LARYNGEAL MALIGNANCY: PRESENTATION & MANAGEMENT

One of the most common cancers of the upper aerodigestive tract after oral cancers, Laryngeal cancer has an approximate representation of one-third of all head and neck cancers together the world over. The majority of these tumors are of the squamous cell variant and an early diagnosis helps in a better prognosis and overall quality of life and survival.

RISK FACTORS

• Tobacco: smoking being a 70-95% association estimate is considered the most important risk factor

• History of smoking or current smoking has a higher relative risk of laryngeal cancers. Secondhand smoke has shown a significant increase in risk

• Alcohol: independent use and association being unclear, in combination with smoking and heavy consumption of alcohol have shown a greater than average effect on causality

• Laryngopharyngeal reflux and its association (1)

• Low fruit and vegetable intake (2)

• Human Papilloma Virus 16,18 have been detected in 21% of advanced laryngeal cancers showing some association with the disease process more so in women than men (3)

• Asbestos, Paint fumes, Tar and leather products, and others

PRESENTATION

Male gender seems to be affected more commonly than female and there is a genetic association of the disease which needs to be elicited in the patient history if any. Clinical manifestations depend on the site of the tumor location

 Glottic tumors:

o Voice change- an early symptom

o Hemoptysis

o Dyspnea & dysphagia

o Respiratory distress

o Loss of weight

o Throat pain or referred pain to the ear

 Supraglottic tumors:

o Aspiration on swallowing

o Sore throat

o Lump or foreign body sensation throat

o Neck mass

 Subglottic tumors:

o Airway obstruction

o Dysphagia

o Hemoptysis

Late symptoms across the whole site spectrum are shown to have weight loss, appetite loss, dysphagia, aspiration, and airway compromise.

Complete history along with a family history of cancers and personal history of substance abuse is important. Complete physical examination with the examination of the neck with lymph nodal assessment is done.

MANAGEMENT

Investigation:

• Fibreoptic endoscopy: assessment of primary lesion- size site and extent of the lesion and adjoining area are noted. Biopsy during the examination can also be done

• Imaging: Contrast-enhanced CT neck, CT thorax, and PET/CT to rule out metastasis

• Panendoscopy with biopsy of suspicious lesions in the hypopharynx / alimentary tract for skip lesions along with barium studies

• Blood investigation workup including Liver and Kidney function

At the end of the investigative assessment, the following must be well-recognized and worked up:

• Cord fixity and degree of mobility on phonation and respiration

• Involvement of the base of the tongue, paraglottic and pre-epiglottic space, carotid artery, thyroid cartilage, esophagus, adjoining structures

• Lymph node and distant metastasis status

Treatment:

American Joint Committee on Cancer, 8th Edition Cancer Staging Manual (AJCC) gives a staging system for the primary tumor of glottic, supraglottic, and subglottic cancers where the extent of local disease spread, and cord fixity are accounted for. The following tables show tumor staging, nodal staging, and stage groupings according to T,N,M for the subsites of laryngeal cancers(4)

Image:AJCC tumor staging as per subsites of larynx

The goals in the treatment of the larynx are healing the patient with laryngeal preservation of function to a degree that’s maximumly acceptable to disease clearance and minimizing treatment morbidity as much as possible without compromising the outcome of the intervention.

Early laryngeal cancers (T1-2N0)- single, locally-directed treatment modality, whether local radiation therapy or surgery. Transoral laser microsurgery is gaining popularity in the management of these early cancers.

T1-2N0 glottic surgery or local radiation therapy is recommended as only the primary tumor requires addressal considering the sparse lymphatic drainage of the true glottis. transoral laser excision, laryngofissure, and partial laryngectomy may be considered in these lesions with high evidence of success comparable to radiotherapy as well.

T1-2N0, Selected T1-2N1/T3N0-1 Supraglottic Cancer-larynx-sparing surgical or RT monotherapy including management of neck with procedures such as endoscopic resection or partial supraglottic laryngectomy for T1-2 and low-volume T3 disease, with neck dissection often indicated T2 or T3 lesions. Adjuvant RT in cases with nodal positivity, extracapsular invasion, or margins being positive.

T3-4N1-3 disease- involve combination therapy with laryngeal preservation surgery with radiation therapy and cisplatin-based chemotherapy regimens.T4 disease requires total laryngectomy with adjuvant RT or chemoradiation with salvage surgery. (5) (6)

Image: Gluck sorensons incision given and flaps exposed upto the level of mandible and upper border hyoid. Endotracheal tube in tracheostoma.

Image: Anterior border Sternocleidomastoid identified and dissected to delineate the Internal Jugular Vein. Positive nodal metastasis with enlarged lymph nodes sent as an inclusive part of the laryngectomy specimen.

Image: Incised suprahyoid musculature and incised entry into the pharynx

Image: Total laryngectomy specimen dissected free and removed.

Image: Laryngectomy specimen with level 2a,2b and 3 lymph node and fibrofatty fascial complex

Image: Closure of the mucosal layer and creation of neopharynx and stoma then sutured to the skin.

Post-laryngectomy rehabilitation helps the patient lead a better quality of life post-surgery which includes

• Voice rehabilitation: esophageal speech, electrolarynx, or prosthetic speech using tracheoesophageal fistulization and prosthesis-based speech

• Swallow rehabilitation

• Pulmonary rehabilitation by training for stomal breathing and aids such as heat and moisture exchanger

• Olfactory rehabilitation techniques such as nasal airflow inducing maneuver (7)

Summing Up

Here in our center at Bangalore Head and Neck Sciences and Bangalore ENT Institute & Research Center, end-to-end cancer care is provided to all cancer patients. From diagnosis through management and rehabilitation, patients and their loved ones are handheld across thorough and evidence-based disease management in line with international protocols alongside the necessary supportive care and counseling at every step of the way thereby empanelling all our patients to deal with various aspects of the management in a strengthened and appropriate manner.

REFERENCES

(1) Coca-Pelaz A, Rodrigo JP, Takes RP, Silver CE, Paccagnella D, Rinaldo A, et al. Relationship between reflux and laryngeal cancer. Head Neck. 2013; 35: 1814-1818.

(2) Maasland Denise HE, van den Brandt PA, Kremer B, Goldbohm RA, Schouten LJ. Consumption of vegetables and fruits and risk of subtypes of head–neck cancer in the Netherlands Cohort Study. International Journal of Cancer. 2015; 136: 396-409.

(3) Hernandez BY, Goodman MT, Lynch CF, Cozen W, Unger ER, Steinau M, et al. Human Papillomavirus Prevalence in Invasive Laryngeal Cancer in the United States. PLoS One. 2014; 9: e115931.

(4) Koroulakis A, Agarwal M. Laryngeal Cancer. [Updated 2022 Mar 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan

(5) Rosenthal DI, Mohamed AS, Weber RS, Garden AS, Sevak PR, Kies MS, Morrison WH, Lewin JS, El-Naggar AK, Ginsberg LE, Kocak-Uzel E, Ang KK, Fuller CD. Long-term outcomes after surgical or nonsurgical initial therapy for patients with T4 squamous cell carcinoma of the larynx: A 3-decade survey. Cancer. 2015 May 15;121(10):1608-19.

(6) Dziegielewski PT, Reschly WJ, Morris CG, DeJesus RD, Silver N, Boyce BJ, Santiago I, Amdur RJ, Mendenhall WM. Tumor volume as a predictor of survival in T3 glottic carcinoma: A novel approach to patient selection. Oral Oncol. 2018 Apr;79:47-54.