Tumorile laringelui

Dr. Mugur Grasu Elena Turiac

Clasificare
I Tumori benigne
-

- reprezinta ~10% din toate tumorile laringelui

papiloame (cele mai frecvente 85%, HPV) - fibroame, angiofibroame, fibromixom - adenoame (rare) - tumori miogene, lipoame, hemangioame, condroame, fibroneuroame (foarte rare) II Tumori maligne - Epiteliale (carcinomul cu celule scuamoase, carcinomul anaplastic, adenocarcinomul, carcinomul adenoid chistic, carcinomul mucoepidermoid, carcinomul cu celula acinica, melanomul malign) - Tesut conjunctiv (fibrosarcom, liposarcom, sarcom osteogenic, condrosarcom, leiomiosarcom, rabdomiosarcom, angiosarcom, limfom Hodgkin si non-Hodgkin, tumori neurogene)

Simptomatologie

Mici = asimptomatice Mari = raguseala, stridor, dispnee, tuse, durere, hemoptizie etc.

Investigatii
Endoscopie CT MRI PET CT histopatologic

stadializare, detectarea recidivei

I. Tumori benigne - Papilom

Infectie HPV Tipuri

Juvenila se caracterizeaza prin leziuni multiple, similare unor negi, extinse uneori la trahee si eventual cu determinari pulmonare sub forma de noduli multipli Adulta se prezinta sub forma unor leziuni unice

Excrescente nodulare la nivelul corzilor vocale adevarate si false Imagistic nespecific (contur nodular ce proemineaza in caile respiratorii aeriene).

I. Tumori benigne - Condrom Tumori cartilaginoase rare, greu de diferentiat de condrosarcoame, atat imagistic, cat si histologic Intereseaza frecvent cricoidul care apare expandat, cu multiple calcificari Imagistic
masa hipodensa spontan cu matrice condroidala IRM masa hipersemnal T2
CT

I. Tumori benigne Hemangiom

Foarte rare cazuri raportate in literatura de specialitate Tipuri

Infantila

frecvent subglotic uneori se asociaza cu hemangioame cutanate mai rare ca tipul infantil poate aparea oriunde la nivelul laringelui frecvent sub forma cavernoasa

Adulta

Imagistic

CT priza intensa de contrast IRM hipersemnal T2, cu priza intensa de contrast

I. Tumori benigne - Lipom

Frecvent la nivelul regiunii supraglotice Tumori mobile ce pot proemina in trahee sau esofag Imagistic

Edoscopic masa sesila sau polipoida la nivelul submucoasei CT leziune omogena, fara priza de contrast, cu densitati negative (-65 - -125UH) IRM semnal asemanator grasimii subcutanate (hiperintens T1, descreste intensitatea in T2, intensitate foarte joasa in T1 cu supresie de grasime) CT+IRM = diagnostic definitiv

TAKE HOME POINT

Leziunile benigne ale laringelui sunt rare si au un aspect neinvaziv, bine definit, cu ritm scazut de crestere Diagnosticul= endoscopie + histopatologie +/- CT/IRM (in cazurile in care nu se poate face diferentierea intre benign vs malign)

II. Tumori maligne Carcinom cu celule scuamoase

Reprezinta 75% din totalul tumorilor maligne Clasificare

Spraglotic Glotic Subglotic

The American Joint Committee on Cancer (AJCC) has designated clinical staging using the TNM classification as documented below

TNM Staging of Layngeal Cancer Primary Tumour (T) TX: Primary tumour cannot be assessed. T0: No evidence of primary tumour. Tis: Carcinoma in situ Supraglottis T1: Tumour limited to one subsite of supraglottis with normal vocal cord mobility. T2: Tumour invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx. T3: Tumour limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex). T4a: Tumour invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus). T4b: Tumour invades prevertebral space, encases carotid artery, or invades mediastinal structures Subsites include the following: ventricular bands (false cords), arytenoids, suprahyoid epiglottis, infrahyoid epiglottis, aryepiglottic folds (laryngeal aspect). Glottis T1: Tumour limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility. T2: Tumour extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility. T3: Tumour limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex). T4a: Tumour invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus). T4b: Tumour invades prevertebral space, encases carotid

Subglottis T1: Tumour limited to the subglottis. T2: Tumour extends to vocal cord(s) with normal or impaired mobility. T3: Tumour limited to larynx with vocal cord fixation. T4a: Tumour invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus). T4b: Tumour invades prevertebral space, encases carotid artery, or invades mediastinal structures. Regional Lymph Nodes (N) NX: Regional lymph nodes cannot be assessed (eg. Previously removed). N0: No regional lymph node metastasis. N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension. N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension. N3: Metastasis in a lymph node more than 6 cm in greatest dimension. Distant Metastasis (M) MX Distant metastasis cannot be assessed. M0 No distant metastasis. M1 Distant metastasis.

STAGE GROUPING

0 I

T Tis T1

N N0 N0

M M0 M0

II III
IV a IV b IV c

T2 T3 T1-T3 T4a T1-T4a T4b

Any T Any T

N0 N0 N1 N0-1 N2 Any N
N3 Any N

M0 M0 M0 M0 M0 M0
M0 M1

Carcinom cu celule scuamoase - Supraglotic

Imagistic

Trasaturi generale

masa infiltrativa cu priza moderata de contrast la nivelul corzilor vocale false, pliu ariepiglotic si spatiile pre-epiglotic si paraglotic, ce asociaza adenopatii maligne dimensiuni variabile
asimetrie tisulara supraglotica cu efect de masa scleroza cartilagiului priza moderata de contrast hipo-izosemnal T1 hipersemnal T2 T1 C+ cu priza omogena sau heterogena de contrast activitate crescuta la nivelul tumorii

CT

IRM

PET

Diagnostic diferential

laringocel artrita reumatoida laringiana sarcoidoza laringelui condrosarcom carcinomul adenoid chistic

Carcinom cu celule scuamoase - Glotic

Imagistic

Trasaturi generale

masa invaziva la nivelul corzilor vocale adevarate dimensiuni variabile deobicei mici cand sunt detectate
asimetrie tisulara la nivelul corzilor vocale adevarate masa infiltrativa sau vegetanta cu priza de contrast hipo-izosemnal T1 hipersemnal T2 T1 C+ cu priza omogena de contrast activitate crescuta anormala la nivelul tumorii

CT

IRM

PET

Diagnostic diferentiat

artrita reumatoida laringiana sarcoidoza laringelui condrosarcom carcinomul adenoid chistic

Carcinom cu celule scuamoase - Subglotic

Imagistic

Trasaturi generale

masa invaziva cu priza de contrast centrata subglotic si deasupra marginii inferioare a cartilajului cricoid dimensiuni variabile
densitate tisulara proeminenta in caile respiratorii de la nivelul cartilajului cricoid masa infiltrativa sau vegetanta cu priza de contrast hipo-izosemnal T1 hipersemnal T2 T1 C+ cu priza heterogena de contrast activitate crescuta la nivelul tumorii

CT

IRM

PET

Diagnostic diferential

artrita reumatoida laringiana modificari post-traumatice condrosarcom carcinomul adenoid chistic

II. Tumori maligne Condrosarcom

Imagistic

Trasaturi generale

masa expansiva cu calcificari arciforme sau inelare ce se intinde la nivelul cartilajului laringian cu suprafata mucoasei intacta dimensiuni 1 6 cm

CT

masa hipodensa spontan, cu priza moderata de contrast

izosemnal fata de muschi in T1 hipersemnal T2 hipersemnal STIR T1 C+ cu priza heterogena de contrast

IRM

Diagnosticul poate fi suspectat pe CT sau IRM, dar trebuie confirmat cu biopsie

II. Tumori maligne

Adenocarcinomul, carcinomul adenoid chistic si carcinomul mucoepidermoid

apar la nivelul glandelor salivare minore nu pot fi diferentiate imagistic de carcinomul cu celule scuamoase diagnostic = biopsie

Liposarcomul lipom cu zone tisulare cu prize de contrast Metastazele

piele (melanom), rinichi, san, plaman, prostata, colon, stomac si ovar caracteristici imagistice nespecifice

TAKE HOME POINT

Leziunile maligne au caracter invaziv Fumatul + alcoolul = factori de risc Implica cel mai frecv regiunea glotica Endoscopia (depisteaza) CT/IRM/PET CT (stadializare, recidiva, conduita terapeutica) Biopsie (pentru confirmarea diagnosticului)