Laryngel cancer
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Laryngel Cancer - PowerPoint PPT Presentation

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Laryngel Cancer. It is the most common cancer of the upper aerodigestive tract. . Subtypes. Glottic Cancer: 59% Supraglottic Cancer: 40% Subglottic Cancer: 1% Most subglottic masses are extension from glottic carcinomas. Risk Factors. Etiology .

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Laryngel Cancer

It is the most common cancer of the upper aerodigestive tract.

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  • Glottic Cancer: 59%

  • Supraglottic Cancer: 40%

  • Subglottic Cancer: 1%

  • Most subglottic masses are extension from glottic carcinomas

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  • The incidence of laryngeal tumors is closely correlated with smoking, as head and neck tumors occur 6 times more often among cigarette smokers than among nonsmokers.

  • The age-standardized risk of mortality from laryngeal cancer appears to have a linear relationship with increasing cigarette consumption.

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  • Death from laryngeal cancer is 20 times more likely for the heaviest smokers than for nonsmokers.

  • The use of unfiltered cigarettes or dark, air-cured tobacco is associated with further increases in risk.

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Risk Factors<<<

  • Although alcohol is a less potent carcinogen than tobacco, alcohol consumption is a risk factor for laryngeal tumors.

  • In individuals who use both tobacco and alcohol, these risk factors appear to be synergistic, and they result in a multiplicative increase in the risk of developing laryngeal cancer.

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Risk Factors

  • Human Papilloma Virus 16 &18

  • Chronic Gastric Reflux

  • Occupational exposures

  • Prior history of head and neck irradiation

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  • The prognosis for small laryngeal cancers that do not have lymph node metastases is good, with cure rates of 75-95%, depending on the site, the size of the tumor, and the extent of infiltration.

  • Advanced disease has a worse prognosis.

  • Supraglottic cancers usually manifest late and have a poorer prognosis.

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Sex & Age Incidence

  • In the 1950s, the male-to-female ratio in patients with laryngeal cancer was 15:1.

  • This number had changed to 5:1 by the year 2000, and the proportion of women afflicted by the disease is projected to increase in years to come.

  • These changes are likely a reflection of shifts in smoking patterns, with women smoking more in recent years.

  • Laryngeal cancer most commonly affects men middle-aged or older. The peak incidence is in those aged 50-60 years.

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Histological Types

  • 85-95% of laryngeal tumors are squamous cell carcinoma

  • Histologic type linked to tobacco and alcohol abuse

  • Characterized by epithelial nests surrounded by inflammatory stroma

  • Keratin Pearls are pathognomonic

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Histological Types

  • Verrucous Carcinoma

  • Fibrosarcoma

  • Chondrosarcoma

  • Minor salivary carcinoma

  • Adenocarcinoma

  • Oat cell carcinoma

  • Giant cell and Spindle cell carcinoma

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The supraglottic larynx

  • It consists of epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids

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The glottic larynx

  • It consists of the true vocal cords and anterior commissure and posterior commissure

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The subglottic larynx

  • It consists of the region between the vocal cords and the trachea.

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Pre-epiglottic fat space

  • The pre-epiglottic fat is located in the anterior and lateral aspects of the larynx and is often invaded by advanced cancers.

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  • The first-echelon lymphatics for the supraglottic larynx are the subdigastric nodes and the middle anterior cervical nodes and the second-echelon lymphatics are the lower anterior cervical nodes

  • The first-echelon lymphatics for the subglottic larynx are the Delphian node, the lower anterior cervical nodes and paratracheal nodes, and the supraclavicular nodes, and the second-echelon lymphatics are the mediastinal nodes.

  • Glottic and subglottic tumors metastasize to ipsilateral lymph nodes, but supraglottic tumors often spread to nodes on both sides of the neck.

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In the supraglottis, the T stages are as follows

  • T1: Tumor limited to 1 subsite of the supraglottis with normal vocal cord mobility

  • T2: Tumor invasion of the mucosa of more than 1 adjacent subsite of the supraglottis or glottis or of a region outside the supraglottis , without fixation of the larynx

  • T3: Tumor limited to the larynx with vocal cord fixation and/or invasion of any of the postcricoid area or pre-epiglottic tissues

  • T4: Tumor invasion through the thyroid cartilage and/or extension into

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In the glottis, the T stages are as follows:

  • T1: Tumor limited to the vocal cord with normal mobility

  • T2: Tumor extension to the supraglottis and/or subglottis and/or impaired vocal cord mobility

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

  • T4: Tumor invasion through the thyroid cartilage and/or other tissues beyond the larynx .

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In the subglottis the T stages are as follows

  • T1: Tumor limited to the subglottis

  • T2: Tumor extension to a vocal cord with normal or impaired mobility

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

  • T4: Tumor invasion through cricoid or thyroid cartilage and/or extension to other tissues beyond the larynx

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Supraglottic carcinomas

  • The epiglottis is the most frequent location for cancers that arise in the supraglottic larynx. These lesions are often exophytic and circumferential masses

  • Tumors of the aryepiglottic fold are typically exophytic lesions that, when detected early, are confined laterally along the aryepiglottic fold.

  • Advanced lesions may extend laterally to involve the adjacent wall of the pyriform sinus or medially to invade the epiglottis.

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Supraglottic carcinomas

  • Squamous cell cancers that arise from the false vocal cords and laryngeal ventricle tend to be ulcerative and infiltrative with a limited exophytic component. Deep invasion by such tumors results in their access to the paraglottic space, and this may lead to fixation of the supraglottic larynx.

  • Because of their close proximity, these tumors may extend inferiorly to involve the true vocal cords.

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Glottic carcinomas

  • The true vocal cords are the most common site of laryngeal carcinomas; the ratio of glottic carcinomas to supraglottic carcinomas is approximately 3:1.

  • The anterior portion of the true vocal cord is the most common location of squamous cell cancer, with most lesions occurring along the free margin of the vocal cord.

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Glottic carcinomas

  • Anteriorly, the tumor may extend to anterior commissure, where it may involve the contralateral true vocal cord.

  • The likelihood of nodal involvement associated with glottic carcinomas depends on the stage of the tumor. The incidence of early T1 lesions has been reported to be as low as 2%. This figure increases to approximately 20% for T3 and T4 lesions.

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Subglottic carcinomas

  • Subglottic carcinomas are rare and account for only 5% of all laryngeal carcinomas.

  • When present, these lesions are characteristically circumferential and often extend to involve the undersurface of the true vocal cords

  • They have a tendency for early invasion of the cricoid cartilage and extension through the cricothyroid membrane.

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  • Hoarseness

    • Most common symptom

    • Small irregularities in the vocal fold result in voice changes

    • Changes of voice in patients with chronic hoarseness from tobacco and alcohol can be difficult to appreciate

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  • Other symptoms include:

    • Dysphagia

    • Hemoptysis

    • Throat pain

    • Ear pain

    • Airway compromise

    • Aspiration

    • Neck mass

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  • Patients presenting with hoarseness should undergo an indirect mirror exam and/or flexible laryngoscope evaluation

  • Malignant lesions can appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color

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  • Good neck exam looking for cervical lymphadenopathy and broadening of the laryngeal prominence is required

  • The base of the tongue should be palpated for masses as well

  • Restricted laryngeal crepitus may be a sign of post cricoid or retropharyngeal invasion

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Work up

  • Biopsy is required for diagnosis

  • Performed in OR with patient under anesthesia

  • Other benign possibilities for laryngeal lesions include: Vocal cord nodules or polyps, papillomatosis, granulomas, granular cell neoplasms, sarcoidosis, Wegner’s granulomatosis

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Work up

  • Other potential modalities:

    • Direct laryngoscopy

    • Bronchoscopy

    • Esophagoscopy

    • Chest X-ray

    • CT or MRI

    • Liver function tests with or without US

    • PET ?

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  • Premalignant lesions or Carcinoma in situ can be treated by surgical stripping of the entire lesion

  • CO2 laser can be used to accomplish this but makes accurate review of margins difficult

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  • Early stage (T1 and T2) can be treated with radiotherapy or 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

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  • XRT complications include:

    • Mucositis

    • Odynophagia

    • Laryngeal edema

    • Xerostomia

    • Stricture and fibrosis

    • Radionecrosis

    • Hypothyroidism

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  • 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

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  • Chemotherapy can be used in addition to irradiation in advanced stage cancers

  • Two agents used are Cisplatinum and 5-flourouracil

  • Cisplatin thought to sensitize cancer cells to XRT enhancing its effectiveness when used concurrently.

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  • 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

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Supraglottic laryngectomy

  • T1,2, or 3 if only by preepiglottic space invasion

  • Mobile cords

  • No anterior commissure involvement

  • FEV1 >50%

  • No tongue base disease past circumvallate papillae

  • Apex of pyriform sinus not invloved

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Total Larygectomy

  • Indications:

    • T3 or T4 unfit for partial

    • Extensive involvement of thyroid and cricoid cartilages

    • Invasion of neck soft tissues

    • Tongue base involvement beyond circumvallate papillae