ABSTRACT
Stage IV: T4N0,N1M0 or any T,N2,N3M0 or any T, and N, M1
II. INCIDENCE
A. Male:female = 6:1
B. Usually presents in the 5th to 7th decade of life
C. Incidence is 2.7 cases per 100,000 people
III. ANATOMIC CONSIDERATIONS
A. Anatomic Boundaries
1. Larynx in general
. Anteriorly: the lingual epiglottis, thyrohyoid membrane, anterior commissure, thyroid cartilage, cricothyroidmembrane, anterior cricoid cartilage
. Posteriorly and laterally: the aryepiglottic folds, arytenoids and intraarytenoid space, mucous membrane of cricoid cartilage, vestibule, ventricle, and subglottic space
2. Supraglottis
. Extends from the vallecula to the laryngeal ventricle
. Epiglottis, aryepiglottic folds, arytenoids, false cords
3. Glottis
. True vocal cords
. Anterior and posterior commissures
B. Most Frequent Sites of Tumor Involvement
1. Glottis-most common site
2. Subglottis location represents <2% of all laryngeal tumors
C. Lymphatic Drainage
1. Supraglottis-drains into levels I, II, III
2. Glottis
. Drains into levels II, III, IV, Delphian (pretracheal)
. True vocal cords are devoid of lymphatic vessels
. Metastasis as a late phenomenon
3. Subglottis-drains into levels II, III, IV
4. Bilateral drainage of supraglottis and subglottis
5. Adjacent tissue spread from glottis and subglottis
D. Anatomic Factors Pertinent to Tumor Spread
1. Broyle’s ligament
. Attaches the vocalis tendon to the thyroid cartilage
. Potential site of tumor spread through the fenestrations in the cartilage
2. Elastic membranes
. Prevent early tumor spread between compartments
. Act as a relative barrier to early cartilage invasion
. Conus elasticus and/or quadrangular membrane
3. Potential spaces
. Allow spread of tumor outside the larynx
. Pre-epiglottic space and paraglottic space
E. Vocal Cord Fixation
1. Invasion of the vocal cord proper, cricoarytenoid muscle or joint, or recurrent laryngeal nerve
2. May be mimicked by tumor mass on adjacent
IV. DIAGNOSIS
A. Physical Examination
1. Thorough exam of head and neck
2. Evaluation of all mucosal surfaces
3. Palpation for cervical adenopathy
4. Flexible laryngoscopy
5. Panendoscopy and biopsy
B. Radiographic Studies
1. CT for advanced lesions prior to endoscopy and biopsies and for nodal staging
2. MRI may add complementary information regarding cartilage invasion
C. Symptoms
1. Supraglottis
. Early: neck mass, dysphagia, odynophagia, globus sensation, referred otalgia
. Late: hoarseness, stridor, ‘‘hot potato’’ voice
2. Glottis
. Early: hoarseness
. Late: dysphagia, odynophagia, globus sensation, referred otalgia, cough, hemoptysis, stridor
3. Subglottis-dyspnea, stridor (late presentation)
V. ETIOLOGY
A. Social habits-cigarette smoking and alcohol abuse
B. Viral agent-laryngeal papillomatosis
C. Occupational exposure-asbestos, nickel and fossil fuels
VI. HISTOPATHOLOGY
A. Squamous Cell Carcinoma
1. Accounts for >90% of all laryngeal tumors
2. Grading:
. Gx-Grade not assessed
. G1-well differentiated
. G2-moderately differentiated
. G3-poorly differentiated
B. Verrucous Carcinoma
Accounts for 2% of vocal cord cancers
VII. TREATMENT
A. Carcinoma In Situ
Vocal cord stripping during microlaryngoscopy
B. Supraglottis and Glottis
1. T1 and T2: radiation or partial laryngectomy
2. Advanced disease: total laryngectomy, combined therapy, and organ sparing protocols
3. Radiation for N1 tumors
4. Surgery for N2-3 tumors
5. Relative contraindications to partial laryngectomy include vocal cord fixation, invasion of the thyroid cartilage, and invasion of the intraarytenoid space
C. Subglottis
Radiation therapy, laryngectomy, and neck management
D. Organ-Sparing Therapy
1. Radiation therapy in smaller tumor
2. Laryngectomy for salvage of T3, T4 failures
3. Role of chemotherapy is still under investigation
4. Neoadjuvant (anterior) chemotherapy
. Three cycles of chemotherapy followed by radiotherapy for major or complete responders (e.g., >70%)
. Poor responders (e.g.,<70%) go on to surgical arm with postoperative adjuvant radiation therapy
