management of carcinoma larynx radiation oncologist perspective

1. ROLE OF RADIOTHERAPY AND
CHEMOTHERAPY IN CARCINOMA
LARYNX
By
Dr. Brijesh Maheshwari
Moderator- Dr. Pavan Kumar

2. TNM STAGING

3. SUPRAGLOTTIS

4. GLOTTIS

5. SUBGLOTTIS

6. NODAL STAGING

7. GROUP STAGING
STAGE T N M
0 T is N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1-3 N1 M0
IVA T4a N0 M0
T4a N1 M0
T1-4a N2 M0
IVB T4b Any N M0
AnyT N3 M0
IVC Any T Any N M1

8. WORK UP
• H&P, including hoarseness, pain, dysphagia, odynophagia,otalgia, trismus.
• All patients should have nasopharyngolaryngoscopy.
• Biopsy tumor and/or lymph node(s).
• Labs include CBC, chemistries, BUN/Cr, LFTs, baselineTSH.
• Imaging includes thin-cut CT and/or MRI of the head and neck and chest
imaging. Consider FDG-PET scan for stages III–IV.
• Preventive dental care and extractions should occur 10–14 days before RT.
• Baseline speech, swallowing, and nutrition evaluations. If locally advanced,
consider baseline audiometry too.

9. TREATMENT ALGORITHM

10. MANAGEMENT OF CARCINOMA IN SITU :
Stripping of the cord
Excised using CO2 laser
Early RT (better chance of preserving good voice)

11. EARLY GLOTTIC CARCINOMA
• RT is preferred for T1 & T2 lesions.
• Major advantage of RT is better quality of voice.
• Partial laryngectomy as salvage surgery after RT failure.
• Total laryngectomy - for local recurrence after salvage
partial laryngectomy.

12. MODERATELY ADVANCED GLOTTIC CANCER
•The patients with favourable fixed cord lesions (T3)
is advised of alternatives of RT with surgical salvage
or immediate total laryngectomy
•Major difficulty in using RT for more advanced
lesions is distinguishing radiation edema from local
recurrence during follow up .

13. ADVANCED GLOTTIC CARCINOMA
• Mainstay of treatment is total laryngectomy with or without
adjuvant RT with or without concurent chemotherapy (cisplatin
35mg/m2 every week).
• If lymph nodes are clinically positive, bilateral selective neck
dissection is performed at the time of laryngectomy.
• If neck is clinically negative before surgery and post op RT is
planned, neck dissection may be withheld and RT may be used
to treat both sides of neck.

14. POST OP RT IS INDICATION
• Close or positive margins
• Significant subglottic extensions
• Cartilage invasion
• Perineural invasion
• Perivascular invasion
• Extension into soft tissues of neck
• Multiple positive neck nodes
• Extracapsular extension

15. Definitive RT is prescribed for
Patients who refused total laryngectomy
Patients medically unsuitable for major surgery

16. DOSE PRESCRIPTION
•For T1 66 Gy , in 2Gy per # over 7 weeks , once a
day 5 days a week.
•Standard fractionation T2, T3 & T4 is 70Gy in 35 #
in 2Gy per # over 7 weeks , once a day 5 days a
week.

17. T1-2 N0 GLOTTIC CARCINOMA
• T1-2N0 glottic carcinomas are treated with a pair of small, lateral,
opposed photon fields that encompass only the larynx proper.

20. B/L OPPOSITE FIELD WITH LAN

22. 3D CRT plan

24. • This has led several groups to assess the role of intensity-
modulated radiation therapy (IMRT) in irradiating the larynx
while sparing the carotid vessels.

25. IMRT PLAN

26. TARGET VOLUMES
• GTV – gross tumor and involved nodes
• CTV – usually stratified to cover regions at different risk of
failure. CTV is the glottic larynx with a border at least 10 mm
superiorly and inferiorly from the GTV.
– High risk CTV-
– Intermediate Risk CTV
– Low risk CTV
• PTV – margin for setup and motion errors. PTV is CTV with a 3–
5 mm isotropic margin
• Organs at risk and Planning OAR volume (PRV)

27. 9 FEILD BEAM PLACEMENT

28. DOSE COLOR WASH

29. T3-T4 GLOTTIC NODE POSITIVE TUMOURS
• Requires larger portals, which include level II and level III lymph
nodes.
• Level IV lymph nodes can be included in separate low neck portal
• Definitive dose
• 66 – 70 Gy / 33-35 # / 6 – 7 weeks
• Phase I - 46 Gy/ 23 #
• Phase II- 20-24 Gy/ 12 #
• Post-op dose
• 6O Gy/30 # /6 wks
• Phase I - 46 Gy/ 23 #
• Phase II- 14 Gy/ 7 #

32. SUPRAGLOTTIC CANCER
• EARLY AND MODERATELY -ADVANCED SUPRAGLOTTIC
CANCERS-
1. Treatment of primary lesion for early group is by RT
or supraglottic laryngectomy , with or without adjuvant
RT .
2. Total laryngectomy is rarely indicated as initial treatment
for this group of patients and is reserved for treatment
failures.

33. ADVANCED SUPRAGLOTTIC LESIONS
• Total laryngectomy is main surgical option .
• Selected advanced lesions , especially those that are mainly
exophytic may be treated by RT and concomitant
chemotherapy with total laryngectomy reserved for RT failures.
• For patients whose primary lesions is to be treated by a total
or partial laryngectomy and who have resectable neck
disease , surgery is the initial treatment and post op RT is
added if needed. If neck disease is unresectable pre op RT is
used .

34. LATERAL OPPOSED PORTAL BORDERS FOR EARLY
SUPRAGLOTTIC CANCER

35. LAN

36. IMRT PLAN

37. DOSE PRESCRIPTION
•Dose for post op RT is 60 - 70 Gy in 2.0Gy per #, 1 #
/day , 5 days per week.
•If post op RT is added after a supraglottic
laryngectomy , the dose is lowered to 55.8 Gy ,1.8
Gy/ #.
•Dose of pre op RT is same as for patients treated with
RT alone – 50 to 60 Gy at 1.8 – 2.0 Gy/ #.

38. TOXICITES
• Acute Toxicites
• Mucositis
• Dysphagia
• Xerostomia
• Dysgeusia
• Loss of appetite
• Skin reaction
• Voice hoarseness
• Cough
Late toxicities
• Subcutaneous fibrosis
• Xerostomia
• Dental decay
• Hypothyroiditis
• m Cord
• edema
• Laryngeal chondronecrosis
2nd malignancies

39. CHEMOTHERAPY

40. CONCURRENT
CHEMOTHERAPY
• High dose CISPLATIN 100mg/m2 3 weekly (preferred)
(category 1)
• CETUXIMAB (category 1)
• Weekly CISPLATIN 35mg/m2 (category 2b)
• Post operative chemoradiation : cisplatin (category 1 for
high risk)

41. INDUCTION CHEMOTHERAPY
• No improvement in overall survival with the incorporation of induction
chemotherapy.
• If induction is chosen :
DOCETAXEL/CISPLATIN/5-FU (CATEGORY 1)
PACLITAXEL/CISPLATIN/5-FU
• Following induction : weekly CARBOPLATIN OR CETUXIMAB typically used
in concurrent chemoradiation.
• Following cisplatin based induction chemotherapy : high dose 3 weekly
cisplatin chemoradiotherapy is not recommended due to toxicity.

42. PALLIATIVE CHEMOTHERAPY
For recurrent/unresectable/metastatic (incurable) :
• Combination therapy :
CISPLATIN or CARBOPLATIN + 5-FU+ CETUXIMAB (category 1)
CISPLATIN OR CARBOPLATIN + PACLITAXEL OR DOCETAXEL
CISPLATIN + 5-FU
CISPLATIN + CETUXIMAB
• Single agents : cisplatin, carboplatin, paclitaxel, docetaxel, 5-FU,
methotrexate, capecitabine, cetuximab etc.

43. FOLLOW UP
• Follow up of patients with early lesions is planned for
every 4 to 8 weeks for 2 years, every 3 months for
the 3rd year and every 6 months for years 4 and 5,
and then annually for life.
• If recurrence is suspected but the biopsy is negative,
patients are re-examined at 2 to 4 weeks intervals until
the matter is settled.

44. CONCLUSION
•The most common predisposing factors are
smoking cigarettes and alcohol.
•For Early-stage cancers of the larynx RT is
preferred to preserve better quality of voice
and organ preservation.
•For advanced cancer larynx and fixed vocal
cord lesion surgery is the mainstay treatment

45. THANK YOU