ca larynx

1. CARCINOMA LARYNX
PRINCIPLES OF MANAGEMENT
Aakanksha Aggarwal
DNB Resident

2. ANATOMY
GLOTTIS
True vocal cords
Anterior commissure
SUPRAGLOTTIS
Epiglottis
False vocal cords
Ventricles
Aryepiglottic folds
Arytenoids
SUBGLOTTIS (2 cm)
5 mm below the free
edge of true vocal
cords
Lower margin of cricoid
cartilage

3. • Supraglottis - rich capillary lymphatic plexus
• No capillary lymphatics of true vocal cords
• Subglottis – relatively few capillary lymphatics
• Lymphatic spread
rare in glottic cancer
(unless tumor
extends)

4. STAGING

7. Management
• Surgery
• Radiotherapy
• Chemotherapy
TREATMENT GOALS
• Primary goal - Cure / Local control
• Secondary goal – Organ preservation

8. EARLY STAGE (I-II) (T1-T2, N0)
• Single modality (Surgery or RT)
• Equally effective
ADVANCED STAGE (III/IV) (T1-2, N1-3 / T3-4, N0-N+)
• Multimodality
• Preop RT f/b surgery
• Surgery f/b post op RT/CT-RT
• Neoadj chemo f/b surgery
• Neoadj chemo f/b RT
• RT with concurrent chemotherapy
• RT with biolological therapy

9. Surgical treatment - approaches
SUPRAGLOTTIC LARYNX
• Supraglottic Laryngectomy
• Extended Supraglottic Laryngectomy
GLOTTIC LARYNX
• Cordectomy
• Vertical Partial Laryngectomy
• Supracricoid Partial Laryngectomy
• Total Laryngectomy

10. SUPRAGLOTTIC (horizontal partial) LARYNGECTOMY
• Indication: Voice preservation surgery for early
supraglottic lesion
• Parts removed:
Epiglottis, AE folds, false cords, upper part of thyroid
cartilage. Hyoid bone may be removed if epiglottic space
involved.

11. EXTENDED SUPRAGLOTTIC LARYNGECTOMY
• Indication: Supraglottic lesion with <1 cm bas of tongue
invasion
• Parts removed
Same as SGL with ipsilateral base of tongue upto
circumvallate papillae

12. CORDECTOMY
• Indication: Small lesion or early T1a lesion of middle 1/3rd
of vocal cord
• Involved vocal cord is removed

13. VERTICAL PARTIAL LARYNGECTOMY
• Indication:
Lesion of mobile cord extending to anterior commissure,
I/L vocal process & anterio-superior portion of arytenoid
Subglottic extension < 5 mm
Fixed vocal cord lesion not crossing midline
Not involving > than anterior third of opposite cord

14. • Parts removed: Adjacent thyroid cartilage, one true vocal
cord and upto 1/3rd of other true vocal cord

15. SUPRACRICOID PARTIAL LARYNGECTOMY
• Indication:
Selected T2 and T3 glottic disease
Involving b/l posterior commissure only
Lesion on mobile cord extending to anterior commissure
Cord fixation in an otherwise T2 lesion

16. • Parts removed: Both true and false cords, entire thyroid
cartilage, may remove arytenoids

17. TOTAL LARYNGECTOMY
• Indication: Lesions with transglottic or extensive (> 1 cm)
subglottic, salvage for RT failure
• Parts removed: Larynx is totally removed with airway
interruption and respiration being performed through
tracheal stoma

18. • Morbidity of laryngectomy
Loss of natural voice
Altered deglutition
Permanent stoma
Pharyngocutaneous fistula (upto 30%)
Stomal stenosis (25% - 40%)
Aspiartion (upto 40% with partial laryngectomy)

19. Combined modality treatment
• Preop RT f/b Surgery
• Surgery f/b Post op RT/CT-RT
• Neoadj chemotherapy f/b surgery
• Neoadj chemotherapy f/b RT
• Radiotherapy with chemotherapy
• Radiotherapy with biological therapy

20. RADIOTHERAPY
• Excellent local control and cure rates only in early
laryngeal cancers
• Biggest advantage as definitive management is organ
preservation
• Patients receive 2.25 Gy per fraction once daily to 63 Gy
(T1and T2a) or 65.25 Gy (T2b)
• RT for T3 and T4 lesions is delivered at 1.2 Gy per
fraction twice daily to 45.6 Gy. The portals are then
reduced to include only the primary lesion ; final tumor
dose is 74.4 Gy.

21. CHEMORADIOTHERAPY
• Cisplatin based
• In a sequential or concurrent manner to patients with
advanced laryngeal cancer
• Concurrent chemoradiotherapy considered standard
of care when attempting laryngeal preservation in
locally advanced disease

22. Management of Recurrence
• Worsening laryngeal edema
• Cord fixation (local recuurence)
• RT failures (T1-T2) salvaged by cordectomy, partial
laryngectomy, or total laryngectomy
• Salvage rate for T3 lesions recurring after RT is approx
60 %
• Salvage by RT based treatment for recurrences after
partial laryngectomy approx 50 %

23. Thank You