Larynx

Limits/Boundaries

The boundaries are the epiglottis edge and caudally the inferior side of the cricoid. Three areas are distinguished:

supraglottis: (suprahyoid) laryngeal, lingual side and free edge of epiglottis, aryepiglottic fold, arythenoid (epilarynx), false cords, infrahyoid epiglottis en sinus Morgagni.
glottis (vocal folds, anterior and posterior commissure).
subglottis (0,5 cm below free edge of vocal cords) until inferior side of cricoid.

Histology

Squamous Cell Carcinoma (> 90%).

Differentiation with pre-malignant leasions (sometimes leucoplakia) (mild/moderate/severe dysplasia (=CIS) and hyperplasia).
In patients with laryngeal cancer. lung cancer is is relatively often seen as a second primary.

In patients with other, rare histologies, treatment has to be individualized (small cell undifferentiated, neuro-endocrine, salivary gland, sarcomas).

Special history / Complaints

Hoarseness > 3 weeks
Swallowing complaints > 6 weeks
Irradiating earache (uitstralend)
Stridor
Coughing
Foetor ex ore
Neck swelling
Smoking
Alcohol

Diagnostics

Meticulous description of tumor extent and metastases.
Make drawing.
(In)direct laryngoscopy and stroboscopy.
In general a direct laryngoscopy under general anesthesia is needed to take biopsies and desribe extent.
Excisional biopsy only in case of doubt at histology, if needed use CO₂ laser for deep biopsies or excision. Transcutaneous cytology sometimes possible. Sometimes biopsy is possible at indirect laryngoscopy.

Radiology

CT-scan (thin slices + bonesetting, after contrast, if possible volumetrics, not indicated in T1a)
US-FNAC (T2-4) see guidelines
PET-CT (N2b or more advanced, zie richtlijnen)
Chest X-ray, OPG
stroboscopy + pictures
Swallow videofluoroscopy in case CO2 laser is planned in supraglottic lesions

Consultation

Dentist
SLP (logopedie) (phonetography, voice recordings)

TNM-classification

Based on clinical laryngoscopy, radiology.

I.SUPRAGLOTTIS

Tis carcinoma in situ
T1 tumor limited to one subsite with normal mobility of vocal cords
T2 tumor extending to more than one subsite or to the glottis, medial wall of s. piriformis or base of tongue, no vocal cord fixation
T3 tumor limited to the larynx with vocal cord fixation and/or infiltration of the pre-epiglottic space, paraglottic space or post-cricoid area or erosion of the cartillage
T4a tumor with extension outside the larynx: through cartilage, soft tissues of the neck, thryroid gland, esophagus, deep tongue musculature
T4b tumor invading prevertebral space, mediastinum or encasement of carotid artery

II.GLOTTIS

Tis carcinoma in situ
T1 tumor limited to vocal cords with normal mobility
- T1a tumor limited to one vocal cord
- T1b tumor of both vocal cords (only UICC)
T2 tumor extending to supraglottis and/or subglottis, and/or with impaired mobility of vocal cords
T3 tumor limited to the larynx with vocal cord fixation and/or infiltration of the paraglottic space or erosion of the cartillage
T4a tumor with extension outside the larynx: through cartilage, soft tissues of the neck, thryroid gland, trachea, esophagus, deep tongue musculature
T4b tumor invading prevertebral space, mediastinum or encasement of carotid artery

III.SUBGLOTTIS

Tis carcinoma in situ
T1 tumor limited to subglottis
T2 tumor beperkt tot de larynx met uitbreiding naar een of beide stembanden with normal or impaired mobility of vocal cords
T3 tumor limited to the larynx with vocal cord fixation
T4a tumor invading thyroid or cricoid cartilage or with extension outside the larynx: through cartilage, soft tissues of the neck, thryroid gland, trachea, esophagus, deep tongue musculature
T4b tumor invading prevertebral space, mediastinum or encasement of carotid artery

N- en M-classification, stage: see introduction

Treatment

Supraglottis

TIS Surgery with CO₂ laser. Radiotheray in case recurrent or extensive lesionand CO2 has failed
T1 horisontal/partial laryngectomy with CO₂ laser (in case arythenoid is not involved) or radiotherapy
T2 radiotherapy or in case of limited lesion CO₂ laser. In elderly or poor pulmonary function: no CO2 laser.
T3 accelerated radiotherapy. Bij zeer volumineuze tumoren laryngectomie overwegen (dan ipsilaterale level 2-4 en 6 dissectie)
T4 chirurgische behandeling, totale larynxextirpatie en ipsilaterale level 2-4 en 6 dissectie. CCRT indien patient TLE weigert.

Glottis

Tis Microlaryngoscopisch met instrumentarium of CO₂ laser
T1ab CO₂ laser resectie of radiotherapie, afhankelijk van voorkeur patiënt en verwachte stemkwaliteit (zie video T1a en T2)
T2 radiotherapie, incidenteel CO₂ laser resectie
T3 radiotherapie tenzij indicatie tot tracheotomie bestaat, dan totale larynxextirpatie
T4 chirurgische behandeling: totale larynxextirpatie + paratracheale dissectie

Subglottis

T1 radiotherapie
T2 radiotherapie
T3 radiotherapie tenzij indicatie tot tracheotomie bestaat dan totale larynxextirpatie
T4 chirurgische behandeling: totale larynxextirpatie + paratracheale dissectie

Postoperatieve radiotherapie bij irradicaliteit, perineurale groei, subglottische uitbreiding en T4 tumoren.

Indien tumorproces inoperabel: radiotherapie of RADPLAT.

N+

Indien primair chirurgische behandeling: ipsilaterale halsklierdissectie (niveaus II t/m V). Bij N2c bilaterale nekdissectie (niveaus II t/m V). Vrijwel altijd met postoperatieve radiotherapie.
Indien primair radiotherapeutische behandeling:
N1 locoregionale radiotherapie
N2-3: locoregionale chemoradiatie

Recidief

Na chirurgische behandeling van het carcinoma in situ kan bij een beperkt recidief deze herhaald worden of moet in geval van een uitgebreider recidief radiotherapie volgen.
Na radiotherapie: indien mogelijk chirurgie (CO₂ laser, larynxextirpatie, partiële laryngectomie, halsklierdissectie).
Bij laryngectomie ook halsklierdissectie indien initieel N+, anders alleen paratracheaal.
Na chirurgie: zo mogelijk heroperatie met (palliatieve) radiotherapie.
Eventueel cytostatische therapie, bij voorkeur in onderzoeksverband.
Metastasen: palliatieve chemotherapie/experimentele trial/metastatectomie

Voor het beleid t.a.v. stemrevalidatie en stemprothese zie: Provoxweb