This document discusses the staging and treatment of cancer of the larynx. It begins by outlining the staging of tumors (T1-T4) and corresponding treatment options, which may include radiation therapy, laser excision, or chemotherapy with radiation. For advanced cancers involving cartilage or more than one region of the larynx, a total laryngectomy may be required. Neoadjuvant chemotherapy can help reduce tumor size to make surgery easier but does not improve prognosis. The document then covers the epidemiology, risk factors, anatomy, pathology, clinical evaluation, and management considerations for the neck lymph nodes depending on whether the cancer is early or advanced stage and located in the supraglottis, glottis, or

1. RX of Ca Larynx
1. Clinical examination
2. D/L
3. CT (PET Scanning after 3 months of RT)
Staging of ca then Rx.
T1NoMo - RT or LASER Excision. If recur following RT, LASER Is only indication.
T2NoMo-RT
T3NoMo –Chemotherapy CIs-platinin plus RT .( Upto If it is inner periostum is involved,RT). Or
Cetuximab plus RT.
T4NoMo- Cartilage is involved,sclorosed thickened - total Laryngectomy.
Neo- adjuvant chemotherapy to reduced size of tumor. Not reduced prognosis or distant
metastasis. So operation can be done easily.
Rr of hypopharynx. Total Laryngectomy plus partial pharyngectomy ( 2.5 cm is needed to
create minimum 1cm lumen which is essential to functioning pharynx.)

2. Cancer of the Larynx
Incidence: Laryngeal cancer acconts for 1% to 2% of new cases of cancers worldwide.
Epidemiology & pathogenesis: M:F ratio 3 to 5: 1. Female riskincreasing due to increased smoking.
Peak incidence sixth &seventh decade of life.
Tobacco: increased risk of cancer proportion to number of cigarettes consumed.
Alcohol: increased relative risk (2.2) of cancer compared to nondrinkers ,increased risk of
supraglottic cancer.
Occupation: refinery products,
Nickel
Leather works
Paint ,wood dust
Other: Possible GERD,human papilloma virus(HPV).
Oncological anatomy:
: supraglottis
Aryepiglottic fold (laryngeal aspect)
Arytenoids
False vocal cords
Glottis includes superior & inferior surface of the true vocal cords including anterior & posterior
commissures.It extend from lateral margin of the ventricle 1cm inferiorly.
Subglottis extends lower border of the glottis to the inferior border of thecricoid cartilage.
Important laryngeal spaces
Pre-epiglottic space: hyepiglottic ligament& vallecula.
Anteriorly ;thyrohyoid ligament,thyroid cartilage, hyoid bone.
Posteriorly;Epiglottis,thyroepiglottic ligament.(epiglottis has foramina, cancer from the laryngeal
surface can penetrate into pre-epiglotic space that is upstage cancer from T1 to T3.
Paraglottic space:a potential space that lies outside of the laryngeal inlet deep to the mucosa.

3. Lateral: anteriorly thyroid cartilage,posteriorly mucosa over medial wall of piriform sinus.
Medial: quadrangular membrane above,conus elasticus below.
Pathology
1)Cancer progression: normal epithelium(insult/carcinogen)>mucosal hyperplasia/metaplasia>
Dysplasia (mild/moderate/severe)> carcinoma in situ>cancer.
The higher the degree of dysplasia,the increased likelihood of transformation to invasive carcinoma.
Mild 7%
Moderate 18%
Severe 24%
2)spread of cancer
Increased risk of metastases to base of tongue, vallecula, hypopharynx.
Metastases occur mainly level II,III,IV.
a)supraglottis majority of cancer located on epiglottis,Endophytic infrahyoid SCC can spread via
epiglottic foramina into the preepiglottic space/base of the tongue /vallecula.Aryepiglottic cancer
behave similarly to piriform sinus cancer.the rich lymphatic network explain the high risk of cervical
metastases.
The incidence of metastases per T stage:
T1 63%
T2 70%
T3 79%
T4 83%
Midline lesion may metastases bilaterally.
In patient with an ipsilateral lymph node greater than 2cm ,the risk of contralateral metastases is
40%.
b)Glottis; most cancer involve anterior 2/3rd of True vocal cords.Cervical metastases from T1 &T2
lesion very low.
T1 less than 1%
T2 less than 5%
T3/T4 20 to 25%
Broyles ligament serves as a barrier to cancer ,however direct invasion to thyroid cartilage.

4. Paraglottic space involvement >vocal cords fixation.
Extension to beyond larynx >spread to extralaryngeal tissues or Dolphian node.
Transglottic lesion imply cancer that involves the glottis incontinuity with another region of the
larynx(subglottis /supraglottis).the incidence of metastases /cartilage invasion is higher in these
cases.
c) Subglottis; less common
more aggressive with infiltrative growth pattern.
Incidence of metastases 20-30% especially to paratracheal lymph node.
Risk of recurrence if paratracheal nodes not addressed at time of laryngectomy.
Clinical Evaluation ;
Symptoms:
Hoarseness of voice
Reapiratory embarrassment
Throat pain
Cough,heamoptysis
Referred ipsilateral otalgia
Dysphygia
Examinarion:
Through head &ncek examination including palpation of the floor of mouth& oropharynx (base of
tongue involvement )
Palpation of neck & larynx.
I/D or Fol
Investigations
FNAC neck mass if primary tumour is not clinically apparent,
D/L to biopsy &staging of tumour &exclude synchronus primary tumour.
CXR to exclude pulmonary metastases
Pulmonary function tests if laryngeal surgery considered,
CT or MRI to determine extend of tumour,airway patency,cartilage involvement (MRI may be more
sensitive),subglottic extent,paraglottis/preepiglottic space involvement,hypopharyngeal
involvement.

5. CBC& serum electrolytes.
Treatment
The treatment option of laryngeal cancer are multiple;
surgery
1)partial laryngectomy
Open: laryngofisure& cordectomy
Vertical
Horizontal
Supracricoid
Endoscopic: CO2 laser
2)Total laryngectomy.
Radiotherapy & chemotherapy
Ideally the treatment should include a single modalities if possible .
TL± Radiotherapy offer the best survival advantage,however with the morbidity of this operation
&quality-of-life changes that this procedure.Organ preservation procedures&chemotherapy
protocols have been developed.
The treatment of laryngeal cancer can be classified into two groups;
1)Early i.e T1 &T2 N0
2)Advanced i.e T3 &T4, N+ neck.
Management of the neck
1)supraglottic cancer:
Primary surgery ;N0 neck ,bilateral selective neck dissection (level II,III ,IV)
N+neck may require radical /modified radical neck dissection.
Primary Radiotherapy ±chemotherapy;
N0 neck: elective bilateral irradiation
N+ neck: Definitive chemo/radiation ± planned neck dissection(PND)
2)Glottic cancer:
Primary surgery

6. N0 neck :Ipsilateral neck dissection
N+neck: may require radical /modified radical neck dissection.
Primary ;Radiotherapy±chemotherapy:
N0 neck :unlikely to require neck irradiation.
N+neck: Definitive chemo/radiation ± Planned neck dissection(PND).
3) Subglottic: treatment scenario similar to that of supraglottic however paratracheal node
dissection is required if total laryngectomy to be performed.

7. N0 neck :Ipsilateral neck dissection
N+neck: may require radical /modified radical neck dissection.
Primary ;Radiotherapy±chemotherapy:
N0 neck :unlikely to require neck irradiation.
N+neck: Definitive chemo/radiation ± Planned neck dissection(PND).
3) Subglottic: treatment scenario similar to that of supraglottic however paratracheal node
dissection is required if total laryngectomy to be performed.