Tumours of the Larynx

Question 1

Fully describe the anatomy of larynx and discuss tumours in this region

Answer 1

Anatomy:
Larynx is divided into three regions: 
- supraglottic, 
- glottic, 
- subglottic. 

The region affected is important for the clinical decision, and treatment

• Glottic region has no lymphatic vessels or big vessels -> tumour will be limited here. It’s considered less malignant than the other sites. Conservative treatment is
mandatory -> very conservative radiotherapy.
It is not mandatory to treat the lymphatic level, only in the advanced disease of the glottic region, because in a limited lesion, a metastasis is quite impossible.

• Supraglotic region is a LYMPHOPHILIC region and for this reason you have to take care of neck metastasis.
• Subglottic region tumours are very rare. Normally when the subglottic region is involved from a glottic tumour, the tumour will move down; causing the region to be a malignant region.

Question 2

Describe the symptoms of a laryngeal tumour

Answer 2

Symptoms depend on the region

Supraglottic tumour
It is quite similar to the hypopharyngeal tumour.
The patients with this tumour usually arrive with a NON advanced disease.
o Reflex ear pain
o A lesion of the branch of the glossopharyngeal nerve
o Dysphagia

Glottic tumour
o The first symptom is dysphonia - the patient is diagnosed early.
o In an advanced disease, a bulky tumour - inspiratory dyspnoea. It is an urgent issue and has to be treated fast , sometimes, with a tracheostomy (not intubation).

Subglottic tumours
o Inspiratory dyspnoea.

Question 3

How is a laryngeal tumour diagnosed?

Answer 3

via Endoscopy - usually narrow band imaging.

In case of advanced disease, the first exam is CT, NOT MRI

Question 4

Describe the diffusion pathways of a laryngeal tumour

Answer 4

There are LYMPHATIC, CONTINUITY and HEMATOLOGICAL Diffusion pathways

Lymphatic
o Supraglottic tumour- the most important neck levels are: II,III and IV. (only II,III,VI levels are treated surgically)
o Glottic tumour doesn’t involve any level.
o Subglottic tumour - involves the VI level. If treated surgically also II,III,IV and VI level have to be treated, like the thyroid tumour.

Continuity
Endo-laryngeal pathways and extra (para) laryngeal diffusion of the tumour.

Supraglottic tumour

• Can Infiltrate the epiglottic cartilage and go straight anteriorly through the great epiglottic space of the soft tissue surrounding the upper part of the larynx.
• An endolaryngeal diffusion - inferiorly in the glottis region causing a glottic/supraglottic tumour.
• Run along the aryepiglottic, fold and go straight posteriorly and directly into the hypopharynx. This could involve the medial wall of the piriform sinus.

Hematological
Present only in very advanced T4 laryngeal cancer. Sometimes present with a laryngeal tumour in patients presenting a synchronous lung tumour. Hematological metastasis can be monolateral or bilateral.
o Distal metastasis location includes: Lung, liver, Bone, Brain.
o Usually the tumor is squamous cell carcinoma; sometimes with multiple sites of tumours.
o In the case of laryngeal tumour check for a hypopharyngeal tumour, sometimes dysplasia or renoplastic disease in one subsite and a tumour in another subsite are seen (example: cancer of vocal chords and dysplasia or supraglottic lesions).

Question 5

Detail the TNM classification of Laryngeal cancer

Answer 5

Supraglottic / Subglottic
o T1: tumour limited to 1 subsite, normal cord mobility.
o T2: tumor invades more than one subsite without larynx fixation
o T3: With larynx fixation (the tumour has spread deeply in the surrounding)
And / Or
Invasion of one of the following: retrocricoid region, preepiglottic space, paraglottic space and/or minimal cartilagineus erosion.
o T4: The oral cavity and oropharyngeal cancer.
• T4a invasion of the thyroid cartilage and/or of the neck soft tissues, trachea, extrinsic tongue muscles, prethyroid muscles, thyroid or esophagus
• T4b invasion of the prevertebral space or of mediastinal structures or encases the carotid artery. It is not possible to do a surgery on this.

Glottic
o T1: limited to vocal cords with normal vocal cord mobility (anterior or posterior commissure).
• T1a: tumour limited to 1 vocal cord
• T1b: both vocal cords are involved.
The region of the anterior vocal cord commissure is very difficult to examine in that case ask for a CT scan.
o T2: tumor invades more than one subsite without larynx fixation
o T3: tumor limited to the larynx with fixation of the vocal cord and/or invasion of the paraglottic space
o T4: when you have a very advanced disease
• T4a invasion of the thyroid cartilage and/or of the neck soft tissues, trachea, extrinsic tongue muscles, prethyroid muscles, thyroid or esophagus
• T4b invasion of the prevertebral space or of mediastinal structures or encases the carotid artery

Question 6

Detail the instrumental investigations forlaryngeal tumours

Answer 6

Narrow Band Imaging (NBI) is a particular endoscopy that allows us to check the vascular structures - even very small, very limited superficial lesions

For advanced lesions CT scan is performed, NOT MRI!!
(It’s difficult to visualize laryngeal tumours on MRI)

Usually a biopsy is taken under generalized anesthesia.

Question 7

Fully describe the treatment of laryngeal tumours

Answer 7

We can treat with

1. surgery,
2. Radiotherapy
3. Chemoradiotherapy. (organ preservation protocol)

Surgery
Endoscopically a minimally invasive surgery - Endoscopic surgery with CO2 laser
o Partial laryngectomy.
o Total laryngectomy
o Circular pharyngolaryngectomy
These last 2 types of procedures are surgeries where the patient has a definitive tracheostomy with a speaking problem.
The 2 types of partial surgery, the patient will slowly restart to regain the ability to speak.

Radiotherapy
In case of limited lesion, radiotherapy is useful.

3. Organ preservation protocol with chemoradiotherapy

The higher the TNM class, the more aggressive the therapy.
Radiosurgery and CO2 laser is the mildest treatment
Total laryngectomy + Radical neck dissection + chemotherapy is the most aggressive

Subglottic tumours are treated pretty aggressively