Laryngeal Tumors PDF 2022-23

Laryngeal Tumors SS Block-ENT academic year 2022-23 Dr.Abdulsalam M.I/ENTsurgeon Laryngeal diseases Pachydermia  PREMALIGNANT LESIONS  Epithelial changes that may give rise to carcinoma.  The gross cinical appearance is highly variable  It is histological diagn...

Laryngeal Tumors SS Block-ENT academic year 2022-23 Dr.Abdulsalam M.I/ENTsurgeon Laryngeal diseases Pachydermia  PREMALIGNANT LESIONS  Epithelial changes that may give rise to carcinoma.  The gross cinical appearance is highly variable  It is histological diagnosis 1. Leukoplakia: white patches of mucosa That can not rubbed away. 2. Erythroplakia:reddish non-keratinized Lesion with strong possibility of malignant trans formation. 3. Pachydermia :epithelial thickening covered by keratin scales  BENIGN LARYNGEAL TUMORS  Benign neoplasms are uncommon in the larynx compared with their malignant counterparts. 1. PAPILLOMAS 2. NEUROENDOCRINE TUMORS ❖ Paragangliomas ❖ carcinoids ❖ SCHWANNOMAS  arise around the superior laryngeal nerve ❖ NEUROFIBROMAS 3. Vascular tumors 3. Vascular tumors  Hemangiomas:simple (capillary) or cavernous.  Lymphangiomas 4. Leiomyoma 5. chondroma  INTRODUCTION  Laryngeal carcinoma is the most common head and neck cancer worldwide.  Without a functioning larynx, quality of life is hugely affected.  Each year, 11,000 new cases of larynx cancer will be diagnosed in the United States (1% of new cancer diagnoses), and approximately one third of these patients will die of their disease.  The cardinal symptoms of all laryngeal neoplasims weather benign or malignant is persistant hoarsness. MALIGNANT NEOPLASIMS OF THE LARYNX Epidemiology: Each year, 11,000 new cases of larynx cancer will be diagnosed in the United States (1% of new cancer diagnose). male-to-female ratio for larynx cancer is 4:1,shift in this ratio can be expected. ! Larynx cancer is most prevalent in the sixth and seventh decades of life. more prevalent among lower socioeconomic groups. More than 90% of larynx cancer is squamous cell carcinoma (SCC) and is directly linked to tobacco and excessive alcohol use.  RISK FACTORS 1. tobacco use 2. Excessive ethanol use 3. Male sex 4. Infection with human papillomavirus 5. Increasing age 6. Diets low in green leafy vegetables 7. Diets rich in salt preserved meats and dietary fats 8. Metal/plastic workers 9. Exposure to paint 10. Exposure to diesel and gasoline fumes 11. Exposure to asbestos 12. Exposure to radiation 13. Laryngopharyngeal reflux  PATHOPHYSIOLOGY  the larynx is an essential organ that is responsible for the following vital functions: ❖ Maintaining an open air way ❖ Vocalizing ❖ Protecting the lungs from more direct exposure to noxious fumes and gases of unsuitable temperatures ❖ Protecting the lungs from aspiration of solids and liquids ❖ Allowing leverage, by closing the glottis during a Valsalva maneuver, to increase upper-body strength and to ease solid-waste removal CONT.  Malignant tumors of the larynx affect laryngeal physiology depending on tumor location and size  Supraglottic tumors usually cause upper airway obstruction. Conversely, glottic tumors affect initially voice quality. Incidence by the site  Supraglottic—40%  Glottic—59%  Subglottic—1% ANATOMIC SUBSITES AND PATTERNS OF SPREAD OF LARYNGEAL TUMORS  The spread of cancers arising in the larynx follows fairly predictable patterns.  Because the supraglottis arises from a different embryologic source than the glottis and subglottis, its lymphatic drainage patterns are significantly separate and different. This separation is often referred to as compartmentalization of the larynx, as described by Pressman. I. SUPRAGLOTTIC TUMORS: ❖ Involve the region bounded superiorly by the free border of the epiglottis and inferiorly by the false vocal folds and the laryngeal ventricles.  tend to spread by local extension.  There is a strong tendency for supraglottic tumors to spread via lymphatics.  long delays in presentation to primary care are common due to the vagueness of symptoms such as ‘globus’ and otalgia  more often diagnosed with nodal metastases and, therefore, at a higher clinical stage.  The patients often present at advanced stage (stridor) 2-GLOTTIC CANCER  tends to present early with voice change.  The true vocal folds are unusual in that they have very sparse lymphatic drainage.  Glottic carcinoma have better prognosis not only due to earlier presentation but also because of limited lymphatic drainage 3-SUBGLOTTIC CANCERS:  The subglottic region begins10 mm below the vocal folds and extends inferiorly to the level of the inferior border of the cricoid cartilage.  Primary tumors in the subglottis are rare.  The risk of lymphatic spread in these tumors is probably intermediate between supraglottic and glottic tumor.  airway obstruction (biphasic stridor)  DISTANT METASTASIS  usually a late event.  At presentation, 25% will have regional nodal metastasis, and only 8 to 10% have distant metastasis.  The lung, liver, and bone are the most frequently involved sites for metastatic disease.  CLINICAL EVALUATION ❖ Clinical presentations: Symptoms: 1. hoarseness persisting for three weeks or more (some would say even less time than this) should be referred urgently to an otolaryngologist for examination(progressive unremitting hoarsness) Hoarsness major presenting symptom in patients with glottic cancer.  In supraglottic tumors, hoarseness tends to occur later, when tumors have become bulky and overhang the glottis or spread through the paraglottic space to fix the vocal fold. 2. Dysphagia and odynophagia : Late symptoms (arytenoid dysfunction) More with supraglottic tumor because adjacent to base of the tongue May indicate hypopharyngeal involvment. 3. Cough and Hemoptysis  Cough is generally a sign of low-grade aspiration owing to loss of laryngeal sphincteric function and is most commonly seen in glottic tumors.  Hemoptysis is seen mainly in patients with large, fungating, friable supraglottic neoplasms. 4. Foul odor is seen in larger tumors, mainly in the supraglottis, that exhibit significant necrosis. 5. Pain: late sign, sometime reffered otalgia Indicate:_cartilage involvment or extralaryngeal spread 6. Weight loss: indicate poor prognosispossibly already exhibiting distant metastasis. 7. Stridor :indicate advanced disease PHYSICAL EXAMINATION  All patients with hoarseness of 2 weeks or longer without a clear-cut diagnosis should undergo evaluation by a head and neck specialist.  The larynx should be assessed by all means available to the physician until he/she is satisfied that an adequate examination has been achieved. Indirect mirror laryngoscopy in a cooperative patient can be quite adequate and gives an undistorted view of the larynx.  FLEXIBLE OR RIGID FIBER-OPTIC LARYNGOSCOPY SHOULD BE USED IN MOST CASES IN WHICH CANCER IS SUSPECTED. Malignant laryngeal lesions can appear to be fungating, friable, nodular, or ulcerative, or simply as changes in mucosal color.  Video documentation is useful for patient teaching, for review by the examiner, for presentation to other consultants not present at the endoscopy, and for comparison to the treated larynx after radiation or organ-conserving surgery.  Videostroboscopy  Neck examination is always performed when a diagnosis of laryngeal cancer is suspected IMAGING STUDIES 1. CT scan ❖ Better to show cartilage invasion ❖ Less characterization 2. MRI ❖ Detect small focus of tumor ❖ Differentiate between edema and tumour ❖ Not very usefull in detecting cartilage invasion 3. Positron emission tomography (PET) ❖ Important in detecting recurrence in irridiated patient. ENDOSCOPY AND BIOPSY  Direct laryngoscopy:Once a clinical diagnosis of laryngeal cancer is suspected, direct examination and biopsy under general anaesthesia is mandatory mandatory. TUMOR STAGING (TNM)  The objectives of staging are: 1. to aid the clinician in the planning of treatment. 2. to give some indication of prognosis. 3. to assist in evaluation of the results of treatment. 4. to facilitate the exchange of information between treatment centres. CLASSIFICATION FOR THE SUPRAGLOTTIS.  T1Tumour limited to one subsite of supraglottis with normal vocal cord mobility.  T2Tumour invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g. mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx  T3Tumour limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues, paraglottic space and/or with minor thyroid cartilage erosion (e.g. inner cortex)  T4aTumour invades through thyroid cartilage and/or invades tissues beyond the larynx, e.g. trachea, soft tissues of the neck, including deep/extrinsic muscle of the tongue (genioglossus, hyoglossus, palatoglossus and styloglossus), strap muscles, thyroid and oesophagus  T4bTumour invades prevertebral space, mediastinal structures or encases carotid artery CLASSIFICATION FOR THE GLOTTIS  T1aTumour limited to one vocal cord (may involve anterior or posterior commissure) with normal mobility  T1bTumour involves both vocal cords (may involve anterior or posterior commissure) with normal mobility  T2Tumour extends to supraglottis and or subglottis, and/or with impaired vocal cord mobility  T3Tumour limited to larynx with vocal cord fixation and/or invades paraglottic space, and/or with minor thyroid cartilage erosion (inner cortex)  T4aTumour invades through thyroid cartilage or invades tissues beyond the larynx, e.g. trachea, soft tissues of neck including deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus and styloglossus), strap muscles, thyroid and oesophagus  T4bTumour invades prevertebral space, mediastinal structures, or encases carotid artery CLASSIFICATION FOR THE SUBGLOTTIS.  T1Tumour limited to subglottis  T2Tumour extends to vocal cord(s) with normal or impaired mobility  T3Tumour limited to larynx with vocal cord fixation  T4aTumour invades through cricoid or thyroid cartilage and/or invades tissues beyond the larynx e.g. trachea, soft tissues of neck including deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus and styloglossus), strap muscles, thyroid and oesophagus  T4bTumour invades prevertebral space, mediastinal structures, or encases carotid TREATMENT OF CANCERS OF THE LARYNX 1. A. TREATMENT OF EARLY-STAGE LARYNX CANCER:  Early-stage larynx cancer (Stages I and II) can be treated with either surgery or radiation in single- modality therapy.  Aim:cure tumor and preserve larynx  Surgical procedures use in early glottic carcinoma: 1. Microlaryngeal surgery:operating microscope and microlaryngeal dissection instruments. The carbon dioxide laser also used. 2. Hemilaryngectomy:removal of one vertical half of the larynx 3. Supraglottic laryngectomy:removal of the supraglottis or the upper part of the larynx.  Supracricoid laryngectomy:This is a newer surgical technique, which expands on the traditional supraglottic laryngectomy procedure to preserve voice for those with cancers located at the anterior glolttis. RADIATION THERAPY:  Advantages over surgery Better voice quality.  Disadvantages longer treatment period and complication of radiation. TREATMENT OF ADVANCED-STAGE LARYNX CANCER  Advanced-stage larynx cancer (Stages III and IV) was historically treated by dual-modality therapy with surgery and radiation.  Total laryngectomy:This remains the mainstay of treatment for advanced laryngeal cancer and has 150 years of proven oncological safety.  —A total laryngectomy entailsthe removal of the entire larynx, including the thyroid and cricoid cartilages, possibly some upper tracheal rings, and the hyoid bone.  Adjuvant radiation should start within 6 weeks of surgery TREATMENT OF THE NECK IN LARYNX CANCER  A neck without clinically apparent nodal metastases should be treated in larynx cancer if the risk of nodal metastasis exceeds 20–30%. 1. Neck dissection 2. Radiotherapy 3. Combined of 1 and 2