Laryngeal Cancer Flashcards
Is laryngeal cancer the m/c site of H&N malignancy?
No. Oral cancer is. However, laryngeal CA is 2nd m/c
Boundaries of the larynx
Hyoid to the inferior cricoid cartilage
Quadrangular membrane
fibroelastic membrane
supports supraglottis
extends from epiglottis to arytenoid and corniculate cartilage
Conus elasticus
fibroelastic membrane
supports vocal fold
extends from cricoid to merge w/ vocal ligament (resists spread of glottic and subglottic CA)
Pre-epiglottic space
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
Paraglottic space
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
Reinke’s space
Superficial lamina propria of true vocal fold
Lack of lymphatics and blood vessels
Broyles’ tendon
Insertion of vocalis tendon to thyroid cartilage
No perichondrium at insertion site
Boundaries of supraglottis
Hyoid to apex of ventricle
Boundaries of glottis
Apex of ventricle to 1 cm below true vocal folds
Boundaries of sub-glottis
1 cm below TVC to inferior cricoid cartilage
What is the m/c subsite of laryngeal CA?
Glottic (about 2/3)
Supraglottic is about 1/3
Most common supraglottic subsite for CA
Infrahyoid epiglottis
What are the subsites of the suprglottis
- Suprahyoid epiglottis
- Infrahyoid epiglottis
- AE fold
- Arytenoid
- False cords
Development of the larynx
- Supraglottis is from the 3rd and 4th branchial arches
- Glottis and Subglottis from the 6th branchial arch
Where do supraglottic tumors invade
Superiorly toward BOT or pre-epiglottic space
Embryologic fusion plane b/w supraglottis and glottis prevents spread in that direction
Regional metastasis of supraglottic cancer
B/l necks, II-IV
25-75% risk
What is a marginal tumor
It is a tumor found at the AE fold
Usually a basaloid SCCa
Aggressive
Similar to a hypopharyngeal piriform sinus tumor
T1 Supraglottic cancer
one subsite
T2 Supraglottic cancer
invades
- mucosa of more than one adjacent subsite of supraglottis
- glottis
- region outside of supraglottis (BOT, vallecula, medial piriform sinus wall)
T3 Supraglottic cancer
- vocal fold fixation
- invades postcricoid area
- invades pre-epiglottic space
- invades paraglottic space
- invades inner cortex of thyroid
T4a supraglottic cancer
Moderately advanced local dz, invasion
- through thyroid cartilage
- tissues beyond larynx
T4b supraglottic cancer
Very advanced local dz, invasion
- prevertebral space
- carotid encasement
- mediastinal structures
What are the barriers of spread of glottic CA
- Vocal ligament
- Thyroglottic ligament
- Conus elasticus
How is the thyroid cartilage invaded in glottic CA?
The anterior commissure does not have an inner perichondrium
In glottic CA, what does vocal fold fixation suggest?
Involvement of
- thyroarytenoid, lateral or posterior cricoarytenoid, and interarytenoid muscles
- Extension into cricoarytenoid joint
- PNI
T1 glottic CA
Limited to vocal folds (may involve ant or post commissure)
T1a: one vocal fold involved
T1b: b/l vocal fold involvement (5% regional mets)
T2 glottic CA
- Extension to subglottis or supraglottis
- Impaired vocal fold mobility
T3 glottic CA
- vocal fold fixation
- invasion of paraglottic space
- invasion of inner cortex of thyroid cartilage
T4a glottic CA
Moderately advanced local dz, invasion
- Outer cortex of thyroid cartilage
- Tissue beyond larynx
T4b glottic CA
Very advanced local dz, ivasion
- prevertebral space
- carotid encased
- mediastinal structures
Where does subglottic CA usually extend?
Cricoid cartilage
T1 subglottic CA
Limited to subglottis
T2 subglottic CA
involves vocal folds with normal or impaired mobility
T3 subglottic CA
limited to larynx with fixed vocal folds
T4a subglottic CA
Invades
- cricoid
- thyroid cartilage
- tissues beyond larynx
T4b subglottic CA
Invades
- prevertebral space
- carotid encased
- mediastinal structures
What is basaloid SCCa
A more aggressive high grade variant of SCCa
Verrucous carcinoma
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
Laryngeal CA biopsy techniques
- 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
MAN of early supraglottic CA (T1-T2)
- 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
MAN of advanced supraglottic CA (T3-T4)
- Multimodality Rx: TL + postop RT vs chemo/RT for organ preservation
- N0 neck: Elective IPSI SND II-IV
- N1-N3 neck: Mod RND
MAN of early glottic CA (T1-T2)
- Single modality Rx: RT
- Surgery (cordectomy, endoscopic, partial laryngectomy) for failed RT
- Neck: elective ND NOT indicated
MAN of advanced glottic CA (T3-T4)
- Multimodality Rx: TL (may consider conservation laryngectomy) w/ postop RT vs chemo/RT w/ salvage TL for poor responders
- Neck: IPSI Mod RND
MAN of subglottic CA
- Single or multimodality Rx
- -Extended TL w/ postop RT and/or chemo
- -RT or chemo/RT
-Neck: IPSI Mod RND for nodal dz
CI for Partial laryngectomy
- Fixed vocal folds (except supracricoid laryngectomies)
- Cartilage invasion
- Subglottic extension
- Signficant OP extension
- Interarytenoid involvement
- Tumor spread into neck
What is a supraglottic laryngectomy
Horizontal hemilaryngectomy Removes: -Epiglottis -AE folds -False vocal folds -Pre-epiglottic space -Portion of the hyoid bone -Thyroid cartilage
What does a supraglottic laryngectomy spare
- TVC
- Arytenoids
What is an extended supraglottic laryngectomy
May extend to include excision of the BOT, hypopharynx, or one arytenoid
Benefits of endoscopic laser supraglottic laryngectomy over traditional SL
- Trach not required
- Improved postop swallow (preserves SLN, tongue base, hyoid, and suprahyoid muscles)
Indications for a supraglottic laryngectomy
-T1 or T2 (limited T3) supraglottic CA
Does not involve
- Vocal fold
- Ventricle
- Thyroid cartilage
- Arytenoid
- Interarytenoid rgion
- Piriform
- BOT
What is a Vertical Partial Laryngectomy (Hemilaryngectomy)?
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)
Indications for a Vertical Partial Laryngectomy
-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
What is an extended hemilaryngectomy?
-For select T3 lesions or arytenoid involvement
Removes:
- One vocal fold
- Arytenoid
- Overlying thyroid cartilage (3 mm posterior strip of cartilage preserved)
What is a supracricoid laryngectomy?
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
Indications for a supracricoid laryngectomy?
-Select T3-T4 supraglottic CA that may involve the pre-epiglottic space, paraglottic space, ventricle, limited thyroid cartilage, or epiglottis
Contraindications for supracricoid laryngectomy
- 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
What is a total laryngectomy?
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
What is a near total laryngectomy (3/4 laryngectomy)?
- Creates a communication b/w trachea and pharynx for phonation
- Must keep one arytenoid to prevent aspiration through shunt
Postoperative complications for laryngeal CA surgery
- 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
Postoperative laryngectomy options for voice
- Electrolarynx
- Esophageal speech
- Tracheoesophageal puncture
What is the MCC of failure of TEP speech?
Pharyngeal constrictor spasm
Decrease risk by performing a generous cricopharyngeal myotomy
