Case Report

LARYNGEAL CARCINOMA

Presentator : Pradhana Fajar Wicaksana

Moderator : Dr.dr. Sagung Rai Indrasari.,Mkes.,Sp.T.H.T.K.L (K), FICS

Department of Health Ear Nose Throat - Head Neck Surgery

Faculty of Medicine, Universitas Gadjah Mada / Dr.Sardjito Hospital
Yogyakarta
2018
 INTRODUCTION in tobacco and alcohol or chronic infection
by human papillomavirus (HPV) or
The American Cancer Society
Epstein-Barr virus1,2. Several physical and
estimated that in the United States there
viral causative agents associated with the
would be 10,600 cases of laryngeal
development of HNSCC can cause defined
carcinoma diagnosed in 1999, and 4,200
molecular changes that result in
deaths. This accounts for 0.9 percent of
malignancy. Worldwide, tobacco and
cancers from all sites and 0.8 percent of all
alcohol products are the leading risk factors
cancer deaths. Laryngeal carcinoma makes
for development of HNSCC 2.
up 1 to 2 percent of cancers worldwide, and
the incidence is increasing. Spain has one of The spread of tumors within the
the highest rates in the world with Basque larynx is not haphazard; rather, it occurs in
and Navarra regions reaching a rate of 20 a relatively predictable fashion under the
cases per 100,000 persons. There is also a influences of local subsites. These
very high incidence in France, Italy, and influences include anatomic defenses such
Poland. Men are affected 4 times more as perichondrium and cartilage, as well as
frequently than women in the United States anatomic weaknesses such as blood vessels
and up to 10 times more frequently in other and lymphatic channels. Furthermore, the
countries. This ratio is higher for glottic supraglottis arises from different
cancer than supraglottic1. embryologic anlage than the glottis and
subglottis, thus producing unique routes of
Over 90 percent of all laryngeal
lymphatic spread 3. The majority of larynx
cancers are squamous cell carcinoma,
cancers are found in the glottic region
Other histologic types include lymphoma,
(56%) followed by the supraglottic region
spindle-cell carcinoma, neuroendocrine
(41%), while tumors of the subglottic
carcinoma, minor salivary gland
region are relatively infrequent (1 to 2%) It
carcinomas, mucosal melanoma, and
is important to realize that tumors in these
various sarcomas. Metastatic lesions and
different regions of the larynx have
direct extension of thyroid carcinoma are
different clinical behaviors. Supraglottic
other rare possibilities1.
tumors, for example, have a much higher
Development of HNSCC (Head rate of occult and bilateral metastasis than
Neck Squamous Cell Carcinoma ) has been glottic primaries. The regional lymph nodes
associated with repeated exposure to and of the neck in patients with advanced stage
injury by chemical carcinogens contained supraglottic tumors and clinically negative
necks must therefore be addressed in folds is an important area of relative
treatment planning 1. vulnerability to tumor invasion. Here the
anterior vocal ligament and vessels
The majority of supraglottic tumors
perforate the thyroid cartilage, violating the
begin on the epiglottis and tend to advance
protective barrier of the perichondrium.
by local invasion. Initial barriers to spread
Tumors that are relatively small in size can
include the perichondrium and cartilage of
quickly gain T4 staging by penetration of
the epiglottis, with deeper resistance to
2,3
the cartilage . Subglottic tumors arise 10
invasion including the thyroepiglottic
mm or more below the glottis and are rare,
ligament and finally the thyroid cartilage.
comprising less than 1% of laryngeal
quadrangular membrane of the
tumors. Direct invasion may occur
aryepiglottic fold may help to contain
anteriorly through the cricothyroid
superior and lateral invasion. Supraglottic
membrane or inferiorly within or external
tumors tend to spread by lymphatic
to the trachea. Transglottic tumors may
invasion, with over 30% of clinically N0
involve all three subsites of the larynx. The
cases demonstrating involved lymph nodes
spread of these tumors is dictated by the
on final pathology. The supraglottic
areas they invade 3.
lymphatic drainage is through the
thyrohyoid membrane following the Assessment of the patient with
superior laryngeal veins to levels II and III laryngeal cancer begins with a through
in the neck. Glottic tumors arise on the history and physical examination. Patients
vocal fold or up to 10 mm inferior to it. The with supraglottic cancers often remain
vocal folds are known to have very limited asymptomatic until a relatively large tumor
lymphatic drainage, and glottic tumors bulk is present. Nodal metastasis is often
remain contained until lateral invasion the initial complaint. Patients with glottic
allows entry into the paraglottic space, a tumors tend to present early, with
vertical portal of spread to the rest of the hoarseness as their chief complaint.
larynx. Vocal fold tumors allow diagnosis Subglottic tumors are rare and may present
at an early stage owing to ensuing with stridor or hemoptysis. Several key
hoarseness, and lateral invasion is symptoms should be noted in the history.
manifested by vocal cord paresis or Neoplasms of the Larynx and
paralysis from interference with function of Laryngopharynx. Hoarseness is the major
the thyroarytenoid muscle or cricoarytenoid presenting symptom in patients with glottic
joint. The anterior commissure of the vocal cancer. The examiner must determine the
duration of this symptom, its progression, CT and MRI. These have been refined to
and associated symptoms. The degree of the point that they can provide important
voice alteration is related to the extent of the information on invasion of cartilage, local
lesion 2. Hoarseness is commonly present spaces, and regional structures, as well as
for 3 months or longer in patients who demonstrate lymph nodal metastases. Both
present with vocal fold cancer. As many as technologies have sensitivities ranging
30% have been hoarse for a year or more. from 60 to 80%, with specificities between
3
In supraglottic tumors, hoarseness tends to 70 and 90% . When all clinical
occur later, when tumors have become investigations have been performed,
bulky and overhang the glottis or spread staging of the tumor is possible. The system
through the paraglottic space to fix the used in the United States is the tumor, node,
vocal fold. The voice change seen with metastasis (TNM) classification created by
supraglottic lesions tends to be more of a the American Joint Committee on Cancer,
muffled voice, somewhat similar to the “hot which separates patients into stages I to IV,
potato” voice of epiglottitis. Some patients with higher stages carrying a poorer
with supraglottic tumors have no prognosis 1,3,4.
hoarseness at all and may be asymptomatic
CASE REPORT
or have other complaints 2.
A 53 years old male came to the
Complete laryngoscopy is required,
sardjito hospital with a chief complaint
either with a mirror or a fiberoptic
hoarseness. He complained hoarseness
endoscope, and any abnormality in vocal
since 3 years ago and become heavier in
fold motion should be noted.
last 2 months. The complaint never get
Videostroboscopy can be important in the
better. Sometimes he feels want to cough
evaluation of early glottic cancers as
and a little bit out of breath. He denied any
progression from Cis to invasive carcinoma
hard to swallow food or to drink , choking,
will be demonstrated by tethering of the
and ears complaint. He said that he was a
mucosa to the underlying stroma with
smoker since 40 years old, he spent 1 pack
dyskinesia of the mucosal wave.
of kretek cigarette for all day. From the
Documentation of the size, location, and
previous illness, he denied diabetic mellitus
fixation of any cervical lymph nodes is
(-), hypertension (-) and ashtma (-). From
important. The current modalities most
family history there is no any same
commonly used for imaging of the upper
complaint. From physical examination,
aerodigestive tract in the United States are
general condition is compos mentis, well
nourished. Blood pressure 110/80 mmhg, laryngectomy (TLE) and radiotheraphy.
heart rate 80x/minutes, respiration rate Total laryingectomy was performed on
24x/minutes, body temperature 36,8’c. January 2, 2018 then followed by
From indirect laryngoscopy examination, medications : infus RL 1500 cc
we found bumpy mass that hard to evaluate. :D5%:aminofluid 1:1, ceftriaxon injection 1
From oropharynx examination, we found gr/12h, ketorolac injection 30mg/8h, nacl
normal T1-T1 palatine tonsils. from Nose 0,9% nebulization/8h. Wound dressing
and ears examination within normal limit. every 2 days. Patient also get education to
From neck examination there is no avoid swallowing for 2 weeks for fistula
enlargement. From supporting test purpose.
examination, flexible laryngeal endoscopy
Patient underwent treatment in the
and ct scan were performed. On laryingeal
ENT ward for 13 days for the postoperative
endoscopy found reddish bumpy mass
care. Patient was planned radioteraphy on
which easily to bleed in glotis dextra. From
february 15, 2018. The problem in this
soft tissue collie x ray we found there is
patient is diagnosis.
unclear narrowing airway. The ct scan
showed laryingeal mass dextra which may
narrowing airway patency. The patient was DISCUSSION
done for tracheotomy on july 20 2017 due
The diagnosis of laryngeal
to dyspneu that increases overtime. And
carcinoma should be considered when
was planned for direct laryngoscope and
hoarseness is present for more than 2 to 3
biopsy on august 4 2017. on august 10 2017
weeks. Glottic carcinoma presents early
the result of biopsy PA showed laryngeal
with hoarseness due to vocal cord
mass: Squamous carcinoma cell moderately
involvement. Other signs of glottic
differentiated. Patient also done for thorax
carcinoma are hemoptysis, airway
x ray examination which obtained normal
embarassment—especially with exertion,
cor and lungs and no pulmonary metastase.
halitosis, and the so-called hot potato voice.
Based on the results of physical Cancers of the supraglottic larynx generally
examination and supporting examination present later due to lack of symptoms in the
that has been done, the diagnosis of this early stages. Common signs and symptoms
patient is Larynx carcinoma (PA: SCC include difficulty swallowing, otalgia, and
Moderately differentiated ) T4N0M0 odynophagia. Following the history, the
stadium IVa. Patient was planned for Total next step in diagnosis is a careful
examination of the larynx by a qualified erosion (inner cortex). T4a: Tumor invades
specialist1,3. Factors affecting choice of through the thyroid cartilage and/or extends
treatment can be divided into patient factors to other tissues beyond the larynx (eg,
and tumor factors. As demonstrated in trachea, soft tissues of the neck, including
multiple clinical trials, survival is thyroid, pharynx). T4b: Tumor invades the
statistically equivalent in selected patients vertebral pre space, up to the carotid artery
with advanced cancer of the larynx who are or invade mediastinal structures 6.
treated with either chemotherapy and
Nodes staging are : NX Regional
radiation therapy or surgery and radiation
lymph nodes cannot be assessed. N0 No
therapy3.
regional lymph node metastasis, N1
In this case, the patient was
Metastasis in a single ipsilateral lymph
diagnosed as carcinoma larynx T4N0M0
node, 3cm or less in greatest dimension.
stadium IVa which is suspect origin site
When we do neck palpation, we found there
from glottis based on anamnesis, physical
is no enlargement of the neck, which mean
examination And supporting examination (
there is no involvement of node lymph of
CT scan, Flexible laryngoscopy and
the neck according to AJCC 2010. Neck
Histopatology). The patient was undergone
staging is enhanced with both modalities,
for tracheotomy due to dyspneu caused by
which have similar sensitivities and
laryngeal mass which narrowing upper
specificities for detecting nodal metastases.
respiratory tract.
Both types of imaging still miss a
According to American Joint
significant percentage of occult metastatic
Committe on Cancer 2010 (AJCC), The
disease in necks staged N0 clinically.
present staging system. The patient had
Glottic tumors arise on the vocal fold or up
T4aN0MO. T1: Limited tumors in the vocal
to 10 mm inferior to it. The vocal folds are
cords (may involve the anterior or posterior
known to have very limited lymphatic
comissura), which normal mobility. T1a:
drainage, and glottic tumors remain
Tumors are limited to one side of the vocal
contained until lateral invasion allows entry
cords. T1b: Tumor on two sides of the vocal
into the paraglottic space, a vertical portal
cords. T2: The tumor has spread to
of spread to the rest of the larynx 2. The true
supraglottic and / or subglottic areas (and /
vocal cords have very little lymphatic
or with impaired vocal cord mobility). T3:
drainage. Cervical metastases are
Tumors limited to the larynx, with fixation
infrequent with T1 and T2 tumors7.
of the vocal cords and or invaded the glottic
chambers, and / or minor thyroid cartilage
 Metastase staging are : MX Distant distant metastatic : total laryngectomy and
metastasis cannot be assessed. M0 No neck dissection followed by radiotheraphy.
distant metastasis. M1 Distant metastasis. advanced T4 disease is best treated with
Based on x ray there is no pulmonal total laryngectomy6,7. The standard
metastase or distant metastase. Glottic treatment for T3 glottic cancer has been
primaries are the least likely to metastasize. laryngectomy. However, many T3 lesions
The most common site of distant metastasis are now being treated with concomitant
is the lung (50 to 80% of metastases), chemoradiotherapy, with salvage
followed by the liver and bone. 2,3. laryngectomy required in ~25% of patients
for residual/recurrent disease or laryngeal
TNM classification for this patient is
dysfunction. It should be remembered,
T4aN0M0, in stadium IVa. Based on
However, that partial laryngectomy and
AJCC2,6.
conservational surgical procedures which
Stadium 0 Tis N0 M0 preserve the function of the larynx may be
Stadium I T1 N0 M0
2,6
Stadium II T2 N0 M0 options in selected patients . .Due to the
Stadium III T3 N0 M0 sparse lymphatic network and low
T1-3 N1 M0
Stadium IVa T1-4a N2 M0 incidence of cervical metastases, elective
Stadium IVb T4b any N M0 neck dissection is indicated only for
any T N3 M0
Stadium IVc any T any N M1 transglottic lesions. Palpable disease
obviously requires neck treatment. Cure

Treatment for this patient is total rates by tumor size alone are as follows: T1,

laryngectomy without neck dissection that 90%; T2, 80%; T3,50%; and T4, 40%.

has been done on January 2 2018. Neck involvement worsens the prognosis

According to the modul 6

the treatment is dramatically7.

depend on stadium of cancer which The patient also was scheduled for
classified into stadium I-IV. Stadium I : radiotherapy on february 15 2018. In
Radiotherapy, if fail should continued with stadium IVa, the treatment not only total
partial laryngectomy / total laryngectomy. laryngectomy but also following by
Stadium II: partial laryngectomy / total radiotherapy6. Primary radiotherapy has
laryngectomy. Stadium III : With or been used extensively to treat advanced
without N1: total laryngectomy with or laryngeal cancers, particularly in centers
without neck dissection, followed by outside the United States. When radiation is
radioteraphy. Stadium IV: Without N1 or used as single-modality therapy, surgery is
kept in reserve for salvage of treatment ed. Illinois: BC Decker Inc, 2003.
failures. In general, when this approach has p.1310-12.
been analyzed critically, radiation alone has 3. James B Snow Jr, John Jacob
not fared as well as surgery for resectable Ballenger, Ballenger’s Manual
lesions2. Histopathology result of this Otorhinolaryngology. Illinois: BC
patient is SCC moderately differentiated, It Decker Inc, 2003. p.474-475.
was initially felt that radiation was effective 4. Daniel G. Deschler, Terry Day. Neck
against cancer because tumor cells were Dissection Classification And TNM
more sensitive to ionizing radiation than Staging of Head & Neck Cancer.
normal cells of the same tissue type. Alexandria: American Academy of
Although this has been found not to be the Otolaryngology Head and Neck
case from tissue culture studies, it is clear Surgery Foundation, Inc.2008.
that tissues with a large portion of 5. Claudio Russel, Basil Matta.
proliferating cells (high growth fraction) Tracheostomy. Multiprofessional
are more susceptible to the lethal effects of Handbook. United States Of
radiation7 . America: Cambridge University
Press.2004.
SUMMARY
6. Modul Utama Onkologi Bedah
We reported a male, 53 years old, with Kepala Leher. Edisi II. Kolegium
the diagnosis Larynx Carcinoma (PA: SCC Ilmu Kesehatan Telinga Hidung
moderately differentiated) T4N0M0 Stage Tenggorok Bedah Kepala Leher.
IVa. The patient has been done Total 2015.
laryngectomy and also was planned for 7. John Andrew Ridge et al. Head and
radioteraphy. Neck Tumor. Cancer management.
New York : The Oncology
group.2003.
REFERENCES

1. Jatin P. Shah et al. Atlas of Clinical

Oncology cancer of the Head and
Neck. London: BC Decker
Inc.2001.p.69-70.
2. James B Snow Jr, John Jacob
Ballenger,Ballenger’sOtorhinolaryng
ology Head and Neck Surgery. 16th