4--

6 week intervals. After first year decreases to6 week intervals. After first year decreases toevery 2 months. Third and fourth year everyevery 2 months. Third and fourth year everythree months, with annual visits after thatthree months, with annual visits after that

5 year survival5 year survival

Stage IStage I >95%>95%

Stage IIStage II 8585--90%90%

Stage IIIStage III 7070--80%80%

Stage IVStage IV 5050--60%60%

PrognosisPrognosis


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PrognosisPrognosis

Patients considered cured after beingPatients considered cured after being

disease free for five yearsdisease free for five years Most laryngeal cancers reoccur in the firstMost laryngeal cancers reoccur in the first

two yearstwo years

Despite advances in detection andDespite advances in detection and

treatment options the five year survivaltreatment options the five year survival

has not improved much over the last thirtyhas not improved much over the last thirtyyearsyears


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Laryngeal CA Slides 070720