Laryngeal Cancer

Intro & Risks - Larynx Lowdown

• Laryngeal Cancer: Uncontrolled cell growth in larynx tissues, primarily affecting voice and breathing.
• India Epidemiology: Significant burden, ~2-3% of all cancers. Peak incidence 50-70 yrs; M:F ratio ~10:1.
• Major Risk Factors (synergistic effects common):
  • Tobacco (smoking, smokeless) - strongest, dose-dependent.
  • Alcohol (especially with tobacco).
  • HPV (oncogenic types 16, 18).
  • Chronic GERD.
  • Occupational exposure (e.g., asbestos, nickel, wood dust, paint fumes).
  • 📌 Mnemonic for key risks: "T.A.H.O.G." (Tobacco, Alcohol, HPV, Occupational, GERD).

⭐ Squamous cell carcinoma (SCC) is the most common histological type (>90%).

Anatomy & Staging - Voice Box Map

• Laryngeal Subsites & Lymphatics:

  • Supraglottis: Epiglottis to ventricle. Rich lymphatics (Levels II-IV, bi.).
  • Glottis: True cords, commissures. Sparse lymphatics.

    ⭐ Glottic cancer: early hoarseness, better prognosis (sparse lymphatics).

  • Subglottis: Below glottis to cricoid. Paratracheal, pretracheal, Level IV, mediastinal.

• T-Stage Highlights (AJCC 8th):

  Site	T1	T2	T3	T4a
  Supra	1 subsite, NM	>1 subsite/region, no fix	CF / PES/PGS/thyroid inner inv.	Thru thyroid / beyond larynx
  Glot	VC(s), NM	Extends supra/sub / IM	CF / PGS/thyroid inner inv.	Thru thyroid / beyond larynx
  Sub	Limited to subglot	Extends to VC(s)	CF	Invades cricoid/thyroid / beyond larynx
  (T4b: Prevertebral, carotid, mediastinum)

• Common Metastasis: Lungs, liver, bones.

• 📌 SGS for subsites: Supraglottis, Glottis, Subglottis.

Signs & Diagnosis - Symptom Sleuth

• Symptoms by Laryngeal Subsite:
  • Glottis: Persistent hoarseness (earliest symptom), dyspnea, stridor (late).
  • Supraglottis: Dysphagia, odynophagia, referred otalgia (CN IX, X - Trotter's sign), muffled "hot potato" voice, globus sensation, neck mass. Often asymptomatic initially.
  • Subglottis: Biphasic stridor, dyspnea, cough. Symptoms often late.
• Diagnostic Workup:
  • History & Clinical Examination: Assess risk factors (smoking, alcohol).
  • Laryngeal Visualization:
    • Indirect Laryngoscopy (IDL) or Flexible Nasopharyngolaryngoscopy (NPL) for initial assessment.
  • Definitive Diagnosis:
    • Direct Laryngoscopy (DL) under GA + Biopsy (gold standard).
  • Staging:
    • CECT Neck & Chest: Assesses primary tumor (T), nodes (N), distant metastasis (M).
    • MRI: For soft tissue delineation, cartilage invasion, perineural spread.
    • PET-CT: For distant mets, synchronous primary, or suspected recurrence.

⭐ Any patient with hoarseness persisting for more than 3 weeks requires laryngoscopic examination to rule out malignancy.

Management & Prognosis - Treatment Tactics

• Treatment Modalities:
  • Surgery:
    • Conservation Laryngeal Surgery (CLS): Cordectomy, Transoral Laser Microsurgery (TLS), Partial Laryngectomy.
    • Total Laryngectomy (TL).
  • Radiotherapy (RT): Definitive, Adjuvant, Palliative. Techniques: IMRT, VMAT.
  • Chemotherapy:
    • Induction (neoadjuvant).
    • Concurrent Chemoradiotherapy (CCRT): Cisplatin (100 mg/m²) standard.
  • Immunotherapy: Pembrolizumab (PD-1 inh.) for recurrent/metastatic disease.
• Stage-wise Treatment:
  • Early (T1/T2, N0): Single modality.
    • RT (preferred for T1a glottis).
    • CLS (TLS for T1/selected T2).
  • Locally Adv. (T3/T4a, N+ resectable):

    ⭐ Concurrent chemoradiation (CCRT) is the standard of care for organ preservation in locally advanced resectable laryngeal cancer.

    • CCRT (organ preservation strategy).
    • TL + neck dissection, then Adjuvant RT/CCRT if high-risk features.
• Voice Rehabilitation (Post-TL): Tracheoesophageal Puncture (TEP), Electrolarynx, Esophageal speech.
• Key Prognostic Factors: Stage (TNM), Tumor site (glottic best), Nodal status, Surgical margins, General health.

High‑Yield Points - ⚡ Biggest Takeaways

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