Laryngeal Carcinoma

laryngeal carcinoma accounts for

approximately 40% of carcinomas of the
head and neck. It is most common between
the ages of 45 and 75 years. At the present
time men are ten times more frequently
affected than women, although in the last
few decades the number of female patients
in Gurope and the United States has
increased due to increased incidence of
smoking in women.
Symptoms.
Hoarseness is the first and main symptom
when the tumor affects the glottis. Further
symptoms, which may occur alone or in
combination depending upon site and extent,
include a feeling of a foreign body, clearing
the throat, pain in the throat or referred
elsewhere, dyspnea, dysphagia, congh, and
hemoptysis. Regional lymph node
metastases may also occur.
Note: Hoarseness persisting for more than 2
to 9 weeks must always be investigated by a
speclalist, and omission of this step is
dangerous.
Pathogenesis.

Invasive carcinoma may develop from epithelial

dysplasia especially from carcinoma in situ.
More tban 90% of laryngeal carcinomas are
keratinizing or nonkeratinlizing squamous cell
carcinomas. Rare malignant forms include
verrucous carcinoma, adenocarcinoma,
carcinosarcoma,fibrosarcoma,and
chondrosarcoma.
Most patients with squamous carcinoma of the
larynx were or are heavy cigarette smokers
and, in addition, often heavy drinkers. Chronic
expisure to initation with heavy metals such as
chromium. nickel, uranium, or asbestos, and
irradiation are rarer causes.There are racial
differences in the frequency of site distribution
within the larynx.For example. supraglottic
carcinoma is commoner in Spain and in parts
of South America than in the Federal Republic
of Grmany.
Laryngeal carcinoma infiltrates locally in the mucosa
and beneath the mucosa and metastasizes via the
lymphatics and the bloodstream. The limits of
vascular spread are embryologically determined
.Thus, supraglottic carcinomas usually remain
confined to the supraglottic space and spread
anteriorly into the preepiglottic space, whereas
glottic carcinomas seldom spread into the
supraglottic area bat rather info the subglottic
space.
A transgloltic carcinonza is a glottic carcinoma
involving the ventricle and the vestibalar folds in
which the site of origin can no longer be
recognized . The characteristics of the intralaryngeal
lymphatics inpflence the frequency of regional lymph
node metartases. Other factors infiuencing the
frequency of metastases are the duration of the
sylnptoms, the histologic differentiation, and the size
and site of the tumor. Lymph node metastases at
this time of presentation are rare in carcinomas of
the vocal cord, bnt are found in about 20% of
subglottic carcinomas, about 40% of supraglottic
carcinomas, and in about 40% of transglottic
carcinomas.
Contralaleral metastases are unusual in
unilateral glottic tumors. Bilateral nlerastases
become more common if the carcinoma
crosses the midline, e.g., at the anterior or
posterior commissure or in the trachea, or if the
tumor arises primarily in the supraglottic space.
Distant hernatogenoIH Hlerasrases are
relatively unusual in laryngeal carcinoma at the
time the patient is first seen. Second primary
carcinomas of the respiratory and digestive
tracts (synchronous or metachronous) also
occur.
Diagnosis.

The clinical diagnosis rests initially on the findings

of indirect laryngoscopy and telescopic
laryngoscopy. The site and extent of the tumor and
the mobility of the vocal cord must be assessed . It
is very important to carry out microlaryngoscopy.
This allows accurate evaluation of the site and
extent of the tumor, provides a view of hidden
angles such as the ventrtcle and the piriform sinus,
and allows assessment of the snperficial
characteristics such as nodular,
exophytic,granulomatous, ulcerating, etc.
.Increasingly, CT and MRI are used to acquire
data on the depth of involvement.Differential
diagnosis. This includes chronic laryngttis and
its specific forms, and benign laryngeal
tumors.
Table 4.9 Classincalion and involvement of Larnygeal
Carcinomas According to the TNM System
Glottis(80%)
Tis = preinvasive carcinoma, carcinoma in situ
T1 = tumor confined to the glottis with normal cord
movement
T1a = one cord
T1b = both cords
T2 = cord tumor with extension subglottically or
supraglottically with normal or slightly impaired cord
mobility
T3 = tumor confined to the larynx with fixation of one
or both cords
T4 = tumor extending beyond the larynx, e.g.,
extending into the thyroid cartilage, piriform sinus,
postcricoid region or into adlacant skin
Subglottis(5%)
Tis = preinvasive carcinoma, carcinoma in situ
T1 a=tumor of the subglottic region with normal cord
mobility
T1a = one side subglottis
Tlb = both subglottis areas
T2 = tumor of the subglottic region with extension to one
or both cords
T3 = tumor confined to the larynx wilh fixation of one or
both cords
T4 = tumor extending bnyond the larynx, e.g. into the
postcricoid region, trachea or skin
Supragloffis
(15%)
Tis = preinvasive carcinoma, carcinoma in situ
T1 = tumor confined to the supragloltic area with normal
cord mobility
T1a = tumor confined to the laryngeal surface of the
epiglottis, one aryepiglottic fold, one ventricle or one false
cord
T1b = tumor of epigloffis involvemenl of one ventricle or
false cord
T2 = tumor ofthe epiglotis, ventricle or false cord extending
to the cord without fixation
T3 = tumor confined to the larynx with vocal cord fixation
and destruction or other signs of deeo infiltration
T4 = tumor axtending beyond the limits of the larynx with
involvement of the piriform sinus, postcricoid region
vallecula or tongue base
Treatment.

If untreated, laryngeal carcinoma leads to death

within an average of 12 months by asphyxia,
bleeding, metastases, infection, or cachexia. The
existence of cardiovascular or pulmonary diseases
and diabetes mellitus determines the course of
treatment and the course of the disease. The
indications for radiotherapy or surgery for laryngeal
carcinoma vary depending on the site and stage of
the tumor.
They are often used in combination.
Chemotherapy alone has so far proved to be
useless for this type of tumor. Radiotherapy is
mainly given as telecobalt megavoltage
radiation. Except for T1 N0 glottic tumors and for
some T2 N0 tumors, and especially if lymph
node metastases are present, surgery is clearly
superior to radlotherapy .
Radiotherapy is appropriate for patients with
inoperable tumors. patients who refuse
cancer surgery, and laryngeal tumor
manifestations that are not amenable to
surgical palliation. Extension of laryngeal
carcinoma to the hypopharynx is another
possible indication for radiotherapy.
The combination of surgery and postoperative
radiotherapy appears to yield the best results
for selected patients in advanced stages.
Complicalions after radiotherapy include
persistent edema which makes it difficult to
assess the local appearances and detect a
recurrence. The edema is usually due to
chondroradionecrosis leading to cartilaginous
necrosis and which may reqoire
laryngectomy. Other complications include
dysphagia, ageusia, xerostomia and the sicca
syndrome. If surgery must be undertaken
after a full course of radiotherapy, the wound
healing and prognosis are considerably
worse.