laryngeal cancer

1. LARYNGEAL CARCINOMA
DR SWARNITA SAHU
DNB RESIDENT
RADIATION ONCOLOGY
BATRA HOSPITAL
NEW DELHI

2. SUPRAGLOTTIS
epiglottis
arytenoid
aryepiglottic folds
false vocal cords
ventricle
GLOTTIS
(extends till 0.5 cm inferior from
the free margin of TVC)
vocal cord
anterior commissure
SUBGLOTTIS
0.5 mm below the free margin of
vocal cord to inferior border of
cricoid

3. • SHELL OF THE LARYNX:
Hyoid bone
Thyroid cartilage
Cricoid cartilage
• EXTERNAL FRAMEWORK
Thyrohyoid membrane
Cricothyroid membrane
Cricotracheal ligaments & membranes
• INTERIOR FRAMEWORK (mobile)
Epiglottis
Arytenoid
Corniculate
cuneiform

4. LYMPHATICS:
GLOTTIC – NO
LYMPHATICS

5. CT ANATOMY:

7. EPIDEMIOLOGY
• m/c HEAD & NECK CANCER
• 2% of the total cancers
• Glottic : supraglottis – 3:1
• SMOKING
• Alcohol and GERD in SMOKERS

8. CLINICAL FEATURES
EARLY LOCALLY ADVANCED METASTATIC
Hoarseness Ear pain (via vagus & auricular nv
Arnold)
hemoptysis
Foreign body sensation Pain over thyroid cartilage Persistent cough
Sore throat stridor Weight loss
Dysphagia hemoptysis
Cough Lump in the neck
Bad breath

9. CLINICAL SIGNS (ADV STAGES): imp in staging
• PRE-EPIGLOTTIC SPACE INVASION:
fullness of the valleculae or palpation of fullness above the
thyroid notch with widening of the space b/w hyoid &
thyroid.
• POST CRICOID EXTENTION: if laryngeal click disappears
• THYROID CARTILAGE INVASION: difficult
localized pain & tenderness, small bulge over ala of
thryroid cartilage

10. WORK UP :
• INDIRECT OR DIRECT LARYNGOSCOPY:
Ventricle, Subglottis, apex of PFS, post cricoid area- DL (not in IDL)

11. IMAGING
• CECT : IOC (before biopsy)
• MRI : for subtle exolaryngeal spread or early cartilage destruction
(but increased scan time---- motion artifacts)
• GLOTTIC :
T1 /early T2 – not appreciated in CT/MRI
for subglottic extention
early cartilage invasion- axial scans X
coronal & sagittal scans
• SUPRAGLOTTIC: CT
CAREFULL WORKUP IS IMP : MARKED DIFF IN MANAGEMENT OF EARLY & ADV CASES

12. STAGING (AJCC 8TH)
T STAGE SUPRA GLOTTIS SUB
Tx
Tis
T1 – SAME SUBSITE T1a- one vocal cord
T1b- both vocal cord
T2 - MUCOSA OF OTHER SUBSITES WITH OR WITHOUT IMPAIRED MOBILITY OF VOCAL CORD
Outside supraglottis(BOT,
valleculae, pyriform sinus)
T3 – LIMITED TO LARYNX WITH VOCAL CORD FIXATION &/OR INVADES : paraglottic space
inner cortex of thyroid cartilage
Postcricoid
Preepiglottic space
T4 – MODERATELY ADVANCED OR VERY ADVANCED :
4a- outer cortex of thyroid cartilage
tissues beyond larynx
4b- pretebral space
carotid artery
mediastinal structures

13. PROGNOSTIC STAGE GROUPS:

14. GLOTTIC SUPRAGLOTTIC SUBGLOTTIC
• presents very early (even Tis)
• Earliest symptom- hoarseness
• lack lymphatics-
spread to lymph nodes is very rare
• Slow growing
ONLY H&N CANCER WHERE
ELECTIVE NODAL IRR X
VERY GOOD PROGNOSIS- early
presentation(even Tis-hoarseness)
& late spread
• nodal mets occur early
upper & middle jugular
often silent .
• Spread : submucosal
POOR PROGNOSIS:
early spread & late presentation.
Rare(1-2%)
Spread: submucosal
Earliest symptom: stridor
Late symptom: hoarseness
Hoarseness of voice indicates:
Invasion of vocal cord
Invasion of cricoarytenoid muscle or joint
Recurrent laryngeal nv inv

15. Treatment overview:
EARLY LARYNGEAL CANCER (T1-2N0)
STAGE Rx RECOMMENDATION
Tis Endoscopic resection (stripping/laser)
Or
Definitive radiotherapy
T1-2N0
(glottic)
Definitive RT
OR
Alt: cordectomy or partial laryngectomy +/- selective neck dissection
Post op RT (close margin, PNI, LVSI)
T1-2N0
(supraglottic)
Definitive RT
OR
Partial supraglottic laryngectomy +/- selective neck dissection
Post op chemo RT- +margin
Post op RT- close margin, PNI, LVSI.

16. REMOVES MUCOSA OF CORD
SE- HOARSENESS
REMOVES- PART OF ONE CORD
SE-HOARSENESS
• Cordectomy

17. PARTIAL LARYNGECTOMY (voice preservation)
VERTICAL HORIZONTAL
REMOVES:
• False cord
• Epiglottis
• Aryepiglottic folds
• Pyriform sinus
REMOVES :
Half of thyroid cartilage
Portion or all of 1 TVC
Upto <1/3 (5mm) of other TVC

18. CONVENTIONAL : OPPOSED LATERAL BEAMS
• T1N0:
5 x 5 cm field
SUPERIOR - bottom of hyoid bone
INFERIOR - bottom of cricoid
POSTERIOR - anterior edge of vertebral bodies
ANTERIOR - 1cm flash
• T2N0:
6 X 6 cm field
INFERIOR: one tracheal ring below cricoid

19. IMRT-SIMULATION :
• Supine & neck extended
• vertex to carina
• EARLY :
iv contrast can be omitted (but helps in carotid artery delineation).
• ADVANCED:
Arms at the side, sholders are immobilized & extended down towards the feet.

20. DEFINITON
GTV Gross disease
CTV Entire larynx
PTV 0.5 – 1 cm expansion of CTV
(0.3cm near the carotid arteries
if CAROTID SPARING IMRT)
SUPERIOR-
Thyroid notch
INFERIOR-
T1N0: bottom of cricoid.
T2N0: first tracheal ring.
PTV – 2cm above n
below the GTV.

21. • T1N0: 63Gy/2.25
• T2N0: 65.25Gy/2.25
79.25/1.2 (twice a day)
CONCURRENT CHEMOTHERAPY IS NOT
RECOMMENDED ALONG WITH DEFINTIVE
RADIOTHERAPY

22. OUR INSTITUTE :
T1N0
66Gy @ 2Gy/#

23. OUR INSTITUTE:T2N0
70Gy @ 2Gy/#

24. ADVANCED LARYNGEAL CANCER
STAGE Rx RECOMMENDATION
T1-2N+ or T3
Concurrent chemo-RT.
If < CR, salvage surgery ± neck dissection.
If residual neck mass after RT or initial N2–3 post-RT, consider neck dissection
OR
Alternative: total laryngectomy and ipsilateral ± contralateral neck dissection.
Post-op chemo-RT for +margin or nodal ECE.
Post-op RT for pT3–4, pN2–3, close margin, PNI, LVSI, ≥1 cm subglottic extension, and/or
cartilage invasion.
OR
Induction chemo may be considered.
If CR or PR, proceed with concurrent chemo-RT as above.
If < PR or progression, proceed to surgery ± neck dissection as indicated
UNRESECTABLE Concurrent chemo-RT If unable to tolerate chemo, definitive RT with altered fractionation

25. • Removes:
Hyoid
Thyroid
Cricoid
Epiglottis
Strap muscles
Patient left with PERMANENT TRACHEOSTOMY +
PHARYNGEAL RECONSTRUCTION.
• Sites of failures:
Tracheal stoma
Base of tongue
Neck nodes
• Rehabilitation by:
Tracheo-oesophageal speech
Artificial electro-larynx
Oesophageal speech

26. IMRT: (INTACT LARYNX)
VOLUME DEFINITION
CTV CTV 70- whole larynx
involved node
CTV 54- elective nodal levels
PTV 3 TO 5 mm margin (risk of intrafraction or tumor motion)
NODAL COVERAGE:
LEVEL II-IV : always included
LEVEL IB &V : if nodes involved
LEVEL VI : subglottic & soft tissue extention

27. • POST OP RT INDICATIONS:
pT3-4
pN2-3
extra nodal extention
close/positive margin.
PNI/LVSI +
• CHEMO INDICATIONS:
+ margin
extranodal extention

28. POST OP RT
VOLUMES
CTV66 Operative bed (positive margins)
Areas of ECE
Stoma boost if indicated
CTV60 Entire operative bed (inc scar)
Involved Lymph nodes
CTV54 CTV 60-66
Elective nodal levels (same as before)
Level VI – always covered (since stoma
made thro it)
PTV 3 to 5 mm from CTV

29. PLAN ASSESSMENT
• 95% PTV: prescribed dose
• Dose constraints:
1. Brainstem: max <50Gy
2. Optic nerve & chiasm : max< 54Gy
3. Spinal cord : max< 45Gy
4. Mandible : max< 70Gy
5. Brachial plexus: max <65Gy
6. Parotid : mean< 26Gy
7. Submandibular gland: mean < 39Gy
8. Cochlea: max <50Gy

30. IMPORTANT TRIALS

31. RTOG 90-03- a randomized trial of altered fractionation
radiation for locally advanced head and neck cancer
• 1113 patients
• nonmetastatic stage III and IV
• compared standard fractionation radiation therapy to three experimental
fractionation schedules.
STANDARD HYPERFRACTIONATION ACC FRAC. WITH SPLIT ACC FRACTIONATION
WITH BOOST
70Gy/35# @ 2Gy/#
Once daily
5days/week
Over 7 weeks
81.6Gy/68# @1.2Gy/#
Twice daily(>/= 6hrs)
5 days/week
Over 7 weeks
67.2Gy/42# @1.6Gy/#
Twice daily (>/=6 hrs)
5days/week
Over 6 weeks
2 weeks REST after 38.4 Gy
72Gy/42#@ 1.8Gy/#
Once daily
(last 12 days, 1.5Gy/#
boost >/=6hrs after large
field )
Over 6 weeks
IMPROVED LOCAL CONTROL WITH HYPERFRACTIONATION & ACC FRACTIONATION
SURVIVAL & TOXICITY = SAME

32. VA trial (stage III n IV)
• larynx preservation (induction chemotherapy definitive RT) vs laryngectomy
and postoperative RT.
• Cisplatin/5FU x 2 cycles (3rd cycle if PR/CR)-RT
if < CR/PR -- Sx - RT
• RESULTS:
SIMILAR SURVIVAL RATES
More Distant mets in surgery arm.
More locally persistent disease in chemotherapy arm.
SALVAGE LARYNGECTOMY – 56% of T4 pts.

33. RTOG 91-11
• three arms.
• Induction chemotherapy --RT
• Concurrent chemotherapy with radiation therapy
• Radiation therapy alone.
• This landmark trial demonstrated improved larynx preservation rates and
improved locoregional control with concurrent chemoradiation therapy
compared with induction chemotherapy followed by radiation or radiation
therapy alone for patients with stage III and IV laryngeal carcinoma.

34. Yamazaki et al. (T1N0M0 glottic)
• hypofractionation vs standard fractionation in early-stage larynx cancer.
• 2.25 Gy/day VS 2.0 Gy/day
• shorter total treatment duration time
• RESULTS:
The 5-year local control improved ( 77% to 92% ) with hypofractionation.
without a significant increase in toxicity.
• CONCLUSION:
This landmark trial helped change the standard of care in favor of using such
modest hypofractionation in the curative-intent management of stage I patients with
laryngeal carcinoma.