ent

1. MANAGEMENT OF EARLY
LARYNGEAL CANCER
DR.KARISHMA MISHRA

2. DIAGNOSIS

3. LARYNGOSCOPY
• In the outpatient setting, the larynx is best assessed using the fexible
nasal laryngoscope
• For example,If salivary pooling in the pyriform sinus in the setting of a
small glottic tumour should trigger concern and prompt examination
of the hypopharynx and upper oesophagus
• Laryngeal dysplasia-The clinical appearance of an inflamed,
erythematous larynx, with leukoplakia or erythroleukoplakia.
• However, clinically abnormal areas in the larynx do not always exhibit
histopathological evidence of LD and LD can be detected under the
microscope in clinically normal appearing epithelium

4. • Cancers present as proliferative, infilltrative lesions or a mix of both.
These are easily recognized as abnormalities on endoscopic
examination.
• Non-squamous cancers, can present as submucosal masses,is difficult
to spot in endoscopy.

6. RADIOLOGICAL
• Imaging for laryngeal mass
lesions should include as a
minimum cross-sectional
imaging for all tumour stages.
• MRI,CT scan and hrct chest is
done sometimes.
• MRI scans have higher
sensitivity than CT scans in
assessing cartilage invasion.

7. CECT
• Contrast-enhanced CT performed during quiet breathing is the
preferred method of evaluating the hypopharynx due to its shorter
acquisition time, facility for multiplanar reconstruction and ability to
assess the chest and abdomen in one sitting.
• Three-dimensional CT laryngography with modified valsalva
manoeuvre is informative for the diagnosis of PS apex involvement

11. Laryngeal dysplasia management
• Excision technique
There is no gold standard in the tool used to resect the LD lesion. However, cold steel or laser
resection is recommended over monopolar cautery .
• In laser excision ,carbon dioxide laser is recommended owing to the laser properties enabling
minimal penetration, thus reducing collateral damage.
• Laser ablation (i.e. laser used on the surface of the lesion to destroy the epithelium rather than
excising it) is discouraged as no specimen will be available for diagnosis and there is a higher risk
of damage to the voice.
• Vocal cord stripping is not recommended at all owing to the high risk of damage to the vocal
cord.
• Radiotherapy should be offered only in rare circumstances for patients where there is very high
risk/ suspicion of conversion to malignancy and surgical resection is not possible owing to
patient or tumour factors.
The histology should be studied in the context of the clinical findings post-operatively. If there is
a report of severe dysplasia and the follow-up endoscopy shows a proliferative lesion, the
patient should be re-biopsied at the earliest opportunity. The presence of dysplasia at the
margins should not be of great concern, especially in mild dysplasia. This is not an indication for
a repeat excision.

14. LARYNGEAL MALIGNANCY
• Management of early stage laryngeal cancers
• Mangement of advanced laryngeal cancers

15. STAGING

18. NECK NODES

20. • EARLY STAGE- STAGE 0,1,2
• LATE STAGE- STAGE 3,4

21. RECOMMENDED TREATMENTS
• TLM- TRANSORAL LASER MICROSURGERY
• RT- RADIOTHERAPY
• OPL-OPEN PARTIAL LARYNGECTOMY
• TORS-TRANSORAL ROBOTIC SURGERY
• TL-TOTAL LARYNGECTOMY
based on patient choice, local expertise, tumour
and patient factors

26. TLM
• Transoral laser microsurgery (TLM) is a minimally invasive surgical approach
to functional organ preservation for cancer of the upper aerodigestive
tract. It involves tumour resection using specialized endoscopic
instruments, microscopes and lasers(CO2), with the wound bed often left
to heal by secondary intention
• The standard of care for surgical treatment of mid-cord glottic cancers is
TLM.
• For mid-cord lesions staged T1a, TLM excision has a very high cure rate
with the undeniable advantage of higher laryngeal preservation rates
• TLM is less commonly used for T1 cancers that involve the AC and for T2
cancers as the impact on the voice is considered to be greater, although
cure rates are equal or less than those achieved by RT

27. • All glottic cancers resected by the TLM approach should be classified
as per the European Laryngological Society (ELS) system,which
describes six types of cordectomy based on the extent of resection of
the vocal cord and the adjoining structures

31. • Clinicopathologial correlation is very
important in TLM
• It is important that the resection specimens
are orientated for the pathologist; small
specimens sent in a fixative solution can
cause shrinkage and curling of the tissue
hindering accurate histological
interpretation.
• Popular option is to use dehydrated
cucumber as a mount with the specimen
anchored to it by tissue glue.

32. • The specimens resected by TLM will have much smaller margins than
traditional open surgery, with margins of the order of a millimetre being
appropriate, which should not be misinterpreted as close or positive margins.
• Thus, the pathologist should be fully apprised of the nature of the resection
and there should be clear channels of communication between the surgeon
and the pathologist.

33. TLM IN EARLY SUPRAGLOTTIC CANCER
• All supraglottic cancers resected by a transoral approach should be
classified as per the ELS system, which describes four types of
supraglottic laryngectomy based on the extent of resection.
• Unlike glottic cancer, where possible, a conscious effort should be
made to achieve surgical margins of at least 5mm during resection
• Unlike glottic cancers, patients following transoral resections for
supraglottic tumours can be expected to have significant swallowing
dysfunction in the early stages.

38. ADVANTAGES
• Better voice quality improvement post op compared to RT
• Minimal swallowing difficulty
• Cost effective
• Early return to work
• No tracheostomy required
LIMITATIONS
• Exposure on suspension laryngoscopy
• Severe submucosal fibrosis
• Cervical spondylosis
• Anatomical peculiarities like dental arch and bulky tongue
• Previous exposure to RT
• These patients are treated with RT,OPLor BOTH

39. RADIOTHERAPY
• RT as a single modality offers an alternative to organ preserving
surgical options in the treatment of early LSCC (glottic and
supraglottic).
• The long-term local control rates following RT alone for early
supraglottic carcinomas are also similar to surgery with 5-year local
control rates of 100% for T1 and 86% for T2.

40. • Glottic carcinoma: RT is delivered using megavoltage photons (4 to
6MV), the target volume encompasses the primary tumour.
• The treatment is usually delivered using two lateral fields covering the
laryngeal skeleton from thyroid notch superiorly to the inferior border
of cricoid.
• The field size ranges from 4 × 4 cm to 5 × 5 cm, with larger field size
for T2 tumours, depending on the extent of tumour.
• The most commonly used fractionation regime is 50 to 55 Gy in 16 to
20 daily fractions over 3 to 4 weeks.

41. • Supraglottis: The target volume for radiation treatment encompasses
the primary tumour and lymph nodes bilaterally (Level II–IVa) due to
high risk of microscopic lymph node metastasis.
• The at risk nodal levels are treated to a reduced dose (prophylactic
dose). NO prophylactic dose for neck in glottis cancers.
• The fractionation regime commonly used is same as for glottic
carcinomas- 50 to 55 Gy in 16 to 20 daily fractions over 3 to 4 weeks.

42. OPEN PARTIAL LARYNGECTOMY
• Mainly 2 types:
• VERTICAL PL
• HORIZONTAL PL

43. • Procedures that can be applied to glottic disease include several
vertical hemilaryngectomy modifications and horizontal supracricoid
laryngectomy with cricohyodoepiglottopexy (CHEP)
• For supraglottic disease, supraglottic laryngectomy and supracricoid
laryngectomy with cricohyoidopexy (CHP) have been developed, both
of which are horizontally oriented procedures.

44. • VERTICAL OPL
• This procedure may be an Anterolateral, frontolateral or anterior
vertical partial laryngectomy
• Frontolateral and anterior vertical done for AC TUMORS

45. • In frontolateral vertical laryngectomy , the vertical cartilage cut in
the thyroid is performed 1 cm paramedian from the anterior midline
on the contralateral thyroid ala.
• This procedure is preferred if the tumour involves the VC on the
ipsilateral side, the anterior commissure and up to one-third of the
contralateral VC.

46. • Anterior vertical laryngectomy makes use of two
paramedian thyroid cartilage incisions, each
positioned approxmately 1cm paramedian from the
anterior midline.
• This procedure may be preferred for an anterior
commissure tumour that involves no more than the
anterior third of one or both VCs.
• After tumour removal, the remnant posterior VCs are
reattached to the anterior aspects of the remnant
thyroid ala that are approximated in the midline.
• Formation of anterior laryngeal web is avoided with
the use of a silastic keel, positioned at the anterior
commissure between the VCs, which is removed
endoscopically after 4 weeks.

47. HORIZONTAL OPL
• Supracricoid partial laryngectomy (SCPL) with
cricohyoidoepiglottopexy (CHEP)
• Done for Glottic tumours that extend across the midline through the
anterior commissure and involving the anterior third of opposite vf

48. • Supracricoid partial laryngectomy -resection of both true cords, both
false cords, the entire thyroid cartilage, paraglottic spaces bilaterally,
and a maximum of one arytenoid.
• Essential goals of this operation include careful preservation of the
bilateral superior laryngeal nerves (SLNS) for optimal sensation
during swallowing, functional preservation of at least one recurrent
laryngeal nerve (RLN) for airway closure during attempted speech and
swallowing, and adequate recreation of a functional neoglottic valve.
• Functional separation of the airway and the alimentary tract is
possible provided at least one arytenoid is preserved.

49. Horizontal supraglottic partial laryngectomy (HSPL)
In this procedure, the epiglottis, (part of the) hyoid bone, pre-epiglottic space, thyrohyoid
membrane, upper half of the thyroid cartilage, aryepiglottic fold and part of the false cords are
removed

50. INDICATION OF OPL
• In the case of untreated early laryngeal cancers, the treatment choice
is typically made between primary radiation and conservation
laryngectomy.
• Retrospective data suggest that surgical therapy may be superior with
regard to local control, larynx preservation and disease-specific
survival.
• When surgical treatment of early laryngeal cancers is preferred, TLM
has now largely replaced open partial laryngectomy due to its lower
morbidity, better voice quality, better swallowing and lower cost.

51. Limitations
• Good local control but slower recovery compared to TLM
• Tracheostomy tube and Nasogastric feeding required for some days
• Associated with greater incidence of aspiration and pneuomonia
• Not well tolerated in poor pulmonary functions tests (PFT) like copd
and in elderly

54. REFERENCE
• SCOTT BROWN
• SULTAN PRADHAN

55. THANK YOU