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Head and Neck > Laryngeal Cancer > Flashcards

Laryngeal Cancer Flashcards

1
Q

Is laryngeal cancer the m/c site of H&N malignancy?

A

No. Oral cancer is. However, laryngeal CA is 2nd m/c

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2
Q

Boundaries of the larynx

A

Hyoid to the inferior cricoid cartilage

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3
Q

Quadrangular membrane

A

fibroelastic membrane
supports supraglottis
extends from epiglottis to arytenoid and corniculate cartilage

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4
Q

Conus elasticus

A

fibroelastic membrane
supports vocal fold
extends from cricoid to merge w/ vocal ligament (resists spread of glottic and subglottic CA)

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5
Q

Pre-epiglottic space

A 
Midline fibrofatty-filled space
Bounded by:
-Hyoid
-Thyrohyoid membrane
-Hyoepiglottic ligament
-Thyroepiglottic ligament
-Epiglottis

tumor may enter from anterior commissure or supraglottic extension
Continuous with paraglottic space

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6
Q

Paraglottic space

A

Fibrofatty-filled space outside of conus elasticus and quadrangular membrane
Allows transglottic extension
Borders:
-Superomedial: quadrangular membrane
-Mid-medial: ventricle
-Inferomedial: conus elasticus
-Posterior: Piriform sinus mucosa
-Inferior: space b/w thyroid and cricoid cartilage
-Lateral: thyroid cartilage and cricothyroid membrane

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7
Q

Reinke’s space

A

Superficial lamina propria of true vocal fold

Lack of lymphatics and blood vessels

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8
Q

Broyles’ tendon

A

Insertion of vocalis tendon to thyroid cartilage

No perichondrium at insertion site

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9
Q

Boundaries of supraglottis

A

Hyoid to apex of ventricle

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10
Q

Boundaries of glottis

A

Apex of ventricle to 1 cm below true vocal folds

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11
Q

Boundaries of sub-glottis

A

1 cm below TVC to inferior cricoid cartilage

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12
Q

What is the m/c subsite of laryngeal CA?

A

Glottic (about 2/3)

Supraglottic is about 1/3

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13
Q

Most common supraglottic subsite for CA

A

Infrahyoid epiglottis

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14
Q

What are the subsites of the suprglottis

A
  • Suprahyoid epiglottis
  • Infrahyoid epiglottis
  • AE fold
  • Arytenoid
  • False cords
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15
Q

Development of the larynx

A
  • Supraglottis is from the 3rd and 4th branchial arches

- Glottis and Subglottis from the 6th branchial arch

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16
Q

Where do supraglottic tumors invade

A

Superiorly toward BOT or pre-epiglottic space

Embryologic fusion plane b/w supraglottis and glottis prevents spread in that direction

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17
Q

Regional metastasis of supraglottic cancer

A

B/l necks, II-IV

25-75% risk

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18
Q

What is a marginal tumor

A

It is a tumor found at the AE fold
Usually a basaloid SCCa
Aggressive
Similar to a hypopharyngeal piriform sinus tumor

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19
Q

T1 Supraglottic cancer

A

one subsite

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20
Q

T2 Supraglottic cancer

A

invades

  • mucosa of more than one adjacent subsite of supraglottis
  • glottis
  • region outside of supraglottis (BOT, vallecula, medial piriform sinus wall)
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21
Q

T3 Supraglottic cancer

A
  • vocal fold fixation
  • invades postcricoid area
  • invades pre-epiglottic space
  • invades paraglottic space
  • invades inner cortex of thyroid
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22
Q

T4a supraglottic cancer

A

Moderately advanced local dz, invasion

  • through thyroid cartilage
  • tissues beyond larynx
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23
Q

T4b supraglottic cancer

A

Very advanced local dz, invasion

  • prevertebral space
  • carotid encasement
  • mediastinal structures
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24
Q

What are the barriers of spread of glottic CA

A
  • Vocal ligament
  • Thyroglottic ligament
  • Conus elasticus
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25
Q

How is the thyroid cartilage invaded in glottic CA?

A

The anterior commissure does not have an inner perichondrium

26
Q

In glottic CA, what does vocal fold fixation suggest?

A

Involvement of

  • thyroarytenoid, lateral or posterior cricoarytenoid, and interarytenoid muscles
  • Extension into cricoarytenoid joint
  • PNI
27
Q

T1 glottic CA

A

Limited to vocal folds (may involve ant or post commissure)
T1a: one vocal fold involved
T1b: b/l vocal fold involvement (5% regional mets)

28
Q

T2 glottic CA

A
  • Extension to subglottis or supraglottis

- Impaired vocal fold mobility

29
Q

T3 glottic CA

A
  • vocal fold fixation
  • invasion of paraglottic space
  • invasion of inner cortex of thyroid cartilage
30
Q

T4a glottic CA

A

Moderately advanced local dz, invasion

  • Outer cortex of thyroid cartilage
  • Tissue beyond larynx
31
Q

T4b glottic CA

A

Very advanced local dz, ivasion

  • prevertebral space
  • carotid encased
  • mediastinal structures
32
Q

Where does subglottic CA usually extend?

A

Cricoid cartilage

33
Q

T1 subglottic CA

A

Limited to subglottis

34
Q

T2 subglottic CA

A

involves vocal folds with normal or impaired mobility

35
Q

T3 subglottic CA

A

limited to larynx with fixed vocal folds

36
Q

T4a subglottic CA

A

Invades

  • cricoid
  • thyroid cartilage
  • tissues beyond larynx
37
Q

T4b subglottic CA

A

Invades

  • prevertebral space
  • carotid encased
  • mediastinal structures
38
Q

What is basaloid SCCa

A

A more aggressive high grade variant of SCCa

39
Q

Verrucous carcinoma

A

AKA Akerman’s tumor

  • slow growing, locally destructive
  • rare mets
  • excellent prognosis
  • glottis is m/c site in larynx
  • Gross: rought, warty (exophytic), fungating, gray-white
  • Histopath: benign appearing (nonmitotic, no infiltration), well-diff squam w/ papillary projections, extensive hyperkeratosis, BM intact, “pushing” margins
  • Tx: single modality RT vs surg
40
Q

Laryngeal CA biopsy techniques

A
  • Incisional biopsy
  • Excisional biopsy
  • Vocal fold stripping (removes vocal fold cover); impairs mucosal wave
  • Microflap excision (dissects superficial lamina propria, spares vocal ligament); better preservation of mucosal wave
41
Q

MAN of early supraglottic CA (T1-T2)

A
  • Single modality rx: RT vs supraglottic laryngectomy
  • N0 neck: elective b/l SND vs elective RT
  • N1-N3 neck: Mod RND
  • Adjuvant Rx: postop RT for
  • -positive or close margins
  • -multiple positive neck nodes
  • -ECS/NCI/Intravascular invasion
  • -Invasion of bone, cartilage, or soft tissue
42
Q

MAN of advanced supraglottic CA (T3-T4)

A
  • Multimodality Rx: TL + postop RT vs chemo/RT for organ preservation
  • N0 neck: Elective IPSI SND II-IV
  • N1-N3 neck: Mod RND
43
Q

MAN of early glottic CA (T1-T2)

A
  • Single modality Rx: RT
  • Surgery (cordectomy, endoscopic, partial laryngectomy) for failed RT
  • Neck: elective ND NOT indicated
44
Q

MAN of advanced glottic CA (T3-T4)

A
  • Multimodality Rx: TL (may consider conservation laryngectomy) w/ postop RT vs chemo/RT w/ salvage TL for poor responders
  • Neck: IPSI Mod RND
45
Q

MAN of subglottic CA

A
  • Single or multimodality Rx
  • -Extended TL w/ postop RT and/or chemo
  • -RT or chemo/RT

-Neck: IPSI Mod RND for nodal dz

46
Q

CI for Partial laryngectomy

A
  • Fixed vocal folds (except supracricoid laryngectomies)
  • Cartilage invasion
  • Subglottic extension
  • Signficant OP extension
  • Interarytenoid involvement
  • Tumor spread into neck
47
Q

What is a supraglottic laryngectomy

A 
Horizontal hemilaryngectomy
Removes:
-Epiglottis
-AE folds
-False vocal folds
-Pre-epiglottic space
-Portion of the hyoid bone
-Thyroid cartilage
48
Q

What does a supraglottic laryngectomy spare

A
  • TVC

- Arytenoids

49
Q

What is an extended supraglottic laryngectomy

A

May extend to include excision of the BOT, hypopharynx, or one arytenoid

50
Q

Benefits of endoscopic laser supraglottic laryngectomy over traditional SL

A
  • Trach not required

- Improved postop swallow (preserves SLN, tongue base, hyoid, and suprahyoid muscles)

51
Q

Indications for a supraglottic laryngectomy

A

-T1 or T2 (limited T3) supraglottic CA

Does not involve

  • Vocal fold
  • Ventricle
  • Thyroid cartilage
  • Arytenoid
  • Interarytenoid rgion
  • Piriform
  • BOT
52
Q

What is a Vertical Partial Laryngectomy (Hemilaryngectomy)?

A

Removes:

  • One vocal fold from ant commissure to vocal process (1/2 of opposite vocal fold may be removed)
  • IPSI false cord
  • ventricle
  • Paraglottic space
  • Overlying thyroid cartilage (3 mm posterior strip of cartilage preserved)
53
Q

Indications for a Vertical Partial Laryngectomy

A

-Select T1-T2 glottic CA

Tumor does not

  • Extend beyond 1/3 of opposite cord
  • Extend >10 mm of anterior subglottis
  • Extend > 5 mm of posterior subglottis

Does not involve

  • Post commissure
  • Cricoarytenoid joint
  • AE fold
  • Posterior surface of the arytenoid
  • Paraglottic space
54
Q

What is an extended hemilaryngectomy?

A

-For select T3 lesions or arytenoid involvement

Removes:

  • One vocal fold
  • Arytenoid
  • Overlying thyroid cartilage (3 mm posterior strip of cartilage preserved)
55
Q

What is a supracricoid laryngectomy?

A

Remove:

  • Entire thyroid cartilage
  • B/l TVC and FVC
  • One arytenoid (may spare both if not involved)
  • Paraglottic space

Spares:

  • Cricoid cartilage
  • Hyoid bone
  • At lease one arytenoid (for speech and swallow)

May reconstruct with cricohyoidopexy (CHP) or cricohyoidoepiglottopexy (CHEP) if epiglottis spared

56
Q

Indications for a supracricoid laryngectomy?

A

-Select T3-T4 supraglottic CA that may involve the pre-epiglottic space, paraglottic space, ventricle, limited thyroid cartilage, or epiglottis

57
Q

Contraindications for supracricoid laryngectomy

A
  • ARYTENOID FIXATION
  • Infraglottic extent of tumor reaching upper border of cricoid
  • Major pre-epiglottic involvement
  • Invasion of cricoid, perichondrium of thyroid, hyoid, posterior arytenoid mucosa
  • Extralaryngeal involvement
  • Poor pulm fnc
58
Q

What is a total laryngectomy?

A

Removes

  • Entire larynx (TVC, FVC, cricoid, thyroid cartilage, both arytenoids, epiglottis, pre-epiglottic and paraglottic spaces, hyoid bone)
  • Creates complete separation of pharynx and trachea
  • No risk of aspiration
  • Requires a permanent stoma
59
Q

What is a near total laryngectomy (3/4 laryngectomy)?

A
  • Creates a communication b/w trachea and pharynx for phonation
  • Must keep one arytenoid to prevent aspiration through shunt
60
Q

Postoperative complications for laryngeal CA surgery

A
  • Fistula (inc risk w/ RT)
  • Tracheotomy complications (PTX, hemorrhage, subcu emphysema)
  • Speech alteration
  • Persistent aspiration, bronchopneumonia, deglutition
  • Delayed decannulation (2/2 laryngeal edema and stenosis)
  • Esophageal or pharyngeal stenosis
  • Perichondritis and chondritis
  • Stomal stenosis
61
Q

Postoperative laryngectomy options for voice

A
  • Electrolarynx
  • Esophageal speech
  • Tracheoesophageal puncture
62
Q

What is the MCC of failure of TEP speech?

A

Pharyngeal constrictor spasm

Decrease risk by performing a generous cricopharyngeal myotomy

Head and Neck (12 decks)

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