LARYNGEAL CANCER

By Brenna Deneher
 HEAD & NECK CANCER OVERVIEW
• Encompasses cancers of the oral cavity, pharynx,
larynx, paranasal sinuses, nasal cavity, and salivary
glands
• Represents approximately 4% of all cancers in the U.S.
• Twice as common in men than women
• More than 65,000 men and women are estimated to be
diagnosed with H&N cancer in 2017
 WHAT IS LARYNGEAL CANCER?
• Most common head and neck cancer
• The American cancer society estimates that in 2017 there will be approximately
13,360 new cases of laryngeal cancer in the U.S. alone—10,570 in men and 2,790
in women
• 3,660 of these individuals are predicted to die from this diease
• Commonly presents as squamous cell carcinoma
• Comprised of carcinomas arising in any of the three regions of the larynx:
supraglottis (30%), glottis (65%), and subglottis (5%)
• 3:1 glottic to supraglottic carcinoma primary incidence
• Male-dominated disease—90% of all cases
• Peak incidence between the ages of 50 and 60 years old
 ETIOLOGY
• Smoking
• Alcohol consumption
• Genetic predisposition
• P53 gene
• HPV
• Diet high in fats and red meat
• Exposure to asbestos, wood dust, paint, isopropyl alcohol, and formaldehyde
• Jobs that involve repetitive strain on vocal cords
• Older age
 Avoid tobacco and
•Tobacco is the number one causative factor behind
second hand smoke laryngeal cancer
exposure

•Alcohol increases the cancer-causing effect of

Reduce alcohol tobacco
consumption •Together alcohol and tobacco usage increase the risk
of developing laryngeal cancer

PREVENTION •Strong correlation between HPV and head & neck

cancers
•Smokers are more susceptible to HPV infections due to
a weakened immune system and damage to the cells
HPV Vaccine lining the throat
•Although HPV has the strongest correlation with the
development of pharyngeal cancers, there is still a
weak correlation laryngeal
•Gardasil vaccine now protects against 9 strains of HPV

•#OperationOral—campaign geared toward public

Screening education on HPV and non-HPV associated oral
cancer

Maintain Healthy Diet

 #OPERATION ORAL PROJECT
• Social media campaign aimed at educating young people on the
prevalence of HPV related head and neck cancers along with the
importance of vaccination
• Started in 2015 by two dental students at the University of South Carolina
• Traveled across the US providing free head and neck screenings to promote
awareness
• Early detection
 COMMON PRESENTING SIGNS
AND SYMPTOMS
• Hoarseness
• Sore throat
• Persistent cough
• Lump in the neck or throat
• Dyspnea
• Odynophagia
• Pain when swallowing
• Ear pain
 SIDE EFFECTS & MANAGEMENT
• Mucositis—Painful inflammation & ulceration of the mucous membranes ~ 30 Gy
• Magic mouth wash
• Salt and baking soda gargles
• Pain meds
• Xerostomia—Dry mouth due to reduction of saliva ~ 10 to 20 Gy
• Biotene
• Salt and baking soda gargles
• Humidifier by bed
• Increase fluid intake
• Erythema—Reddening of the skin due to congested capillaries ~ 20 to 30 Gy
• Apply moisturizing lotion—the DOES NOT contain alcohol—at least once a day (but not 4 hours before treatment)
• Avoid exposing skin to extreme temperatures and shaving
• Dry Desquamation—Shedding of outermost layer of skin ~ 30 to 40 Gy
• Lidocaine may be added to the lotion
• Aquaphor to relieve pain/tenderness
• Moist Desquamation—Skin that weeps as it thins and sloughs off ~ 40 to 50 Gy
• Aerate skin
• Silver sulfadiazine, Burrow’s compress, hydrogel sheets, Domboro’s solution
 LARYNX ANATOMY &
ANATOMICAL BOUNDARIES
• Supraglottis—the area above the vocal
cords
• Contains the epiglottis
• False vocal cords are located here
• Borders—Top of the epiglottis to 1cm
superior of the true vocal cords
• Glottis—Area containing the true vocal
cords
• Subglottis—Area below the vocal cords
• Borders—1cm inferior of the true
vocal cords to the bottom of the
cricoid cartilage (approx. C6
vertebral level)
ANATOMY
 LYMPH NODE DRAINAGE
• Supraglottic:
• Jugulodigastric node
• Superior, deep, and mid jugular
nodes
• Rouviere’s node
• 50% of patients have lymph
involvement at the time of diagnosis
• Glottic:
• Rarely spreads to the lymph nodes
except in tumors extending beyond
the borders of the larynx (T3 or T4)
• Subglottic:
• Pretracheal nodes, prelaryngeal
(Delphian) node, paratracheal
nodes, deep cervical nodes, and
supraclavicular nodes
 METASTASIS
• Recurrence or metastasis usually occurs within the first 2 to 3 years following
treatment
• Common metastatic sites:
• Lung
• Liver
• Bone
• Routes of Spread:
• Blood
• Lymph
• Direct invasion
 DIAGNOSTIC STUDIES
• Biopsy
• Laryngoscopy
• Endoscopy
• CT—with or without contrast
• MRI
• PET-CT
• Bone scan
 LARYNX STAGING—PROGNOSTIC GROUPS
(T)
• T1a—Tumor is confined to 1 true
vocal cord with normal mobility
• T1b—Tumor involves both vocal
cords but mobility is normal
• T2—Tumor extends to the
supraglottis, and/or subglottis,
and/or impairs vocal cord mobility
• T3—Tumor causes total vocal cord
fixation but does not extend
beyond the borders of the larynx
• T4a—Tumor invades through the
thyroid cartilage and/ to other
tissues beyond the larynx (i.e.
trachea, thyroid, pharynx, soft
tissues
• T4b—Tumor invades pre-vertebral
space, encases the carotid artery,
or invades the mediastinum
(N) (M)
• NX—Regional metastasis cannot • MX—Distant metastasis cannot be
be assessed assessed
• N0—No evidence of regional • M0—No distant metastasis
metastasis to the cervical lymph • M1—Distant metastasis present
nodes
• N1—Disease present in a single
neck node of up to 3 cm in
greatest dimension
• N2—Disease present in a single
neck node greater than 3 cm but
less than 6 cm in greatest
dimension or present in multiple
nodes
• N3—Disease present in any node
greater than 6 cm in greatest
dimension
 ANATOMIC STAGING
STAGE (T) (N) (M)
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
III T1-3 N1 M0
IVA T4 N0-N1 M0
IVA T1-4 N2 M0
IVB T1-4 N3 M0
IVC T1-4 N0-3 M1
 TREATMENT CONSIDERATIONS
• Historically, larynx cancer treatment utilized aggressive surgery as a means of
achieving cure
• Today, it is understood that survival cannot be measured solely in terms of
mortality
• Treatment options now evaluate a variety of factors
• Quality of life after treatment
• Voice preservation—loss of vocalization can have both huge psychological and
socioeconomic effect
• Cosmetic outcome
• Maintenance of an airway
• Stage is the biggest consideration
 MOST COMMON TREATMENT—
EARLY STAGE
• Most commonly utilize radiation with concurrent chemo
• 5-FU
• Cisplatin
• Parallel opposed lateral fields
• 5x5 or 6x6 with wedges
• 2D or 3D planning
• Doses between 6000 and 7000 cGy
• 200 to 225 cGy per fraction
LATERALS ONLY
LATERALS ONLY ISODOSE LINES
LATERALS ONLY DVH
 MOST COMMON TREATMENT—
MID-STAGE
• Surgery & pre or post operative radiation therapy
• Previously did supraglottic laryngectomy
• Partial laryngectomy
• Chemotherapy used when there are positive margins post op
• 5-FU
• Cisplatin
• Superficial tumors may tx with EBRT alone
• IMRT with or without supraclav field
• Dose can vary from 5000-7000 cGy
• 200 to 225 cGy/fxn
 MOST COMMON TREATMENT—
LATE STAGE
• Total laryngectomy
• IMRT radiation treatment
• Dose between 6000-7000 cGy
• Large fields to include nodes
• Chemotherapy
• 5-FU
• Cisplatin
IMRT DOSE DISTRIBUTIONS
 TREATMENT OPTION 2—IMRT FOR
EARLY STAGE
• IMRT treatment planning is typically utilized for late stage laryngeal cancer so
the PTV can be shaped to modulate dose to the lymph nodes
• IMRT for early stage allows for reduction of dose to the carotid arteries
• In the case of recurrence, carotid dose can be a limiting factor when it comes
to treatment options
• High carotid dose can lead to vascular disease, carotid artery stenosis, and
increased risk of ischemic stroke
• Doctor must be confident in the GTV borders to allow for proper PTV margin
placement
• Studies have found the 10 year incidence of cerebrovascular events in
patients treated with radiation therapy alone is approximately 34%
• IMRT should be utilized to reduce dose to critical structures even in early stage
patients
 OPTION 3—TRANSORAL LASER MICROSURGERY
FOR EARLY STAGE LARYNGEAL CARCINOMA
• Transoral laser microsurgery is an innovative technique that replaces more
invasive laryngectomy resection procedures with a single outpatient
procedure
• Local control rates between 75% and 93%
• 97% survival rate over a 5 year period
• Smaller tumors treated with TOML had better voice outcomes than partial
laryngectomy
• TOML offers shorter treatment and recovery times, reduced hospital stay,
and preservation of treatment options in the case of recurrence
• Comparable results to radiation therapy, but TOML is much cheaper
 PERSONAL OPINION
• Radiation therapy offers the best voice outcomes for laryngeal cancer
patients
• For this reason, it should be attempted first for early stage larynx cancer before
surgery
• IMRT treatment planning should be utilized over opposed laterals
• It allows more treatment options in the case of recurrence because dose to
critical structures can be kept low
• Reduces the risk of cardiovascular incidents due to carotid artery toxicities
• Can produce highly conformal dose distributions with steep dose gradients to
target areas of concern while sparing nearby critical organs
 REFERENCES
• Laryngeal and Hypopharyngeal Cancer. American Cancer Society.
https://www.cancer.org/cancer/laryngeal-and-hypopharyngeal-cancer.html. Accessed
November 1, 2017.
Washington CM, Leaver DT. Principles and practice of radiation therapy. St. Louis, MO:
Elsevier Mosby; 2016.
• Gomez D, Cahlon O, Mechalakos J, Lee N. An investigation of intensity-modulated
radiation therapy versus conventional two-dimensional and 3D-conformal radiation
therapy for early stage larynx cancer. Radiation Oncology. https://ro-
journal.biomedcentral.com/articles/10.1186/1748-717X-5-74. Published August 26, 2010.
Accessed November 1, 2017.
• Rubinstein M, Armstrong WB. Transoral laser microsurgery for laryngeal cancer: A primer
and review of laser dosimetry. Lasers in Medical Science. 2011;26(1):113-124.
doi:10.1007/s10103-010-0834-5.
• Berania I, Dagenais C, Moubayed SP, et al. Voice and Functional Outcomes of Transoral
Laser Microsurgery for Early Glottic Cancer: Ventricular Fold Resection as a
Surrogate. Journal of Clinical Medicine Research. 2015;7(8):632-636.
doi:10.14740/jocmr2216w.