Cancer & Cancer clips how cancer grows and spreads how cancer grows and spreads.
Laryngel Cancer
-
Upload
cain-mcconnell -
Category
Documents
-
view
18 -
download
0
description
Transcript of Laryngel Cancer
![Page 1: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/1.jpg)
Laryngel Cancer
It is the most common cancer of the upper aerodigestive tract.
![Page 2: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/2.jpg)
Subtypes
• Glottic Cancer: 59%
• Supraglottic Cancer: 40%
• Subglottic Cancer: 1%
• Most subglottic masses are extension from glottic carcinomas
![Page 3: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/3.jpg)
Risk Factors
![Page 4: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/4.jpg)
Etiology
• The incidence of laryngeal tumors is closely correlated with smoking, as head and neck tumors occur 6 times more often among cigarette smokers than among nonsmokers.
• The age-standardized risk of mortality from laryngeal cancer appears to have a linear relationship with increasing cigarette consumption.
![Page 5: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/5.jpg)
Etiology
• Death from laryngeal cancer is 20 times more likely for the heaviest smokers than for nonsmokers.
• The use of unfiltered cigarettes or dark, air-cured tobacco is associated with further increases in risk.
![Page 6: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/6.jpg)
Risk Factors<<<
• Although alcohol is a less potent carcinogen than tobacco, alcohol consumption is a risk factor for laryngeal tumors.
• In individuals who use both tobacco and alcohol, these risk factors appear to be synergistic, and they result in a multiplicative increase in the risk of developing laryngeal cancer.
![Page 7: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/7.jpg)
Risk Factors
• Human Papilloma Virus 16 &18
• Chronic Gastric Reflux
• Occupational exposures
• Prior history of head and neck irradiation
![Page 8: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/8.jpg)
Mortality/Morbidity
• The prognosis for small laryngeal cancers that do not have lymph node metastases is good, with cure rates of 75-95%, depending on the site, the size of the tumor, and the extent of infiltration.
• Advanced disease has a worse prognosis.
• Supraglottic cancers usually manifest late and have a poorer prognosis.
![Page 9: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/9.jpg)
Sex & Age Incidence
• In the 1950s, the male-to-female ratio in patients with laryngeal cancer was 15:1.
• This number had changed to 5:1 by the year 2000, and the proportion of women afflicted by the disease is projected to increase in years to come.
• These changes are likely a reflection of shifts in smoking patterns, with women smoking more in recent years.
• Laryngeal cancer most commonly affects men middle-aged or older. The peak incidence is in those aged 50-60 years.
![Page 10: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/10.jpg)
Histological Types
• 85-95% of laryngeal tumors are squamous cell carcinoma
• Histologic type linked to tobacco and alcohol abuse
• Characterized by epithelial nests surrounded by inflammatory stroma
• Keratin Pearls are pathognomonic
![Page 11: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/11.jpg)
Histological Types
• Verrucous Carcinoma
• Fibrosarcoma
• Chondrosarcoma
• Minor salivary carcinoma
• Adenocarcinoma
• Oat cell carcinoma
• Giant cell and Spindle cell carcinoma
![Page 12: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/12.jpg)
Anatomy
![Page 13: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/13.jpg)
The supraglottic larynx
• It consists of epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids
![Page 14: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/14.jpg)
The glottic larynx
• It consists of the true vocal cords and anterior commissure and posterior commissure
![Page 15: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/15.jpg)
The subglottic larynx
• It consists of the region between the vocal cords and the trachea.
![Page 16: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/16.jpg)
Pre-epiglottic fat space
• The pre-epiglottic fat is located in the anterior and lateral aspects of the larynx and is often invaded by advanced cancers.
![Page 17: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/17.jpg)
Lymphatics • The first-echelon lymphatics for the supraglottic
larynx are the subdigastric nodes and the middle anterior cervical nodes and the second-echelon lymphatics are the lower anterior cervical nodes
• The first-echelon lymphatics for the subglottic larynx are the Delphian node, the lower anterior cervical nodes and paratracheal nodes, and the supraclavicular nodes, and the second-echelon lymphatics are the mediastinal nodes.
• Glottic and subglottic tumors metastasize to ipsilateral lymph nodes, but supraglottic tumors often spread to nodes on both sides of the neck.
![Page 18: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/18.jpg)
In the supraglottis, the T stages are as follows
• T1: Tumor limited to 1 subsite of the supraglottis with normal vocal cord mobility
• T2: Tumor invasion of the mucosa of more than 1 adjacent subsite of the supraglottis or glottis or of a region outside the supraglottis , without fixation of the larynx
• T3: Tumor limited to the larynx with vocal cord fixation and/or invasion of any of the postcricoid area or pre-epiglottic tissues
• T4: Tumor invasion through the thyroid cartilage and/or extension into
![Page 19: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/19.jpg)
In the glottis, the T stages are as follows:
• T1: Tumor limited to the vocal cord with normal mobility
• T2: Tumor extension to the supraglottis and/or subglottis and/or impaired vocal cord mobility
• T3: Tumor limited to the larynx with vocal cord fixation
• T4: Tumor invasion through the thyroid cartilage and/or other tissues beyond the larynx .
![Page 20: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/20.jpg)
In the subglottis the T stages are as follows
• T1: Tumor limited to the subglottis• T2: Tumor extension to a vocal cord
with normal or impaired mobility• T3: Tumor limited to the larynx with
vocal cord fixation• T4: Tumor invasion through cricoid or
thyroid cartilage and/or extension to other tissues beyond the larynx
![Page 21: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/21.jpg)
Staging- Nodes
N0 No cervical lymph nodes positive
N1 Single ipsilateral lymph node ≤ 3cm
N2a Single ipsilateral node > 3cm and ≤6cm
N2b Multiple ipsilateral lymph nodes, each ≤ 6cm
N2c Bilateral or contralateral lymph nodes, each ≤6cm
N3 Single or multiple lymph nodes > 6cm
![Page 22: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/22.jpg)
Supraglottic carcinomas
• The epiglottis is the most frequent location for cancers that arise in the supraglottic larynx. These lesions are often exophytic and circumferential masses
• Tumors of the aryepiglottic fold are typically exophytic lesions that, when detected early, are confined laterally along the aryepiglottic fold.
• Advanced lesions may extend laterally to involve the adjacent wall of the pyriform sinus or medially to invade the epiglottis.
![Page 23: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/23.jpg)
Supraglottic carcinomas
• Squamous cell cancers that arise from the false vocal cords and laryngeal ventricle tend to be ulcerative and infiltrative with a limited exophytic component. Deep invasion by such tumors results in their access to the paraglottic space, and this may lead to fixation of the supraglottic larynx.
• Because of their close proximity, these tumors may extend inferiorly to involve the true vocal cords.
![Page 24: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/24.jpg)
Glottic carcinomas
• The true vocal cords are the most common site of laryngeal carcinomas; the ratio of glottic carcinomas to supraglottic carcinomas is approximately 3:1.
• The anterior portion of the true vocal cord is the most common location of squamous cell cancer, with most lesions occurring along the free margin of the vocal cord.
![Page 25: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/25.jpg)
Glottic carcinomas
• Anteriorly, the tumor may extend to anterior commissure, where it may involve the contralateral true vocal cord.
• The likelihood of nodal involvement associated with glottic carcinomas depends on the stage of the tumor. The incidence of early T1 lesions has been reported to be as low as 2%. This figure increases to approximately 20% for T3 and T4 lesions.
![Page 26: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/26.jpg)
Subglottic carcinomas
• Subglottic carcinomas are rare and account for only 5% of all laryngeal carcinomas.
• When present, these lesions are characteristically circumferential and often extend to involve the undersurface of the true vocal cords
• They have a tendency for early invasion of the cricoid cartilage and extension through the cricothyroid membrane.
![Page 27: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/27.jpg)
Presentation
• Hoarseness– Most common symptom– Small irregularities in the vocal fold result in
voice changes– Changes of voice in patients with chronic
hoarseness from tobacco and alcohol can be difficult to appreciate
![Page 28: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/28.jpg)
Presentation
• Other symptoms include:– Dysphagia– Hemoptysis– Throat pain– Ear pain– Airway compromise– Aspiration– Neck mass
![Page 29: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/29.jpg)
Presentation
• Patients presenting with hoarseness should undergo an indirect mirror exam and/or flexible laryngoscope evaluation
• Malignant lesions can appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color
![Page 30: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/30.jpg)
Presentation
• Good neck exam looking for cervical lymphadenopathy and broadening of the laryngeal prominence is required
• The base of the tongue should be palpated for masses as well
• Restricted laryngeal crepitus may be a sign of post cricoid or retropharyngeal invasion
![Page 31: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/31.jpg)
Work up
• Biopsy is required for diagnosis
• Performed in OR with patient under anesthesia
• Other benign possibilities for laryngeal lesions include: Vocal cord nodules or polyps, papillomatosis, granulomas, granular cell neoplasms, sarcoidosis, Wegner’s granulomatosis
![Page 32: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/32.jpg)
Work up
• Other potential modalities:– Direct laryngoscopy– Bronchoscopy– Esophagoscopy– Chest X-ray– CT or MRI– Liver function tests with or without US– PET ?
![Page 33: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/33.jpg)
![Page 34: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/34.jpg)
Treatment
• Premalignant lesions or Carcinoma in situ can be treated by surgical stripping of the entire lesion
• CO2 laser can be used to accomplish this but makes accurate review of margins difficult
![Page 35: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/35.jpg)
Treatment
• Early stage (T1 and T2) can be treated with radiotherapy or surgery alone, both offer the 85-95% cure rate.
• Surgery has a shorter treatment period, saves radiation for recurrence, but may have worse voice outcomes
• Radiotherapy is given for 6-7 weeks, avoids surgical risks but has own complications
![Page 36: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/36.jpg)
Treatment
• XRT complications include:– Mucositis– Odynophagia– Laryngeal edema– Xerostomia– Stricture and fibrosis– Radionecrosis– Hypothyroidism
![Page 37: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/37.jpg)
Treatment
• Advanced stage lesions often receive surgery with adjuvant radiation
• Most T3 and T4 lesions require a total laryngectomy
• Some small T3 and lesser sized tumors can be treated with partial larygectomy
![Page 38: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/38.jpg)
Treatment
• Chemotherapy can be used in addition to irradiation in advanced stage cancers
• Two agents used are Cisplatinum and 5-flourouracil
• Cisplatin thought to sensitize cancer cells to XRT enhancing its effectiveness when used concurrently.
![Page 39: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/39.jpg)
Treatment
• Modified or radical neck dissections are indicated in the presence of nodal disease
• Neck dissections may be performed in patients with supra or subglottic T2 tumors even in the absence of nodal disease
• N0 necks can have a selective dissection sparing the SCM, IJ, and XI
• N1 necks usually have a modified dissection of levels II-IV
![Page 40: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/40.jpg)
Supraglottic laryngectomy
• T1,2, or 3 if only by preepiglottic space invasion
• Mobile cords• No anterior commissure
involvement• FEV1 >50%• No tongue base disease
past circumvallate papillae
• Apex of pyriform sinus not invloved
![Page 41: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/41.jpg)
Total Larygectomy
• Indications:– T3 or T4 unfit for partial– Extensive involvement of thyroid and cricoid
cartilages– Invasion of neck soft tissues– Tongue base involvement beyond
circumvallate papillae
![Page 42: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/42.jpg)
Total Laryngectomy
![Page 43: Laryngel Cancer](https://reader035.fdocuments.in/reader035/viewer/2022070400/5681355c550346895d9cc341/html5/thumbnails/43.jpg)