Diagnosis

Patients with advanced glottic cancers will present with symptoms similar to patients with early glottic cancers. As listed earlier these include hoarseness or a change in the quality of voice, odynophagia, halitosis or otalgia. Not suprisingly the more ominous symptoms, such as hemoptysis, dysphagia, airway compromise and neck mass are more common in advanced stage disease. Additionally, the supraglottic and subglottic lesions tend to be less symptomatic and their insidious growth results in a high percent of patients presenting with advanced stage disease.

As mentioned earlier, adequate examination of the larynx by use of the laryngeal mirror or a rigid telescope or fiberoptic flexible nasopharyngoscope is essential to staging and treatment planning (Figure 8-4).20 Critical in this evaluation is assessment of the epicenter of the tumor, vocal fold mobility, extra-laryngeal involvement and regional lymph nodes in the neck. Although early tumors are often adequately assessed by history and physical exam alone, appropriate evaluation of advanced lesions usually requires radiographic imaging to ascertain the depth of the tumor involvement, preepiglottic space extension, paraglottic extension, cartilage involvement and extra-laryngeal spread. High-resolution CT scans with thin cuts through the larynx usually give adequate information regarding these aspects (Figure 8-5).21 Additionally, in patients with necks which are difficult to assess clinically, radiographic evaluation may add information in establishing the regional lymph node status.

The staging of patients with advanced cancers of the larynx is outlined in Table 8-1.18 As with other sites in the head and neck, the complex anatomy in this region makes accurate staging challenging. At times, the location of the lesion appears to carry more weight than the tumor burden. For example, a relatively small tumor on the posterior aspect of the larynx which involves the post-cricoid area will be stage T3, while a bulky tumor replacing the aryepiglottic fold, epiglottis and spilling down the medial wall of the pyriform sinus will be staged a T2 as long as the vocal cord remains mobile. While survival has been related to both T stage and N stage, it

Paraglottic Space Anatomy
Figure 8-3. Whole organ sections showing tumor involving the preepiglottic and paraglottic space.
A

is most profoundly affected by the nodal status of the patient.2,10,11 It has long been known that regional lymph node involvement in head and neck cancer patients decreases survival by approximately 50 percent.10,11 The present staging system of the American Joint Committee for Cancer (AJCC) groups both patients with locally advanced tumors (T3N0) and patients with regional lymph node metastasis (T1-

3N1) together into stage III.18 This may arbitrarily group 2 subsets of patients together who have vastly different prognoses. Both the stage as well as the nodal status must thus be considered when interpreting results from the treatment of larynx cancer.

Just as there are ominous symptoms in patients with advanced cancer of the larynx, there are also several physical findings that are harbingers of clin-

Figure 8-4. Endoscopic view and assessment of a laryngeal cancer using the A-0°; B-30°; C-70°; D-120° telescopes.

Figure 8-5. A, Axial CT of advanced laryngeal primary tumor demonstrating paraglottic involvement and cartilage destruction but without extension into the soft tissues of the neck. B, Axial CT of advanced laryngeal primary tumor demonstrating cartilage destruction and extension into the soft tissues of the neck.

Figure 8-5. A, Axial CT of advanced laryngeal primary tumor demonstrating paraglottic involvement and cartilage destruction but without extension into the soft tissues of the neck. B, Axial CT of advanced laryngeal primary tumor demonstrating cartilage destruction and extension into the soft tissues of the neck.

ically aggressive behavior. Extensive spread into the soft tissues of the neck, involvement of the overlying skin, regional lymph node metastases which are fixed or limited in vertical mobility, and bulky disease low in the neck all suggest a poor prognosis.

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