Laryngeal

• 3 anatomical regions:

  • supraglottic = epiglottis, false vocal chords, ventricles, aryepiglottic folds, arytenoids
  • rich lymphatic drainage (jugulodiagastric + mid jugular)
  • glottic = true vocal chords, anterior and posterior commissures
  • no lymph nodes in true vocal chords
  • most common site of laryngeal cancer
  • subglottic = inferior to true vocal chords - lower border of cricoid cartilage of first tracheal ring
  • rare primary cancer
  • LN = paratracheal, pre tracheal, inferior jugular, mediastinal (sometimes)
• True / False: laryngeal is the most common type of head and neck cancer

  • true
• Etiology:

  • smoking
  • alcohol
  • HPV +
  • p53 mutation
  • poor nutrition and vitamin deficiency
  • lower socioeconomic status
• Clinical Presentation:

  Supraglottic:

  • dysphagia
  • enlarged lymph nodes
  • otalgia (CN X involvement)

  Glottic:

  • hoarseness of voice (develops early)
  • pharyngitis

  Subglottic:

  • no symptoms until locally extensive → hoarseness of voice
• Natural History:

  • glottic lesions: spread by local invasion to supraglottic and subglottic regions
  • lymphatic spread:
  • supraglottic: level II, III, IV
  • glottic: level II, III, IV, VI
  • bilateral or contralateral mets are rare - devoid of lymphatics
  • subglottic: level VI
  • mets: lung is most common site (others: mediastinal nodes, bone, liver)
• Prognostic Indicators:

  • Poor:
  • cord immobility
  • stage III and IV
  • close / positive surgical margins
  • perineurial, lymphovascular or extra capsular (nodal) spread
  • primary tumour in oral cavity
• Diagnostic Investigations:

  • physical exam → palpation of nodes
  • biopsy: endoscopic, fine needle aspiration
  • chest x ray → lung mets
• Pathology:

  • most: Squamous cell carcinoma (95%)
  • increased mortality due to advanced stage disease
  • non SCC: adenocarcinoma, rare sarcoma
  • keratin not present in cells
  • strong association with HPV positivity
• Early stage = stage 1 and 2
• Locally advanced = stage 3
• Advanced stage = stage 4
• T staging: supraglottic

  • stage I: one section of supra glottis (epiglottis, vocal folds)
  • stage II: multiple adjacent areas of supra glottis / into the glottis, vocal cords can move
  • stage III: confined to larynx, vocal cords cannot move, thyroid cartilage / 1 lymph node on same side of neck that is 3 cm or less
• T staging: glottic

  • stage I: only in vocal cords
  • stage II: top of larynx above vocal cords, bottom of larynx, below vocal cords - vocal cords do not move normally
  • stage III:
  • only in larynx, vocal cords cannot move
  • spread into 1 nearby lymph node on same side of neck as tumour (no larger than 3 cm)
• T staging: subglottic

  • stage I: confined to subglottis
  • stage II: vocal cords - may be impaired or able to move normally
  • stage III:
  • confined to larynx, vocal cords unable to move
  • spread to 1 lymph node on same side of neck that is 3 cm or less
• Stage IV for all cancers that start in larynx:

  • a: moderately advanced local disease
  • cricoid or thyroid cartilage, outside of larynx, soft tissue of neck, thyroid gland, esophagus
  • 1 node on same side between 3 - 6 cm
  • multiple nodes on same side, none larger than 6 cm
  • nodes on opposite side, none larger than 6 cm
  • b: very advanced local disease
  • area in front of spine, carotid artery, lungs
  • lymph node greater than 6 cm
  • c: distant organs → lungs, liver, bones
• Goal of laryngeal treatment:

  • laryngeal preservation to improve quality of life - best functional result and least risk of serious complication
• Types of Treatment:

  • depends on lymph node status of neck + presence of distant mets
  • surgery:
  • smaller, early stage = laser surgery, vocal cord stripping / cordectomy
  • larger, more advanced = partial laryngectomy + lymph node dissection
  • external beam radiation:
  • preserve voice
  • reserve surgery for salvage
  • post op → positive margins, subglottic extension
  • chemotherapy:
  • chemo RT, pre or post surgical, pre RT
  • cisplatin, docetaxel
  • biological therapy
  • cetuximab
  • cannot tolerate chemo RT
• Stage 1:

  • supra glottis:
  • EBRT = 66 - 74 Gy
  • surgery = laryngectomy
  • glottis:
  • EBRT = 66 - 74 Gy
  • surgery: laser excision, partial or hemi-laryngectomy, cordectomy, total laryngectomy
  • subglottis:
  • EBRT = 66 - 74 Gy
  • voice preservation
  • +/- surgery (if RT failure)
• Stage II:

  • supra glottis:
  • EBRT (tumour, LN) = PORT: 66 - 74 Gy
  • surgery: laryngectomy
  • glottis:
  • EBRT
  • surgery: laser or laryngectomy (partial, hemi, total)
  • subglottis:
  • EBRT - voice preservation
  • +/- surgery (if RT failure)
• Stage III:

  • supra glottis + glottis (add clinical trial):
  • concurrent chemo RT = neoadjuvant chemo → concurrent chemoRT (60 - 72 Gy)
  • definitive RT (if no concurrent chemo and surgery)
  • surgery +/- PORT
  • subglottis:
  • laryngectomy + thyroidectomy + tracheal node dissection + PORT
  • definitive RT (altered fractionation) + induction chemo
  • clinical trial
• Stage IV:

  • supra glottis + glottis:
  • same as stage III
  • + clinical trial: EBRT (60 - 72 Gy)+ targeted therapy
  • subglottis:
  • same as stage III + clinical trial
• Metastatic Disease:

  • surgery +/- EBRT
  • EBRT
  • chemotherapy
  • immunotherapy
  • clinical trial
• Radiation Therapy: glottis

  • setup:
  • 4 point shell
  • knee + ankle rest
  • energy: 6 MV
  • dose:
  • 66 Gy / 33 fractions = T1
  • 70 Gy / 35 fractions = T2
  • fields: lateral POP
  • sup: thyroid notch
  • inf: cricoid cartilage (C6)
  • ant: clear skin by 1 - 1.5 cm at vocal cords → anterior commissure of thyroid cartilage
  • post: between anterior edge and middle of vertebral body (anterior portion of pharyngeal wall)
  • may add bolus
• True / False: surgery is mainstay treatment for early stage disease

  • FALSE: Radiation is the mainstay of treatment for early disease
• RT: supraglottic

  • technique: IMRT or VMAT / conventional shrinking fields (off cord and below mandible)
  • dose: 66 - 70 Gy / 33 - 35 fractions
  • decrease dose if chemo
  • pro:
  • voice preservation, decrease carotid dose, decrease contralateral parotid dose
  • fields:
  • sup: along mandible (jugulodiagastric + middle jugular)
  • inf: inferior of clavicle
  • ant: clear skin
  • post: spinal accessory chain
• T3 treatment:

  • larger portals → include lymph nodes (level: II - IV)
  • bilateral coverage: 54 - 60 Gy
  • T3: larynx preservation

  T4 treatment:

  • larger portals + level VI nodes
  • larynx preservation rarely achievable
• TD 5/5:

  • spinal cord: myelitis
  • TD 5/5:
  • 5 cm: 50 Gy
  • 10 cm: 50 Gy
  • 20 cm: 47 Gy
  • larynx: edema
  • 45 Gy
  • thyroid: thyroiditis
  • 45 Gy
• Acute reactions:

  • increased voice hoarseness → rest voice
  • edema → maintain fluid and nutritional levels
  • erythema, dry and moist desquamation → skin care instructions
• Chronic reactions:

  • telangiectasia
  • hypothyroidism
  • malnutrition
• Rehab:

  • swallowing
  • esophageal dilation
  • speech
  • esophageal speech
• Hoarseness is early in glottic cancers

  • but late symptom for: supraglottic and subglottic cancer
• Early stage (T1 - T2) treated with: surgery or radiation
• Moderately advanced (T3) treated with: radiation +/- chemo
• Advanced (T4) treated with: surgery → post op chemo RT