Cancer Larynx

Contents
1. Definition
2. Epidemiology
3. Etiology
4. Anatomical sites of larynx
5. Tumor, node, metastasis (TNM) system and Histologic
grading
6. Laryngeal carcinoma based on anatomical sites
supraglottic, glottic and subglottic cancer
7. Laryngeal carcinoma based on histologic classification
8. Diagnosis
9. Principle of Treatment



Definition
Laryngeal carcinoma is cancer of the larynx,
including the vocal cords (glottis), supraglottis,
and subglottis.(Ferri's Clinical Advisor 2014)








Epidemiology
Laryngeal carcinoma is the most common
malignancy among head and neck
There are 12,000 new cases per year in the
U.S.
Male predominance, M:F (10:1)
4
th
to 7
th
decade, peak incidence at sixth
decade

Ferri's Clinical Advisor 2014
Aetiology
Smoking
Alcohol
Previous radiation
Genetic
Occupational exposure
Gastroesophageal reflux disease (GERD)
Human papillomavirus
Cummings Otolaryngology Head & Neck Surgery , Fifth Edition
Larynx is divided into 3 regions:

1. Supraglottis
2. Glottis
3. Subglottis

This division reflects the embryologic structure of
the larynx and the anatomic barriers to spread of
cancer.
Anatomical Sites of Larynx
Classification of sites and various sub-
sites under each site in larynx
Site Sub-sites
Supraglottis Suprahyoid epiglottis
Infrahyoid epiglottis
Aryepiglottic folds
Arytenoids
Ventricular bands/ false cords

Glottis True vocal cord including anterior
and posterior commissure

Subglottis Subglottic up to the lower border
of cricoid cartilage

AJCC (American Joint Committee on Cancer) Classification 1997
Anatomic regions and structures of the
larynx.
horizontal plane 1 cm below the apex of the ventricle, or 0.5 cm below the free edge of the true vocal cords. Head and
neck surgeons typically refer to the former definition and radiation oncologists refer to the latter. The subglottis extends
down to the inferior margin of the cricoid cartilage and the beginning of the trachea.
FIGURE 31-1!
Anatomic regions and structures of the larynx.
The appearance of the larynx as seen in the indirect mirror examination is shown in Fig. 31-2 . The cartilaginous
framework of the larynx is important in diagnostic radiology and in evaluating simulation and port films. The relationship of
the various cartilages to surface anatomy is shown in Fig. 31-3 . The thyroid, cricoid, and the majority of the arytenoid
cartilages are composed of hyaline cartilage, which begins to ossify at approximately 20 years of age. The epiglottis, the
corniculate and cuneiform cartilages, and the apex and vocal process of the arytenoids are made up of elastic cartilage,
which does not ossify and therefore is not radiopaque.
FIGURE 31-2!
Structures of the larynx as seen by indirect mirror examination.
Leibel and Phillips Textbook of Radiation
Oncology , Third Edition
cancer outlined earlier. The TNM staging system further subdivides the supraglottis and glottis of the larynx
into multiple subsites, used to define the T stage ( Table 107-1 ).
6
Figure 107-1.
Classification of laryngeal lesions by the anatomic site involved.
(Adapted from Ogura JH, Biller HF. Partial and total laryngectomy and radical neck dissection. In:
Maloney WH, ed. Otolaryngology. Vol 4. New York: Harper & Row; 1971.)
Table 107-1
Anatomic Sites and Subsites of the Larynx
Site Subsite
Supraglottis
Suprahyoid epiglottis
Infrahyoid epiglottis
Aryepiglottic folds, right and left (laryngeal surfaces)
Arytenoids, right and left
Ventricular bands, right and left
Glottis
True vocal cords, right and left (including the anterior and posterior
commissures)
Subglottis No separate subsites defined
From Greene F, Page D, Fleming I, et al. AJCC Cancer Staging Manual. 6th ed. New York: Springer; 2002.
The supraglottis is composed of the suprahyoid and infrahyoid epiglottis (both the lingual and the laryngeal
surfaces), aryepiglottic folds (laryngeal surfaces only), arytenoids, and ventricular bands (false vocal cords).
The boundary between the suprahyoid and infrahyoid epiglottis is a horizontal plane passing through the hyoid
Cummings Otolaryngology Head & Neck
Surgery , Fifth Edition
FIGURE 31-3!
A, Anterior view of surface anatomy with cartilages shown. B, Lateral view of surface anatomy with cartilages
shown.
The anterior limits of the larynx consist of the lingual surface of the suprahyoid epiglottis, the thyrohyoid membrane, the
anterior commissure, and the anterior wall of the subglottic region, which is composed of the thyroid cartilage, the
cricothyroid membrane, and the anterior arch of the cricoid cartilage (see Fig. 31-3 B). To avoid underdosing the anterior
portion of the larynx when using megavoltage radiation to treat larynx cancer, it is important to remember that the anterior
commissure usually lies within 1 cm of the skin surface and that bolus may be required to deliver adequate dose to this
area. The posterior and lateral limits include the aryepiglottic folds, the arytenoids, the interarytenoid space, and the
posterior surface of the subglottic space formed by the mucous membrane covering the cricoid cartilage. Superiorly, the
epiglottis demarcates the boundary with the pharynx, which is usually at the lower border of the C3 vertebra. The inferior
extent of the larynx is at the lower margin of the cricoid, which is typically at the level of the C6 vertebra ( Fig. 31-4 ). The
anatomy of the larynx can also be appreciated on computed tomography (CT) scans. The key structures are seen in Fig.
31-5 .
FIGURE 31-4!
Structures of the larynx as seen from behind.
FIGURE 31-5!
Structures of the larynx as seen on computed tomography scans at the level of true vocal cords (A) and
subglottis (B).
Pathologic Conditions
Squamous cell carcinomas account for at least 95% of all malignant neoplasms of the larynx. Carcinomas arising from the
true vocal cords are usually well differentiated or moderately well differentiated, whereas carcinomas of the supraglottis
and subglottis are less differentiated. Carcinoma in situ (CIS) occurs in the vocal cords but is rare in the supraglottis. CIS
is a pathologic entity representing carcinomatous changes confined to the thickened epithelium without breaching the
lamina propria. As in other malignancies, invasion through the basement membrane distinguishes invasive carcinoma
from CIS. When carcinogens promote DNA damage, they lead to a multistep progression of hyperplasia, dysplasia, in situ
carcinoma, and invasive malignant lesions. Thus, it is common to see abnormal specimens that contains areas of
dysplasia, CIS, and invasive carcinoma.
Verrucous carcinoma is an uncommon but distinct variety of squamous cell carcinoma. It accounts for less than 5% of all
larynx cancers. It is a bulky, exophytic, papillomatous, low-grade squamous cell carcinoma. Typically it has a heavily
keratinized surface and a blunt, well-demarcated, invasive, deep margin, often with a broad base. Other rare tumors of the
larynx include malignant minor salivary gland tumors, small cell carcinoma (SCC), lymphoma, plasmacytoma,
chemodectoma, carcinoid, pseudosarcoma, soft-tissue sarcoma, chondrosarcoma, malignant melanoma, and metastatic
disease. The management of these tumors is dictated primarily by their histology rather than the location.
Structures of the larynx as seen from behind.
Leibel and Phillips Textbook of Radiation
Oncology , Third Edition
TNM system
T: tumor and its extent

N: indicates regional lymph node enlargement
and its size

M: distant metastasis


Histologic Grading
(WHO 1987- Modified Broders Classification)
Grade 1 : Well differentiated
- Excessive keratin pearl formation
Grade 2: Moderately differentiated
- Moderate keratin formation
Grade 3: Poorly differentiated
- Keratin formation is only detected by
cytokeratin immunohistochemical reaction or
electron miscroscopy
Supraglottic Cancer
Extent:
The common sites: Epiglottis, false cord followed
by aryepiglottic fold
Spread:
For supraglottic cancer: Locally spread or invade the
adjoining areas like vallecula, base of tongue and
pyriform form
Nodal metastasis:
Occur early. Upper and middle jugular nodes are
often involved. Bilateral metastasis can be seen in
epiglottic cancer
Symptoms:
Always silent
Throat pain, dysphagia, referred pain to ear,
painful neck swelling
Hoarseness of voice late symptom
Weight loss, airway obstruction, halitosis
late features

Supraglottic Cancer
Glottic Cancer
Extent:
The most common site for laryngeal carcinoma, especially
free edge and upper surface of vocal cord in its anterior
middle third
Spread: Locally may spread to
Anteriorly: Anterior commissure
Posteriorly: Vocal process and arytenoid region
Superiorly: Ventricle and false cord
Inferiorly: Subglottic region
Early stage: Vocal cord is mobile
Late stage: Fixation of cord spread to thyroarytenoid mucscle
bad prognosis
Nodal metastasis: Not common



Glottic Cancer
Symptoms:
Hoarseness of voice early sign
Stridor
Laryngeal obstruction

Subglottic Cancer
Extent: From the glottic area to lower border of cricoid
cartilage
Rare
Spread:
Spread around anterior wall to the opposite side
Spread downward to the trachea
Upward spread to vocal cord is late symptoms no early
hoarseness of voice
Invade cricothyroid membrane, thyroid gland
Nodal metastasis:
Prelaryngeal nodes
Pretracheal nodes
Paratracheal nodes
Lower jugular nodes


Subglottic Cancer
Symptoms:
Stridor and laryngeal obstruction
Hoarseness of voice
Histologic Classification
Epithelial cancers:
Squamous cell carcinoma
Basaloid squmous carcinoma
Verrucous carcinoma
Adenocarcinoma
Pseudosarcoma
Anaplastic cancer
Transitional cell carcinoma
Neuroendocrine tumors, including small cell and
carcinoid
Sarcoma: Metastatic malignancies

Squamous cell carcinoma
More than 95% of laryngeal tumours are
squamous cell carcinoma
Common site: Glottic region true vocal cord


Squamous Cell Carcinoma
Four subtypes:
1. Glottic carcinoma
2. Supraglottic carcinoma
3. Subglottic carcinoma
4. Transglottic carcinoma: cross the ventricle from the
supraglottic area to involve the true and false vocal folds
or involve the glottis and extend subglottically more than
10mm or both

Glottic carcinomas (50%-60%)
Supraglottic carcinomas (30%-40%)
Subglottic carcinomas are uncommon (5% or less).

Diagnosis
1. History
2. Indirect laryngoscopy
3. Neck examination
4. Radiology
5. CT Scan
6. Direct laryngoscopy
7. Microlaryngoscopy
Persistent or gradually increasing hoarseness
of voice for 3 weeks
1.History
2. Indirect laryngoscopy
Appearance of lesion

Vocal cord mobility

Extent of disease

3. Examination of the Neck
Extralaryngeal spread of disease

Nodal metastasis
4. Radiology
X-ray Chest

Soft tissue lateral view neck


5. CT scan
Extent of tumour
Invasion
Destruction of cartilage
Lymph node involvement
6. Direct laryngoscopy
Hidden area of larynx

Extent of the disease


7. Microlaryngoscopy
Small lesion of vocal lesion

For accurate biopsy specimens

Treatment
Depends upon the site of lesion, extent of lesion,
presence or absence of nodal and distant
metastases.
Radiotherapy

Surgery
Conservative
Total laryngectomy

Combined therapy
1. Radiotherapy
Early lesions which neither impair cord
mobility nor invade cartilage or cervical nodes

Not suitable for lesion with fixed cords,
subglottic extension, cartilage invasion, and
nodal metastasis
2. Surgery
a. Conservative surgery
i. Preserve the voice
ii. Avoid a permanent tracheal opening
iii. Includes:
Excision of vocal cord after splitting the larynx
(cordectomy via laryngofissure)
Excision of vocal cord and anterior commissure
(partial frontolateral laryngectomy)
Excision of the epiglottis
2. Surgery
b. Total laryngectomy
Indications:
i. T3 lesion with cord fixation
ii. All T4 lesion
iii. Invasion of thyroid and cricoid cartilage
iv. Bilateral arytenoid cartilage involvement
v. Posterior commissure lesion
vi. Failure after conservative surgery or radiotherapy
vii. Transglottic cancer
Contraindication: Patient with distant metastasis
3. Combined Therapy
Surgery may be combined with pre-operative
or post-operative radiotherapy
To reduce the recurrence
References (Draft)
Ferri's Clinical Advisor 2014, Fred F. Ferri, 643-643.e1
Diseases of ear, nose and throat, P.L Dhingra, 3
rd
edition
Cummings Otolaryngology Head & Neck Surgery , Fifth Edition, Paul W.
Flint, Bruce H. Haughey, Valerie J. Lund, John K. Niparko, Mark A.
Richardson, K. Thomas Robbins, and J. Regan Thomas CHAPTER 107, 1482-
1511
Leibel and Phillips Textbook of Radiation Oncology , Third Edition,
Richard T. Hoppe, Theodore Locke Phillips, and Mack Roach, Chapter 31,
642-665
Atlas of Head and Neck Pathology , Second Edition, Bruce M. Wenig
Chapter 13, 439-532