喉癌診斷與治療

耳鼻咽喉頭頸外科學第三篇

喉科學（4）第十章喉腫瘤CarcinomaoftheLarynx

CarcinomaofthelarynxEpidemiologyAccountsfor1%ofallnewcancersdiagnosedintheU.S.and0.75%ofallcancerdeaths.Accountsfor30%inallheadandneckcancers.Morefrequentlyhappenedinpatientsattheageof50~70.M:Fratio:5~10:1(foreigncountry)，6.75:1(shanghai).EtiologyCigaretteWine(combinedsmokingandalcoholabuseincreasestheriskby50%overtheadditiverate)AirpollutionVirus(HPV)precancerouslesions(Leukoplakia,Papilloma)sexhormones

LeukoplakiaofthelarynxPathologyNearly98%aresquamouscellcarcinoma.Adenocarcinoma,undifferentiatedcarcinomaandlymphosacomaarerare.Clinicalclassification:Glotticcarcinoma(60%)：welldifferentiated,latemetastasisSupraglotticcarcinoma(30%)：poordifferntiated,earlymetastasisSubglotticcarcinoma(6%)：poordifferentiated,earlymetastasisAnatomicdivisionsofthelarynxSpreadoflaryngealcancer⒈DirectspreadSupraglotticcancer→a)epiglottis,pre-epiglotticspace,vallecula,andtonguebase.b)piriformsinus,lateralwallofhypopharynx.c)paraglotticspace,ventricleortheVC.Glotticcancer→a)anteriorly,contralateralVC.b)posteriorly,arytenoidcartilagec)superiorly,supraglotticarea.d)inferiorly,paraglotticspaceandsubglotticarea.Subglotticcancer→a)superiorly,glottis.b)anteriorlyandlaterally,strapmuscleandthyroidgland.c)posteriorly,esophagus.⒉LymphnodesmetastasesSupraglotticcancer

→haveapropensitytospreadtocervicallymphnodesbilaterallyattheearlystages.Generally,theriskofoccultoractualmetastasesfromT1,T2,T3andT4tumorsis20%,40%,60%,and80%.Glotticcancer

→CVisvirtuallydevoidoflymphatics,involvementofcervicalnodesattheearlystagesisnotcommon.＜8%ofpatientswithT1andT2tumorswillhavenodalinvolvement.Glotticcancer

→Onlyatthelaterstages(T3,T4),prelaryngealnodes,paratrachealnodesandothercervicalnodes(levelⅡ～Ⅳ)couldbeinvolved.Subglotticcancer

→tendtospreadtoparatracheallymphaticsandthentoothercervicallymphnodes(levelⅡ～Ⅳ)。⒊DistantmetastasisviabloodUsuallydistantmetastasiswillnotoccuruntillaterstageoflaryngealcarcinoma.ClinicalmanifestationsSupraglotticcarcinoma：MightbeasymptomaticForeignbodysensationPainwhileswallowingThroatburnsEnlargementofcervicallymphnodesGlotticcarcinoma：HoarsenessistheearlysymptomRespiratoryobstructionwillhappeninlatestageSubglotticcarcinoma：Therearenodefinitivesymptomsintheearlystage.Dyspneaandmassintheneckarethemaincomplaininthelatestage.SupraglotticcarcinomaGlotticcarcinomaPhysicalexaminationLaryngoscopicexaminationcanfindamassononeorbothvocalcordsFixationofthevocalcordsiscommonMassintheneckCarcinomaofthelarynxDifferentialdiagnosisTuberculosisofthelarynx：chestX-rayfilmPapillomaofthelarynxSyphilisofthelarynx

TreatmentThemodalityoftreatmentdependson:TheexactsiteofthelesionEarlyoradvancedstagePresenceorabsenceofneckmetastasisDistantmetastasisAgeandsometimesthepatient’swishEarlylaryngealcarcinoma(T1/T2)isusuallymanagedwithsinglemodalityoftreatmentandrespondswelltoradiation,transorallaserresection,orpartiallaryngealsurgery.Primarycureratesof80to85%areexpected.Themanagementofadvancedlaryngealcarcinomaismorecontroversial.Theaimistooptimizedisease-freeandoverallsurvivalwhilepreservingqualityoflife.Generallyspeaking,combinedtherapyiswidelyused,asitcanachievebettersurvivalratesthansingle-modalitytreatment.Surgery+radiotherapyorradiotherapy+surgeryaretwocommonlyusedmodalities.

Surgicaltreatment1.PartiallaryngectomyTransorallaserresectionLaryngofissurewithcordectomyVerticalpartiallaryngectomyFrontolateralpartiallaryngectomyHorizontalpartiallaryngectomyHorizontalverticalpartiallaryngectomySupracricoidpartiallaryngectomyNeartotallaryngectomy(Pearson’soperation)2.Totallaryngectomy3.NeckdissectionRadicalneckdissectionFunctionalneckdissectionSelectiveneckdissectionRehabilitationofspeechaftertotallaryngectomyBlom-SingervalveEsophagealspeechElectricallarynx

Radiotherapy1.T1N0M0tumorslocate