Laryngeal Cancer

dr. Tanim arief, SpTHT-KL

 Definition
Laryngeal cancer occurs when cells in the
lining of the throat grow uncontrollably and
form tumors that can invade normal tissues
and spread to other parts of the body.

Smith, 2003
 Etiology and risk factor
Smoking
Excessive ethanol use
Infection with human papilloma virus
Increasing age
Diets rich in spicy foods
Chewing of betel leaf
Exposure to sulfuric acid
Exposure to radiation
Laryngopharyngeal reflux

Domanowski, 2007
 Etiology
Smoking is the most important risk factor for laryngeal
cancer.
Heavy chronic consumption of alcohol, particularly
alcoholic spirits, is also significant.
When combined, these two factors appear to have a
synergistic effect.
Some other quoted risk factors are likely, in part, to be
related to prolonged alcohol and tobacco consumption.
These include:
low socioeconomic status
male sex
greater than 55 years.
 Incidence

Lalwani, 2007
 Distribution

35 % Supraglottic
60 % Glottic
Subglottic

Distribution site of laryngeal tumor

Jatin Shah, 2004

 Histological Types
Squamous Cell Carcinoma

Lalwani, 2007
 Signs and Symptoms
The symptoms of laryngeal cancer depend on the size and
location of the tumor. Symptoms may include the following:
Hoarseness or other voice changes
A lump in the neck
A sore throat or feeling that something is stuck in the
throat
Persistent cough
Stridor
Bad breath

Lalwani, 2007
 Signs and Symptoms
Supraglottis
sore throat, hemoptysis, aspiration, dysphagia, odynophagia,
airway obstruction (stridor), referred otalgia, weight loss, globus
sensation
Glottis
hoarseness, aspiration, dysphagia, odynophagia, airway
obstruction, weight loss, sore throat
Subglottis
airway obstruction (biphasic stridor), hoarseness, dysphagia,
odynophagia, hemoptysis, weight loss, sore throat

Pasha, 2005
 Diagnosis
Physical Examination
Laryngoscopy
Neck Examination
Assessment of Nutritional Status

Lalwani, 2007
Probst Grevers Iro, 2006
 Diagnosis
Imaging Studies
CT scanning
Plain radiography of the chest
Biopsi

Smith, 2007
 Management
SURGICAL TREATMENT OF LARYNGEAL CANCER
Microlaryngeal Surgery
Hemilaryngectomy
Supracricoid Laryngectomy
Total Laryngectomy

Pasha, 2005
 Management
NONSURGICAL MEASURES
Photodynamic Therapy
Radiation Treatment
Chemotherapy

Lalwani, 2007
 Prognosis

Lalwani, 2007
 Prognosis

Lalwani, 2007
Thank You
 Function
The larynx is an essential organ that is responsible for the
following vital functions:

Maintaining an open air way

Vocalization
Protection of the lungs from more direct exposure to
noxious fumes and gases of unsuitable temperatures
Protection of 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
 Patterns of Metastasis
Anterior oral cavity Glottic larynx: T3

30% 2%
20%
20%

10% 30%
0% 5% 5%
15%
10%
10%
(Shah, 2001)
 Photodynamic Therapy
A photosensitizing agent (a
chemical preferentially taken up
by tumor tissue and sensitive to
specific wavelengths of light) is
administered intravenously.
A laser is then used to activate
the photosensitizing agent and
induce the destruction of tumor
tissue.
Effective in treating cancers as
deep as 5 mm, with similar local
control and survival rates as
traditional treatment modalities.
The side effects of photodynamic
therapy include light sensitivity.
 Radiotherapy
Radiation given as the primary treatment for
larynx cancer or as an adjuvant treatment
following surgery is most often done using an
external-beam technique.
A dose of 60007000 cGy is administered to the
tumor site(s)
When the risk of locoregional nodal metastasis in
a clinically negative neck exceeds 20 30%, 5000
cGy is delivered prophylactically to the neck as
well.
 Radiotherapy
The indications for adjuvant postoperative radiation
include:
advanced-stage disease
positive margins
an extracapsular spread of tumor in a lymph node
the perineural or angiolymphatic spread of tumor
the subglottic extension of tumor
the involvement of nodes in multiple neck levels
(in particular, levels IV or V, or the mediastinum).
 Radiotherapy
The short-term side effects The long-term side effects
of radiation, lasting up to include:
6 weeks after the xerostomia
conclusion of therapy, fibrosis
include:
mucositis edema
odynophagia impaired taste
dysphagia chondroradionecrosis and
osteoradionecrosis
skin breakdown hypothyroidism
a loss of taste an increased risk for
edema radiation-induced
sarcoma.
 Chemotherapy
Cisplatinum and 5-fluorouracil are the two agents
found to be the most effective against larynx
cancer.
Recently, taxane and docetaxel (eg, Taxotere) are
showing some usefulness without the side effects
of cisplatinum, which include neurotoxicity,
ototoxicity, and renal toxicity.
Chemotherapy is not considered a first-line
treatment or standard of care for early-stage
(Stages I and II) larynx cancer.
 Cordectomy via Laryngofissure or
Transoral (Laser)
Indications:
T1 glottic cancer limited to middle third of the
vocal fold
no extension of tumor to vocal process or
anterior commissure;
no invasion into subglottis, ventricle, or false
cord
 Cordectomy via Laryngofissure or
Transoral (Laser)
Technique: external approach, divides
laryngeal cartilage at midline,
enter glottis at anterior commissure to
remove involved vocal fold
up to the vocal process of the arytenoid;
transoral approaches may
utilize laser (CO2)
 Cordectomy via Laryngofissure or
Transoral (Laser)
Advantages:
external approach provides better access
Transoral approach avoids external scar and
tracheotomy
Disadvantages:
external approach requires initial tracheotomy
morbidity associated with external approach
 Horizontal Hemilaryngectomy
Rationale for Procedure:
embryological boundary between false and
true vocal folds results in independent
lymphatic drainage
Supraglottic cancer tends to have pushing
borders rather than infiltrating borders
 Horizontal Hemilaryngectomy
Indications:
T1 or T2 (limited T3) supraglottic tumors;
tumor does not involve vocal fold, ventricle,
thyroid cartilage, arytenoid, interarytenoid
region, pyriform, or base of tongue
good pulmonary function tests (forced
expiratory volume [FEV1] >5060%); patient
must also give consent for possible total
laryngectomy
 Horizontal Hemilaryngectomy
Technique:
removes epiglottis
aryepiglottic folds
false vocal folds
preepiglottic space
portion of the hyoid bone
thyroid cartilage (spares true vocal folds and
arytenoids)
 Horizontal Hemilaryngectomy
Advantages:
good voice quality,
potential for decannulation,
Adequate swallow
Disadvantages:
requires initial tracheotomy,
extensive postoperative rehabilitation for
swallowing (especially after postoperative
radiation)
 Vertical Partial Laryngectomy
(Hemilaryngectomy)
Indications:
select T1T2 glottic carcinomas
tumor does not extend beyond 13 of
opposite cord
<10 mm of anterior subglottic
extension, or <5 mm of posterior
subglottic extension
no posterior commissure,
cricoarytenoid joint, aryepiglottic
fold, posterior surface of the
arytenoid, or paraglottic space
involvement
good pulmonary function tests
(forced expiratory volume [FEV1]
>5060%)
patient must also give consent for
possible total laryngectomy
 Vertical Partial Laryngectomy
(Hemilaryngectomy)
Technique:
removes one vocal fold
from anterior commissure
to vocalprocess (12 of
the opposite vocal fold
may be removed)
ipsilateral false cord
ventricle
paraglottic space
overlying thyroid cartilage
(3 mm posterior strip of
cartilage preserved)
 Vertical Partial Laryngectomy
(Hemilaryngectomy)
Advantages:
allows decannulation
functional glottic voice
Disadvantages:
risk of aspiration
requires initial
tracheotomy
 Supracricoid Laryngectomy
Rationale for Procedure:
goal is to achieve
decannulation
good swallowing
voice function with
comparable local
control
survival rates versus a
total laryngectomy
 Supracricoid Laryngectomy
Indications:
select T24 glottic and
supraglottic cancers that
may involve the pre-
epiglottic space, paraglottic
space ventricle
Limited thyroid cartilage, or
epiglottis
good pulmonary function
tests (forced expiratory
volume [FEV1] >5060%);
patient must also give
consent for possible total
laryngectomy
 Supracricoid Laryngectomy
Contraindications:
arytenoid fixation
infraglottic extent of tumor
reaching upper border of
cricoid cartilage
major pre-epiglottic
involvement
invasion of the cricoid
cartilage, perichondrium of
thyroid cartilage, hyoid bone,
posterior arytenoid mucosa
extralaryngeal involvement
poor pulmonary function
 Supracricoid Laryngectomy
Technique:
remove entire thyroid cartilage
bilateral true and falsevocal
folds, one arytenoid (may
spare both arytenoids if not
involved), and paraglottic
space;
spares cricoid cartilage, hyoid
bone, and at least one
arytenoid cartilage (for speech
and swallowing);
May reconstruct with
cricohyoidopexy (CHP) or
cricohyoidoepiglottopexy
(CHEP) if epiglottis is spared
 Supracricoid Laryngectomy
Advantages:
allows decannulation
functional glottic voice
Disadvantages:
risk of aspiration,
requires initial
tracheotomy,
dysphonia
 Total Laryngectomy
Indications:
standard therapy for
any laryngeal cancer
that precludes
conservative
management (advanced
disease, recurrence,
radiation failure,
patients with poor
pulmonary function)
 Total Laryngectomy
Technique:
removes entire larynx
(true and false vocal folds,
cricoid and thyroid
cartilage, both
arytenoids, epiglottis,
pre-epiglottic and
paraglottic spaces, and
hyoid bone),
creates complete
separation between
pharynx and trachea
 Total Laryngectomy
Advantages:
no risk of aspiration
fair voice quality (with
tracheoesophageal
speech)
Disadvantages:
requires a permanent
stoma