Larynx

* A CT scan should be done prior to biopsy so that abnormalities that may be caused by the biopsy are not confused with tumor. || Lymphatic spread from glottis cancer occurs only if the tumor extends to the supraglottic or subglottic areas. The subglottic area has few lymphatics. The lymphatic trunks pass through the cricothyroid membrane to the pretracheal (Delphain) lymph nodes in the region of the isthmus. The subglottic area also drains posteriorly through the cricotracheal membrane, with some trunks going to the paratracheal lymph nodes and others continuing to the inferior jugular chain. 1  See photos below for examples of lymph node chains in the neck. 3 || G1 Well differentiated squamous cell carcinoma. G2 Moderatelly differentiated squamous cell carcinoma G3 Poorly differentiated squamous cell carcinoma. G4 Undifferentiated 3 ||
 * ​ Epidemiology: || Cancer of the larynx is the most common head and neck cancer, excluding skin cancers. There is about a 2% total cancer risk. 1  Most laryngeal cancers are glottic (60-65%), 30-35% arise in the supraglottis, and <5% in the subglottic sites. The male-to-female ratio is 4.5:1, with a peak incidence in the sixth and seventh decades of life. 2 ||
 * Etiology: || Heavy tobacco use and alcohol consumption are common causative factors. A person who smokes 30 cigarettes per day is 18 times more likely and a daily cigar smoker who does not inhale is 10 times more likely to develop laryngeal cancer than a nonsmoker. 2 ||
 * Signs & Symptoms: || * Glottic carcinomas usually present with persistant hoarseness. This is much less common with supraglottic carcinomas, which usually present with sore throat.
 * Referred otalgia (ear pain) is not uncommon with supraglottic lesions.
 * Advanced exophytic carcinomas can cause dyspnea.
 * Cervical lymphadenopathy, especially jugulodigastric, may be a presentation of supraglottic carcinoma, but virtually never of glottic carcinoma. 2 ||
 * Diagnostic Procedures: || <span style="color: #800000; font-family: Arial,Helvetica,sans-serif;">* Fiber-optic illuminated endoscopes (rigid and flexible) are used routinely to complement the laryngeal mirror examinations.
 * <span style="color: #800000; font-family: Arial,Helvetica,sans-serif;">A CT is preferred to MR because the longer scanning time for MRI resulting in motion artifacts. <span style="color: #800000; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">1
 * Histology: || <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">95% of diagnosed cases are squamous cell carcinoma. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">4 ||
 * Lymph Node Drainage: || <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">The supraglottic structures mainly drain by way of the subdigastric lymph nodes; a few drain to the middle internal jugular chain lymph nodes.
 * || [[image:Head_and_neck_nodes_rev.jpg width="391" height="290" align="left"]] ||
 * Metastatic Spread: || <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">Direct invasion, lymphatics. <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">3 ||
 * Grading: || <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">Gx Grade of differantion cannot be assessed
 * Staging: || <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">AJCC/TNM

Glottic T1 Confinement to true vocal cords: normal mobility; includes anterior or posterior commissure T2 Supraglottic or subglottic extension: normal or impaired mobility T3 Confinement to larynx proper; cord fixation T4 Cartilage destruction and/or extension out of larynx Supraglottic T1 confinement to site of origin; normal mobility T2 Extension to glottis or adjacent supraglottic site: normal or impaired mobility T3 Confinement to larynx proper: cord fixation and/or extension into hypopharynx or preepiglottic space T4 Massive tumor; cartilage destruction and/or extension out of larynx Subglotic T1 Confinement to subglottic region T2 Glottic extension; normal or impaired mobility T3 Confinement to larynx proper: cord fixation T4 Massive tumor: cartilage destruction and/or extension out of larynx <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">3 || -The voice begins to improve approximately 3 weeks after completion of treatment, usually reaching a plateau in 2 to 3 months. -Edema of the larynx is the most common sequelae after irradiation for glottic or supraglottic lesions. It may be accentuated by prior radical neck dissection and may require 6 to 12 months to subside. -Soft tissue necrosis leading to chondritis occurs in less than 1% of patients, usually in those who continue to smoke. -Corticosteroids such as dexamethasone have been used to reduce radiation induced edema after recurrence has been ruled out by biopsy. If ulceration and pain occur, administration of an antibotic, e.g. tetracycline, may help. -It is unusual for patients to require a tracheotomy before irradiation unless severe lymphedema develops at the time of direct laryngoscopy and biopsy. In patients who have recovered from direct laryngoscopy and biopsy without obstruction, a tracheotomy rarely has been required during a fractionated course of irradiation. -Patients treated twice a day with 1.2Gy fractions (continuous course technique) to total doses of 74.0Gy usually have brisker acute reactions than those treated once a day with 2Gy fractions. Approximately 10% treated with b.i.d. irradiation require nasogastric feeding tubes because of difficulty in swallowing. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">1 ||
 * Radiation Side Effects: || <span style="color: #0000ff; font-family: 'Comic Sans MS',cursive;">​- <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The voice may improve as the tumor regresses during the first 2 to 3 weeks but it generally becomes horse again because of radiation induced changes, even as the tumor continues to regress.
 * Prognosis: || <span style="color: #0000ff; font-family: 'Comic Sans MS',cursive;">​ <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Prognosis for small laryngeal cancers that have not spread to lymph nodes is very good, with cure rates of 75% to 95% depending on the site, tumor bulk and degree of infiltraton. Although most early lesions can be cured by either radiation therapy or surgery. Patients with a preradiation hemoglobin level higher than 13 g/dl have higher local control and survival rates than patients who are anemic. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">8 <span style="color: #0000ff; font-family: 'Comic Sans MS',cursive;">

​ <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Overall Survival Table: <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">6 || <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">Vocal Cord Carcinoma: Radiation Therapy Techniques <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;"> T1: Thyroid notch (superior border) to inferior cricoid (inferior border). Flash anteriorly and posterior border depended on tumor extension. Total dose is 66 Gy in 2 Gy fractions. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">1 <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;"> See image of an Early Stage treatment field below. <span style="color: #00ff40; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">5
 * Treatments: || <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Vocal Cord Carcinoma: Recommended Treatment
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Early Stages: Radiation therapy preferred (90% control rate for T1 lesions & 70-80% control rate for T2 lesions). Surgery (hemilaryngectomy or cordectomy) if radiation fails.
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Advanced Stages: Total laryngectomy with or without radiation. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">1
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Advanced Stages: Total laryngectomy with or without radiation. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">1
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Supine, 4 or 6 MV, parallel-opposed equally weighted fields.

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T2: 4 cm X 4 cm to 6 cm X 6 cm (depending on tumor size). Total dose is 70 Gy in 2 Gy fractions. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">1 <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;"> See image of a Stage 2 treatment field below. <span style="color: #00ff40; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">5



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T3 & T4: Large fields to include the jugulodigastric and middle jugular nodes. The inferior jugular lymph nodes are included in a separate low-neck field. Total dose is 72 Gy in 2 Gy fractions or 74.4 to 76.8 Gy in 1.2 Gy fractions b.i.d. Field size is reduced to cover only the primary tumor after 45.6 Gy. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">1 <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;"> See image of a Stage 3 & 4 treatment field below. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">5

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 * || Supraglottic Carcinoma: Recommended Treatment

<span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Supraglottic Carcinoma: Radiation Therapy Techniques || <span style="color: #0000ff; display: block; font-family: Arial,Helvetica,sans-serif; text-align: center;">
 * Early Stages: Surgery, radiation therapy, or both. Combined treatment modality is used when there is advanced neck disease. Radiation is used to treat the primary lesion, and surgery is used to treat the neck disease. If both the primary lesion and neck disease are removed surgically, then radiation therapy is only used post-operatively if positive margins, positive nodes, or extra-capsular extension are present.
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Advanced Stages: Total laryngectomy, radiation therapy followed by total laryngectomy (if radiation fails), or neoadjuvant chemotherapy followed by radiation. <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">1
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Field size and dose are similar to those used for glottic tumors.
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">For T2 or greater, regional lymphatics must be treated (electron beams may be used to treat posterior cervical nodes to avoid overdosing the spinal cord).
 * <span style="color: #00ff00; font-family: Arial,Helvetica,sans-serif;">Post-op treatment: Total dose of 60-70 Gy in 2 Gy fractions, once per day, five days a week. Lower neck is treated to 50 Gy in 2 Gy fractions. For subglottic extension, an electron boost to the stoma for a total of 10 Gy in 2 Gy fractions using 10-14 MeV. <span style="color: #00ff40; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">1 ||
 * TD5/5: || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The organs at risk in the fields can include the brachial plexus, glottic larynx, parotid gland (one or both), the spinal cord and thyroid. Please see the table below for the TD5/5 information. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">6 <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Traditional TD5/5 doses are highlighted in red. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">7
 * Treatment Planning Photos: || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Digitally Reconstructed Radiographs (DRR) of Glottis. <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">9 <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">

<span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;"> || <span style="font-family: Arial,Helvetica,sans-serif;">References **<span style="font-family: Arial,Helvetica,sans-serif;"> 1. Chao KS, Perez CA, Brady LW. //<span style="font-family: Arial,Helvetica,sans-serif;">Radiation Oncology - Management Decisions, //<span style="font-family: Arial,Helvetica,sans-serif;"> 2nd ed: 265-274. Philadelphia, PA //<span style="font-family: Arial,Helvetica,sans-serif;">: //<span style="font-family: Arial,Helvetica,sans-serif;"> Lippincott, Williams & Wilkins, 2002. 2. Rubin P. //<span style="font-family: Arial,Helvetica,sans-serif;">Clinical Oncology - A multidisciplinary approach for physicians and students, //<span style="font-family: Arial,Helvetica,sans-serif;"> 8th ed: 435-6. Philadelphia, PA: W.B. Saunders Company, 2001. 3. Washington CM, Leaver D, eds. //<span style="font-family: Arial,Helvetica,sans-serif;">Principles and Practice of Radiation Therapy, 2 // <span style="font-family: Arial,Helvetica,sans-serif;">nd ed: 693-709. Philadelphia, PA: Mosby Inc, 2004. 4. Lenards, N. //<span style="font-family: Arial,Helvetica,sans-serif;">Clinical Oncology for Medical Dosimetrists: Larynx. // <span style="font-family: Arial,Helvetica,sans-serif;"> Course content - Larynx, Slide 6. December 2009. 5. Lenards, N. //<span style="font-family: Arial,Helvetica,sans-serif;">Clinical Oncology for Medical Dosimetrists: Larynx. // <span style="font-family: Arial,Helvetica,sans-serif;"> Course content - Larynx, Slide 9. December 2009. 6. Hansen Ek, Schrechter NR. Cancer of the Larynx and Hypoharynx. In: Hansen EK, Roach M. //<span style="font-family: Arial,Helvetica,sans-serif;">Handbook of Evidence-based Radiation Oncology, //<span style="font-family: Arial,Helvetica,sans-serif;"> 1st ed: 115-123. New York, NY: Springer, 2007. 7. MedPhysFiles. Compiled and distributed by Childress, N. <span style="font-family: Arial,Helvetica,sans-serif;">@http://www.medphysfiles.com/index.php?name=Downloads&file=details&id=4 <span style="font-family: Arial,Helvetica,sans-serif;">. Accessed June 9, 2009. 8. National Cancer Institute. Laryngeal Cancer (PDQ): Treatment. <span style="font-family: Arial,Helvetica,sans-serif;">[]. Accessed January 4, 2010. 9. Digitally Reconstructed Radiographs courtesy of Ginnie Dea, RT(T), Alta Bates Summit Comprehensive Cancer Center.
 * || [[image:RSagLarynx_rev.png width="256" height="228" align="left" caption="Glottis-Sagittal View"]] ||

Ginnie is bright blue. Bridget is green. Sheri is brown. Zack is purple.