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Treatment of carcinoma larynx
- 1. Treatment of Carcinoma Larynx Dr. A Nikhil Kumar
- 5. Management of carcinoma larynx Diagnostic Work up for Carcinoma of The Larynx General History Physical examination Indirect laryngoscopy Direct laryngoscopy Biopsies Radiographic studies Chest x-ray films Computed tomography with contrast (before biopsy) Magnetic resonance imaging (selected cases)
- 6. History • Hoarseness • True vocal cords involved • Recurrent laryngeal nerve involved • Glottic cancer – early stage • Supraglottic cancer – extensive disease • Sore throat • Pain on swallowing • Usually mild • Most frequent initial symptom • Ear pain • Referred pain to the ear • Via vagus nerve and auricular nerve of Arnold
- 7. • Pain localized to the thyroid cartilage • Thyroid cartilage invasion • Airway obstruction • Sensation of a “lump in the throat.” • A mass in the neck may be the first sign of a supraglottic cancer. • Late symptoms • Weight loss • Foul breath • Dysphagia • Aspiration
- 8. Physical examination • Inspection and palpation of neck • Laryngeal mirror examination • Flexible fiber optic endoscopes Vocal cord mobility Pre-epiglottic space invasion Postcricoid extension Invasion of the thyroid cartilage
- 9. • Vocal cord mobility • Mobile, partially fixed, and fixed • Pre-epiglottic space invasion • Diffuse, firm fullness above the thyroid notch • Widening of the space between the hyoid and the thyroid cartilages • Ulceration of the infrahyoid epiglottis or fullness of the vallecula • Postcricoid extension • Laryngeal click disappears • Thyroid cartilage protrude anteriorly, producing a fullness of the neck • Invasion of the thyroid cartilage • Localized pain • Tenderness to palpation • Small bulge over one ala of the thyroid cartilage
- 10. Radiographic studies • Method of choice – CT scan with contrast enhancement • Should be performed before biopsy • Preferred to magnetic resonance (MR) imaging • CT slices 1 to 2 mm thick are obtained through the larynx • CT scan of the entire neck to detect positive, nonpalpable lymph nodes • Contrast enhancement outline the blood vessels and thyroid gland • Magnetic resonance imaging (selected cases) • To define subtle exolaryngeal spread • Early cartilage destruction • Early invasion of the base of the tongue
- 11. • CT in Vocal cord Carcinoma • Not helpful for well-defined, easily visualized T1, or early T2 vocal cord carcinomas • Excellent for determining subglottic extension • Extension outside the larynx into the soft tissues of the neck • Potential for determining thyroid or cricoid cartilage invasion • Supraglottic Carcinoma • For viewing the preepiglottic and paraglottic fat spaces • Soft-tissue extension into the neck or base of the tongue
- 12. AJCC 8th ED Staging of Larynx
- 13. Ca supra glottis
- 14. Ca supra glottis
- 15. Ca supra glottis
- 21. Ca Larynx
- 22. Nodal staging (cN) N Number Side Size ENE +/- N1 Single Ipsilateral </=3cms - N2 a Single Ipsilateral >3-</=6cms - b Multiple Ipsilateral >3-</=6cms - c S/M Bilateral/contralateral >3-</=6cms - N3 a Any Any >6cms - b Any Any Any +
- 23. Nodal staging (pN) N Number Side Size ENE +/- N1 Single Ipsilateral </=3cms - N2 a Single Ipsilateral/contralateral </=3cms + Ipsilateral >3-</=6cms - b Multipl e Ipsilateral >3-</=6cms - c S/M Bilateral/contralateral >3-</=6cms - N3 a Any Any >6cms - b Any Any Any +
- 25. Treatment recommendations •Goals of treatment • Cure with best functional results • Decrease the risk of serious complications
- 26. TREATMENT RECOMMENDATIONS •Tis •Endoscopic resection (stripping/laser) •Definitive RT
- 27. TREATMENT RECOMMENDATIONS • T1-2N0 Glottic • Definitive RT • cordectomy or partial laryngectomy ± selective neck dissection • Post-op RT (close/+margin, PNI, LVSI) • T1-2N0 supraglottic • Definitive RT • partial supraglottic laryngectomy ± selective neck dissection • Post-op chemo-RT (+ margin) • Post-op RT( close margin, PNI, LVSI)
- 28. TREATMENT RECOMMENDATIONS • T1-2N+ or T3 requiring total laryngectomy • Concurrent chemo-RT • If < CR • salvage surgery ± neck dissection • If residual neck mass after RT • initial N2–3 post-RT • Neck dissection
- 29. TREATMENT RECOMMENDATIONS–Alternative • Total laryngectomy ipsilateral ± contralateral neck dissection • +Margin or nodal ECE • Post-op chemo-RT • pT3–4, pN2–3 • close margin, PNI, LVSI • ≥1 cm subglottic extension, cartilage invasion • Post-op RT
- 30. TREATMENT RECOMMENDATIONS • Resectable T4 • Total laryngectomy + ipsilateral / bilateral neck dissection • Post-op RT (Post-op chemo-RT for +margin or ECE)
- 31. TREATMENT RECOMMENDATIONS–Alternative • T1-2N+ or T3 & Resectable T4 • Induction chemo • If CR or PR • Concurrent chemo-RT • If < PR or progression • surgery ± neck dissection
- 32. TREATMENT RECOMMENDATIONS •Unresectable •Concurrent chemo-RT •If unable to tolerate chemo •Definitive RT with altered fractionation
- 33. Radiotherapy techniques • Position : • Supine with arms at sides • Shoulders relaxed downward • Neck neutral or extended. • Immobilization • 5-point thermoplastic head and shoulder mask • Simulation • 3 mm CT slices • From vertex to midchest • IV contrast to delineate major blood vessels
- 34. Radiotherapy techniques • Beam arrangement: (conventional) • 3-field approach • Opposed laterals • Matched to an anterior lower neck field • cover primary site and cervical/SCV LN at risk • Beam energy: 6MV • Isocenter: • Single isocenter used for both fields
- 36. Treatment port for early stage Ca Larynx • Anterior :1.5-2 cms beyond thyroid cartilage • Superior : Top of thyroid cartilage • Posterior : Anterior margin of vertebral bodies • Inferior : Below cricoid cartilage
- 37. Lateral DRR of a field used to treat a T1 glottic carcinoma
- 38. Treatment fields for T-2 tumors of Larynx • Anterior :1.5-2 cms beyond thyroid cartilage • Posterior : Mid-vertebral bodies • Superior : Supraglottic extension+2-3cm margin • Inferior : Infraglottic extension+2-3cm margin
- 39. Lateral opposed portal borders for early supraglottic cancer
- 40. Treatment fields for T3/T4/N+ Ca Larynx
- 41. Treatment fields for Supraglottic tumors
- 42. Portal borders for T3 larynx cancer
- 43. Anterior lower neck treatment portal • Superior: Match with inferior border upper neck lateral fields • Inferior: Inferior edge of the clavicular head • Lateral: Two thirds of the clavicle or 2 cm lateral to adenopathy
- 45. Volumes to be treated • IMRT – recommended for advanced lesions • GTV = clinical and/or radiographic gross disease • CTV1 = 5 mm margin on primary and 3–5 mm margin on nodes • CTV2 = High-risk areas and nodal levels • CTV3 = Elective nodal levels +/- tracheostoma • PTV = CTV + 3–5 mm • Extended-field whole neck IMRT preferred for larynx
- 46. Volumes to be treated • High-risk volume • Tracheostoma : if emergent tracheostomy • Subglottic extension • Tumor invasion of soft tissues of neck • Extra nodal extension in level VI • Close/positive margin • Nodal coverage • Levels II–IV • Include IB and V on the involved N+ neck • Level VI if subglottic or soft tissue extension
- 47. Dose prescription • T1-2N0 Glottic larynx • If 2 Gy/fx is used – total dose >66 Gy • If 2.25 Gy/fx is used (preferred) • Tis: 56.25–60.75 Gy. • T1N0: 63 Gy. • T2N0: 65.25 Gy. • Evidence: Yamazaki IJROBP 2006
- 48. Dose prescription • T3–4 and LN+: concurrent chemo-RT • Standard-fractionation RT with cisplatin 100 mg/m2 q3 weeks ×3c • Alternatively, cisplatin 40 mg/m2 weekly ×6c or cetuximab • 70 Gy at 2 Gy/fx • Definitive IMRT: • PTV1: 2.12 Gy/fx to 69.96 Gy • PTV2: 1.8 Gy/fx to 59.4 Gy • PTV3: 1.64 Gy/fx to 54.12 Gy • Evidence: MACH-NC Meta-analysis (Pignon Radiother Oncol 2009) 33# SIB technique
- 49. Dose prescription • Post-op RT • 60–66 Gy at 2 Gy/fx to high-risk areas and the post-operative bed • 54 Gy to elective nodal volumes • Chemo-RT indications • Nodal ECE • +Margin • Evidence: EORTC 22931 (Bernier NEJM 2004) ; RTOG 95–01 (Cooper NEJM 2004, IJROBP 2012); Combined analysis (Bernier Head Neck 2005)
- 50. DOSE LIMITATIONS • Spinal cord max ≤45 Gy • Brainstem max ≤54 Gy • Parotid gland mean ≤ 26 Gy and V20 Gy ≤ 50% • Submandibular mean ≤ 39 Gy • Mandible max ≤70 Gy • Retina max ≤45 Gy • Cochlea mean (max) ≤ 37 (45) Gy • Thyroid mean (max) ≤ 35 (45) Gy.
- 51. FOLLOW-UP • 85–90% of locoregional recurrences occur within 3 years • Year 1 : every 1–2 months • Years 2–3 : every 3 months • Years 4–5 : every 6 months • Annually thereafter • Imaging of neck if new signs or symptoms suggestive of recurrence • Progressive laryngeal edema • Fixation of previously mobile cord • Persistent throat pain H&P indirect mirror exam
- 52. Complications of Head and Neck Radiotherapy • Mucositis & Skin Toxicity • Taste Changes & Xerostomia • Osteoradionecrosis & Soft Tissue Necrosis • Fibrosis & Trismus • Endocrine Dysfunction • Laryngeal Edema • Dysphagia & Pharyngeal Dysfunction • Brachial Plexopathy • Spinal Cord Injury
- 53. •Thank you