Management of supraglottic and glottic larynx cancer has been revised lately. This presentation gives an overview of guidelines for management of laryngeal cancer. includes latest NCCN guidelines.

1. MANAGEMENT OF
CARCINOMA LARYNX
DR FARAZ BADAR
23/11/2019
MEDANTA
MODERATOR : DR SAUMYA RANJAN/ DR SUSOVAN BANNERJI

2. EPIDEMIOLOGY & RISK FACTORS
• 2% of the total cancer burden and 0.3% of all
cancer deaths
• The second most common head and neck
cancer site after Oral cavity
• At diagnosis, 51% localized, 29%  regional
spread, and 15% distant metastases.
• The ratio of glottic to supraglottic carcinoma is
approximately 3:1.
• INDIA : 2.5 % of all cancers.
• Strongly associated with tobacco smoking.

3. ANATOMY
• The larynx is divided into the
supraglottis, glottis, and
subglottis.
• EXTENT : From cranial border of
third to caudal border of sixth
cervical vertebrae
• SUPRAGLOTTIS :Subsites include
1. Epiglottis
2. False vocal cords
3. Ventricles
4. Aryepiglottic folds
5. Arytenoids.
(FAVEA)

4. • GLOTTIS  Vocal cords
and anterior
commissure.
• SUBGLOTTIS  extends
from a point 5 mm
below the free margin
of the vocal cord to the
inferior border of the
cricoid cartilage.

5. • Larynx 9 cartilages. 3
are paired and 3
unpaired.
• Paired Arytenoids,
Cuneiform and
Corniculate
• Unpaired Epiglottis,
Thyroid, Cricoid
• Muscles of larynx
Intrinsic and Extrinsic
• Intrinsic Control
movement of cord
• Extrinsic Swallowing

6. • All intrinsic muscles of larynx are supplied by
RLN except CRICOTHYROID  s/b Superior
laryngeal nerve. (Ext branch)
• EXT ms  1. suprahyoid. 2. Infrahy. 3.
Stylopharyngeous
• Suprahyoid  DSMG 
Digastric/Stylohyoid/mylohyoid/Geniohyoid
elevate larynx
• Infrahyoid  4 pairs depress larynx 
Sternohyoid/sternothyroid/thyrohyoid/omohy
oid

7. LYMPHATIC DRAINAGE
SUBSITE DRAINAGE
Supraglottis Subdigastric (level II)>> middle internal
jugular chain (level III)
Glottis No capillary lymphatics of the true vocal
cords
Subglottis • Pretracheal (Delphian) lymph nodes
• Paratracheal (level VI) lymph nodes

8. PATHWAYS OF SPREAD
• Two major pathways 1.
Local. 2. Lymphatic
• Local spread 
• Epiglottis : invades
vallecula, Base of tongue,
false cords, Aryepiglottic
folds, medial wall of the
pyriform sinus.
• False cord: Usually
submucosal with little
exophytic component. Early
involvement of paraglottic
fat space and pre-epiglottic
space

9. • Aryepiglottic
Fold/Arytenoid : Early
lesions are exophytic.
• Extend to adjacent sites
and eventually cause
fixation of the larynx,
which is due to
involvement of the
cricoarytenoid muscle
or joint >>invasion of
the recurrent laryngeal
nerve.

10. Glottic larynx
• Most lesions of the true
vocal cord begin on the free
margin and upper surface of
the cord.
• The anterior portion of the
cord  most common site.
• Anterior commissure
involvement, is said to occur
when no tumor-free cord
can be seen anteriorly
• Extension to the posterior
commissure is uncommon.

11. Subglottic Larynx
• Subglottic cancers are rare.
• Most involve the inferior surface of the vocal
cords by the time they are diagnosed.
• Most lesions are bilateral or circumferential on
presentation.
• There is early involvement of cricoid cartilage
because there is no intervening muscle layer.
• Partial or complete fixation of one or both cords
is common.
• Misdiagnosis or diagnostic delay is frequent.

12. LYMPHATIC SPREAD : SUPRAGLOTTIC CA.
• The disease spreads mainly to the level II nodes.
• The incidence of clinically positive nodes is 55% at the
time of diagnosis; 16% are bilateral1
• Stage wise involvement2 : T1–T2 27% 40%; T3–T4
55%–65%
1. Lindberg R et al., Cancer 1972
2. Wang CC, Radiation therapy for head and neck neoplasms, 1996

13. LYMPHATIC SPREAD : GLOTTIC CANCER
• No capillary lymphatics of
the true vocal cords
• Supraglottic spread 
associated with
metastasis to the level II
nodes.
• Anterior commissure and
anterior subglottic
invasion  associated
with involvement of the
midline pretracheal
lymph node (level VI).
Stage Perez Wang
T1 0 0%–2%
T2 < 2% 2%–7%
T3-T4 20%- 30% 15%–30%

14. CLINICAL PRESENTATION
 SUPRAGLOTTIC CANCER - Pain on swallowing, lump in
the throat.
• Pain referred to ear, Neck mass
 GLOTTIC CANCER - Hoarseness (very early) ,sore throat,
ear pain.
• Pain localized to the thyroid cartilage and airway
obstruction  features of advanced lesions.
 Late symptoms include weight loss, foul breath,
dysphagia, and aspiration.

15. DIAGNOSTIC WORKUP
 HISTORY : including smoking history (no. of pack years smoked)
 PHYSICAL EXAMINATION : including laryngeal mirror examination
complimented by Flexible fiberoptic endoscopes.
 IMAGING STUDIES : CT scan with contrast enhancement is the method of
choice for studying the larynx.
 The CT scan (1-2 mm slice thickness) should be performed before biopsy so
that abnormalities that may be caused by the biopsy are not confused with
tumor.
 CT is preferred to magnetic resonance (MR) imaging because the longer
scanning time for MR results in motion artifact
 MRI is useful to detect early cartilage destruction and Base of tongue invasion
 PET/CT for stage III/IV disease

16. STAGING : SUPRAGLOTTIC CANCER
TX
• Primary tumor can not be assessed
Tis
• Carcinoma in situ
T1
• Tumor limited to one subsite of supraglottis with normal vocal cord
mobility
T2
• Invasion of mucosa of more than one adjacent subsite of supraglottis or glottis or
region outside the supraglottis (e.g., mucosa of the base of the tongue, vallecula,
medial wall of the pyriform sinus) without fixation of the larynx.
T3
• Limited to the larynx with vocal cord fixation and/or invades any of the
following area: postcricoid space, pre-epiglottic space, paraglottic space,
and/or inner cortex of the thyroid cartilage
T4 • Moderately advanced or very advanced disease

17. T4a
• Moderately advanced local disease; tumor invades through
the thyroid cartilage and/or invades tissues beyond the larynx
(e.g., trachea, soft tissues of the neck including deep extrinsic
muscles of the tongue, strap muscles, thyroid, or esophagus)
T4b
• Very advanced local disease; tumor invades prevertebral
space, encases carotid artery, or invades mediastinal
structures

18. STAGING : GLOTTIC CANCER
TX
• Primary tumor cannot be assessed
Tis
• Carcinoma in situ
T1
• Tumor limited to the vocal cord(s) (may involve the anterior or posterior commissure) with normal mobility
• T1a Tumor limited to one vocal cord
• T1b Tumor involves both vocal cords.
T2
• Tumor extends to the supraglottis and/or subglottis with impaired
vocal cord mobility.

19. T3
• Tumor limited to the larynx with vocal cord fixation and/or
invasion of paraglottic space and/or inner cortex of the thyroid
cartilage
T4a
• Moderately advanced local disease; tumor invades through the outer cortex of
the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea,
cricoid cartilage, soft tissues of the neck including deep extrinsic muscle of the
tongue, strap muscles, thyroid, or esophagus)
T4b
• Very advanced local disease; tumor invades the prevertebral
space, encases the carotid artery, or invades mediastinal
structures

20. STAGING SUBGLOTTIC CANCER
TX
• Primary tumor can not be assessed
Tis
• Carcinoma in situ
T1
• Limited to subglottis
T2
• Extends to vocal cords with normal or impaired
mobility

21. T3
• Limited to larynx with vocal cord fixation and/or Invasion
of paraglottic space and/or inner cortex of thyroid
cartilage
T4a
• Invades through thyroid cartilage outer cortex, trachea,
soft tissues of neck, deep extrinsic muscles of tongue,
strap muscles, thyroid, or esophagus.
T4b
• Invades prevertebral space, encases carotid artery, or
invades mediastinal structures.

22. CLINICAL NODAL STAGING
NX
• Regional lymph nodes cannot be assessed
N0
• No regional lymph node metastases
N1
• Metastases in a single ipsilateral lymph node, ≤3 cm in greatest dimension,
ENE(−)
N2
•N2a: Metastases in a single ipsilateral lymph node >3 cm, but ≤6 cm in greatest dimension and ENE
(−)
•N2b: Metastases in multiple ipsilateral lymph nodes, ≤6 cm in greatest dimension, and ENE (−)
•N2c Metastases in bilateral or contralateral lymph nodes ≤6 cm in greatest dimension and ENE (−)
N3 • N3a Metastases in a lymph node >6 cm in greatest dimension and ENE (−)
• N3b Metastases in any lymph node(s) and clinically over ECE (+)

23. PATHOLOGICAL NODAL STAGING
NX
• Regional lymph nodes cannot be assessed
N0
• No regional lymph node metastases
N1
• Metastases in a single ipsilateral lymph node ≤3 cm in greatest
dimension and ENE (−)
N2
•N2a Metastases in a single ipsilateral or contralateral lymph node ≤3 cm in greatest dimension and
ENE (+), or in a single ipsilateral lymph node, >3 but ≤6 cm in greatest dimension and ENE (−)
•N2b Metastases in multiple ipsilateral lymph nodes ≤6 cm in greatest dimension and ENE (−)
•N2c Metastases in bilateral or contralateral lymph nodes ≤6 cm in greatest dimension and ENE (−)
N3
• N3a Metastases in a lymph node >6 cm in greatest dimension and ENE (−)
• N3b Metastases in a single ipsilateral lymph node >3 cm in greatest dimension and ECE (+), or in multiple ipsilateral,
contralateral, bilateral lymph nodes, any with ENE (+)

24. AJCC PROGNOSTIC STAGE GROUPS
When T is… And N is… And M is… Then Stage group
is..
Tis N0 M0 0
T1 N0 M0 I
T2 N0 M0 II
T3 N0 M0 III
T 1 , T2, T3 N1 M0 III
T4a N0, N1 M0 IVA
T 1, T2, T 3 ,T 4 a N2 M0 IVA
Any T N3 M0 IVB
T4b Any N M0 IVB
Any T Any N M1 IVC

25. TREATMENT OF SUPRAGLOTTIC
CANCER

26. OVERVIEW
Stage Treatment Guidelines
T1-T2 N0M0 Definitive RT (preferred) or supraglottic laryngectomy, with or
without adjuvant RT
T1-T2 N+, T3-T4aN0-
N+
• Concurrent RT +CT
• Post treatment ,if residual neck node is there, with a
complete response at primary  neck dissection.
• If the primary does not attain a complete response then the
patients should be considered for salvage surgery and neck
dissection.
T4aN0-N+ • Surgery followed by post-op chemo-RT.
• If unresectable, definitive concurrent Radiotherapy +
Chemotherapy

27. NCCN
EARLY STAGE DISEASE DEFINITIVE RT / SUPRAGLOTTIC PARTIAL LARYNGECTOMY
NECK IS ALWAYS TREATED EVEN FOR T1 TUMORS

28. STAGE III  ATTEMPT LARYNX PRESERVATION WITH CONCURRENT CTRT

29. STAGE III/SELECT IVA CONCURRENT CTRT IS TOC. SURGERY COMES AS A SECOND
OPTION

31. TOTAL LARYNGECTOMY+ NECK DISSECTION  TOC. SELECT LESIONS MAY BE TREATED
WITH CONCURRENT CTRT WITH TOTAL LARYNGECTOMY RESERVED AS SALVAGE

32. Surgery for supraglottic cancer
Supraglottic Laryngectomy Supracricoid Laryngectomy
Used for lesions involving the epiglottis, a single
arytenoid, the aryepiglottic fold, or the
false vocal cord
lesions extending from the
supraglottis into one or both
vocal cords
Structures
resected
1. Hyoid bone
2. Epiglottis
3. Superior half of thyroid cartilage
4. AE folds, and
5. False cords to arytenoids.
1. Bilateral true and false
cords,
2. Paraglottic space
3. Preepiglottic space
4. Epiglottis, and
5. Thyroid cartilage.
Containdication Extension of the tumor to the true vocal
cord, the anterior commissure, or both
arytenoids, fixation of the vocal cord, or
thyroid or cricoid cartilage invasion
Vocal cord fixation (RELATIVE
C/I),Extension to the cricoid
and thyroid cartilage

33. • Total laryngectomy with or without neck
dissection is surgery of choice for advanced
lesions.
• Removal of the hyoid, thyroid and cricoid
cartilage, epiglottis, and strap muscle with
reconstruction of the pharynx
• Permanent tracheostomy is always needed
• Speech may be reconstituted with a prosthesis
or with an electrolarynx

34. Mould and scan
• Supine position with hands by
side
• Head immobilized in neutral
neck position
• Head and neck thermoplastic
cast (S- frame)
• Use appropriate head rest
• Scan limit – Base of skull to
sterno-clavicular joint
• Slice thickness  2mm- 3mm

35. 2D planning
• The primary lesion and both sides of
the neck are treated with opposed
lateral portals.
• 15 degree wedges are used to
compensate for the contour of the
neck
• The lower neck nodes are irradiated
through a separate anterior portal
• Field borders:
• Superior superior to mandibular
angle
• Inferior  bottom of cricoid cartilage
• If Subglottic extension is present,
shoulders should be pulled down as
much as possible.
• Anterior  0.5–1 cm skin fall-off to
neck and one-third of mandible
• Posterior Usually spinous
processes

36. Portal borders for T3 larynx cancer.
Initial lateral fieldSchematic diagram of the low-neck field

37. Portal borders for T3 larynx cancer.
b off-cord lateral c cone down

38. Conformal Planning#
 T1
• GTV- P = All gross primary disease
• CTV-P1 (yellow) = GTV-P + 5 mm in all
directions.
• CTV-P2(green) = GTV-P + 10 mm in all
directions.
• CTV-P2 includes the pre-epiglottic space and
the para-laryngeal space.
• Excludes the thyroid cartilage and the air
cavity.
• Ventricle  CTV-P2 extend into the glottic
area.
• Aryepiglottic fold and supra-hyoid
epiglottis CTV-P2 extend into the vallecula.
• Inter-arytenoid mucosa it is
recommended that the posterior pharyngeal
wall is excluded from the CTV-P2
# GREGOIRE GUIDELINES

39.  T2
• CTV-P1 = GTV-P + 5 mm margin in all directions.
• CTV-P2 = GTV-P + 10 mm margin in all
directions.
• CTV-P2 includes the pre-epiglottic space, the
para-laryngeal space, thyroid cartilage
• Excludes strap muscles and the air cavities
• Ventricle  CTV-P2 extend into the glottic area.
• Aryepiglottic fold and supra-hyoid epiglottis
CTV-P2 extend into the vallecula.
• inter-arytenoid mucosa it is recommended
that the posterior pharyngeal wall is excluded
from the CTV-P2

40.  T3
• CTV-P1 = GTV-P + 5 mm margin in
all directions.
• CTV-P2 = GTV-P + 10 mm margin
in all directions.
• In all cases, CTV-P2 includes part
of the thyroid cartilage in relation
to the GTV-P and the pre-
epiglottic space.
• Does not extend outside of the
thyroid cartilage except if it is
infiltrated.
• Should not include the posterior
pharyngeal wall.

41.  T4
• CTV-P1 = GTV-P + 5 mm margin in all
directions.
• CTV-P2 = GTV-P + 10 mm margin in all
directions.
• In all cases, CTV-P2 includes the thyroid
cartilage in relation to the GTV-P, and the
pre-epiglottic space.
• It may extend outside of the thyroid
cartilage, but does not extend beyond the
strap muscles (sterno-thyroid or thyro-hyoid
muscles) unless macroscopically invaded.
• Also include part of thyroid gland
• For tumours infiltrating the prevertebral
space (i.e. T4b), CTVP2 may extend into the
vertebral body.

42. Dose and fractionation#
• T1-T3,N0-N1  66 to 70 Gy in 2Gy per fraction to
High risk PTV and 54 – 63 Gy in 1.8 Gy daily
fractions to Low to intermediate risk PTV
• POST- OPERATIVE  60 – 66 Gy in 2 Gy per
fraction to high risk PTV with adverse features
such as positive margins and 54 – 63 Gy in 1.8 Gy
daily fractions to Low to intermediate risk PTV
• # NCCN Guidelines v3.2019

43. Indications for postoperative RT
• pT3 ,pT4 primary
• N2 or N3 node
• Close margins
• Significant subglottic extension (1 cm or more)
• Cartilage invasion
• Perineural or vascular invasion
• Extension of the primary tumor into the soft
tissues of the neck
• For control of subclinical disease in the opposite
neck

44. • Indications for
postoperative chemoRT
• Positive margin
• Extracapsular nodal
spread
• Indications for
preoperative RT
• Fixed neck nodes
• Have had an emergency
tracheostomy through
tumor
• Direct extension of tumor
involving the skin

45. Selection of low risk nodal target volumes
for laryngeal cancers(GREGOIRE
GUIDELINES)

46. CHEMOTHERAPY
• INDICATION  Definitive chemoradiation for Stage III–
IVB
• AGENT  Cisplatin is standard of care.
• DOSE 100 mg/m2 bolus weeks 1, 4, 7 (NCCN
Category 1) OR 40 mg/m2 weekly (NCCN Category 2B).
• Cetuximab can be used for nonplatinum candidates.
• DOSE loading dose of 400 mg/m2 1 week prior to RT
followed by 250 mg/m2 weekly during RT.
• Use of induction CHT is controversial but has been
used to select pts for laryngectomy versus preservation
and consists of docetaxel, cisplatin, 5-fl uorouracil (TPF)
q3 weeks X four cycles completed 4 to 7 weeks prior to
RT.

47. TREATMENT OF VOCAL CORD CANCER

48. Stage Treatment Guidelines
Carcinoma in
situ
External Beam radiotherapy or Endoscopic removal by laser, stripping of the
cord
T1-T2 N0M0 External Beam radiotherapy Alone, surgery reserved for salvage after RT
failure.
Favorable T3
any N
• Radical External Beam radiotherapy + Concurrent chemotherapy (organ
preservation modality)
• If there is residual neck node, with complete response at primary, to be
taken up for neck dissection.
• If primary does not attain complete response, then should be considered
for salvage surgery and neck dissection
• If primary radical surgery is done, then postoperative Radiotherapy +
concurrent chemotherapy.
Unfavorable
T3- T4
any N
Total laryngectomy with ipsilateral (N0-N1) or
bilateral(N2-N3)neck dissection.
Post operative Radiotherapy

49. NCCN
CIS  ENDOSCOPIC RESECTION/RT
STAGE I/II RT(PREFERRED)/ SURGERY (PARTIAL LARYNGECTOMY)

50. STAGE III  TOC IS CTRT (LARYNX PRESERVATION)
NECK MUST BE TREATED

52. ADVANCED DISEASE  TOTAL LARYNGECTOMY IS TOC

53. Carcinoma in Situ
• Options of treatment include 
o Stripping the cord. (Disadvantage :
Recurrence, hoarseness)
o CO2 laser excision
o EBRT. (Advantage: better voice preservation)
o 5-yr Local control rates for glottic CIS
• Stripping 72%;
• Laser83%;
• RT88%–92%

54. Early Vocal Cord Carcinoma
• Radiation is the initial treatment for T1 and T2
lesions.
• Surgery reserved for salvage.
• Although surgery produces comparable cure
rates for selected T1 and T2 vocal cord lesions,
Radiation is generally preferred.
• The major advantage of Radiation compared
with partial laryngectomy is better quality of
the voice.

55. Moderately Advanced vocal cord
carcinoma
Fixed-cord lesions (T3)
favorable
-confined to one side
-good airway
-reliable for follow up
EBRT with concurrent
chemotherapy
unfavorable
-extensive bilateral
disease
-compromised airway
Treated like advanced
glottic cancer Surgery

56. Advanced Vocal Cord Carcinoma
• Advanced lesions usually show extensive
subglottic and supraglottic extension, bilateral
glottic involvement, and invasion of the
thyroid, cricoid, and/or arytenoid cartilages
• The airway is compromised, necessitating a
tracheostomy
• The mainstay of treatment is total
laryngectomy with neck dissection with or
without adjuvant RT

57. Voice preserving surgical options for
glottic cancer
SURGERY TISSUES RESECTED INDICATION CONTRAINDICATIO
N
ENDOSCOPIC
TECHNIQUES(Muco
sal stripping/
TORS/Electrocauter
y/CO2 laser)
MUCOSA OF VOCAL
CORD
CIS, T1a -
Vertical Partial
laryngectomy/Hemi
laryngectomy
1 true vocal cord
and one-third of
contralateral true
cord.
Vocal cord lesions
up to 1 cm anterior
and 5 mm posterior
subglottic extension
Extension to the
epiglottis, false
cord, or both
arytenoids
Supracricoid partial
laryngectomy
True and false
cords,
paraglottic spaces,
thyroid cartilage
Tumor extension in
supraglottis with
sparing of epiglottis
Extension to the
cricoid and
arytenoid cartilages

58. 2D planning
• Treated with parallel opposed lateral
wedged fields
• 15 degree wedge with heel anteriorly
• Field borders:
• T1 lesions  from the thyroid notch
superiorly to the inferior border of the
cricoid and fall off anteriorly
• Posterior border 1-1.5 cm posterior
to back edge of thyroid cartilage
• For T2 tumors, the field is extended
depending on the anatomic
distribution of the tumor.
• Field size :
• 4 × 4 cm to 5 × 5 cm (plus an
additional 1.0 cm of “flash” anteriorly)
and is occasionally 6 × 6 cm for a large
T2 lesion

59. • T3 and T4 lesions requires larger portals,
which include the neck nodes
• Field borders :
• Superior just above the angle of the
mandible ( to include the jugulodigastric
lymph nodes)
• Inferior  bottom of the cricoid cartilage
if no subglottic spread. Lowered as per
disease extent in subglottic involvement
• Anterior Flash
• Posterior includes a portion of the
spinal cord (for adequate coverage of the
midjugular lymph nodes)
• The level IV lymph nodes are included in
a separate low-neck portal

60. Treatment portal for T3-T4N0 glottic
carcinoma

61. Conformal Planning#
 T1
• GTV- P = All gross primary disease
• CTV-P1 = GTV-P + 5 mm in all
directions.
• CTV-P1 include the paraglottic
space, the anterior commissure
for anterior vocal cord tumour,
the anterior part of the
contralateral vocal cord for
tumour extending to the anterior
commissure, and the vocal
process of the arytenoid cartilage
for tumour extending to the
posterior vocal cord, but excludes
the thyroid cartilage and the air
cavity # GREGOIRE GUIDELINES

62.  T2
• CTV-P1 = GTV-P + 5 mm in all
directions.
• CTV-P2 = GTV-P + 10 mm in all
directions.
• CTV-P2 includes the paraglottic
space, the anterior commissure,
the anterior part of the
contralateral vocal cord for tumour
extending to the anterior
commissure, and the vocal process
of the arytenoid cartilage for
tumour extending to the posterior
vocal cord
• may include the thyroid cartilage in
relation to the GTV-P, but excludes
the cricoid cartilage

63.  T3
• CTV-P1 = GTV-P + 5 mm in all
directions.
• CTV-P2 = GTV-P + 10 mm in all
directions.
• CTV-P2 includes part of the thyroid
cartilage in relation to the GTV-P,
and most likely part of the cricoid
cartilage caudally, the pre-epiglottic
space anteriorly and the medial
wall of the piriform sinus postero-
laterally.
• Does not extend outside of the
thyroid cartilage, except if it is
infiltrated.
• Does not extend outside of the
larynx into the oropharynx, unless
invaded.
• Should not include the posterior
pharyngeal wall.

64.  T4
• CTV-P1 = GTV-P + 5 mm in all
directions.
• CTV-P2 = GTV-P + 10 mm in all
directions.
• CTV-P2 includes part of the thyroid
cartilage in relation to the GTV-P, part
of the cricoid cartilage caudally, and
the pre-epiglottic space, anteriorly.
• Extends outside of the thyroid
cartilage, but does not go beyond the
strap muscles (sterno-thyroid or
thyro-hyoid muscles) unless these
muscles are macroscopically invaded

65. Dose and fractionation#
• Tis,N0  60.75 Gy(2.25 Gy/ fraction) to 66
Gy(2 Gy/fraction)
• T1, N0  63 Gy (2.25 Gy/ fraction, preferred)
to 66 Gy(2 Gy/fraction)
• T2,N0  65.25 Gy(2.25 Gy/ fraction) to 70
Gy(2 Gy/fraction)
• ≥ T2, N1  66 Gy to 70 Gy in 2 Gy/ fraction to
High risk PTV and 54 – 63 Gy in 1.8 Gy daily
fractions to Low- intermediate risk PTV
• # - NCCN guidelines v.3 2019

66. Follow-Up

67. Follow-up paradigm
• History and physical examination +
laryngoscopy on each visit.
• Imaging (for signs/Symptoms)
• TSH (if neck is irradiated) every 6 to 12 months
• Speech/hearing evaluation
• Annual chest X-ray
• Counselling for smoking cessation

68. Radiation Therapy Sequelae
• Tanning or erythema of skin
• Hoarseness of voice
• Mild sore throat
• Edema of the larynx
• Soft-tissue necrosis leading to chondritis
• Dry mouth because of Thick saliva
• Loss of taste
• Sensation of a lump in the throat
• Fatigue
• Dysphagia, odynophagia
• Weight loss
• Hypothyroidism

69. SOME LANDMARK TRIALS

70. VA Larynx Study (NEJM 1991)
• Prospective randomised trial
• N= 332, III–IV locally advanced SCC of larynx
• 63% Supraglottis, 57% vocal cord fixation
• 2 arms (a) induction Chemotherapy followed by Radiation
or (b) Total laryngectomy followed by post-op Radiation.
• Results : Rate of laryngeal preservation was 64% at 2 years
• Conclusion: Induction Chemotherapy followed by definitive
Radiation can be effective in preserving larynx in high
percentage of pts, without compromising OS.

71. Forastiere, RTOG 91-11
• 547 patients randomized, 518
evaluable.
• Median follow up = 3.8 years
(Update published with MFU of
10.8 years)
• Arm A- Three cycles of induction
cisplatin and fluorouracil followed
by RT in complete and partial
responders (like Veterans affairs
study)
• Arm B- RT and concomitant
cisplatin (100 mg/m2 on days 1,
22, and 43 of RT)
• Arm C- once-daily RT (70 Gy in 35
fractions over 7 weeks) alone.

72. • Results: The rates of larynx presentation were significantly improved for
arm B
• Compared to induction, chemoradiation improved larynx preservation,
Loco regional control but not Laryngectomy free survival (which was the
primary end point of study)
• The 5-year survival rates were similar for the three treatment groups
• The likelihood of developing distant metastases was lower for the two
groups of patients that received adjuvant chemotherapy.

73. RTOG 9003
• 1076 patients with stage III/IV disease
• Randomised to 4 arms
• 1.Standard fractionation 2 Gy/#, once a day,
5 days/week, to a total dose of 70 Gy / 35 #/ 7
weeks
• 2. Hyperfractionation 1.2 Gy/#, twice daily
(≥6 hours apart), 5 days/week, to a total dose of
81.6 Gy in 68 fractions/7 weeks
• 3. Accelerated fractionation with split 1.6
Gy/#,twice daily (≥6 hours apart), 5 days /week,
to a total dose of 67.2 Gy in 42 fractions over 6
weeks, including a 2-week rest after 38.4 Gy
• 4. Accelerated fractionation with concomitant
boost1.8 Gy/#, once a day, 5 days /week to a
large field, plus 1.5 Gy/#once a day to a boost
field given 6 or more hours after treatment of
the large field for the last 12 treatments days, to
a total dose of 72 Gy/ 42 #s over 6 weeks

74. Results
• The 5-year local-regional failure rates were as follows :
• Standard fractionation59%
• Hyperfractionation 51%
• Accelerated split course 58%
• Concomitant boost  52%.
• Both the hyperfractionation and concomitant boost schedules
yielded significantly better local-regional control rates
• Trend toward improved overall survival with hyperfractionation but
no difference in cause-specific survival.
• Acute toxicity was increased with all three altered fractionation
schedules;
• There was a modest increase in late effects with the concomitant
boost schedule

75. THANK YOU