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1. Laryngeal
CancerDr ANKITA SINGH PATEL
MBBS,MD(KGMU)
CONSULTANT
Apex Hospital Cancer Institute
TRAINING AND FELLOWSHIP
Fortis Research Institute ,New Delhi
Tata Memorial Hospital,MUMBAI
Mob. 8765845035,9305421547
Email: dr.ankitapatel.onco@gmail.com
WEBSITE: www.apexhospitalvaranasi.com
2.
3. Anatomy – subdivision
SITE SUBSITE
Supraglottis Suprahyoid epiglottis
Infrahyoid epiglottis
Aryepiglottic fold(Laryngeal aspect)
Arytenoids
Ventricular bands (false cord)
Glottis True vocal cords , including ant & Posterior
commissure
Subglottis Subglottis
APEX HOSPITAL CANCER INSTITUTE
5. Patient-related
factors
• Age and gender: MC after age 55.
M:F 4:1
• Lifestyle: cigarette, cigar, and pipe smoking (2–
25× increase) and heavy alcohol consumption (2–
6× increase)
• Past medical history
• Weakened immunity
Environmental
factors
Industrial chemicals: sulfuric acid mist, nickel
or wood dust, or asbestos
RISK FACTORS
APEX HOSPITAL CANCER INSTITUTE
6. INCIDENCE OF CANCER BY SUBSITE
Larynx
Supraglottic 35%
Glottic 65%
Subglottic <1%
Hypopharynx
Pyriform sinus 65%
Pharyngeal wall 20%
Postcricoid 15%
7. Routes of spread for laryngeal
and hypopharyngeal cancer
Stage
Local
Extension
1. Most common manner of spread
2. Spread to cartilages initially causes sclerosis f/b erosion
3. Additional growth results in destruction and penetration of the
cartilages (and precludes laryngeal-preservation strategies)
Regional
lymph node
Metastasis
1. Lymphatic drainage depends on the Extent of primary tumor
origin of the primary disease
2. Hypopharyngeal tumors can spread to the retropharyngeal
nodal chain
Distant
Metastasis
Bones , lungs
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8. Lymph node groups commonly involved
in laryngeal and hypopharyngeal cancer
Site Ipsilateral nodes (%) Contralateral nodes (%)
I II III IV V I I I III IV V
Supraglottic
larynx
1% 39% 26% 8% 0% 5% 12% 5% 3% 3%
Hypopharynx 1% 58% 42% 16% 11% 0% 7% 3% 1% 1%
Hypopharyngeal tumors also spread to the retropharyngeal lymph nodes
Source: Lindberg RD (1972) Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory
and digestive tracts. Cancer 29:1446–1449
APEX HOSPITAL CANCER INSTITUTE
9. Commonly Observed Signs and Symptoms in
Laryngeal and/or Hypopharyngeal Cancer
STAGE DESCRIPTION
Early laryngeal •Hoarseness
•Change in voice quality
Early hypopharyngeal oDifficulty swallowing
oCervical adenopathy
Advanced laryngeal
and/or hypopharyngeal
Hoarseness
Difficulty swallowing
Cervical adenopathy
Weight loss
Throat pain/referred pain in ear/s
Airway obstruction
10. AJCC TNM classification of carcinoma of
SUPRAGLOTTIS
Stage Description
Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Supraglottis
T1 Tumor limited to 1 subsite of supraglottis, with normal vocal cord mobility
T2 Tumor invades mucosa of more than 1 adjacent subsite of supraglottis or
glottis or region outside the supraglottis, without fixation of the larynx
T3 Tumor limited to larynx with vocal cord fixation and/or invades any of the
following: postcricoid area, preepiglottic space, paraglottic space, and/or
inner cortex of thyroid cartilage
T4a Moderately advanced local disease: Tumor invades through the thyroid
cartilage and/or invades tissues beyond the larynx
T4b Very advanced local disease: Tumor invades prevertebral space, encases
carotid artery, or invades mediastinal structures
11. GLOTTIS
T1a Tumor limited to 1 vocal cord with normal mobility
T1b Tumor involves both vocal cords with normal mobility
T2 Tumor extends to supraglottis and/or subglottis, and/or with impaired
vocal cord mobility
T3 Tumor limited to the larynx with vocal cord fi xation and/or invasion of
paraglottic space, an/or inner cortex of the thyroid cartilage
T4a Moderately advanced local disease: Tumor penetrates the outer cortex
of the thyroid cartilage and/or invades tissues beyond the larynx
T4b Very advanced local disease: Tumor invades prevertebral space, encases
carotid artery, or involves mediastinal structures
12. SUBGLOTTIS
T1 Tumor limited to the subglottis
T2 Tumor extends to vocal cord(s) with normal or impaired mobility
T3 Tumor limited to larynx with vocal cord fixation
T4a Moderately advanced local disease: Tumor invades cricoid or
thyroid cartilage and/or invades tissues beyond the larynx
T4b Very advanced local disease: Tumor invades prevertebral space,
encases carotid artery, or involves mediastinal structures
13. HYPOPHARYNX
T1 Tumor limited to 1 subsite of hypopharynx and/or ≤2 cm in greatest
dimension
T2 Tumor invades more than 1 subsite of hypopharynx or an adjacent site,
or measures >2 cm but ≤4 cm in greatest dimension
T3 Tumor >4 cm in greatest dimension or with fi xation of hemilarynx or
extension to esophagus
T4a Moderately advanced local disease: Tumor invades thyroid/cricoid
cartilage, hyoid bone, thyroid gland, or central compartment soft tissue
includes prelaryngeal strap muscles and subcutaneous fat
T4b Very advanced local disease: Tumor invades prevertebral fascia, encases
carotid artery, or involves mediastinal structures
14.
15. STAGE GROUPING
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III
T3 N0 M0
T1-3 N1 M0
Stage IVA
T4a N0-1 M0
T1-4a N2 M0
Stage IVB
T4b any N M0
any T N3 M0
Stage IVC any T any N M1
Early
stage
Advanced
stage
16. Picture of glottic squamous cell carcinoma of the
larynx. The tumor involves the anterior half of
the left vocal cord.
APEX HOSPITAL CANCER INSTITUTE
19. MULTIDISCIPLINARY TEAM
• The management of patients with head and neck cancers is complex.
• All patients need access to the full range of support and specialists with the expertise in the management of
patients with head and neck cancer for optimal treatment and follow up.
Head and neck surgery Speeech and swallowing therapy
Radiation oncology Clinical social work
Medical oncology Nutrition support
Plastic and reconstructive
surgery
Pathology(Cyto and Histo)
Specialised nursing care Diagnostic radiology
Dentistry /Prosthodontics Physical Medicine and
rehabilitation
APEX HOSPITAL CANCER INSTITUTE
20. LARYNX /HYPOPHARYNX CANCER SUSPECTED
COMPLETE HISTORY AND PHYSICAL EXAMINATION
ENDOSCOPY AND BIOPSY
IMAGING LAB STUDIES INTERVENTION
• CT or MRI or PET-CT
With contrast and
thin cuts of primary
and neck
• CECT Thorax
• CBC
• Serum Chemistry
•Dental Prophylaxis if
upper neck nodes
require irradiation
•Speech and Swallowing
evaluation if needed
APEX HOSPITAL CANCER INSTITUTE
21. ADVERSE FEATURES warrenting
adjuvant treatment
• Extracapsular nodal spread
• +ve margin
• pT3,4
• N2,N3 nodal disease
• Perineural invasion
• Vascular embolism(lymphovascular invasion)
APEX HOSPITAL CANCER INSTITUTE
23. CLINICAL
STAGING
TREATMENT OF
PRIMARY AND
NECK
ADJUVANT TREATMENT
Carcinoma in
situ
Endoscopic
resection(preferred)
Or
RT
Amenable to
Larynx
preserving(c
onservation)
surgery (T1-
T2 or select
T3)
RT
Partial laryngectomy /
endoscopic or open
resection as indicated
or neck desection as
indicated.
No adverse
features
OBSERVE
Adverse
features
CRT/RT
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24. CLINICAL
STAGING TREATMENT OF PRIMARY AND NECK
T3
requiring(
amenable
to total
laryngecto
my)
(N0,N1)
RT/CRT
PRIMARY SITE:
CR (N0)
PRIMARY SITE: CR
(N+)
Residual in
neck
Neck dissection
CR Post
treatment
evaluation
-ve Observ
e
Neck
dissecti
on
+v
Primary site: residual
tumor
Salvage
surgery and
neck
dissection
SURGERY
N0 : Laryngectomy
with I/L
thyroidectomy
No adverse
features
N1: Laryngectomy
with I/L
thyroidectomy as
indicated, I/L neck
dissection , or B/L
neck dissection
adverse
features
CRT
Induction
chemother
apy APEX HOSPITAL CANCER INSTITUTE
25. CLINICAL
STAGING TREATMENT OF PRIMARY AND NECK
T3
requiring(am
enable to total
laryngectomy
) (N2,N3)
CRT/RT
PRIMARY SITE:
Complete clinical
response
Residual in
neck
Neck
dissection
Complete
clinical
response of
neck
Post
treatment
evaluation
-ve Observe
Neck
dissection
+v
Primary site:
residual tumor
Salvage
surgery and
neck
dissection
Surgery
Laryngectomy with
I/L thyroidectomy
as indicated, I/L
neck dissection , or
B/L neck dissection
No adverse
features
adverse
features
CRT/RT
Induction
chemother
apy
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26. RESPONSE ASSESSMENT
Response
after
induction
chemother
apy
Primary
site: CR Definitive
RT
Residual
in neck
Neck dissection
CR of neck Post treatment
evaluation
-ve Observe
+ve Neck
dissection
Primary site
: PR
RT / CRT CR Observe
Residual Salvage
surgery
Primary site
<PR Surgery
No
adverse
features
RT
Adverse
features
ECE +/ +ve margin CRT
Other risk factor CRT
27. CLINICA
L
STAGING
TREATMENT OF PRIMARY AND NECK
T4a,any N Surgery
N0 Total laryngectomy +
thyroidectomy as indicated +- U/L
or B/L neck dissection
RT
Or
CRT
Observe for highly selective
cases
N1 Total laryngectomy +
thyroidectomy as indicated + I/L +-
C/L neck dissection
N2-3 Total laryngectomy +
thyroidectomy as indicated +- I/L
or B/L neck dissection
Selected
T4a
patients
who
decline
surgery
CRT Primary
Site:Complet
e clinical
response
Residual in neck Neck
dissection
CR of neck Post treatment
evaluation
-ve Observatio
n
+ve Neck
dissection
Primary Site:
Residual
tumor
Salvage surgery
and neck
dissection
Induction
chemo APEX HOSPITAL CANCER INSTITUTE
31. CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
Amenable to
larynx-
preserving
(conservatio
n)
surgery(T1-2
,N+ and
selected
T3,N1)
CRT/RT Primary
site:CR
Residual in neck Neck
dissection
(ND)
CR of neck Post
treatment
evaluation
-ve obs
+ve ND
RT Primary
site:
residual
tumor
Salvage surgery +neck dissection as
indicated
Partial
Supraglottic
laryngectomy
and neck
dissection
No adverse
feature
Observe / RT
Adverse
feature
CRT/RT
Induction
chemotherap
y
APEX HOSPITAL CANCER INSTITUTE
32. CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
Requiring
(amenable
to) total
laryngectom
y(Most
T3,N2-N3)
CRT/RT Primary
site:CR
Residual in neck Neck
dissectio
n
(ND)
CR of neck Post
treatment
evaluation
-ve obs
+ve ND
Primary
site:
residual
tumor
Salvage surgery +neck dissection as
indicated
Laryngectom
y,I/L
thyroidectom
y with neck
dissection
No adverse
feature
RT
Adverse
feature
CRT/RT
Induction
chemotherap
y APEX HOSPITAL CANCER INSTITUTE
33. RESPONSE ASSESSMENT AFTER NACT
Response
after
induction
chemothera
py
Primary
site: CR Definitive
RT
Residual in
neck
Neck dissection
CR of neck Post treatment
evaluation
-ve Observe
+ve Neck
dissection
Primary
site : PR
RT
Or
CRT
CR Observe
Residual Salvage
surgery
Primary
site <PR Surgery
No adverse
features
RT
Adverse
features
RT/CRT
APEX HOSPITAL CANCER INSTITUTE
34. CLINICAL
STAGING
T4a,N0-
N3
Laryngectomy ,
thyroidectomy
as indicated with
I/L or B/L neck
dissection
Risk factor + RT/CRT
T4a,N0-
N3
patients
who
decline
surgery
RT/CRT
Primary
Site: CR
Residual neck Neck dissection
CR
Neck
Post
treatment
evaluation
-ve Observe
+ve Neck
dissection
Primary
Site:
Residual
disease
Salvage surgery + neck dissection
Induction
chemotherapy APEX HOSPITAL CANCER INSTITUTE
36. CLINICAL
STAGING
TREATMENT OF
PRIMARY AND
NECK
PATHOLOGY
STAGE
ADJUVANT
TREATMENT
Most T1N0 ,
Selected T2NO ,N0
Amenable to larynx
preserving
(conservation)
surgery
Definitive RT
Pimary
Site:Complete
clinical response
Pimary Site:
residual tumor
Salvage surgery +
neck dissection as
indicated
Surgery: Partial
laryngopharyngect
omy (open or
endoscopic ) + I/L
or B/L neck
dissection.
No adverse feature
Adverse feature RT/CRT
APEX HOSPITAL CANCER INSTITUTE
37. CLINICAL
STAGING
TREATMENT
T2-3 , any N
if requiring
(amenable to
)
pharyngecto
my with total
laryngectom
y);
T1,N+
Induction
Chemotherapy
CR RT/CRT
PR Surgery or RT/CRT
Laryngophary
ngectomy +
neck
dissection
Including level
VI
No adverse features
Adverse
features
CRT/RT
CRT/RT Primary
site:compl
ete clinical
response
Residual in neck Neck dissection
Complete
clinical
response
of neck
Post
treatment
evaluation
-ve Observe
+ve Neck
dissectio
n
Primary
site :
residual
tumor
Salvage surgery + neck dissection as
indicated
APEX HOSPITAL CANCER INSTITUTE
38. CLINICAL
STAGING
T4a,any N Surgery and Neck dissection Adverse features RT/CRT
Induction
chemother
apy
CR/PR CRT/RT
<PR or
progression
Salvage surgery + neck
dissection
No adverse features
Adverse
features
RT/CRT
CRT/RT Primary site:
complete
clinical
response
Residual in neck Neck dissection
Complete
clinical
response of
neck
Post
treatment
evaluation
Negative Observe
Positive Neck
dissection
Primary site :
residual
tumor
Salvage surgery + neck dissection as indicated
APEX HOSPITAL CANCER INSTITUTE
39. SUMMARY OF GUIDELINE
STAGE TREATMENT
Tis Endoscopic removal (stripping/laser) or
definitive RT
T1-2N0
glottic
Definitive RT. Advantage of RT is that failures
can be salvaged with partial laryngectomy
and still have third chance with salvage total
laryngectomy.
Alternative, cordectomy or
partial laryngectomy ± selective neck dissection.
Post-op RT for close/+ margin, PNI, LVSIv
APEX HOSPITAL CANCER INSTITUTE
41. Resectable
T1-2N+,
T3N0/+
requiring
total
laryngectomy
Concurrent chemo-RT as in RTOG 91–
11(preferred).
If < CR , salvage surgery and neck dissection may be
performed.
If residual neck mass or initial N2-3, post-RT neck
dissection
Considered
Alternative is total laryngectomy, and I/L or B/l (N0-1)
or bilateral comprehensive neck dissection (N2-3).
Post-op chemo-RT high risk disease.
Induction chemo × 3c may be considered.
If CR or PR, proceed with concurrent chemo-RT
as above.
If < PR or progression, proceed to
surgery and neck dissection as indicated
42. Resectable
T4N0/+
Total laryngectomy and I/L or B/L neck dissection
followed by post-op chemo-RT
Alternative for selected patients is definitive
concurrent chemo-RT as in RTOG 91–11.
Induction chemotherapy may be considered
Unresectable
T3-4 or N+
Concurrent chemo-RT.
If unable to tolerate chemo, definitive RT with
concomitant boost
(CB) and consider concurrent cetuximab
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43. HYPOPHARYNX
Early T1-2 not
requiring total
laryngectomy (T1N0-1,
small T2N0, T1N2)
Definitive RT.
If < complete response, salvage
surgery and neck dissection as
indicated.
If complete response, neck dissection
considered
for N2-3
Alternatively,
partial laryngopharyngectomy and I/L
or B/L selective neck dissection (N0) or
comprehensive neck dissection (N+).
Post-op chemo-RT for high risk factors.
APEX HOSPITAL CANCER INSTITUTE
44. T2-4N0/+
requiring
total
laryngectomy
Concurrent chemo-RT as extrapolated from RTOG 91–11.
Or, induction chemo ×2c (with a third cycle if PR).
If CR at primary site, proceed with definitive RT (³70 Gy).
If primary site has only PR, proceed with concurrent chemo-
RT.
Nonresponders to induction chemo should undergo surgery
→ post-op RT or chemo-RT as indicated.
If residual neck mass after definitive RT or initial N2-3, post-
RT neck dissection considered
Or, laryngopharyngectomy and selective (N0) or
comprehensive neck dissection (N+ or T4).
Post-op chemo-RT forhigh risk factors.
Unresectable
T3-4
or N+
Concurrent chemo-RT. If unable to tolerate
chemo, definitive RT with CB
APEX HOSPITAL CANCER INSTITUTE
45. FOLLOW-UP SCHEDULE AND EXAMINATIONS
SCHEDULE FREQUENCY
First follow-up 2 weeks after radiation therapy
Years 0–1 Every month
Years 1–2 Every 2 months
Years 2–3 Every 3 months
Years 3+ Every 6 months
APEX HOSPITAL CANCER INSTITUTE
46. 1. Posttreatment baseline imaging recommended, and thereafter, as
clinically indicated.
2. CXR annually.
3. TSH every 6–12 month if neck irradiated.
4. Speech, swallow, dental, and hearing evaluations and
rehabilitation as indicated.
5. Smoking cessation counseling
If recurrence is suspected but biopsy is negative,
follow closely (at least monthly) until it resolves.
APEX HOSPITAL CANCER INSTITUTE
47. STAGE 2/5 YEAR OS SURVIVAL
LARYNX HYPOPHARYNX
2 year 5 year 2 year 5 year
I 95 % 88% 65% 35%
II 80% 60% 60% 30%
III 70% 50% 50% 30%
IV 60% 35% 35% 15%
Used with permission from the American Joint Committee on
Cancer (AJCC), Chicago, IL. APEX HOSPITAL CANCER INSTITUTE
58. TECHNICAL ESSENTIALS OF
EXTERNAL BEAM RADIATION
Co60 machine Linear Accelerator
APEX HOSPITAL CANCER INSTITUTE.
Thankyou Cobalt for the service to mankind…Time to bid
goodbye…
58
59. Why to sacrifice if we have better
option !!
59
APEX HOSPITAL CANCER INSTITUTE.APEX HOSPITAL CANCER INSTITUTE
60. WHAT ARE THE MODERN
MODALITIES?
ARE THEY BETTER THAN
CONVENTIONAL TREATMENT?
60
APEX HOSPITAL CANCER INSTITUTE.APEX HOSPITAL CANCER INSTITUTE
72. TPS (Teletherapy Planning system)
(Xio , Monte Carlo Based Planning System as approved by US FDA and AERB)
09-04-2016
E
72
APEX HOSPITAL CANCER INSTITUTE
73. For small cancers in the vocal cords it is
possible to keep the radiation far away from
other normal structures
73
APEX HOSPITAL CANCER INSTITUTE.APEX HOSPITAL CANCER INSTITUTE
76. Patient comes at fixed time,gets treated in 5 min and goes back.
No admission
No iv infusion
Can do household work.
Daily Treatment76
APEX HOSPITAL CANCER INSTITUTE
