carcinoma larynx treatment recomendations

1. Treatment of Carcinoma
Larynx
Dr. A Nikhil Kumar

2. Anatomy of larynx

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

16. Carcinoma
glottis

17. Carcinoma glottis

18. Carcinoma glottis

19. Carcinoma sub glottis

20. Carcinoma sub 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

35. Monoisocentric technique

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

44. Anterior lower
neck treatment
portal

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