This document discusses laryngeal malignancies (cancers). It begins by describing the different subsites of the larynx that can be affected. It then provides an overview, stating that laryngeal cancer is the most common head and neck malignancy in adults, accounting for 25% of head and neck cancers. Risk factors include tobacco, alcohol, radiation exposure, and HPV infection. The TNM classification system for staging laryngeal cancer is described. Treatment options are also summarized, including surgery, radiation therapy, chemotherapy, and palliative care. Vocal rehabilitation methods after laryngectomy such as esophageal speech and electrolarynx are briefly outlined.

1. Laryngeal
Malignancies
Dr. Krishna Koirala

2. Oncological subsites ofOncological subsites of
LarynxLarynx
• Supraglottis
• Epiglottis
• Aryepiglottic
folds
• Ventricular
bands
• Glottis
• True vocal cords
• Anterior
commissure
• Posterior
commissure

4. • Overview
• Most common head and neck malignancy in
adults
• Accounts for 25% of head and neck cancer
and 1% of all cancers
• Peak incidence : 55 - 65 years of age
• 10 : 1 male predilection
• High incidence area - Brazil, Afro- Caribbean
of USA, India, France, Italy, Poland, Spain,
Switzerland
• Low incidence area - Japan, Norway, Sweden

5. • True vocal cordTrue vocal cord :73%:73%
• Aryepiglottic foldAryepiglottic fold : 7%: 7%
• False vocal cordFalse vocal cord : 5%: 5%
• SubglottisSubglottis : 5%: 5%

6. • TypesTypes
• Squamous cell carcinoma (85%)Squamous cell carcinoma (85%)
• Carcinoma in situCarcinoma in situ
• Verrucous carcinomaVerrucous carcinoma
• Undifferentiated carcinomaUndifferentiated carcinoma
• AdenocarcinomaAdenocarcinoma
• Miscellaneous carcinomaMiscellaneous carcinoma
• SarcomaSarcoma

7. • Risk factors
• Tobacco
• Alcohol
• Industrial exposure
• Radiation exposure
• Laryngeal keratosis (3.25-
4.3%)
• Laryngeal papilloma - HPV 16
& 18
• GERD

8. TNM Classification of laryngealTNM Classification of laryngeal
carcinomacarcinoma UICC (1997)UICC (1997)

9. Supraglottis
•T : Primary tumor
• T is : Carcinoma in situ
• T1 : Tumor limited to one subsite of
supraglottis with normal vocal
cord mobility
• T2 : Tumor invades mucosa of more
than one subsite of Supraglottis or
glottis or region outside the
supraglottis ( e.g.. mucosa of base of
tongue, vallecula, medial wall of

10. • T3T3
• Tumor limited to larynxTumor limited to larynx with vocal cordwith vocal cord
fixationfixation &/or&/or invadeinvade any of theany of the
following : post cricoid area, pre -following : post cricoid area, pre -
epiglotticepiglottic tissues, deep base oftissues, deep base of
tonguetongue
• T4T4
• TumorTumor invades through thyroid cartilageinvades through thyroid cartilage
&/or&/or extendsextends intointo softsoft tissues of thetissues of the

11. Glottis
•T is : Carcinoma in situ
•T 1 : Tumor limited to the vocal cords
( may involve anterior or posterior
commissure) with normal mobility
• T1a : Tumor limited to one vocal cord
• T1b : Tumor involves both vocal cords
•T2 : Tumor extends to Supraglottis & /or
subglottis, and / or with impaired vocal

12. • T3T3
• Tumor limited to larynxTumor limited to larynx with vocalwith vocal
cord fixationcord fixation
• T4T4
• Tumor invades through thyroidTumor invades through thyroid
cartilage & /or invades othercartilage & /or invades other
tissues beyond the larynx ( Eg. totissues beyond the larynx ( Eg. to
oropharynx , soft tissues of neck)oropharynx , soft tissues of neck)

13. SubglottisSubglottis
•T isT is : Carcinoma in situ: Carcinoma in situ
•T1T1 : Tumor limited to the subglottis: Tumor limited to the subglottis
•T2T2 : Tumor extends to vocal cord (s) with: Tumor extends to vocal cord (s) with
normal or impaired mobilitynormal or impaired mobility
•T3T3 : Tumor limited to larynx with vocal: Tumor limited to larynx with vocal
cordcord fixationfixation
•T4T4 : Tumor invades through the cricoid or: Tumor invades through the cricoid or
thyroidthyroid cartilage &/or extends tocartilage &/or extends to
other tissuesother tissues beyond the larynxbeyond the larynx
( eg. oropharynx,( eg. oropharynx, soft tissuessoft tissues
of neck)of neck)

14. N0N0 No cervical lymph node involvementNo cervical lymph node involvement
N1N1 Single ipsilateral lymph node ≤ 3cmSingle ipsilateral lymph node ≤ 3cm
N2N2 Nodes more than 3 cm and less than 6Nodes more than 3 cm and less than 6
cmcm
N2aN2a Single ipsilateral node > 3cm and ≤6cmSingle ipsilateral node > 3cm and ≤6cm
N2bN2b Multiple ipsilateral lymph nodes, each ≤Multiple ipsilateral lymph nodes, each ≤
6cm6cm
N2cN2c Bilateral or contralateral lymph nodes,Bilateral or contralateral lymph nodes,
eacheach ≤6cm≤6cm

15. Stage 0 T is N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1,T2,T3 N1 M0
Stage IV A T4 N0/N1 M0
Any T N2 M0
Stage IV B Any T N3 M0
Stage IV C Any T Any N M1

16. Natural history
•Supraglottic tumors
• More aggressive , early lymph node
metastasis
• Direct extension into pre-epiglottic space,
glossoepiglottic fold, and tongue base
•Glottic tumors
• Grow slower and , metastasize late (lack of
lymphatic drainage)
• Extend superiorly into ventricular walls or
inferiorly into subglottic space
•Subglottic tumors
• Uncommon
• Increased chance of bilateral disease and
mediastinal extension

17. • History
• Progressive &
continuous
hoarseness
• Dyspnea & stridor
• Pain and referred
otalgia
• Dysphagia
• Swelling in the
neck
• Haemoptysis
• Examination
• Laryngeal
crepitus
• Examination of
neck
• Indirect
laryngoscopy
• Special
examination
• Flexible NPL
• Videostrobosco
Diagnosis of Laryngeal tumors

18. Investigations
•Direct laryngoscopy and & biopsy
•Panendoscopy
•Contact microendoscopy and contact
videoendoscopy
• Using Methylene blue, toluidine blue, Lugol ‘s
iodine
• Helps to delineate the extend of early lesion
along with their margin
•Autoimmunofluroscence laryngoscopy
• Using lung imaging fluroscence endoscope
(LIFE)

19. • CT scan & MRI
• Helps to determine size, extent of
tumor
• Pre epiglottic & paraglottic extension,
anterior subglottic wedge
• Extension to thyroid cartilage, gland &
strap muscle
• Positron Emission Tomography (PET)
• Useful in detecting subclinicalsubclinical

21. Treatment of Laryngeal
cancers
• Goal of treatment
• Remove the tumor and prevent its
recurrence
• Maintain laryngeal function

22. • Treatment by curative intent
• Surgery ( Partial or Total
Laryngectomy)
• Radiotherapy with or without
Chemotherapy (5 Fluorouracil and
cisplatin)
• Surgery with postoperative
radiotherapy or chemotherapy

23. • Cordectomy
• Supraglottic laryngectomy
• Hemilaryngectomy
• Partial laryngectomy
• Total laryngectomy and
hemithyroidectomy
• Laser surgery
Surgeries performed on
the larynx

24. Chemotherapy
A form of cancer treatment that uses
drugs to stop the growth of cancer
cells, either by killing the cells or by
stopping the cells from dividing eg. 5
Fluorouracil and cisplatin

25. Treatment of Glottic Carcinoma
•T1T2 Glottic Carcinoma
• Radiotherapy : >90% five year survival
rates
• Surgical excision using laser or
endolaryngeal scissors : Similar cure

26. •T3 Glottic Carcinoma
•Small tumor - cure rates in RT with
surgery and Surgery alone - similar
•Large tumor - Surgery - TL+/-neck
dissection

27. Treatment of Supraglottic
Laryngeal cancer
• T1/T2N0 : RT or partial Laryngectomy
• T3N0 : RT / TL
• N1 : RT - controversial

28. Treatment of Subglottic
tumors
•Total Laryngectomy and partial
thyroidectomy
•T1 and T2  RT + f/u and salvage surgery
•Advanced disease/recurrence/cervical

29. Curative treatment of squamous cell carcinomaCurative treatment of squamous cell carcinoma
of larynxof larynx
Glottis N0 N1 N2 N3
T1
T2
T3
T4
RT,?ELS (cordectomy for
recurrence)
RT, Hemilaryngectomy or TL
+ ?RT
?RT, ?surgery (STL or TL +?
RT)
TL + RT
NA or
surgery
TL + ?RT
TL + ?RT
TL + RT
NA or
surgery
NA or
surgery
TL + RT
TL + RT
NA or
surgery
NA or
surgery
TL + RT
TL + RT
Supraglot
tis
N0 N1 N2 N3
T1
T2
T3
T4
RT or endolaryngeal
surgery
RT or surgery (SGL or TL)
+?RT
?RT or surgery (SGL or TL)
+?RT
Surgery + RT
SGL +?RT
SGL or TL + ?
RT
SGL or TL + ?
RT
TL + RT
SGL + RT
SGL or
TL+RT
SGL or TL+RT
TL + RT
NA
TL + RT
TL + RT
TL + RT
Subglotti
s
N0 N1 N2 N3
T1
T2
T3
Radiotherapy
Radiotherapy or surgery
(TL)
TL + ?RT
TL + ?RT
TL + ?RT
TL + RT
TL + RT
TL + RT
TL + RT
TL + RT

30. Recent advances in
treatment
• Chemoprevention : The use of drugs,
vitamins, or other substances to reduce
the risk of developing cancer or to reduce
the risk cancer will recur ( eg.
Isotretinoin )
• Radiosensitizers : Drugs that make tumor

31. Palliative Care
•To ameliorate symptoms
•Used in later stages of diseaseUsed in later stages of disease
•RT/Chemo/analgesicsRT/Chemo/analgesics
•TracheostomyTracheostomy
•Intensive supports to family and friendsIntensive supports to family and friends

32. Vocal rehabilitation afterVocal rehabilitation after
laryngectomylaryngectomy
• Esophageal speech
• Taught to swallow air & hold
• Can speak 6-10 words per breath
• Voice is rough, loud and understandable
• Artificial larynx
• Electrolarynx
• Transoral pneumatic device
• Tracheo-esophageal speech
• Creation of skin-lined fistula or artificial
prosthesis
• Air carried from trachea to oesophagus
• Blom-Singer or Panje prosthesis

33. Esophageal speech
• Air is forced into the top of the esophagus and is
expelled out through the mouth
• Air movement vibrates the esophageal wall to
create the sound

34. ElectrolarynxElectrolarynx