CARCINOMA OF LARYNX AND

HYPOPHARYNX

Małgorzata Czesak PhD

malgorzata.czesak@wum.edu.pl
Epidemiology
• The most common head and neck carcinoma.
• The most common histological type – SCC.
• The highest incidence between the age of 55 and 70 (65%).
Increase in cancer incidence at an earlier age, i.e. around 45 years of age.
• Male/Female ratio = 10/1, now this difference is diminishing because more females
are smokers, about 7/1.
Increase in the incidence of laryngeal cancer in women.
• In 2017, 210,606 people worldwide developed cancer of the larynx.
Epidemiology
• Significant advancement of the disease at the time of reporting to doctor (55% in
stage III and IV).
• Approx. 50% of patients - metastases in the neck lymph nodes.
• Adverse factors:
o A long time from reporting the patient to the doctor until the diagnosis is made
o Little knowledge and underestimation of oncological problems by primary care
physicians
o Diagnostic errors, diagnostic delay
 • Cigarettes and alcohol

• Some chemicals: wood dust, soot or coal dust, paint

fumes, nickel and chrom

Risk factors • HPV infection (especially types 16, 18)

• Radiation exposure (malignant transformation in

respiratory papillomatosis occurs in irradiated patients
even in 30%!!!)
 • Tobacco itself is a more potent risk factor than alcohol.
It increases the risk 30-times. Both these insults when
Risk factors combined increase the risk of malignancy by near 330
times !!!
 • Pre-cancerous condition (WHO) - morphological
changes, which carry an increased risk of malignant
neoplasm.
• Cancer develops in 2-40% of precancerous lesions.
Premalignant • Low grade dysplasia - 2% risk of turning into cancer.
lesions of larynx • High degree of dysplasia - 23-40%
• Most often in the area of the glottis and epiglottis
• A long-term process (4 years on average), the
importance of risk factors such as smoking !!!!
Premalignant lesions of
larynx
1. Leukoplakia
• White spot or plaque that cannot be clinically or
pathologically characterized as another disease
• Referred to as pachydermia, keratosis, hyperkeratosis
• Pachydermia - exophytic lesions covering a large area of the
mucosa, usually in the posterior commissure
• 33% - accompanied by dysplasia
• up to 40% risk of malignant transformation
• the term "leukoplakia" is not a histopathological term, but
merely a clinical descriptive term
 2. Chronic laryngitis
• It develops on the basis of catarrhal laryngitis
Premalignant • The epithelium grows
lesions of larynx • Edema changes in submucosal connective tissue
 3. Erythroplakia
• Mucosal lesion, presenting as a bright red velvety
plaque that cannot be clinically or pathologically
Premalignant characterized as any other disease
lesions of larynx • They are almost always accompanied by features of
dysplasia
 4. Adult papillomas of laryngx
• Squamous papillomas are the most common benign epithelial
tumors of the larynx.
• They constitute about 95% of benign neoplasms appearing in
the larynx, quite often treated as precancerous lesions
• Papillomas of the larynx (papilloma laryngis, papillomatosis
laryngis) are an enlargement of the surface epithelium; they can
Premalignant appear in both children and adults
The pathogenesis of papillomas is closely related to infection
lesions of larynx •
with HPV viruses (mainly type 6 and 11)
• Childhood / multiple changes, recurrence tendency /
• Adults / usually single lesions, more malignant /
• The most common location - vocal folds, from where they can
spread to the folds of the laryngeal pocket, epiglottis, subglottis,
trachea and bronchi
Premalignant lesions of larynx
• Clinical symptoms of precancerous conditions depend on their localization.
• There are no clinical features that would clearly indicate the presence of dysplasia
or cancer in precancerous lesions, therefore any lesions of this type should be
treated as potentially malignant, radically removed and histopathologically
verified.
• Treatment:
o only surgical radical removal of the lesion
o regular follow-up after surgery
o elimination of risk factors
o irradiation is contraindicated and may even induce a neoplastic process
Histopatologic Examination
The current histopathological classification of laryngeal hypertrophic lesions (WHO
2017)
• Changes without dysplasia
• Low grade dysplasia
• Major dysplasia (including carcinoma in situ)
• Invasive cancer
 • squamous cell carcinoma (carcinoma planoepitheliale)
about 95% of cases
• papillary cancer (carcinoma verrucosum) called
Ackerman's tumor
• papillary squamous cell carcinoma
• basaloid squamous cell carcinoma
Histopatologic • spindle cell carcinoma or sarcoma
Examination • chondrosarcoma
• adenocarcinoma (adenocarcinoma)
• melanoma
• lymphatic epithelioma
• plasmacytoma
• lymphomas
 • Supraglottis: above the level of vocal folds. It
comprises the laryngeal epiglottis, false cords,
ventricles, aryepiglottic folds and arytenoids
• Glottis: lie between the vocal folds. Includes the true
vocal cords and the anterior and posterior
commissures
Surgical anatomy of • Subglottis: below the level of vocal folds. It begins
larynx 10mm below the level of the free margin of the vocal
cords and extends to the inferior edge of the cricoid
cartilage

• The location of cancer on different levels determines

different symptoms, clinical course, treatment and
prognosis
 Natural barriers of larynx involved in preventing tumor
spread:
Growth pattern and • Perichondrium covering the laryngeal cartilages
spread of laryngeal • Endolaryngeal ligaments and membranes
carcinoma • Anterior commissure tendon prevents growth from
spreading from one cord to the other
 • Supraglottis - deep upper cervical nodes / II and III /,
subglottic / VI /, less often submandibular / I / and
retropharyngeal
• Glottis - pre-laryngeal, pre-tracheal, paratracheal
Lymph nodes nodes, Delphic knot / VI /, deep upper cervical / II and III
/ and lower / IV /
• Subglottis - prelaryngeal, peritracheal, paratracheal
nodes / VI /, deep lower cervical / IV /, upper
mediastinal nodes / VII /
 • hoarseness / dysphonia /
• shortness of breath / dyspnoe /
• difficulties and pain when swallowing / dysphagia,
odynophagia /
Symptoms • a tumor in the neck

They are determined by the primary location of the

tumor and its advancement
 • Dynamic local growth and early regional transfers
• Initial - dryness, scratching, obstruction in the throat,
uncharacteristic difficulty in swallowing, sore throat when
speaking
• Later - constant pain or with each swallowing of saliva and
eating with radiation to the ear, difficulty in swallowing,
infiltration towards the glottis causes hoarseness and then
shortness of breath, with breakdown - bleeding
Supraglottic cancer • A tumor on the neck - the first symptom of cancer of the
epiglottis in 40%

• Neck lymph node metastases:

o T1 - 20%
o T2 - 40%
o T3 - 60%
o T4 - 80%
TNM CLASSIFICATION
 • Initially - hoarseness increasing or recurring, grunting,
dry cough
• Later - shortness of breath, dysphagia, pain when
Glottic cancer swallowing, ear pain
• metastases from the lymph nodes in the neck
• T1 and T2 - 6% T3 - 20% T4 - 40%
 • Subglottal area - 2.3%
• It develops asymptomatically over a long period
Subglottic cancer
• Late symptoms include shortness of breath and
hoarseness
 • External assessment of laryngeal mobility during
speaking and swallowing
Diagnostics • Palpation (mobility larynx and lymph node
assessment)
 • Indirect laryngoscopy
Diagnostics
 Endoscopic examination Video laryngoscopy (flexible,
rigid):
• Localization of changes
Assessment of anatomical structures
DIAGNOSTICS •

• The condition of the mucosa

• Extent of pathological changes
• Mobility of the vocal folds
 Video laryngostroboscopy (VLS):
Assessment of the vibrational activity of the vocal folds
takes into account:
DIAGNOSTICS • The presence of a marginal shift
• Type of phonation short-circuit
• Simultaneous nature and amplitude of vocal fold
vibrations
 Endoscopy with imaging enhancement
DIAGNOSTICS-
By using filters to select selected lengths of light, it is
CONTEMPORARY possible to visualize the network of capillaries of the
METHODS (NBI) mucosa and vessels in the submucosa.
This is the basis for differentiating dysplastic and
malignant lesions from benign ones.
 DIAGNOSTICS-
DIRECT
LARYNGOSCOPY allows for the assessment of the location and extent of
the tumor and the collection of specimens for
(DIRECTOSCOPY / histopathological examination
MICRODIRECTOSCOPY)
 Stand-alone methods
• Surgery
• Radiotherapy
Associated method
• surgery + radiotherapy + chemotherapy
TREATMENT Complementary methods in the treatment of failures

Chemotherapy is not used as an independent treatment

for laryngeal cancer
Induction or adjuvant chemotherapy in combination with
radiotherapy.
 What influences the decision making?
Tumor
• location of the tumor
• clinical advancement of the tumor
• the result of the histopathological examination
TREATMENT Patient
• general condition of the patient
• occupation
• expectations in relation to the effects of treatment
• the patient's consent to the proposed treatment
• other
 I – II stage of clinical advancement
• surgical treatment or radiation therapy (RTH). The
combination of both methods is often used (always in
sequence: surgery + RTH
Stage III and IV
• surgical treatment and / or radiotherapy (RTH)
TREATMENT
• or chemoradiotherapy (cisplatin, cetuximab) in
patients who are not eligible for resection as well as
conservative management (currently preferred as an
alternative to mutilating surgery).
• chemoradiotherapy in addition to surgery in case of
negative prognostic factors in the
pathomorphological examination
 Depending on the stage of the tumor, the following are
used:
A. Partial removal of the larynx
I. Intra-laryngeal - endoscopic microsurgery with the use
of a laser
SURGICAL
TREATMENT II. Extra-laryngeal (access through laryngeal splitting)
III. Almost complete removal of the larynx
B. Complete removal of the larynx
C. Complete removal of the larynx together with the
lymph nodes.
SURGICAL TREATMENT-
LARYNGECTOMY
The complete removal of the larynx consists in cutting
it off the trachea, the root of the tongue, the laryngeal
part of the pharynx and the esophagus and removing it
together with the hyoid bone and the preglottic space,
and then fusing the tracheal stump with the skin on the
neck (permanent tracheostomy) and closing the cut
part of the pharynx and throat and esophagus.
 In RTH with a radical assumption (exclusive or associated
with CTH), the following is normally used:
• conventional fractionation (1 fractional dose 1.8–2.0
Gy per day for 5 days a week - total dose 70–72 Gy).
• Conformal RTH, based on three-dimensional
treatment planning and implementation, which
RADIOTHERAPY enables safe administration of a high and
homogeneous dose in the irradiated volume with
relative protection of normal tissues.
• Conformal RTH with intensity modulated radiation
therapy (IMRT) - better protection of healthy tissues,
possibility of simultaneous dose increase in the
irradiated volume - the most technologically
advanced form of RTH
 5 years of survival
• 66% - including all patients with laryngeal cancer
• 60% - patients with cancer of the supraglottis
• 80% - patients with glottic cancer
• 15% - patients with cancer of the subglottis

RESULTS In patients with cancer at an early local stage, without lymph node
metastases, the long-term cure rates range from 80 to even 95%.
In patients with locally more advanced laryngeal cancer, long-term survival is
at the level of 50 to 70%, and in many cases organ function is preserved.
With local recurrences of laryngeal cancer, the long-term survival rates after
salvage surgery reach 40-50%.

The presence of lymph node metastases lowers the survival rate to 35% !!!
 After removal of the larynx, the patient undergoes voice
rehabilitation. After partial surgery, e.g. removal of the vocal
fold, rehabilitation of the voice restores its best quality.
After complete surgery, the patient learns to speak "again"
METHODS OF
VOICE Normal voice organ:
REHABILITATION • Larynx - sound generator
• Lungs - a source of energy that excites the generator
• Nasal cavity, paranasal sinuses, laryngeal pockets -
resonant cavities
• Throat, oral cavity - articulation apparatus
 Three methods to recreate the sound generator:

METHODS OF
• Esophageal speech
VOICE
• External sound generator
REHABILITATION
• Tracheoesophageal fistula with the use of a voice
prosthesis
 METHODS OF Esophageal speech
VOICE Two paths of air supply to the pharyngophageal segment
REHABILITATION from the side of the digestive tract from the lungs
 METHODS OF
VOICE External sound generator
REHABILITATION
 METHODS OF Voice prothesis
VOICE Currently, implantation of a tracheo-oesophageal
REHABILITATION prosthesis is the best method of allowing the patient to
speak after the larynx has been completely removed.