Laryngeal cancer

Malignant neoplasms of the larynx

Epithelial: carcinoma

Nonepithelial: (extremely rare)
sarcoma (e.g. Chondrosarcoma)
lymphoma (NHL)
malignant melanoma

pathology

- Squamous Cell Carcinoma (SCC)- 95%
Grades:
G1 well differentiated
G2 moderately differentiated G3 poorly differentiated

  • Variants of SCC
    Verrucous Carcinoma - variant of SCC G1, locally invasive, exophytic warty growth
    Basaloid Squmous Cell Carcinoma - more agressive

Adenocarcinoma; Adenoid Cystic Carcinoma (ACC) - very rare

epidemiology

- most common head&neck malignancy

  • The second respiratory tract neoplasm (after lung cancer)
  • Age40–60
  • Morbidity
    M>F

risk factors

  • Typical
    tobacco smoking (pack-years)
    alcohol abuse (heavy-drinking)
    preneoplastic lesions
    toxic exposure
  • Atypical
    GERD (gastroesophageal reflux disease)
    HPV infections
    genetic factors
  • Symptoms of laryngeal cancer depend on primary localization and local progresion of disease
    - Hoarseness persisting for more than 2 week must be investigated by an ENT specialist

localization

supraglottis 55%
glottis 45%
subglottis < 1%

Supraglottic cancer

  • moderately and poorly differentiated
  • infiltrative growht
    - cervical lymph nodes metastases are common (rich lymphatic vascularity)
  • symptoms of chronic pharyngitis
    feeling that something is catching in the throat persistent
    sore throat
    dysphagia (difficullty swollowing)
    odynophagia (painfull swollowing)
    otalgy (ear pain)
    fetor ex ore (bad breath)
    hoarseness
    haemoptysis (coughing up blood)
    dyspnoe (breathing difficulties)
    a lump/mass on the neck – the first sign in 40%

Glottic cancer

  • develops from the squamous epithelium
  • usually well differentiated
    - cervical lymph nodes metastases are rare and occur late (scant lymphatic vascularity)
  • Symptoms early: hoarseness late: dyspnoe

Subglottic cancer

  • develops in the squamous metaplastic foci (poorly differentiated)
  • cervical and mediastinal lymph nodes metastases are common (rich lymphatic vascularity, lymphatic drainage to the mediastinum
  • Symptoms:
    cough
    hoarseness
    haemoptysis (coughing up blood)
    dyspnoe (breathing difficulties)
    a lump/mass on the neck

TNM Classification

  • T1 – tumor confined to the one region of the larynx; normal cord mobility
    glottis: T1a - one vocal cord T1b - both cords
  • T2 – tumor with extension to more thane one regions; normal or slightly impared cord mobility
  • T3 – tumor confined to the larynx with fixation of one or both cords
  • T4 – tumor extending beyond the larynx

clinical diagnosis

  • Patient history
  • Physical (ENT) examination
    indirect laryngoscopy
    videolaryngoscopy laryngeal
    endoscopy neck palpation
  • Imaging
    neck sonography/CT/MRI
    chest x-ray/CT
    laryngeal tomography (classic)
    CT/MRI

treatment

  • Method of treatment depends on:
    primary localization (SupraG; G, SubG)
    extension and depth of infiltration (T)
    regional/distant metastases (N, M)
    differentiation (G1-G3)
  • Surgical treatment
    partial laryngectomy - endoscopic, classic/external approach (preservation of the vocal function and normal airways)
    total laryngectomy (loss of vocal function, airways and upper part of digestive tract are separated)
    neck dissection (elective, therapeutic)
    postoperative RT (if necessary)
  • RT (+/- chemotherapy)
  • Salvage laryngectomy (partial, total) in case of RT failure Paliative treatment (chemotherapy)

T1: Surgery or RT
T2: Surgery or RT
T3: Surgery +/- RT
T4: Surgery + RT

  • alternative treatment:
    T3/T4 agressive ChT+RT
    „organ preservation strategies” in locally advanced carcinomas
  • 5-year survival similar to S+RT
    weak functional outcome of the larynx
    (voice, tracheotomy)

Supraglottic cancer – surgical treatment

T1, T2 horizontal supraglottic partial laryngectomy
neck dissection
T3, T4 total laryngectomy
neck dissection
- postoperative RT (if necessary e.g. N+; positive margins)

Glottic cancer – surgical treatment

T1a endoscopic/transoral cordectomy (microlaryngoscopy + laser)
T1, T2 cordectomy (external approach)
vertical partial laryngectomy (frontolateral, frontal)
T2/T3 reconstructive laryngectomy (horisontal glottic partial laryngectomy)
T3, T4 total laryngectomy, neck dissection
postoperative RT (if necessary)

results of the treatment

- 5-year survival rate - 66% (all stages)
supraglottis 60% (T1 T2 80%, T3 T4 30%)
glottis: 80% (T1 T2 90%, T3 T4 50-60%)
subglottis: 15%

  • 5-year survival rate is decreased about 50% in patients with cervical lymph nodes metastases (N+)
    and additionally depends on tumor differentiation (G1>>G2>>G3)

patients after total laryngectomy

  • loss of the laryngeal voice
  • airways and upper part of digestive tract are separated
  • breathing through the tracheostomy

Types of voice rehabilitation after total laryngectomy

  • esophageal speech
  • electromechanical speech (electrolarynx)
  • tracheo-esophageal (shunt) speech
  • artificial larynx

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