5. Malignant Tumours of the Larynx (Prof. Hesham Fattah

4/14/2009

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MALIGNANT TUMORSMALIGNANT TUMORSOF THE LARYNXOF THE LARYNX

Prof Prof HeshamHesham AbdAbd Al Al ––FattahFattah

OF THE LARYNXOF THE LARYNX

Department of Otolaryngology H & N SurgeryDepartment of Otolaryngology H & N SurgeryUniversity of AlexandriaUniversity of Alexandria

LARYNGEAL MASSES

TUMOUR-LIKE TUMOURS

CONGENITAL ACQUIRED BENIGN MALIGNANT

•SACCULAR CYST•LARYNGOCELE

•TRAUMATIC•NODULES•POLYPS•INTUBATION GRANULOMA

•INFLAMMATORY

•PAPILLOMA•MJP & ADULT

•HAEMANGIOMA•CHONDROMA

•PRIMARY•INFLAMMATORY•ADV REFLUX LARYNGITIS•RIENKE’S OEDEMA >> D POLYP•VENTRICULAR PROLAPSE

•REACTIVE•HYPERKERATOSIS•LEUKOPLAKIA•ERYTHROPLAKIA

•SCC•VERRUCOUS•ADENOID CYS•LYMPHOEPI

•SECONDARY•HYPOPHARYN•THYROID

•METASTATIC5.5.20085.5.2008 22Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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Normal St Sq Epi Hyerplasia Hyperkeratosis

EPITHELIAL CHANGES IN THE LARYNGEAL M MEPITHELIAL CHANGES IN THE LARYNGEAL M M

Benign Changes

Dysplasia Ca in situ

Premalignant changesMicro invasive Camod Sever

5.5.20085.5.2008 33Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

HYPERPLASIAHYPERPLASIA DYSPLASIADYSPLASIA


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HYPERKERATOSISHYPERKERATOSIS


Erythroplakia

LeukoplakiaLeukoplakia


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SEVER SEVER DYSPLASIADYSPLASIA CA IN SITUCA IN SITU

CA IN SITUCA IN SITU


TT1 1 glotticglottic CaCa


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PapillomaPapilloma--Adult typeAdult type


Precancerous lesionsPrecancerous lesions

Sever Dysplasia Leukoplakia

Erythroplakia Adult Papilloma

Of the larynxOf the larynx5.5.20085.5.2008 1010Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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Malignant Laryngeal Tumors

Primary Secondary Metastatic

1. SCC2. Verrucous Ca3 Spindle Ca 1 Hypopharyngeal Ca3. Spindle Ca4. Lymphoepithelioma5. Glandular Ca6. Sarcoma

1.Hypopharyngeal Ca2.Thyroid Tumours

Adenoid CysticAdenosquamousAdenocarcinoma

10 sites5.5.20085.5.2008 1111Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

SCC of LarynxType of Patient

• Male > 50 ys•Rural >> Urban ( Now-a-days)

• Smoker & Ex-Smoker (up to 20ys)

• Refluxer TakesTakes 1010 2020ys for a Cell toys for a Cell to

male to female =male to female =2222--2525::1 1 in Egyptin Egypt

• Refluxer•Spices Eater•Alcohol Drinker

Takes Takes 1010--2020ys for a Cell to ys for a Cell to turn into Carcinoma in situturn into Carcinoma in situ


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Reflux laryngitis Reflux laryngitis (Laryngopharyngitis) (Laryngopharyngitis) SignsSigns

••CongestionCongestion

••EdemaEdema

••Post Com Post Com

SymptomsSymptoms--2222

HypertrophyHypertrophy

••Interarytnoid foldingInterarytnoid folding

••WebbingWebbing

1212y M spasmodic coughy M spasmodic cough 4545y M on steroids for SLEy M on steroids for SLE5.5.20085.5.2008 1313Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

Predisposing FactorsPredisposing Factors

1.Hydrocarbons2.Tar & Benzopyrenes3.Pesticides4.Radiation5 Genetic ( ariable non consistent genes)5.Genetic (variable non consistent genes)

6.Chronic Inflammation7.Enzymes (acid-pepsin)

8.Viruses (papillomatosis)

•Non-Specific(common)•Specific

•T.B. (rare)•Syphilis ( does not exist)


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LateralMedialArcuate Line

Glottic

I. According to its Location

1 cm

SupraglotticGlotticSubglotticTransglottic sc

ulat

ure

•parallel to vascular arcades

Lateral Arcuate line

Changes:

Tumour Location Cor

d Va

sarcades

•Sٍquamous to pseudo stratified epithelium

•Scarce dispersed to frequent lymphatics

• vocal ligament to vocalis muscle5.5.20085.5.2008 1515Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

II. According to its Pathology 1. N.E.A

Supraglottic are derived from the Supraglottic are derived from the 44thth

BranchialBranchial arch and Glottic & arch and Glottic & subglotticsubglotticfrom the from the 66thth explaining the different explaining the different bldbld

d l h ti l Td l h ti l T

i. Ulcerating(everted edges)

ii. Fungating ( exophytic)

, nerve and lymphatic supply. Tumors , nerve and lymphatic supply. Tumors respect this embryological and respect this embryological and anatomical barrieranatomical barrier

iii. Infiltrating ( submucosal5.5.20085.5.2008 1616Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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II. According to its Pathology2.Microscopic Appearance

ModifiedModified Broder’sBroder’s ClassificationClassification(WHO(WHO 19871987))•Well Differentiated•Moderately Differentiated•Poorly Differentiated

Original Broder’s•Grade I-IV,•0-100%•UndifferentiatedX5.5.20085.5.2008 1717Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

III. According To T.N.M ClassificationT-primary tumour:T1: tumour confined to one anatomical site in the regionT2: tumour involves more than one anatomical sitein the same region or adjacent region without cord fixationg j gT3: Cord fixation or pre-epiglottic/ Postcricoid/ Internal

Perichondrium invasionT4: Cartilage invasion or direct extralaryngeal spread

N-regional Lymph nodeN1: < 3 cm diameter lymph node enlargementN2: 3-6 cm diameter lymph node enlargementN3: >6 cm diameter lymph node enlargement

M-distant metastasesM0: No evidence of distant metastasesM1: Evidence of distant metastases

(AJC 1998/2005)5.5.20085.5.2008 1818Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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StagesStage1: T1N0M0

III. According To T.N.M Classification

Stage2: T2N0M0Stage3: T3N0M0, T1,2,3 N1M0,Stage4: a. T4N0M0

b. Any T , N2 or more , M0b. Any T , N2 or more , M0c. Any T , Any N + M1


Tumour Behaviour ((Spread &Spread & Destruction)Destruction)

Guarded by:1. Host Defenses

a. Ageb. Systemic disease1. Host Defenses

2.Tumour a. Differentiationb. Size > 4 cmc. Thickness >1.5 cmd Location

a. Embryologicalb. Anatomicali. Lymphatics

b Syste c d seasec. Inflammatory Reaction

••LigamentsLigamentsd. Locatione. Margins (Pushing/Infiltrating)

f. Cell Size

ii. Barriersiii. Preformed

Pathwaysiv. Silent or Not

••LigamentsLigaments••CartilagesCartilages

•Broyles Ligament•Pre-epiglottic Sp•Paraglottic Sp


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Tumour Spread1.1.Local ( Direct )Local ( Direct )2.2.Regional (Lymphatic)Regional (Lymphatic) ••PermeationPermeation

••EmbolismEmbolism3.3.Distant(Blood ) Distant(Blood ) 77..5 5 %%4.4.Perineural Perineural

••PerilymphaticPerilymphatic

••Lungs (Lungs (5050--80 80 %)%)••LiverLiver••BonesBones 75 75 % %

DetectedDetectedS d P i Detected Detected after deathafter deathSecond Primary

10-25 % Upper AerodigestiveUpper AerodigestiveOther Organs(Other Organs(1010sites)sites)


ManifestationsManifestationsA. SymptomsA. Symptoms

Early:Early:

Late:Late:1.1.Hot Potato Voice Hot Potato Voice 2.2.StridorStridor3.3. DysphagiaDysphagiaEarly:Early:

1.1.Change of Voice Change of Voice 2.2.HoarsenessHoarseness3.3. F.B. SensationF.B. Sensation4.4. OtalgiaOtalgia

4.4. Lump in the NeckLump in the Neck5.5. PainPain6.6. Bld Tinge SputumBld Tinge Sputum

Very Late:Very Late:gg5.5. Irritative CoughIrritative Cough6.6. Sense of Air WaySense of Air Way

ObstructionObstruction

Very Late:Very Late:1.1.Weight LossWeight Loss2.2.Fetor OrisFetor Oris


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ManifestationsManifestationsB. Signs B. Signs (Inspect, Palpate)Early:Early:11 Neck Free except Marginal TsNeck Free except Marginal Ts1.1.Neck Free, except Marginal TsNeck Free, except Marginal Ts2.2.Laryngeal ExaminationLaryngeal Examination

•• Disturbed Vascular PatternDisturbed Vascular Pattern•• Thickening/Mass/UlcerThickening/Mass/Ulcer

••LumpLumpF ll Th h idF ll Th h id

••Upper Deep C LNUpper Deep C LN••Prelaryngeal LNPrelaryngeal LN

Late:Late:1.1.NeckNeck2.2.Cord FixationCord Fixation

••Fullness Thyrohyoid mFullness Thyrohyoid m••Broadening laryngeal BoxBroadening laryngeal Box••Tender laryngeal BoxTender laryngeal Box

••MechanicalMechanical••InfiltrativeInfiltrative••ParalyticParalytic

MusclesJointJoint5.5.20085.5.2008 2323Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

Diagnosis1.1.HistoryHistory2.2.Clinical ManifestationsClinical Manifestations3.3.Office LaryngoscopyOffice Laryngoscopy4.4.Operating Laryngoscopy & BiopsyOperating Laryngoscopy & Biopsy5.5.Radiological Investigations:Radiological Investigations:

a.a. Plain Neck & ChestPlain Neck & Chestb.b. Barium Swallow & MealBarium Swallow & Mealc.c. Ultrasound AbdomenUltrasound Abdomend.d.MultiMulti--slice CT scan Neck &Upper Chestslice CT scan Neck &Upper Cheste.e. Bone Scan (Whole Body Isotope study)Bone Scan (Whole Body Isotope study)5.5.20085.5.2008 2424Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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ManagementManagementDiagnosis &Diagnosis & TreatmentTreatmentAim of Treatment1.Local Control2.Regional Control3.Distal Control4.Rehabilitatione ab tat o5.Palliation


Local ControlLocal Control1.1.Early ( TEarly ( T1 1 & T& T22))

a.a.Conservative SurgeryConservative Surgeryi.i. EndoscopicEndoscopic ••M L SM L Sppii.ii.Open SurgeryOpen Surgery

b.b.RadiotherapyRadiotherapy2.2.Late ( TLate ( T3 3 & T& T44))

a.a.Total LaryngectomyTotal Laryngectomybb Laryngeal Preservation ProtocolLaryngeal Preservation Protocol

••LaserLaser

b.b.Laryngeal Preservation ProtocolLaryngeal Preservation Protocol( Combined Chemo radiotherapy)( Combined Chemo radiotherapy)


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Local ControlLocal Control1.Early ( T1 & T2)

a.Conservative Surgeryi E d i ••M L SM L S

Local ControlLocal Control

i. Endoscopicii.Open Surgery

M L SM L S••LaserLaser

•Frontal•Frontolateral•Hemilaryngectomy

•Supraglottic Laryngectomy•Extended S L

•BOT Hemilaryngectomy• Supracricoid•¾ Laryngectomy

Glottic SCCGlottic SCC

•BOT•Arytenoid

Supraglottic SCCSupraglottic SCC5.5.20085.5.2008 2727Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah


a.Conservative Surgeryi E d i


LLi. Endoscopicii.Open Surgery

LaserLaser


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5.5.20085.5.2008 Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah 2929

Rt Aryepiglottic SCCRt Aryepiglottic SCC LT Supraglottic SCCLT Supraglottic SCC

One Year AfterOne Year After One Year AfterOne Year After5.5.20085.5.2008 3030Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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a.Conservative Surgeryi E d i ••M L SM L S



M L SM L S••LaserLaser

•Frontal•Frontolateral•Hemilaryngectomy

S i id• Supracricoid•¾ Laryngectomy

Glottic SCCGlottic SCC5.5.20085.5.2008 3131Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

Cordectomy throughLaryngofissure

Frontal Laryngectomy

Leroux –Robert 1957

5.5.20085.5.2008 3232Prof Hesham Abd AlProf Hesham Abd Al--FattahFattahFrontolateralLaryngectomy

Hemilaryngectomy Extended hemi

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a.Conservative Surgeryi E d i



•Supraglottic Laryngectomy•Extended S L

•BOT•Arytenoid•Arytenoid

Supraglottic SCCSupraglottic SCC5.5.20085.5.2008 3434Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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Preop

operative


Local ControlLocal Control1.1.Early ( TEarly ( T1 1 & T& T22))

a.a.Conservative SurgeryConservative Surgeryi.i. EndoscopicEndoscopic ••M L SM L Sppii.ii.Open SurgeryOpen Surgery

b.b.RadiotherapyRadiotherapy2.2.Late ( TLate ( T3 3 & T& T44))

a.a.Total LaryngectomyTotal Laryngectomybb Laryngeal Preservation ProtocolLaryngeal Preservation Protocol

••LaserLaser

b.b.Laryngeal Preservation ProtocolLaryngeal Preservation Protocol( Combined Chemo radiotherapy : ( Combined Chemo radiotherapy : 22cyclescyclesOf Cis/carbo platinOf Cis/carbo platin100100g/mg/m2 2 on day on day 11+ + 5 5 FUFU11--5 5 days….. Response…..days….. Response…..4545Gy+Gy+2525GyGy

…...If no Response…….TL)…...If no Response…….TL)5.5.20085.5.2008 3636Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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After 2 cycles of chemo

After radiotherapy


Regional ControlRegional Control1.1.Prophylactic > NProphylactic > N002.2.Therapeutic > N+Therapeutic > N+2.2.Therapeutic NTherapeutic N1.1.Radical NeckRadical Neck2.2.Modified RNDModified RND

a.a.Accessory NAccessory Nb.b.Jugular VJugular Vc.c. a +b + SCMa +b + SCM

3.3.SelectiveSelective4.4.ExtendedExtended


AccordingAccording to the level clearedto the level cleared

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Memorial SloanMemorial Sloan--Kettering Hospital Kettering Hospital LevelLevel II -- SubmentalSubmental andand submandibularsubmandibular

IaIa -- NodesNodes inin thethe submentalsubmental triangletriangle boundbound byby thetheanterioranterior bellybelly ofof thethe digastricdigastric andand thethe hyoidhyoid boneboneIbIb -- NodesNodes inin thethe triangletriangle boundbound byby thethe anterioranterior andandposteriorposterior belliesbellies ofof thethe digastricdigastric andand bodybody ofof thethemandiblemandible

LevelLevel IIII -- UpperUpper jugularjugular lymphlymph nodes,nodes, includingincludingthethe jugulodigastricjugulodigastric nodesnodes

IIaIIa -- NodesNodes inin thethe regionregion anterioranterior toto thethe spinalspinalaccessoryaccessoryIIbIIb -- NodesNodes inin thethe regionregion posteriorposterior toto thethe spinalspinalaccessoryaccessory

LevelLevel IIIIII -- NodesNodes fromfrom thethe carotidcarotid bifurcationbifurcation toto thetheomohyoidomohyoid musclemuscleLevelLevel IVIV -- NodesNodes ofof thethe lowerlower jugularjugular areaarea thatthatj gj gextendextend fromfrom thethe omohyoidomohyoid toto thethe clavicleclavicleLevelLevel VV -- AllAll lymphlymph nodesnodes withinwithin thethe posteriorposteriortriangletriangle ofof thethe neckneckLevelLevel VIVI -- NodesNodes inin thethe anterioranterior compartmentcompartmentgroup,group, includingincluding thethe lymphlymph nodesnodes thatthat surroundsurroundthethe midlinemidline structuresstructures ofof thethe neckneck (These(These nodesnodesextendextend fromfrom thethe hyoidhyoid bonebone superiorlysuperiorly toto thethesuprasternalsuprasternal notchnotch inferiorlyinferiorly..))

6

7

RND exRND

Types of neck dissectionTypes of neck dissection

MRND I MRND IIIMRND II


Supraomohyoid Ballantyne Central Extended

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RND

MRND III

MRND II


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•Distal Control•Rehabilitation•Palliation

Tracheostomy

1.Voice• Esophageal• Prosthesis

TracheostomyChemotherapyRadiotherapy

2.Swallowing3.Psychological

More than More than 6666GyGy


CisCis//CarboplatinCarboplatin 100100mg/ mmg/ m2 2 Day Day 11& & 55--FU Days FU Days 11--55

Thank You Thank You

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Calcified Calcified Saccular CystSaccular Cyst

•Vestigial Structure•Congenital in origin•Important to Aquatic Apes•Usually Asymptomatic


CYSTSCYSTS

SACCULAR

CORDAL CYST

PATTERN VOCAL CORD VASCULATURE5.5.20085.5.2008 4646Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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NoduleNodule PolypPolypScreamer’sSinger’s

Gelatinous & thrombotic

After laser excisionAfter MLS

Immature >>>> Mature5.5.20085.5.2008 4848Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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PolypsPolyps

1.Gelatinous 2.Hyaline3.Vascular4.Myxomatous5.Mixed

Thrombotic


Rienke’S OedemaRienke’S Oedema Diffuse Cordal PolyposisDiffuse Cordal Polyposis

Ventricular Ventricular prolapseprolapse5.5.20085.5.2008 5050Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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Contact granuloma

Signs:Signs:

Signs of RLPSigns of RLP

••CongestionCongestion••EdemaEdema••InterInter--arytenoid folding>> Webbingarytenoid folding>> Webbing••Contact ulcer>> Contact GranulomaContact ulcer>> Contact Granuloma


TT2 2 SCC Glottic TSCC Glottic T

Two Years AfterTwo Years After5.5.20085.5.2008 5252Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah

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INTUBATIONINTUBATIONGRANULOMAGRANULOMA


ChondromaChondroma

•Arises from the cricoid or thyroid•TL is the treatment•TL is the treatment•Malignancy depends on behavior


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HaemangiomaHaemangioma

•Subglotticg•Posterior•50 % other haemangiomata•Laser Debulking +

Prophylactic Tracheostomy


Documents

5. Malignant Tumours of the Larynx (Prof. Hesham Fattah