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  1. 1. Laryngeal cancer LIU Wei Wei, MD Department of Head and Neck Surgery Email: drliuww@gmail.com
  2. 2. Anatomy
  3. 3. Anatomy
  4. 4. Anatomy
  5. 5. Anatomy
  6. 6. Anatomy
  7. 7. Anatomy
  8. 8. Anatomy
  9. 9. Anatomy
  10. 10. Histology
  11. 11. Laryngeal Epithelium
  12. 12. Goblet Cells and Columnar Mucinous Cells Squamous Epithelium
  13. 13. Epidemiology <ul><li>Incidence rate increase recently </li></ul><ul><li>Region difference of laryngeal cancer incidence </li></ul><ul><li>high in northeast of china </li></ul><ul><li>Presence more in 50-60s </li></ul><ul><li>Males>females </li></ul><ul><li>20 % of all head and neck cancers </li></ul>
  14. 14. Etiology
  15. 15. Etiology <ul><li>Human Papilloma Virus 16 &18 </li></ul><ul><li>Chronic Gastric Reflux </li></ul><ul><li>Occupational exposures </li></ul><ul><li>Prior history of head and neck irradiation </li></ul>
  16. 16. Pathology <ul><li>85-95% of laryngeal tumors are squamous cell carcinoma </li></ul><ul><li>Verrucous Carcinoma </li></ul><ul><li>Fibrosarcoma </li></ul><ul><li>Chondrosarcoma </li></ul><ul><li>Minor salivary carcinoma </li></ul><ul><li>Oat cell carcinoma </li></ul><ul><li>Adenocarcinoma </li></ul><ul><li>Giant cell and Spindle cell carcinoma </li></ul>
  17. 17. In Situ Squamous Cell Carcinoma <ul><li>Dysplastic process involves the entire thickness of the epithelium </li></ul><ul><li>Loss of cellular maturation and polarity </li></ul><ul><li>Increase of nuclear/cytoplaslic ratio </li></ul><ul><li>Normal and abnormal mitoses </li></ul><ul><li>Keratosis and dyskeratosis </li></ul><ul><li>Extension into adjacent seromucinous glands </li></ul>
  18. 18. Microinvasive or Superficially Invasive Squamous Cell Carcinoma <ul><li>Nests of malignant cells that have penetrated the basement membrane and invaded superficially into the submucosa </li></ul><ul><li>Capable of metastasizing </li></ul><ul><li>Development from carcinoma in situ or from epithelium with no evidence of CIS </li></ul>
  19. 19. Invasive Squamous Cell Carcinoma <ul><li>0.5% of all cancers in women </li></ul><ul><li>95% of all laryngeal carcinomas </li></ul><ul><li>2.5% of all cancers in men </li></ul><ul><li>Etiology: ETOH (supraglottic), tobacco (glottic), asbestos, nickel, wood, isopropyl alcohol, radiation </li></ul><ul><li>DD: reactive epithelial changes, pseudoepitheliomatous hyperplasia </li></ul>
  20. 20. Symptoms <ul><li>Sound hoarseness </li></ul><ul><ul><li>Most common </li></ul></ul><ul><ul><li>Tiny lesion on vocal cord can cause sound change </li></ul></ul>
  21. 21. Symptoms <ul><li>others: </li></ul><ul><ul><li>Swallowing difficulty </li></ul></ul><ul><ul><li>Bloody sputum </li></ul></ul><ul><ul><li>Sore throat </li></ul></ul><ul><ul><li>otalgia </li></ul></ul><ul><ul><li>Breathing difficulty </li></ul></ul><ul><ul><li>aspiration </li></ul></ul><ul><ul><li>lymphadenopathy </li></ul></ul>
  22. 22. Clinical feature of different type of Laryngeal cancer <ul><li>Supraglottic </li></ul><ul><li>sound hoarseness not evident in early phase </li></ul><ul><li>foreign body sensation present early </li></ul><ul><li>more common lymphadenopathy </li></ul>
  23. 23. <ul><li>Glottic </li></ul><ul><li>sound hoarseness present early, progressive </li></ul><ul><li>breathing difficulty presents more common </li></ul><ul><li>Subglottic </li></ul><ul><li>rare type </li></ul><ul><li>no evident symptoms in eary phase </li></ul><ul><li>easy to present breathing difficulty </li></ul>Clinical feature of different type of Laryngeal cancer
  24. 24. supraglottic
  25. 25. glottic
  26. 26. subglottic
  27. 27. Clinical examination <ul><li>PE </li></ul><ul><li>larynx shape </li></ul><ul><li>cervical lymph nodes </li></ul><ul><li>Larynx and pharynx examination </li></ul><ul><li>Indirect Laryngoscopy </li></ul><ul><li>Flexible Laryngoscopy </li></ul><ul><li>Stroboscopy </li></ul><ul><li>Panendoscopy </li></ul>
  28. 28. Clinical examination <ul><li>Pathological biopsy </li></ul><ul><li>Imaging </li></ul><ul><li>plain X ray </li></ul><ul><li>CT </li></ul><ul><li>MRI </li></ul><ul><li>PET </li></ul>
  29. 29. Video
  30. 30. Laryngeal TB 病灶多位于杓状软骨间隙 表现为脓性分泌物覆盖的浅表溃疡 肺部大多有结核病灶存在 可有咳嗽、胸痛、午后潮热的症状
  31. 31. Vocal cord nodule <ul><li>Bilateral common </li></ul><ul><li>Located on anterior 1/3 of the cord </li></ul><ul><li>Any age can occure </li></ul><ul><li>Related to loudly speaking </li></ul><ul><li>Can present sound hoarseness </li></ul>
  32. 33. Cord polyp <ul><li>epsilateral </li></ul><ul><li>Located on anterior 1/3 </li></ul><ul><li>Any age group </li></ul><ul><li>Wide base, can have pedicle </li></ul><ul><li>Loud speaking, local infection and smoking related </li></ul><ul><li>Sound hoarseness </li></ul>
  33. 35. Laryngeal Papilloma <ul><li>Benign, exophytic neoplastic growth composed of branching fronds of squamous epithelium with fibrovascular cores </li></ul><ul><li>The most common benign laryngeal neoplasm </li></ul><ul><li>No sex predilection </li></ul><ul><li>Changes in phonation, dyspnea, cough, dysphagia, stridor </li></ul><ul><li>HPV types 6 and 11 </li></ul>
  34. 36. Laryngeal Papilloma <ul><li>Juvenile type: multiple lesions with extensive growth and rapid recurrence, may remit spontaneously or persist into old age </li></ul><ul><li>Adult type: more often single, recurs less often, less likely to spread </li></ul>
  35. 37. <ul><li>Exophytic, warty, friable, tan-white to red growths </li></ul>
  36. 38. <ul><li>Papillary fronds of multilayered benign squamous epithelium containing fibrovascular cores </li></ul><ul><li>Little or no keratin production </li></ul>
  37. 39. Laryngeal Papilloma <ul><li>Absence of stromal invasion </li></ul><ul><li>Certain degree of cellular atypia </li></ul><ul><li>Koilocytic changes </li></ul>
  38. 40. Keratosis 临床表现为声嘶、喉内不适 声带增厚,呈粉红色或白色斑块 病理上为不同程度的上皮增生和角质层 可伴有角化不全和乳头瘤样增生
  39. 41. Laryngeal Leukoplakia
  40. 42. Laryngeal Amyloidosis <ul><li>Extracellular accumulation of fibrillar proteins </li></ul><ul><li>Systemic or localized </li></ul><ul><li>Primary or secondary </li></ul><ul><li>Men > women, in the 5th and 6th decades </li></ul><ul><li>Polypoid mass (glottis and supraglottis) or diffuse mucosal swelling (subglottis) </li></ul><ul><li>Hoarseness </li></ul>
  41. 43. Laryngeal Amyloidosis <ul><li>Extracellular, eosinophilic, amorphous material deposited randomly throughout submucosa; depositions around or within the walls </li></ul><ul><li>Disappearance of the seromucous glands, </li></ul><ul><li>Mixed chronic inflammatory infiltrate </li></ul>
  42. 44. Staging(supraglottic) Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures T4b Tumor invades through the thyroid cartilage and/or invades tissue beyond the larynx (e.g. trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) T4a Tumor limited to larynx with vocal cord fixation and or invades any of the following: postcricoid area, preepiglottic tissue, paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) T3 Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis, or region outside the supraglottis (e.g. mucosa of base of the tongue, vallecula, medial wall of piriform sinus) without fixation T2 Tumor limited to one subsite of supraglottis with normal vocal cord mobility T1
  43. 45. Staging(Glottic) Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures T4b Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus T4a Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) T3 Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility T2 Tumor involves both vocal cords T1b Tumor limited to one vocal cord T1a Tumor limited to the vocal cord (s) (may involve anterior or posterior commissure) with normal mobilty T1
  44. 46. Neck staging Single or multiple lymph nodes > 6cm N3 Bilateral or contralateral lymph nodes, each ≤6cm N2c Multiple ipsilateral lymph nodes, each ≤ 6cm N2b Single ipsilateral node > 3cm and ≤6cm N2a Single ipsilateral lymph node ≤ 3cm N1 No cervical lymph nodes positive N0
  45. 47. 临床分期 M1 Any N Any T IVC M0 N3 Any T M0 Any N T4b IVB M0 N2 T1-4a M0 N0-2 T4a IVA M0 N1 T1-3 M0 N0 T3 III M0 N0 T2 II M0 N0 T1 I M0 N0 Tis 0
  46. 48. Treatment <ul><li>Principle </li></ul><ul><li>early lesion treated mainly by surgery and radiation, however, advanced lesion treated by combined surgery with chemoradiation (combined therapy) </li></ul><ul><li>T1/2 lesion: Rt or Surg. </li></ul><ul><li>For subglottic, total laryngectomy should be done </li></ul><ul><li>Neck dissection for positive lymph nodes </li></ul><ul><li>Adenocarcinoma should be treated by surg. </li></ul><ul><li>For advanced lesion, laryngeal function preservation therapy is another choice </li></ul>
  47. 49. Surgery <ul><li>Laser surgery under laryngoscope </li></ul><ul><li>Partial laryngectomy </li></ul><ul><li>Total laryngectomy </li></ul><ul><li>Neck dissection </li></ul>
  48. 50. Laser surgery
  49. 51. Laser surgery
  50. 53. Vertical partial laryngectomy
  51. 55. Supraglottic partial laryngectomy
  52. 56. Total laryngectomy
  53. 57. Total laryngectomy
  54. 59. Voice reconstruction <ul><li>Blom-singer </li></ul><ul><li>Electrical larynx </li></ul><ul><li>Esophageal sound </li></ul>
  55. 62. Prognosis 50-60% Stage IV 70-80% Stage III 85-90% Stage II >95% Stage I 5 year survival
  56. 63. Thanks! Contact me: LIU Wei Wei [email_address]

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