Laryngeal cancer,

1. MALIGNANT LESIONS OF
LARYNX
Dr Safika Zaman
Dept of ENT & Head Neck Surgery, RKMSP VIMS

2. INTRODUCTION
Complex anatomy of larynx
Functions- breathing airway protection,
and speaking.
Management-balance between primary
oncological control and aims to preserve
and, where possible, restore form and
function, while minimizing treatment
morbidity.

3. GLOBAL EPIDEMIOLOGY
Incidence -2.76 new cases
per 100,000 inhabitants.
Prevalace -14.33 cases
per 100,000 inhabitants.
The incidence and
prevalence have both
increased by 12.0% and
23.8%, respectively during
the past 3 decades.
data source for mentioned study -Global Health Data Exchange (GHDx)
Nocini R, Molteni G, Mattiuzzi C, Lippi G. Updates on larynx cancer
epidemiology. Chin J Cancer Res. 2020;32(1):18-25.
doi:10.21147/j.issn.1000-9604.2020.01.03

4. INDIAN EPIDEMIOLOGY
In India, laryngeal cancer contributes to approximately 3-6% of all
cancers in men. The age-adjusted incidence rate of cancer larynx in
males varies widely among registries, highest is 8.18 per 100,000 in
Kamrup Urban District and the lowest is 1.26 per 100,000 in Nagaland.
The 5-year survival for laryngeal cancer in India is approximately 28%.
Bobdey S, Jain A, Balasubramanium G. Epidemiological review of laryngeal
cancer: An Indian perspective. Indian J Med Paediatr Oncol. 2015 Jul-
Sep;36(3):154-60. doi: 10.4103/0971-5851.166721. PMID: 26855523; PMCID:
PMC4743184.

5. AETIOLOGY
People who smoke more than 25
cigarettes a day, or people who have
smoked for more than 40 years, risk
increases by 40 times.
People who regularly drink large
amounts of alcohol are about 3 times
more likely to develop laryngeal cancer.
Family history
Diet high in red meat, processed food
and fried food might increase risk.
HPV infection
Data souce – NHS website

6. CONT….
Male > female
Age > 60 years
Race – Afro-American population.
Formaldehyde
Asbestos, coal or wood dust, paint or diesel
fumes, nickel, sulphuric acid fumes isopropyl
alcohol

7. PATHOLOGICAL CLASSIFICATION
Well-differentiated squamous cell
carcinoma- most common.
A minority of cases represent squamous
cell variants, including verrucous
carcinoma, sarcomatoid carcinoma, and
neuroendocrine carcinoma.
 Rarely- adenocarcinomas, sarcomas,
lymphoma.
The spectrum of histopathology of the
SCC varies significantly from hyperplasia,
dysplasia carcinoma in situ to an invasive

8. MOLECULAR PATHOLOGY

9. ANATOMY OF LARYNX
1. Supraglottis – laryngeal inlet to
ventricle.
2. Glottis- true vocal folds.
3. Subglottis – true vocal fold to
lower border of cricoid.

10. SURGICAL ANATOMY
Opposite 3rd to 6th vertebrae.
Anterior – skin, infrahyoid muscles,
pyramidal lobe of thyroid.
Lateral – great vessels of neck, thyroid.
Posterior – laryngopharynx, pre vertebral
fascia and muscles.

11. SPACES OF LARYNX
Ventricle- space between true
and false vocal cords.
Paraglottic space- laterally by
perichondrium of thyroid
cartilage and cricothyroid
membrane.
Posteriorly by mucous
membrane of PFS.
Pyriform sinus- medially AE
fold , laterally thyroid cartilage
and thyrohyoid membrane.

12. LYMPHATIC DRAINAGE
Supraglottis – via superior laryngeal
vessels to levels II and III.
Anterior glottis and subglottis –
through cricothyroid ligament
anteriorly to level VI and laterally to
level IV.
Posterior glottis and subglottis –
through cricotracheal membrane to
the paratracheal nodes in level VI
and laterally to level IV.

13. SURGICAL ANATOMY

14. PATHWAY OF CANCER SPREAD
Generally along lines of least resistance in
potential spaces and tissue planes.
Marked out by nerve, blood vessels and
lymphatics passing away from the tumor.
No true anatomical barrier to check spread
between the supra- and subglottis.

15. GLOTTIC CANCER SPREAD
Progress of glottic carcinoma is slow and
predictable
Common site – ant half, AC
Extension in 3 dimensions
Glottic plane-radially (ant-post)
Vertical-AC to supra/subglottic spread
Deep-through vocal lig, conus elasticus,
thryroartenoideus, paraglottic space.
Lymphatic spread less common.
Nodal metastasis seen in level 2,3,4 and
delphian node.

16. SUPRAGLOTTIC CANCER SPREAD
Usually remain localised
Glottic spread relatively late
Tumor behaviour influenced by
Exophytic/ulcerative
Thyroid cartilage involvement through pre
epiglottic & paraglottic space– extralaryngeal
spread

17. CONT…
‘Suprahyoid supraglottic’
carcinomas tend to invade the
pre-epiglottic space and the
deep muscles of the tongue
and spread mucosally into the
piriform fossae rather than
into the paraglottic space.
Supraglottic tumours also have
propensity for bilateral nodal
metastasis.

18. SUBGLOTTIC CANCER
Primary subglottic cancer is rare.
Primary tumour spread circumferentially.
Subglottic extension of glottic cancer is more
common
Thyroid gland and pre/ paratracheal node
involvement more common
Thus subglottic tumours are usually advanced at
presentation.

19. TRANSGLOTTIC CANCER
Transglottic cancer is defined by spread,
both superficially and into the paraglottic
space to span all three laryngeal subsites.
By definition, at least T3 at presentation
Source – Scott Brown`s ENT book

20. EARLY CLINICAL PRESENTATION
Supraglottic Glottic Subglottic
Foreign body
sensation
Referred otalgia
Dysphagia
Odynophagia
Voice change-
hoarseness
Stridor
Voice change
Stridor

21. LATE CLINICAL PRESENTATION
Weight loss, dysphagia, aspiration,
and its sequelae, and airway
compromise.
Fixed, firm, painless masses in the
neck

22. DIFFERENTIAL DIAGNOSIS
Acute sialadenitis
Bacterial lymphadenopathy
Tuberculosis
Benign tumours (rare)
Branchial cleft cyst
Chronic laryngitis
Chronic sialadenitis
Contact granuloma
Hemangioma
HPV papillomas
Laryngocele
Polyps on the vocal cord(s)
Reinke's edema
Thyroglossal duct cyst

23. ASSESSMENT AT OPD
History
Examination of neck – palpation for neck
nodes
tenderness of thyroid
cartilage, laryngeal crepitus, local
induration
Indirect laryngoscopy
Fibre optic laryngoscopy
Work up -CBC, liver and renal function,
blood type, thyroid function, electrolytes,
and albumin levels.

24. RADIOLOGICAL WORK UP
CONTRAST-ENHANCED CT OF THE NECK
MRI
PET/CT TO RULE OUT DISTANT METASTASES
CHEST X-RAY / HRCT CHEST

25. CT DETAILS
Consensus Document for Management of Larynx and
Hypopharynx Cancers as an outcome of ICMR Subcommittee on
Larynx & Hypopharynx Cancers

26. SUPRAGLOTTIC TUMOUR

27. EARLY GLOTTIS CANCER

28. GLOTTIC TUMOUR

29. TRANS GLOTTIS GROWTH

30. MRI
MRI has a better sensitivity, but
less specificity
Laryngeal cartilage invasion
Involvement of the tongue base
T1 axial image

31. ASSESSMENT UNDER GENERAL
ANAESTHESIA
Direct laryngoscopy -enhanced ability
to delineate the extent of disease as
well as the ability to obtain tissue
specimens
Biopsy
fine-needle aspiration (FNA) of any
suspected nodal disease

32. EVALUATION SUMMARY
Vocal cord mobility
Number of regions involved
Presence of cervical or distant metastatic
lesions
Base of the tongue
Paraglottic and pre-epiglottic space
Thyroid cartilage
Carotid artery and sheath
Esophagus
Invasion of soft tissue and adjacent laryngeal
muscles

33. STAGING OF CANCER

34. CONT…

35. TREATMENT - MULTIDISCIPLINARY
TEAM APPROACH
Radiation oncologist
Surgical oncologist
Medical oncologist
Radiologist
Pathologist
Speech therapist
Nutrition specialist and clinical
psychologist

36. GOAL OF TREATMENT
Maximize cure
Preserve the function of Larynx
Preserve the quality of voice
Maintain good quality of life
Palliation of symptoms in patients with incurable disease

37. FACTORS DETERMINING
TREATMENT MODALITY
Stage at presentation
Age
Comorbidities
Surgical access issues
Skills and preferences of the treating multidisciplinary team
Wishes of the patient.

38. TREATMENT OPTIONS
Radiotherapy
Trans oral LASER resection
Open laryngectomies- partial/
total
Concurrent chemo-radiation

39. RADIOTHERAPY
Aim -precise radiation delivery, minimizing the dose to surrounding normal
structures.
Intensity-modulated radiotherapy (IMRT) and volumetric arc therapy (vmat)
now favoured.
Side effects are due to exposure to salivary glands, upper aerodigestive
mucosa, and pharyngeal constrictors.
Hyperfractionation involves two or more smaller doses of radiation on each
treatment day.
Accelerated fractionation refers to the reduced overall treatment time over

40. RADIOTHERAPY PRINCIPLES- NCCN
GUIDELINES

41. SURGERY
Transoral surgery-microscopic or endoscopic
LASER or robotic
Open laryngeal procedures- supraglottic laryngectomy,
supracricoid laryngectomy
Vertical or partial laryngectomy
Total laryngectomy.
Total laryngectomy with adjacent structure removal.

42. TRANS ORAL LASER MICRO
SURGERY
Procedure: laryngoscope placed → view
maximized by applying pressure to the cricoid
→ LASER system set to optimal setting → The
tumour is held using aspirating forceps and
retracted medially →The laser incision
commences posteriorly, or postero-laterally →
The dissection proceeds while maintaining at
least a 1mm margin.
May be necessary to remove the ipsilateral
false cord,
Detailed and accurate pathological assessment.

43. TRANS-ORAL LASER MICRO
SURGERY

44. CONCURRENT CHEMO-RADIO
THERAPY
Veterans Administration (VA) study(1991- RCT, 2 Arm. Inclusion criteria
were patients with stage 3 or 4 laryngeal cancer. The first arm underwent
2–3 cycles of induction chemotherapy, followed by definitive radiotherapy
provided there was tumor response to chemotherapy. Non responders
underwent immediate total laryngectomy. The second arm underwent
total laryngectomy with postoperative radiotherapy. Two-year survival
was equal in both arms (68%); however, 36% of the non-surgical arm
retained their larynx.
(RTOG) 91-11 study published by Forastiere et al. in 2003. This
comprised a three-arm randomized controlled trial on patients with stage
3/4 laryngeal cancer. The first arm consisted of induction chemotherapy
followed by radiation; the second consisted of concurrent
chemoradiotherapy; and the third consisted of radiotherapy alone. This
study showed a superior locoregional control and laryngeal preservation
rate in the concurrent chemoradiotherapy group,

45. CONT…
Chemotherapeutic agents - Taxane, cisplatin,
and 5-fluorouracil.
Patient selection - patient’s general
condition, medical comorbidity, and ability to
tolerate chemotherapy.
Disadvantage – poor functional preservation
of larynx.
Long term toxicity increasing mortality.

47. CONT…

48. CARCINOMA IN SITU

49. EARLY STAGE LARYNGEAL
MALIGNANCY
Zahoor, T., Dawson, R., Sen, M., & Makura, Z. (2017).
Transoral laser resection or radiotherapy? Patient choice
in the treatment of early laryngeal cancer: A prospective
observational cohort study. The Journal of Laryngology &
Otology, 131(6), 541-545.
doi:10.1017/S0022215116010057

50. Results
Sixteen studies were included in the meta-analysis, the majority being
retrospective cohort studies with two prospective cohort studies. Included studies
were rated as either Level II or III evidence. Meta-analysis favoured treatment with
TLM for T1 glottic carcinoma patients for the following outcomes: overall survival
(odds ratio [OR], 1.52; 95% confidence interval [CI], 1.07–2.14; P = 0.02), disease
specific survival (OR, 2.70; CI, 1.32–5.54; P = 0.007), and laryngeal preservation
(OR, 6.31; CI, 3.77–10.56; P < 0.00001). There was no difference in local control
between TLM and RT in T1 glottic cancer (OR, 1.19; CI, 0.79–1.81; P = 0.40).

51. analysis of prognostic factors for Tis-2N0M0 early glottic cancer
with different treatment methods
Guanyu Wanga,2, Guodong Lib,1,2, Jianjun Wua, Penghui Songa,
a Heping Hospital Affiliated to Changzhi Medical College,
Department of Radiotherapy, Changzhi, PR Chinab Shanxi Provincial
People’s Hospital Affiliated to Shanxi Medical University,
Department of Otolaryngology, Taiyuan, PR China

52. EUROPEAN LARYNGOLOGICAL
SOCIETY CLASSIFICATION OF
CORDECTOMIES FOR GLOTTIC
CARCINOMA

53. CONT…

59. CONT…

60. TOTAL LARYNGECTOMY
The first total laryngectomy was reportedly carried out
in 1873 by Billroth
Excellent local and regional control of the disease
Voice production and communication,
Psychological effects due to disfigurement
Production of an end stoma

61. INDICATION OF LARYNGECTOMY
Advanced laryngeal cancer(T3/T4).
Subglottic extension with invasion of the cricoid cartilage.
Laryngeal dysfunction in laryngeal cancer patient.
Post radiotherapy or post chemotherapy patient with severely
dysfunctional larynx.
Laryngeal cancer patient who can not with stand chemotherapy or
radiotherapy.
Completion laryngectomy for failed initial laryngeal conservation
surgeries.
Advanced thyroid tumour with laryngeal extension.

62. VOICE REHABILITATION

63. FOLLOW UP- NCCN PROTOCOL
Objectives- 1. Detect early recurrences
2. Evaluation and management of morbidity
3. Detection of second primary.
Clinical examination including ENT evaluation is done once in 3 months
for the first two years. Once in 4-6 months from third to fifth year. Yearly
follow up after 5 years. TSH evaluation should be done after 6 months of
radiation and periodically
Consensus Document for Management of Larynx and
Hypopharynx Cancers Prepared as an outcome of ICMR
Subcommittee on
Larynx & Hypopharynx Cancers

64. RECURRENT EARLY LARYNGEAL
CANCER
Residual or recurrent laryngeal cancer following RT is a difficult
clinical problem as the disease is more aggressive and carries a poor
prognosis.
Salvage total laryngectomy (STL) is an often recommended option,
even for early radiorecurrent cancer.

65. RECENT ADVANCES - PROTON
BEAM RADIATION THERAPY
Principles – due to the unique inherent physical properties of protons,
PBRT has the advantage of delivering precise radiation to the tumour
but for a significantly lower normal surrounding tissue dose, thereby
improving the therapeutic ratio.
Radiation related morbidity is less.
Costly , available only in few centers in the world.

66. CONT…

67. TRANS-ORAL ROBOTIC SURGERY
(TORS)
https://els-jbs-pro
cdn.jbs.elsevierhealth.com/cms/attachment/98f8360d-160c-44df-
b8d3-835b4d38a5c3/gr2_lrg.jpg
Disadvantages of
conventional
transoral
techniques

68. TRANS-ORAL ROBOTIC
SURGERY(TORS)
Advantages -wider three-
dimensional surgical field
through smaller surgical access
very precise, tremor-free
movement in spaces
It provides an alternate
approach to open surgery.

69. TRANS ORAL ENDOSCOPIC ULTRASONIC
SURGERY (TOUSS)

70. TOUSS
Evaluate the feasibility of TransOral UltraSonic Surgery (TOUSS)
This is a prospective study on 11 consecutive patients with pharyngeal and
supraglottic carcinomas between December 2013 and August 2014. This series
comprised seven early and four locally advanced carcinomas.
All tumours were resected transorally with 35 cm ThunderbeatTM. Exposure was
achieved using GyrusTM FK-retractor and Olympus ENDOEYE Flex 5 mm 2D/10 mm
3D deflecting tip video laparoscopes.
The mean setup for TOUSS and resection time were 16 and 70.9 minutes.
No major intraoperative complications were identified. The average time of
nasogastric feeding tube dependence (n = 9) was 13 days.
The average hospital stay was 14.3 days. Postoperative pain was satisfactory treated
with nonsteroidal anti-inflammatory drugs.

71. TOUSS

72. THANK YOU