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Laryngeal Mass

John F. McGuire, MD, MBA


Case Presentation
• 62 year old male with 8 month history of
increasing hoarseness. Over the past 3
days he has had increased difficulty
breathing and swallowing. He comes to
the emergency room for evaluation
because he “cant breathe”.
History
• PMHx: none
• PSHx: none
• Meds: none
• PHx: 40 pack year smoking history,
weekly to daily alcohol intake
Exam
• Pt has biphasic stridor and appears in
distress.
• Next step???

• Findings in OR: “Exophytic obstructive


transglottic lesion encompassing the left
supraglottic, left glottic and small extention
into the left subglottic regions.”
Differential Dx
• V: hemangioma
• I: TB (20-40% with no lung involvement, used to be MC disease affecting larynx),
histoplasmosis, blasto/coccidio/actino-mycosis, cryptococcosis, Feinberg’s sequence
• T: trauma, fb
• A: relapsing polychondritis, rheumatoid arthritis (MC autoimmune dz to affect larynx,
laryngeal involvement in 26% to 53%), and Wegener's granulomatosis (23% with
laryngeal involvement… think subglottic stenosis: tx??? A: cut, dilate, mitomycin…
not laser)
• M:
• I: sarcoidosis, amyloidosis
• N: granular cell tumors (MC non-epitheliod lesion of larynx), chondrosarcoma,
fibrosarcoma, kaposi’s sarcoma, adenocarcinoma, mucoepidermoid carcinoma,
atypical carcinoid (most common neuroendocrine tumor of larynx), extramedullary
plasmacytoma
• C:

• Common things common: 95% of larygeal CA is SCCA


Topic of this Presentation
• Optical coherence
tomography of the
vocal cords
– OCT is like ultrasound,
but its “light” instead of
“sound”… OCT Today

• think of it as
“ultralight”…
OCT tomorrow???
Laryngeal Cancer
• Hypopharynx cancers: Glottic (62%)
supraglottic (37%) and subglottic (2%).
• Main risk factors: tobacco and alcohol
– Others include HPV, GERD, passive smoke,
(for the test… Plummer-Vinsen Syndrome >>
post-cricoid SCCA)
Clinical Pearls
• 78% of patients with hypopharyngeal
carcinoma have palpable cervical
metastases when initially seen.
• The average duration of symptoms before
presentation is 2 to 4 months.
• 20% have an asymptomatic mass in the
neck, usually ipsilateral, a jugulodigastric
or midjugular lymph node
Anatomy: Think Spaces
• Quadrangular
membrane: Fibrous
drape from
epiglottis over
arytenoids.

• Conus elasticus:
See diagram.

• Anterior
commissure tendon
(Broyles ligament):
- No perichondrium.

• Hyoepiglottic
ligament:
– Roof of the
paraglottic and
preepiglottic
spaces.
Anatomy
• Paraglottic space:
• Superior border :
quadrangular membrane
• Inferior border: conus
elasticus
• Lateral border: inner
surface of the thyroid
cartilage
• Medial border: ventricle
T3 supraglottic cancer
spreading into glottis
through the paraglottic
space.
Anatomy
• Preepiglottic space
• Superior border : hyoepiglottic
ligament
• Anterior border: thyrohyoid
membrane and ligament
• Posterior border: anterior surface
of the epiglottis and thyroepiglottic
ligament

• Clinical note: Almost 50% of


supraglottic carcinomas have
preepiglottic space
involvement… implication is
upstage to T3 tumor. This is
likely secondary to
fenestrations in epiglottic
cartilege.
Is this T1 or T2???
Anatomy and Cancer
• Weak points for the spread of laryngeal cancer

– Broyle’s ligament has no perichondrium, providing carcinoma


direct access to the cartilage.

– Fenestrations within the infrahyoid epiglottis provide a route for


invasion of the preepiglottic space.

– Ossification at the anterior commissure and the posterior border


of the thyroid ala of the thyroid cartilage provide a route for
cancer spread.

– Points of attachment of the cricothyroid ligament and the anterior


origin of the thyroarytenoid musculature provide a route for
cancer spread.
Anatomy: Lymph
Drainage
• Rule of thumb: Glottic and supraglottic
to levels 2-3, subglottic to level 4
• Very sparce lymphatics in TVC,
therefore glottic CA usually better
prognosis (although also usually
detected earlier)
• Delphian node = midline pretracheal
node

• Clinical notes: Supraglottic nodal


– Correlation of presumptive nodal
abnormality on physical exam with spread patterns
pathologic study has been 60% to 70%
and varies between approximately
65% and 80% for imaging studies.
– Glottic and subglottic tumors have a
2% to 5% risk of neck disease unless
the subglottic extension exceeds 10
mm.

Path of
subglottic
tumor spread
Radiology
• Only 46% positive predictive value of CT
for detecting cartilage invasion
• 50% of tumors radiologically staged as T3
had microinvasion of cartilage, usually at
thyroid notch.
• CT most useful, but MRI useful for
detecting submucosal lesions.
• Don’t forget CXR: lung CA most common
second primary.
Staging: Glottic
• T1-tumor limited to the vocal cords
– T1a-tumor limited to one vocal cord
– T1b-tumor involves both vocal cords
• T2-tumor extends to the supraglottis and/or
subglottis and/or impaired vocal cord mobility
• T3-tumor with vocal cord fixation (a cord cannot
move at all)
• T4-tumor invades outside of the larynx (trachea,
soft tissues of the neck, etc.)
Staging: Supraglottic
• T1-tumor limited to one subsite of the supraglottis with
normal vocal cord mobility

• T2-tumor invades one adjacent site of the supraglottis or


glottis or one region outside of the supraglottis without
fixation of the vocal cords

• T3-tumor limited to the larynx with vocal cord fixation or


invasion into the area behind the larynx or in front of the
larynx

• T4- tumor invades outside of the larynx (trachea, soft


tissues of the neck, etc.)
Staging: Nodal Disease
• N0-no spread to lymph nodes
• N1-tumor spread to one lymph node on the same side as
the tumor in the throat. Lymph node must be < 3 cm
• N2a-tumor spread to one lymph node on the same side
as the tumor in the throat. Lymph node is between 3 and
6 cm
• N2b-tumor spread to more than one lymph nodes on the
same side as the tumor in the throat, with none being >6
cm
• N2c-tumor spread to lymph nodes on both sides of the
neck, with none being >6 cm
• N3-tumor spread to a lymph node when the lymph node
is > 6 cm
Overall Stage
• Stage I-T1N0M0
• Stage II-T2N0M0
• Stage III-T1-3N1M0 or T3N0M0
• Stage IVA-T4N0-1M0 or Any T, N2M0
• Stage IVB-Any T, N3M0
• Stage IV-any M1
Carcinoma in situ
• Equal efficacy rates of surgical stripping and
XRT>> what to you do? Why? (10% failure with
XRT in CIS)
• Progression: hyperkeratosis with atypia >> CIS
>> superficially invasive CA >> invasive CA
• 5-30% with pre-malignant lesions will develop
invasive disease
• Appx. 90% cure rate with stripping:
– Caveats:
– May not be true for anterior commisure lesions
– Can require re-stripping
– Need reliable patient, second look 6-12 weeks out standard
Organ Sparing Surgery
• Principles:
– Local control and accurate assesment of 3D extent of
tumor
– The cricoarytenoid unit is the basic functional unit of
the larynx.
• “It is the cricoarytenoid unit, not the vocal folds, that allows
for physiologic speech and swallowing without the
permanent need for a tracheostoma after supracricoid
laryngectomy.”
– Resection of normal tissue to achieve consistent
functional outcomes in terms of speech and
swallowing.
• Standard resections lead to consistent functional outcomes
Organ Sparing Surgery
• Mostly for early laryngeal cancers (T1 and T2)
• Absolute Contraindications:
– arytenoid fixation, thyroid cartilage invasion, interarytenoid
invasion, subglottic extension to involve the cricoid cartilage,
lesions that extend outside the larynx, and preepiglottic space
invasion.
– (a relative contraindication is anterior commisure lesions…
recurrance rates are higher and speech results are variable)
• Preoperative evaluation
– “fixed vs. pseudofixed” TVC
– Pulmonary function testing:
• the real issue is how well pt will tolerate aspiration in early recovery
period
• COPD is relative contraindication
Vertical Hemilaryngectomy

So-called imbrication technique. Local


control is 90-100% for properly selected
lesions (ie T1 lesions). Survival depends
on local control, and the survival rate is
similar.
Supracricoid Partial Laryngectomy
(SCLP)
• All you can eat: resects of both true cords, both false
cords, the entire thyroid cartilage, both paraglottic
spaces bilaterally, and a maximum of one arytenoid.
• Useful for T2 and T3 lesions.
• Consistently low local recurrence rates likely 2nd to the
complete resection of the entire thyroid cartilage and the
bilateral en bloc resection of the paraglottic spaces
• Performed in conjunction with cricohyoidoepiglottopexy.
• “Chronic and inefficient cough, purulent sputum, and/or
an inability to climb 2 flights of stairs without shortness of
breath are strong contraindications against the use of
SCPL-CHEP or SCPL-CHP.”
SCPL
Exclusion Criteria:
-Bulky preepiglottic space involvement
-Gross thyroid cartilage destruction
-Interarytenoid or bilateral arytenoid
involvement
-Fixed arytenoid
-Subglottic extension> 1 cm anteriorly
or > 0.5 cm posteriorly
-Inadequate pulmonary reserve.
Transoral Laser Resection
• At this point, performed only by the
pioneers of our specialty…

• Dr. Armstrong, a few words about basic


principles of the transoral laser
approach???
– Some have compared this approach to Moh’s
surgery, would you agree?
Laryngeal Preservation
• Idea: prevent surgery with chemotherapy
• Current best results from Radiation Therapy Oncology
Group (RTOG), showing that concurrent cisplatin (rather
than induction with cisplatin and 5-FU in the famous VA
study) chemo/XRT has 88% laryngeal preservation rate.
• Distant mets and localregional control best in concurrent
group, but no difference in survival among groups.
• Caveats:
– Larygeal preservation does not imply functional larynx >>
chondronecrosis and aspiration are complications >> up to 40%
of “preserved” larynges require laryngectomy
– Frequent problems with dysphagia/strictures
– Rate of fistula after faile laryngeal preservation goes up to 30-
60%
Neck Dissection in No Neck getting
XRT?
• Incidence of occult mets varies by site,
with glottic being lowest (15%),
supraglottic more (20-38%), and piriform
sinus at highest.
• Any N should get ND.
Complications of TL
• Early Complications
– Drain failure, Hematoma., Infection, Chyle fistula
– Wound dehiscence: Local wound care should suffice for healing by
secondary intention, but if the carotid becomes persistently exposed,
vascularized muscle flap coverage is advisable.
– Pharyngocutaneous fistula.
• At risk: poor nutritional status, positive surgical margins, preoperative
radiotherapy.
• Such fistulas may occur 1 to 6 weeks postoperatively,
• confirmed by a methylene blue swallowing test.
• Management: fistula-track packing, dressings, antibiotic therapy, NPO,
diversion, pressure dressing;operative closure should be considered after 2-3
weeks.
Late Complications
-Stomal stenosis, Pharyngoesophageal stenosis and stricture,
Chronic pharyngocutaneous fistula. Hypothyroidism.
Chyle Fistula
• Chyle fistula 1600 cc/24 hrs. Tx?

– A: If chyle exceeds 600 mL >> early surgical exploration


• prevents adherent fibrinous material and inflammation.

– B: If Chylous fistulae becomes apparent only after enteral feedings are resumed,
and particularly those that drain less than 600 mL of chyle per day
• >>> conservative: closed wound drainage, pressure dressings, and low-fat nutritional
support.

– C: General:
• the area should be observed for 20 or 30 seconds while the anesthesiologist increases
the intrathoracic pressure.
• Even the smallest leak of chylous material should be pursued seriously until it is
arrested. Direct clamping and ligating may be difficult and sometimes
counterproductive because of the fragility of the lymphatic vessels and the surrounding
fatty tissue.
• Hemoclips are ideal to control a source of leakage that is clearly visualized.
Stomal Recurrence
• Prevention of stomal recurrence in
tumor with one cm transglottic
spread.
– postoperative stomal XRT.
– paratracheal lymph node dissection.
• Stomal recurrence classified by
Sisson:
– Type I – tumor involves the superior
one half of the stoma without
esophageal involvement.
– Type II – tumor involves superior one
half of the stoma with esophageal
involvement, or the inferior half of the
stoma
– Type III – Tumor involves the inferior
one half of the stoma and extends into
the mediastinum.
– Type IV-Extends beneath the clavicle

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