Anti-tumour treatmentCurrent opinion in diagnosis and treatment of laryngeal carcinoma
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Anatomy
For clinical and staging purposes, the larynx is currently divided in supraglottic, glottic and subglottic regions.1 Essential laryngeal anatomy is synthesised by Table 1.
Considering the significant metastatic potential of laryngeal carcinoma to the cervical lymph nodes, concise notes of clinical anatomy of cervical lymphatics are mandatory. A widely accepted level-based system can be synthesized as follows:
Level I: submental (IA) and submandibular (IB) lymph nodes;
Levels II (IIA enterior to
Epidemiology
Laryngeal carcinoma is the 11th commonest form of cancer in men world-wide, with 121,000 new cases in 1985.3 It is one of the most common malignancies in Europe, with about 52,000 new cases per year;4 approximately 9500–11,000 new cases of laryngeal cancer are estimated to occur yearly in the United States.5, 6 The yearly incidence rate for men in southern and northern Europe is between 18 per 100,000 and 6 per 100,000, respectively. For women, incidence rate is not higher than 1.5 per 100,000
Signs and symptoms
The most important functions of the larynx are to provide airway patency, protect the tracheo-bronchial tree from aspiration, and allow phonation. Tumours that involve the larynx may impair these function in a variable degree depending on location, size and depth of invasion. The presence of hoarseness, sore throat, shortness of breath, dysphagia or “lump in throat” sensation are all symptoms observed in early or moderately advanced stages of laryngeal cancers. Since lymph node metastases are
Histology
More than 95% of all laryngeal malignancies are squamous cell carcinomas.10, 11 Less common phenotypic expressions of this malignancy can occur. Verrucous squamous cell carcinoma is a locally aggressive but usually non-metastasizing highly differentiated variant.
Table 2 summarizes the histologic typing of primary laryngeal malignancies.
Distant metastases to the larynx are extremely uncommon occurrences (⩽0.2%).12 Cutaneous melanomas are the preponderant primaries metastasizing to the larynx,
Risk factors
Tobacco is the predominant risk factor in laryngeal carcinogenesis. Alcohol is generally regarded as the second major risk factor. In most series, >95% of patients with squamous cell carcinoma of the larynx have a background of tobacco and/or alcohol consumption prior to tumour diagnosis. The appearance of laryngeal cancer has been related to other factors, such as environmental exposure (evidence does not support asbestos exposure itself as increasing the relative risk of laryngeal cancer),
Primary laryngeal squamous cell carcinoma development
Pre-invasive lesions (dysplasia and carcinoma in situ) are characterized by atypical or malignant cytologic features encompassed within the laryngeal squamous epithelium. Dysplasia shows cells which have features of malignancy, but which do not breach the basement membrane to reach into the adjacent lamina propria. In the natural history of laryngeal cancer, both dysplasia and carcinoma in situ of the laryngeal mucosa may subsequently evolve into an invasive neoplasm. It is also a fact that
Clinical assessment
The staging for laryngeal cancers is based on laryngeal sub-sites invasion, vocal cord mobility, and neck involvement. An outpatient setting examination with flexible and rigid laryngoscopes with or without local anaesthesia should assess the lesion extension and vocal cord mobility. The flexible fibro-rhinolaryngoscope has increased the reliability of endoscopy in patients whose larynx was previously difficult to visualize.
Direct laryngoscopy under general anaesthesia may be useful to allow
Treatment of laryngeal primary carcinoma
Regardless of the treatment modality, Tis, T1, T2 laryngeal carcinomas have an 80–90% probability of cure, whereas for more advanced tumours this is approximately 60%. Treatment indications in cancer of the larynx are often controversial, since there are few comparative studies of the different available therapeutic approaches.7 Surgery and radiotherapy are both widely used, and the choice between these two procedures is the most common therapeutic decision which has to be taken. Function
Recurrent laryngeal cancer
Small superficial recurrent cancers without laryngeal fixation or lymph node involvement are successfully treated by radiation therapy or surgery alone, including endoscopic laser excision surgery.66
On the other hand more than 80% of the recurrent tumours are staged as rT3 or rT4. Total laryngectomy is considered the treatment of choice in the majority of these cases of laryngeal carcinoma relapse after partial laryngeal surgery or radiotherapy. Selected recurrent laryngeal cancers may be
Treatment of cervical lymph node metastases
Concise notes regarding surgical classification of neck dissection types are synthesized in Table 6.
Conclusions
Although in the management of laryngeal cancer significant clinical improvements have been allowed by new surgical procedures that have extended the indications to partial laryngectomies and by combination therapies (induction chemotherapy, concurrent administration of chemotherapy and radiotherapy, and adjuvant chemotherapy administered after the patient has been rendered free of disease), the most effective approach to laryngeal cancer remains prevention and early diagnosis when this cancer
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G.M. and R.M.R. contributed equally to the preparation of this manuscript.