Larynx
- 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
- 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
- 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.