Laryngeal

Malignancy
Dr. Vishal Sharma
Overview

• Most common head & neck malignancy in adults

• Accounts for 25% of head & neck cancer

• Accounts for 1% of all cancers

 Supraglottis
• Suprahyoid
Sites & epiglottis
• Aryepiglottic
subsite fold
• Arytenoid
s of • Infrahyoid
larynx epiglottis
• Ventricular
Glottis bands
• Vocal cords
• Anterior
Subglottis
commissure
• Posterior
commissure
Incidence
Glottic: 60-75%

Supraglottic: 20-
30%

Subglottis: 5-
10%
 • Squamous cell carcinoma

(85%)

• Carcinoma in situ

Types • Verrucous carcinoma

• Undifferentiated carcinoma

• Adenocarcinoma

• Miscellaneous carcinoma

• Sarcoma
Risk factors

• Tobacco
• Alcohol
• Industrial exposure
• Radiation exposure
• Laryngeal keratosis
 Supraglottic
Natural History tumors
• More aggressive, early
lymph node metastasis

Subglottic
Glottic
tumors
tumors
• B/L disease &
• Grow slower &
mediastinal
metastasize late
extension
 History taking
Progressive &
continuous
hoarseness

Dysphagia Hemoptysis

Referred otalgia Stridor

Neck swelling
 Examination
Indirect
Laryngosco
py & Examination
Flexible of neck: for
Laryngosco lymph node
py to look enlargement
for
malignancy

Laryngeal
Laryngeal
cartilage
crepitus:
splaying &
absent in
tenderness:
post-cricoid
for cartilage
involvement
involvement
Investigations
Direct Laryngoscopy & biopsy: for supraglottic tumor

Microlaryngoscopy & biopsy: glottic & subglottic tumors

Panendoscopy: for node metastasis of unknown origin

Contact endoscopy using Toluidine blue: early detection

CT scan: pre-epiglottic & paraglottic extension, cartilage

involvement, extra-laryngeal spread
Positron Emission Tomography: recurrent or residual
tumour detection
Epiglottis malignancy
Ventricular band malignancy
Glottic malignancy
Glottic malignancy
Subglottic malignancy
CT scan: Rt vocal cord tumor
CT scan: cartilage invasion
PET scan: neck node metastasis
PET CT scan: laryngeal malignancy
TNM Classification
UICC (1997)
TX = cannot be assessed

T0: = no evidence

Tis: carcinoma in situ

T1 = limited to one site, normal cord mobility

T2 = adjacent site OR impaired cord mobility

T3 = limited to larynx with hemilarynx fixation

T4a = thyroid / cricoid cartilage, thyroid gland, soft
tissue neck, trachea, esophagus
T4b: Prevertebral space, carotid artery, mediastinum 
NX = regional lymph nodes cannot be assessed
N0 = no evidence of regional lymph nodes
N1 = ipsilateral, single, < 3 cm
N2a = ipsilateral, single, > 3 to 6 cm
N2b = ipsilateral, multiple, < 6 cm
N2c = bilateral or contralateral, < 6 cm
N3 = > 6 cm
MX = regional lymph nodes cannot be assessed
M0 = no evidence of regional lymph nodes
M1 = presence of distant metastasis
Supraglottis:
T1 = 1 subsite, normal cord mobility

T2 = > 1 adjacent subsites, no fixation of hemilarynx

Glottis:
1a = 1 vocal cord only, normal cord mobility

1b = both vocal cords, normal cord mobility

T2 = supraglottis / subglottis; OR impaired cord mobility

Subglottis:
T1 = limited to subglottis, normal cord mobility

T2 = extension to glottis OR impaired cord mobility

Stage 0 = Tis NO MO

Stage I = T1 NO MO

Stage II = T2 NO MO

Stage III = presence of T3 or N1

Stage IVA = presence of T4 or N2

Stage IVB = presence of N3

Stage IVC = presence of M1

 Treatment of
Laryngeal Malignancy
Definitive Treatment

• Radical Surgery

• Radical Radiotherapy (6000 cGray over 6 weeks)

• Chemotherapy: 5 Fluorouracil & Cisplatin

• Surgery with post-op Radiotherapy

Surgical Treatment
 Glottic malignancy
 Cordectomy

 Frontal vertical partial laryngectomy

 Lateral vertical partial laryngectomy

 Fronto-lateral vertical partial laryngectomy

 Extended fronto-lateral partial laryngectomy

 Conventional VPL (hemi-laryngectomy)

Cordectomy
Frontal VPL
Lateral VPL
Fronto-lateral VPL
Subtotal bifrontal
laryngectomy
Conventional VPL: hemi-
laryngectomy
Extended hemi-laryngectomy
Supraglottic malignancy
 Epiglottectomy
 Supraglottic (horizontal partial) laryngectomy
 Extended supraglottic laryngectomy

Trans-glottic malignancy
 Subtotal laryngectomy (supra-cricoid laryngectomy
with crico-hyoido-pexy)
 Three-fourth laryngectomy
 Near-total laryngectomy
Supraglottic Laryngectomy
Supraglottic Laryngectomy
Supraglottic Laryngectomy
Three-fourth Laryngectomy
Supra-cricoid Laryngectomy
Supra-cricoid Laryngectomy +
Crico-hyoido-pexy
Near-total Laryngectomy
Near-total Laryngectomy
Near-total Laryngectomy
 Advanced malignancy
1. Total Laryngectomy

 Narrow field: removal of entire larynx only

 Wide field: removal of entire larynx, hyoid bone,

partial pharynx, strap muscles & I/L thyroid lobe

2. Extended (widespread ) total laryngectomy: wide

field total laryngectomy + resection of surrounding

structures (base of tongue, pharynx, thyroid gland)

Narrow field total laryngectomy
Total Laryngectomy
Repair of hypopharynx
Inferior constrictor approximated
Permanent tracheostome
Laryngectomy specimens
Treatment planning
Supraglottis
T1 & T2 tumor limited to supraglottis: Radiotherapy or
Supraglottic laryngectomy
T2 tumor involving glottis: Supracricoid Laryngectomy
or Radiotherapy

T3 & T4 tumor:

Total laryngectomy + post-operative Radiotherapy

or Radical Radiotherapy with salvage surgery

or Chemo-radiation
Glottis
Tis (Ca in situ): Radiotherapy or Endoscopic excision

T1a: Radiotherapy or Vertical Partial Laryngectomy

T1b tumor: Radiotherapy or Supracricoid Laryngectomy

T2 supraglottis: Supracricoid Laryngectomy or RT

T2 involving subglottis: Near-total or Total Laryngectomy

T2 impaired cord mobility: Supracricoid Laryngectomy or RT

T3 & T4 tumor: Total laryngectomy + post-operative RT

or Radical Radiotherapy with salvage surgery

or Chemo-radiation
Subglottis
T1: Total Laryngectomy + hemithyroidectomy or RT (?)

T2: Total Laryngectomy + hemithyroidectomy

T3 & T4: Total Laryngectomy + hemithyroidectomy

+ post-operative Radiotherapy

Neck nodes
N0: B/L selective dissection of levels 2, 3 & 4
or B/L Radiotherapy

N1: B/L modified radical neck dissection

N2 & N3: B/L modified radical neck dissection

+ post-operative Radiotherapy
Voice Rehabilitation
A. Esophageal voice
B. Artificial larynx: Pneumatic, Electrical
C. Shunt technique
1. tracheo-hypopharyngeal shunt
2. esophago-tracheal shunt
D. Valved devices for tracheo-esophageal puncture
1. Blom Singer prosthesis
2. Panje button device
3. Provox prosthesis
E. Surgical reconstruction of larynx
1. Laryngeal replacement (Teflon, Dacron)
2. Laryngeal transplant
Electronic Larynx
Tracheo-esophageal prosthesis
Palliative Care
Used in later stages to ameliorate symptoms

1. Debulking surgery (Laser-assisted)

2. Radiotherapy (short-course)

3. Chemotherapy

4. Tracheostomy

5. Counseling
Thank You