Carcinoma anatomy and epidemiology

1. By-Dr. Satyajeet Rath
Moderator-Dr. Shagun Misra

2. Topics to be covered
 Anatomy
 Radiological anatomy
 Epidemiology
 Routes of spread
 Clinical Presentation
 Examination

3. Introduction :-
 The larynx is an air passage,
a sphincter and an organ of
phonation
 Extends from the root of
tongue to the trachea.
 Projects ventrally between
the great vessels of the neck
 Lies in anterior midline of
neck
 Infront of C3 to C6 vertebrae

4. Contd…
 Covered anteriorly by skin,
fasciae and the hyoid depressor
muscles
 Above, it opens into the
laryngopharynx and forms its
anterior wall
 Below, it continues into the
trachea
 mobile on deglutition.

5. Constituents of Larynx
 CARTILAGES –
 3 Unpaired - thyroid
- cricoid
- epiglottis
 3 paired cartilages –
• arytenoid
• corniculate
• cuneiform
 All cartilages are hyaline except epiglottis ,corniculate,
cuneiform, vocal process and apex of arytenoid

6. Cartilages of Larynx

7. Cartilage of Larynx contd…

9. Membranes and Ligaments
Extrinsic:
 connect thyroid cartilage with epiglottis and hyoid
bone ;cricoid cartilage with trachea
Intrinsic:
 connect cartilages of larynx to each other

10. LIGAMENTS AND MEMBRANES
 EXTRINSIC
LIGAMENTS AND
MEMBRANES
 Thyrohyoid membrane
 Hyo- and
thyroepiglottic
ligaments
 Cricotracheal ligament

12. Intrinsic Ligaments
 Fibroelastic tissue
 Made up of –
Quadrate membrane
Conus elasticus

14. Muscles of Larynx and their function
Abductor Adductors
Cricothyroid is
the only intrinsic
laryngeal muscle
lying outside the
larynx
Transverse
arytenoid is the
only unpaired
intrinsic muscle

15. Laryngeal Cavity
Laryngeal cavity can be
divided into 3 parts –
supraglottis
glottis
subglottis

17. Supraglottic Larynx
 Extend from tip of the
epiglottis to superior
surface of true vocal cord .
 Composed of –
 Epiglottis
 Arytenoid
 Aryepiglottic fold
 False vocal cord
 Posterior tapering shape
reduces area of mucosa in
posterior region
 Majority of Supraglottic
tumors are epiglottic
The inferior boundary of the
supraglottis is a horizontal plane
passing through the lateral margin of
the ventricle at its junction with the
superior surface of the vocal cord.AJCC 2010

18. Glottis
o upper border started from superior
surface of true vocal cords
o Lower border is 0.5 cm below the
free edge of true vocal cord.
o Glottis consists of true vocal cords
and the ant and post
commisures(mucosa between the
arytenoids)
o True vocal cord are 2 cm long and
are thinnest anteriorly and
posteriorly
o Most lesions arise from free edge
and upper surface of ant 2/3
Anterior
Commisure
Posterior
Commisure

19. Vocal Cords

20. Subglottic Larynx
It extends from the lower border of glottis to lower border of cricoid cartilage .
Consists of a mobile upper and fixed lower part.

21. Mucosa
 Mucosa of glottic and Supraglottic regions is
stratified squamous epithelium.
 Mucosa of ventricles and sub-glottic regions is
pseudo-stratified ciliated epithelium
 Supra and sub glottic regions particularly
ventricles are rich in submucosal mucous or minor
salivary glands while glottis is not.

22. Blood Supply
 upper half –
superior laryngeal
artery
lower half-
inferior laryngeal
artery

23. Nerve Supply

24. Contd..

25.  Pre-epiglottic space
(Boyer’s Space)
 Anterior: thyrohyoid membrane &
thyroid cartilage
 Posterior: epiglottis elastic cartilage
 Inferior: Petiole attachment to thyroid
cartilage
 Conduit :
 elastic epiglottic cartilage has
perforations -direct extension of
infrahyoid supraglottic cancer into
this fascia-bound space
 Bilateral neck drainage
 Often invaded by advanced cancers

26. Paraglottic space
 quadrangular membrane
inferiorly
 Conus elasticus anteriorly and
medially
 thyroid cartilage laterally

27. Reinke’s Space
 Mucosa over the vocal
ligament loosely attached
to ligaments.
 Under the epithelium of
vocal cord is a potential
space with subepithelial
connective tissues.

28. Radiological Anatomy

38. Lymphatics
 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)
 Glottic and subglottic tumors metastasize to
ipsilateral lymph nodes, but supraglottic tumors
often spread to nodes on both sides of the neck.

39. Supraglottic lymphatics
 Supraglottis has a rich lymphatic network.
 High propensity for b/l LN mets due to midline
location.
 Primary drainage pattern of supraglottic cancers is the
jugular lymph chain.
 Level 2 nodes mc involved followed by level 3 and 4.
 Level 5 seldom involved.
 Level 1b and 1a almost never involved

40.  The risk of clinically involved lymph nodes is
 approx. 40% for T 1 and T 2 tumors
 approx . 60 % for T 3 and T 4 tumors

41. Lymphatics of subglottis
 The first-echelon lymphatics for the subglottic larynx are
the Delphian node.
 The lymphatics in subglottis is less developed.
 Incidence of lymph node mets varies from 20% to 50%.
 Lymphatics from subglottis form 3 pedicles:
1 anteriorly and 2 posteriorly
 The anterior channels pass through the cricothyroid
membrane and drain into the middle and lower jugular
nodes to terminate in the prelaryngeal node(Delphian
node),from which lymphatics drain into pretracheal and
supraclavicular nodes.

42.  The posterolateral lymphatic
channels pass through cricotracheal
membrane and terminate in high
paratracheal nodes.
 Mediastinal involvement can
occur,if present is considered a
metastasis ( unless it is a level VII
mets in which case it is considered
regional lymph node metastasis ).
Path of Subglottic
Tumor spread

43. Lymphatics of glottis
 True vocal cords are almost devoid of lymphatics.
 Incidence of LN mets at diagnosis approaches
 zero for T1 ,
 2% for T2 ,
 15 to 20% for T3 ,
 20 to 30% for T4.
 Lymphatic spread occurs when tumor extends to
subglottis or supraglottis.

45. Lymphatic Drainage contd..
 With a single lymph node involved by metastatic disease,
the prognosis is said to be reduced by half.
 Criteria that suggest metastatic involvement of a lymph
node include enlarged size, abnormal shape, necrosis, and
extracapsular spread.
 Nodal metastasis at the time of presentation is much more
common from supraglottic carcinomas when compared
with glottic and infraglottic tumors because of the rich
supraglottic lymphatic network.
 The sensitivity of CT and MRI in detecting nodal
metastasis is higher than clinical examination and lower
than PET.
Surg Oncol Clin N Am 23 (2014) 685–707

46. Supra glottis Carcinoma
 Sore throat and odynophagia are the most common
presenting symptoms of carcinoma of the supraglottis.
 Patients often describe the sensation of foreign body and
can have difficulty swallowing.
 Hoarseness occurs in advanced lesions, but is typically
absent in early stages.
 Because of the high incidence of lymph nodes metastasis,a
neck mass can be the first sign of carcinoma of the
supraglottis.

47. Supraglottic Carcinomas
 The epiglottis is the most
frequent location for cancers
that arise in the supraglottic
larynx. These lesions are often
exophytic and circumferential
masses
 Tumors of the aryepiglottic fold
are typically exophytic lesions
that, when detected early, are
confined laterally along the
aryepiglottic fold.
-Advanced lesions may
extend laterally to involve
the adjacent wall of the
pyriform sinus or medially
to invade the epiglottis.

49. Glottic Carcinomas
 The true vocal cords are the most common site of
laryngeal carcinomas; the ratio of glottic carcinomas to
supraglottic carcinomas is approximately 3:1.
 The anterior portion of the true vocal cord is the most
common location of squamous cell cancer.
 Most lesions occur along the free margin of the vocal
cord.

50. CONTD..
 Anteriorly, the tumor may extend to
anterior commissure, where it may
involve the contralateral true vocal
cord.
 Hoarseness is the most common
presenting symptom of early vocal
cord cancer.Thus glottis tumours
are most commonly diagnosed at
early stage.
 Sore throat.otalgia,localized pain result
from cartilage invasion , and dyspnea
are symptoms of advanced disease

51. Sub-glottis Carcinomas
 Subglottic carcinomas are rare and account for only 5%
of all laryngeal carcinomas.
 When present, these lesions are characteristically
circumferential and often extend to involve the
undersurface of the true vocal cords
 They have a tendency for early invasion of the cricoid
cartilage and extension through the cricothyroid
membrane.

52. -Visualizing tumor within the cricoid ring is a clear
indication of subglottic extension.

53. Trans-glottic Carcinomas
 Usually initiate as
supraglottic or
glottic cancers
 As for example
Glottic cancers more
commonly spread to
spraglottic areas.

55. Epidemiology
 MC malignancies of upper aerodigestive tract
 Approx 25% of head and neck tumors
2.63 % of all body cancer.
 Primary glottic cancers 3times more common than
supraglottic
 Subglottic cancers are rare
 80% occur in men.
 Age group 40- 70 yrs.
 Most curable of upper aerodigestive tract cancers

56. GLOBOCAN 2012 (data for ca larynx)
INCIDENCE MORTALITY 5- YEAR
PREVALENCE
Men 4.8 (22900) 4.4 6.8
Women 0.5 0.5 0.4
Both sexes 2.5 (25446) 2.6 2.8
INCIDENCE MORTALITY 5-YEAR
PREVALENCE
Men 1.9 1.6 2.5
Women 0.3 0.3 0.3
Both sexes 1.1 1.1 1.4
INDIA
WORLD

57. NCRP

59. Risk Factors
 Smoking and alcohol are two main risk factors
 In individuals who use both tobacco and alcohol, these risk
factors appear to be synergistic, and they result in a
multiplicative increase in the risk of developing laryngeal
cancer.
 Human Papilloma Virus 16 & 18
 Chronic Gastric Reflux
 Prior history of head and neck irradiation

60.  Occupational exposure to asbestos , diesel fumes ,
rubber ,wood dust
 Vitamin and nutrient deficiency(subglottic ca)
 Mutations in p53,ki-67,EGFR,TGF beta,cyclin D1
 P53 mutation seen nearly in 50% smokers and 55%
drinkers
 Telomerase present in high levels

61. Routes of spread
 LOCAL SPREAD
 No anatomical barrier to growth from one area to another.
 Involvement of vocal cords on the external epithelial
surface is a late phenomenon but sub mucosal extension by
way of para glottic space occur early.
 Fat space is an important venue for submucosal spread of
infrahyoid epiglottis ,false cord and true cord lesions.

62. Distant Metastasis
• Incidence is very low.
• Identified in appro 10 to 20% cases majority have
supraglottic or subglottic primary.
• Lung(60%) is mc site followed by bones(20%) and
liver(10%).
• Brain mets very rare.

63. Histological Types
 95% of laryngeal tumors are squamous cell carcinoma
 Histologic type linked to tobacco and alcohol abuse
 Characterized by epithelial nests surrounded by
inflammatory stroma
 Keratin Pearls are pathognomonic

64. Other Histological Types
 Verrucous Carcinoma
 Plasmacytoma
 Chondrosarcoma
 Malignant Minor salivary carcinoma
 Psuedosarcoma
 Carcinoid
 Plasmacytoma
 Chemodectoma

65. Presentation
 Hoarseness
 Most common symptom
 Small irregularities in the vocal fold result in voice
changes
 Changes of voice in patients with chronic hoarseness
from tobacco and alcohol can be difficult to appreciate

66. Contd…
 Patients presenting with hoarseness should undergo
an indirect mirror exam and/or flexible laryngoscope
evaluation
 Malignant lesions can appear as friable, fungating,
ulcerative masses or be as subtle as changes in mucosal
color
 Video laryngoscopy may be needed to follow up these
subtler lesions

67.  Supraglottic carcinoma-
• Often silent
• throat pain
• dysphagia
• referred pain in ear
• neck mass
• respiratory obstruction
• halitosis
• hoarseness of voice – late symptom

68.  Glottic carcinoma –
 Hoarseness of voice (early sign)
 Stridor
 Weight loss ,halitosis, aspiration can occur with
locally advanced disease.
 Sore throat, localized pain from cartilage invasion ,
dyspnoea are symptoms of advanced disease.
 Ca subglottis rare.
 Usually diagnosed late.

69.  Other symptoms include:
 Dysphagia
 Hemoptysis
 Throat pain
 Ear pain
 Airway compromise
 Aspiration
 Neck mass

70. History
 History-
Any patient in cancer age group having persistent or
gradually increase hoarseness of voice x 3 weeks must be
consider for further evaluation .
 personal history
Family history
Occupational history

71. Examination
 Good neck examination looking for cervical
lymphadenopathy and broadening of the laryngeal
prominence is required
 The base of the tongue should be palpated for masses
as well
 Restricted laryngeal crepitus may be a sign of post
cricoid or retropharyngeal invasion

72. Examination
 See for –
 Appearance of lesion –
 Suprahyoid- exophytic
 Infrahyoid- ulcerative
 Vocal cord – nodular/ ulcer/ thickened
 Ant commissure- granulation tissue
 Subglottic – raised submucosal tissue
 Vocal cord mobility –
 Fixation indicate infiltration into
Thyroarytenoid
Cricoarytenoid
Invlovment of recurrent laryngeal nerve
 Extent of disease

73. Examination of neck –
 lymphnode mass
 extralaryngeal spread -
• palpation of diffuse firm fullness above the thyroid notch with
widening of space between hyoid and thyroid indicate invasion of
preepiglottic space.
• growth through cricohyoid membrane may produce midline
swelling.
• thyroid cartilage invasion may cause perichondritis and on
palpation may be tender .

74. Diagnostic Evaluation
 Careful history and clinical examination.
 D/L scopy and biopsy is the most valuable step in
diagnosis and staging.
 Rigid endoscope requires anaesthesia,better
visualisation of subglottis and ant commissure.
 Assesment of vocal cord mobility

75. CT SCAN
 CECT and contrast MRI are useful in diagnostic imaging.
 Preferably done before biopsy.
 In cancers of the larynx, cross-sectional imaging with CT
provides valuable information regarding primary tumor
staging and treatment
 Malignancies of the larynx are primarily imaged with CT,
because of lower image degradation from breathing ,
swallowing and coughing during examination.
 CT and MRI play a superior role, especially in evaluating
the deep spaces of the head and neck.

76. Contd…
 Characteristics such as tumor volume, sclerosis of laryngeal
cartilage on CT have been found to have prognostic value.
 Limitations of CT include subtle evaluation of tumor
induced cartilage and bone defects , detection of
superficial tumors.
 CT evaluation is much faster than MRI and has practical
advantages as cost , speed and availability.
 CT Scan is used for lymph node delineation and
radiotherapy contouring.
 MRI is more resource-intensive and less available than CT.

77. MRI Scan
 Staging accuracy for MRI in ca larynx is higher due to
more accurate assessment of cartilage invasion , pre
epiglotic and paraglottic extension.
 Gross cartilage invasion can be detected on CT;
however, early cartilage abnormalities are detected
better on MRI.
 Areas of cartilage involvement result in high signal
intensity on T2W images and contrast-enhanced T1W
images.
Surg Oncol Clin N Am 23 (2014) 685–707

78. PET Scan
 The role of PET scan in the routine initial work up
remains investigational.
 Useful in detection of occult nodal and distant mets.
 To distinguish between recurrence and post treatment
changes.
 A pretreatment standardized uptake value (SUV) of
less than 9.0 in the primary tumor has been shown to
be associated with less frequency of disease recurrence
and improved disease-free survival.
 PET/CT is the modality of choice for therapy
assessment and is performed 12 weeks after
completion of chemoradiation.
Surg Oncol Clin N Am 23 (2014) 685–707

80. Direct Laryngoscopy

81. Indirect Laryngoscopy contd…
 Patient is seated opposite the examiner.
 Asked to protrude the tongue which is wrapped in
gauze
 And held by examiner b/w thumb and middle finger .
 Index finger is used to keep upper lip out of way.
 Warm the laryngeal mirror , introduced into the
mouth and held firmly against uvula and soft palate .
 To see movement of cords asked the patient to take
deep inspiration , say” Aa” (adduction ) and ” Eee” (for
adduction and tension ).

82. Indirect Laryngoscopy

84. Metastatic Work up
 Chest xray sufficient in early stages at low risk for
mets.
 CT scan in locally advanced disease.
 PET scan in detection of distant mets.
 PFTs for patients considered for surgery.
 Bronchoscopy and oesophagoscopy to rule out
synchronous tumours.
 Routine lab tests include complete blood count,LFTs.
 Attention to anemia.

85. Thank You