Learning objectives Describe anatomically and clinically the di ifference between laryngeal cancer and hypopharyngeal cancer Be able to describe clini

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1 Laryngeal cancer Hanwei PENG, MD, PhD Thyroid Surgery Research Center, SU UMC Head and Neck Department, Cancer Hospital, SUMC

2 Learning objectives Describe anatomically and clinically the di ifference between laryngeal cancer and hypopharyngeal cancer Be able to describe clinical presentations o f 3 common clinical types of laryngeal cancer Figure out currently known etiology of lary yngeal cancer Make a treatment protocol for a typical lar ryngeal cancer with certain clinical stage

3 Issues to be covered Anatomy and physiology Epidemiology Etiology Clinical types and their clinical presentation Diagnosis and differential diagnosis Staging Treatment principle Case analysis

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5 Anatomic differences of L arynx and hypopharynx ct ction Items tomic feature sites: Airway Breath/phonation Cartilage framework Supraglottis Epiglottis, Aryepiglottic fold Arytenoid False vocal cord Ventricle Larynx Glottis Vocal cords Anterior and posterior comm missure Subglottis Digestive Swallowing Muscular hypopharynx Posterior cricoid area Piriform sinus Posterior wall

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10 Blood supply:superior superior and inferior laryngea al artery, cricothyroid artery Innervation: superior laryngeal nerve, recurr rent laryngeal nerve Lymphatics: Supraglottis:rich, rich, drain to level II an nd level III in early stage Glottis: scanty, not metastasize until advanced stage, T3/T4 Subglottis: rich, drain firstly to level VI, then to level III/IV/V

11 Epidemiology Second common caner of the upper aerodiges tive track ( oral cavity, naso-, oro-, hypo- pharynx, larynx, nose) Glottic>supraglottic>subglottic Male>female (mainly glottis) Age>40 ys Prevalent area Sporadic Northeast China Italy, Brazil, India

12 Etiology Smoking, alcohol Air pollution Professional exposure: painters, metalworking g, plasticworking machine operators, construction workers, and those exposed to di iesel and gasoline fumes, those exposed to therapeutic ti doses of radiation. Virus infection:hpv16, HPV18, HPV33 GERD (gastroesophageal reflux disease) Oncogenes, Anti-oncogenes:Ras/Myc/p53

13 Clinical types of laryngeal cancer LC Supra-glottis Glotti is Sub-glottis Gross-appearance: Ulcerative, Exophytic, Sessile, Polypoid Pathologic types Scc (90%) Acc Sarcoma Others

14 Tumor spread Local invasion Lymphatic metastasis Supraglottis,30%-60%, bilateral Glottis: rare Subglottis: %, bilateral Distant metastasis:1-4%, lung, liver, bone

15 Clinical manifestati ion Subtype Supraglottis Glottis Subglottis Asymptomatic Early stage Non-specific symptom, eg. pharyngeal paraesthesia Hoarseness (progressive) Asymptomatic Advanced stage Dysphonia, dysphagia, odynophagia, otalgia, stridor, dyspnea, hemoptysis Neck mass (cervical metastasis), bilateral, level II and III, any stage Distant metastasis associated symptoms (lung, liver, bone) Dyspnea, hemoptysis Cervical lymph node metastasis (Low incidence, occur mainly in advanced stage) Stridor, hemoptysis, dyspnea, hoarseness Cervical lymph node involvement

16 Diagnostic workup History Physical examination (larynx, neck nodule, indirect laryngoscopy) step1 Other head and neck organ examina ation Fibro-laryngoscopy step2 Laryngeal videostroboscopy Biopsy (gold standard for diagnosis) Step3 Pan CT/MRI with contrast Barium X-ray, Chest X-ray, liver ult trasound Pan-endoscopy under general anesth hesia Caution: confirm airwa ay patency, emergency tracheotomy if needed

17 Differential diagnos sis Tuberculosis of the larynx Vocal cord polyp Granuloma Papilloma Premalignant disorders: laryngeal leukop plakia, keratosis Amyloidosis of the larynx Laryngopharyngeal reflux (LPR)

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24 Treatment principle es General principle: Treatment selection base on patient factors, tumor factors, and institution factors Single treatment modality for early stage, multidisciplinary therapy for advanced d stage; Stage I / II, surgery or RT Stage III /IV, combined modality

25 Radiotherapy Curative radiotherapy (radical dose, RT or C hemo-rt) Neoadjuvant RT (preoperative p RT) Adjuvant RT (postoperative RT)

26 Surgery Transoral laser surgery Partial laryngectomy y Total laryngectomy Neck dissection Phonation reconstruction

27 Chemotherapy Neoadjuvant chemo Adjuvant chemo Palliative chemo

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31 Summ mary Larynx and hypopharynx are in the vicinity but different embryologically and anatomically. Laryngeal cancer clinically i ll divided id di into supra aglottis, glottis, and subglottis, each hh has different clinical manifestation. Glottis > supraglottis >subglottis,male> fema ale. Currently known carcinogenic factors include smoke and alcohol, air pollution, HPV (16,18,33) infection; GERD and genetic suscep ptibility may play a role. Single treatment modality (surgery or RT) is generally used for early stage LC, combined modality should be considered for advanced staged LC

32 With regard to laryngeal cancer, which s tatement is correct? 1. Squamous cell carcinoma is the most com mmon pathologic type 2. Single radiotherapy or single surgery is generally administered for advanced stage laryngeal cancer 3. Laryngeal cancer can be divided into sup praglottis, glottis, subglottis, and pyriform sinus. 4. Laryngeal cancer with early stage can be cured using single radiotherapy or single surgery 5. Cervical lymph node metastasis is comm on in early staged glottis laryngeal cancer

33 Case presentation and analysis History Male, 55 ysold,,p progressive hoar rseness for 2 years, dyspnea for 1m. Smoking for 20 ys, smoking inde ex 300. PE Good general status, Dyspnea grade I, No enlargement of the larynx, no lymphadenopathy under palpation, Indirect laryngoscope: invisible due to poor lift up of the epiglottis.

34 Case presentation and analysis Q1 what is the most possible disorder? A.Vocal cord polyp B.Glottis laryngeal cancer C.Laryngeal papilloma D.Laryngeal amyloidosis B Q2 what is(are) the mispractice for this patient? A.Fiberoptic layngoscopy + biopsy B.Laryngofissure directly C.CT CT scan first, so that further management could be decided based on the site and extension of the tumor AC Q3 final diagnosis is glottis laryngeal squamous cell carcinoma, ct2n0m0,what is(are) the treatment option(s)? A. Radiotherapy B. Transoral laser surgery C. Laryngofissure + cordectomy D. Curative chemotherapy ABC