Carcinoma Larynx Laryngeal cancer is the most common cancer of the upper aerodigestive tract.

Etiology: The incidence of laryngeal tumors is closely correlated with smoking, as head and neck tumors occur 6 times more often among cigarette smokers than among nonsmokers. The age-standardized risk of mortality from laryngeal cancer appears to have a linear relationship with increasing cigarette consumption. Death from laryngeal cancer is 2 times more likely for the heaviest smokers than for nonsmokers. The use of unfiltered cigarettes or dark, air-cured to!acco is associated with further increases in risk. "lthough alcohol is a less potent carcinogen than to!acco, alcohol consumption is a risk factor for laryngeal tumors. #n individuals who use !oth to!acco and alcohol, these risk factors appear to !e synergistic, and they result in a multiplicative increase in the risk of developing laryngeal cancer. Mortality/Morbidity: The prognosis for small laryngeal cancers that do not have lymph node metastases is good, with cure rates of $%-&%', depending on the site, the size of the tumor, and the e(tent of infiltration. "dvanced disease has a worse prognosis. )upraglottic cancers usually manifest late and have a poorer prognosis. Sex: #n the *&% s, the male-to-female ratio in patients with laryngeal cancer was *%:*. This num!er had changed to %:* !y the year 2 , and the proportion of women afflicted !y the disease is pro+ected to increase in years to come. These changes are likely a reflection of shifts in smoking patterns, with women smoking more in recent years. Age: ,aryngeal cancer most commonly affects men middle-aged or older who are smokers and who use alcohol. The peak incidence is in those aged % -6 years. Regions of the larynx The laryn( is divided into - anatomic regions: the supraglottic laryn(, the glottis, and the su!glottic region. The supraglottic larynx consists of epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids. The anatomic borders are as follows: superior, epiglottis; inferiorly, point at which the vocal cord epithelium turns upward to form the lateral wall of the ventricle; anterior, posterior edge of the vallecula superiorly and anterior false cord inferiorly; and posterior, the arytenoids. The glottic larynx consists of the true vocal cords and anterior commissure.

The anatomic borders are as follows: superior, point at which the vocal cord epithelium turns upward to form the lateral wall of the ventricle; inferior, 5 mm below the free margin of the vocal cords; anterior, the anterior commissure, which is usually located within 1 cm of the skin surface (an important consideration in planning for radiation therapy); and posterior, the posterior commissure. The subglottic larynx consists of the region !etween the vocal cords and the trachea. The anatomic borders are as follows: superior, 5 mm below the free margin of the vocal cords, and inferior, the inferior aspect of the cricoid cartilage. re!epiglottic fat space The pre-epiglottic fat is located in the anterior and lateral aspects of the laryn( and is often invaded !y advanced cancers. The anatomic borders are as follows: superior, hyoid !one and hyoepiglottic ligament. inferior, conus elasticus. anterior, thyrohyoid mem!rane. posterior, anterior wall of the pyriform sinus. and lateral, thyroid cartilage wall. #nvasion of the pre-epiglottic fat has significant surgical implications, so evaluation of this space should !e part of any radiologic analysis. Lymphatics The first-echelon lymphatics for the supraglottic laryn( are the su!digastric nodes and the middle anterior cervical nodes /level -0, and the second-echelon lymphatics are the lower anterior cervical nodes /level 10. The glottic laryn( contains few lymphatics, and nodal spread occurs only with primary e(tension to the supraglottis or su!glottis. 2or tumors with spread to the supraglottis, the su!digastric nodes are at risk. 2or tumors with spread to the anterior commissure and anterior su!glottis, the middle and lower anterior cervical nodes, the Delphian node, and the lateral paratracheal nodes are at risk. The first!echelon lymphatics for the subglottic larynx are the "elphian node# the lower anterior cervical nodes and paratracheal nodes, and the supraclavicular nodes, and the secondechelon lymphatics are the mediastinal nodes. 3lottic and su!glottic tumors metastasize to ipsilateral lymph nodes, !ut supraglottic tumors often spread to nodes on !oth sides of the neck. Le$els of the nec%: The neck is divided into % levels: Le$el & includes the su!mental 4 su!mandi!ular triangles Le$el &&, the superior +ugular chain nodes e(tending from the skull !ase down to the carotid !ifurcation and posteriorly to the posterior !order of the )56 muscle. Le$el &&&, the +ugular nodes from the carotid !ul! inferiorly to the omohyoid muscle. Le$el &'# the +ugular nodes from the omohyoid muscle to the clavicle Le$el ', the posterior triangle !ounded !y the sternocleidomastoid anteriorly, the trapezius posteriorly, and the omohyoid inferiorly.

Clinical "etails: 6ost laryngeal cancers arise in the glottic region and are symptomatic early as a result of hoarseness and changes in the voice. &n the supraglottis# the T stages are as follo(s: T): Tumor limited to * su!site of the supraglottis with normal vocal cord mo!ility T*: Tumor invasion of the mucosa of more than * ad+acent su!site of the supraglottis or glottis or of a region outside the supraglottis , without fi(ation of the laryn( T+: Tumor limited to the laryn( with vocal cord fi(ation and7or invasion of any of the postcricoid area or pre-epiglottic tissues T,: Tumor invasion through the thyroid cartilage and7or e(tension into soft tissues of the neck, thyroid, and7or esophagus. Subsites include the follo(ing : false cords, arytenoids, suprahyoid epiglottis, infrahyoid epiglottis, and aryepiglottic folds /laryngeal aspect0. &n the glottis# the T stages are as follo(s: T*: Tumor limited to the vocal cord with normal mo!ility T2: Tumor e(tension to the supraglottis and7or su!glottis and7or impaired vocal cord mo!ility T-: Tumor limited to the laryn( with vocal cord fi(ation T1: Tumor invasion through the thyroid cartilage and7or other tissues !eyond the laryn( . &n the subglottis the T stages are as follo(s: T): Tumor limited to the su!glottis T*: Tumor e(tension to a vocal cord with normal or impaired mo!ility T+: Tumor limited to the laryn( with vocal cord fi(ation T,: Tumor invasion through cricoid or thyroid cartilage and7or e(tension to other tissues !eyond the laryn( Regional lymph nodes# - stages are as follo(s: 89: :egional lymph nodes cannot !e assessed 8 : 8o regional lymph node metastasis 8*: 6etastasis in a single ipsilateral lymph node, - cm or less in greatest dimension 82: 6etastasis in a single ipsilateral lymph node more than - cm !ut not more than 6 cm in greatest dimension, metastases in multiple ipsilateral lymph nodes with none more than 6 cm in greatest dimension, or metastases in !ilateral or contralateral lymph nodes none more than 6 cm in greatest dimension 8-: 6etastasis in a lymph node more than 6 cm in greatest dimension. Supraglottic carcinomas: The epiglottis is the most fre;uent location for cancers that arise in the supraglottic laryn(. Tumors may arise from either the suprahyoid or infrahyoid epiglottis. These lesions are often e(ophytic and circumferential masses that, when detected early, are confined to the midline of the supraglottis.

Tumors of the aryepiglottic fold are typically e(ophytic lesions that, when detected early, are confined laterally along the aryepiglottic fold. "dvanced lesions may e(tend laterally to involve the ad+acent wall of the pyriform sinus or medially to invade the epiglottis. );uamous cell cancers that arise from the false vocal cords and laryngeal ventricle tend to !e ulcerative and infiltrative with a limited e(ophytic component. Deep invasion !y such tumors results in their access to the paraglottic space, and this may lead to fi(ation of the supraglottic laryn(. <ecause of their close pro(imity, these tumors may e(tend inferiorly to involve the true vocal cords. .lottic carcinomas The true vocal cords are the most common site of laryngeal carcinomas. the ratio of glottic carcinomas to supraglottic carcinomas is appro(imately -:*. The anterior portion of the true vocal cord is the most common location of s;uamous cell cancer, with most lesions occurring along the free margin of the vocal cord. "nteriorly, the tumor may e(tend to anterior commissure, where it may involve the contralateral true vocal cord. The likelihood of nodal involvement associated with glottic carcinomas depends on the stage of the tumor. The incidence of early T* lesions has !een reported to !e as low as 2'. This figure increases to appro(imately 2 ' for T- and T1 lesions. Subglottic carcinomas )u!glottic carcinomas are rare and account for only %' of all laryngeal carcinomas. The su!glottic region is more commonly involved !y the direct e(tension of a glottic or supraglottic carcinoma than !y tumors elsewhere. =hen present, these lesions are characteristically circumferential and often e(tend to involve the undersurface of the true vocal cords. They have a tendency for early invasion of the cricoid cartilage and e(tension through the cricothyroid mem!rane. >rimary su!glottic carcinomas have a propensity to drain to the paratracheal lymph nodes. The reported incidence of clinically positive nodes in patients with su!glottic carcinoma is * '. &nter$ention: )upraglottic cancer: Treatment of the primary tumor >artial laryngectomy may !e feasi!le in select patients. During supraglottic laryngectomy, the upper portion of the thyroid cartilage and its contents, the false vocal cords, the epiglottis, and the aryepiglottic folds are removed. This surgery can preserve the patient?s speech and swallowing, !ut more e(tensive resection increases the demands on lung function, limiting the utility of that procedure. Standard supraglottic laryngectomy is contraindicated when the following are present: /*0 e(olaryngeal spread, /20 vocal cord fi(ation, /-0 involvement of !oth arytenoids, /10 a tumor-free

margin of less than - mm !etween the inferior aspect of the tumor and the anterior commissure, and /%0 invasion of the thyroid or cricoid cartilage. #n patients with T* or T2 tumors, local control rates with conventional fractionated radiation therapy /6%-$ 3y in 6-$ wk0 are higher than @ ' overall. T- tumors may also !e treated with radiation therapy. 6ore-advanced disease re;uires com!ined-modality treatment often entailing total laryngectomy. :adiation therapy or induction chemotherapy followed !y radiation therapy may !e offered with curative intent. Treatment of the nec% Treatment of the neck is necessary !ecause of the high incidence of cervical metastases. "!out one third of clinically negative necks have metastatic neck nodes, and the incidence of recurrence in the untreated neck is high. #n the surgical treatment of T* or T2 primary tumors, !ilateral modified radical neck dissection is recommended .lottic cancer: Treatment of the primary tumor " variety of surgical procedures are availa!le for treating glottic carcinomas. "dvanced lesions are treated with total laryngectomy. Aarly lesions may !e treated with radiation therapy or surgery, such as cordectomy or hemilaryngectomy. 5arcinoma in situ is highly cura!le with microe(cision, laser vaporization, or radiation therapy. Treatment recommendations should !e !ased on the e(tent of local disease. T* and T2 tumors may !e treated !y means of partial laryngectomy or radiation therapy /6%-$ 3y in 6.%-$ wk0. T- lesions are !eing treated with primary radiation therapy, followed !y salvage laryngectomy if residual disease or recurrence is present. #nduction chemotherapy followed !y radiation can also !e used to preserve the laryn(. T1 disease is !est treated with total laryngectomy. Treatment of the nec% <ecause of the sparse lymphatic network and the low incidence of cervical metastases, elective neck dissection is indicated only for transglottic lesions. >alpa!le nodal disease re;uires treatment of the neck. Subglottic cancer Total laryngectomy with neck dissection is the usual treatment recommendation. 5om!ination therapy /surgery plus ad+uvant radiation therapy0 is recommended for more advanced disease.