NEOPLASMS OF THE LARYNX
Benign neoplasms of the larynx Epithelial tumours Single papilloma of the larynx Multiple papillomas of the larynx Connective-tissue tumours Fibroma of the vocal cord ChondromaAngioma Others : lipoma. rhabdomyoma and leiomyoma.Malignant neoplasms of the larynx Epithelial tumours Squamous-cell carcinoma Others: Adenocarcinoma, Cylindroma, Basal-cell carcinoma Connective-tissue tumours Malignant lymphoma, Leiomyosarcoma Plasmacytoma, Fibrosarcoma
Squamous Cell Carcinoma 5th-6th decades M/F:3/1, Smoker/Non:6/1
Pathologically range from highly keratinized to anaplastic types. Biopsy is always necessary, both for diagnosis and to determine the degree of differentiation , which assists in the choice of treatment. Clinically the growth may be ulcerative or proliferative.The topographical types 1. Supraglottic carcinoma : arising in the upper part of the larynx above the vocal cord. Hoarseness may be relatively late and is preceded by a sense of discomfort in the larynx.
2. Glottic carcinoma. Commonest , majority show keratinization. Carcinoma-in-situ the change is confined to the surface epithelium without invasion of the supporting connective tissue . Site : free edge or the flat upper surface of the cord, usually in its central portion or its anterior half.C/F: hoarseness LN. Negative
:Direct spread Forwards to the anterior commissure ,may spread across the midline to the anterior end of the opposite cord .Laterally to pre-epiglottic space. Backwards to the vocal process, is usual and may occur early. Upwards into the ventricular band ,is late . Downwards into the subglottic space on the same side or below the anterior commissure. It may reach the trachea. Lymphatic spread: rare < 4%.
Clinical features. Hoarseness, gradually increasing Pain (often referred to the ear), Dyspnoea, and dysphagia are caused by perichondritis as the disease advances. Indirect laryngoscopy : * A nodular or generalized swelling of the cord * White papilliferous excrescence or an ulcer- ated area or a plaque. * Impaired movement of the affected cord Metastasis in the lymphatic glands of the neck appears as a hard painless mass beneath the sternomastoid.
3. Subglottic carcinoma. The incidence is midway between that of glottic and supraglottic cancer. Site: is usually the subglottic surface of the cord, but sometimes it is immediately below the anterior commissure Direct spread: Upwards to the cord edge. This may be late. Downwards to the trachea. Circumferential spread. The posterior wall is attacked last.
Lymphatic spread. in the lower deep cervical, cricothyroid, paratracheal and mediastinal lymph nodes. Clinical features. Hoarseness results from infiltration of the cord and may therefore be late in appearing. Stridor presents as the growth increases in size.
Diagnosis a.History & Clinical ex. b.Radiography, particularly CT or MR scanning. c.Endoscopy with biopsy.
Summary of UICC classificationTumour Glottis TI Limited/mobile. One cord.Both cords. T2 Extension to supra- or sub- glottis/mobile. T3 Fixation of cord(s). T4 Extension beyond the larynx. Supra- and sub-gloltis TI Limited/mobile. T2 Extension to glottis/mobile.T3 Fixation of cord(s). T4 Extension beyond the larynx. Regional Lymph Nodes All regions NI Homolateral movable. N2 Contra- or bilateraJ movable.N3 Fixed.
Treatment 1.Laser : esp. in Ca.in situ,but today become wider uses2.Radiotherapy is indicated in: Anaplastic tumours. Early cordal growths Tumours which only slightly exceed the limitations demanded by partial laryngectomy. . In general growths in the posterior half of the larynx and those involving cartilage are less suitable for radiotherapy . In some centres radiotherapy combined with hyperbaric oxygen to increase the cancericidal effects is proving successful with some of the more extensive growths.
3.Chemotherapy 4. Surgery failure of radiotherapy, primary curative treatment, in advanced cases Total laryngectomy. Partial laryngectomy
Management of cervical lymph-node metastases 1. Observation. In cancers limited to one vocal cord. Continued strict and regular observation, however, is essential if metastases are to be detected early. 2. Presentation. Palpable nodes in the neck at presentation should be treated by block neck dissection unless the patient is unfit, or in advanced cases. 3. Prophylactic treatment. Radiotherapy of the more advanced cancers of the larynx should include the lymphatic areas. 4. Treatment of postoperative and post-irradiational lymph-node metastases. Metastases after radiotherapy or surgery should be treated by block neck dissection.