Larynx Oncology and Technique

Oncology Summary
Composed of 3 regions; supraglottis (superior end, above vocal cords), glottis (region around vocal cords, holds thyroid cartilage) and the subglottis (region inferior to vocal cords). Ratio of glottic to supraglottic rumours is approx 3:1 (Head And Neck Cancer: a Multidisicplinary approach. Louis B. Harrison, Roy B. Sessions, Waun Ki Hong.)

Oncology
Majority (>90%) are squamous cell carcinomas. Majority of laryngeal epithelium is composed of squamous cells. Remainder may be adenocarcinoma, lymphoma, melanoma and sarcoma.

Epidemiology
5% of all carcinomas UK 2.5% of cancer deaths most common head and neck cancer.

Aetiology
risk factors include smoking, heavy drinkers and alcoholism, low socioeconomic status, previous malignancy

Ages of incidence
Peak incidence at 60-64 years. Rises rapidly from 40 years old, falling again after peak at 60-64. (graph from cancer research).

M:F ratio
More common in males. 18th most common cancer for males in the UK. Ratio of 5:1 between males and females. Male incidence: 1 in 175 Female incidence: 1 in 856

Signs and symptoms

Persistent lump in throat Persistent sore throat Hoarseness Nasal stuffiness Bad breath Dysphagia Enlarged lymph nodes in neck

Routes of spread
Dependant on region

Investigations
Neck palpation for presence of masses. Indirect laryngoscopy may allow visualisation of a tumour mass. If suspicious mass found, biopsy is performed.

Pathology
Staging and grading Staging determines treatment choice and options 0: carcinoma in situ, cancer cells in mucosa. Unsymptomatic. 1: carcinoma beginning to invade into tissues underlying mucosa surface. Vocal cords are still free. No lymphatic spread or invasion of surrounding structures. 2: cancer has grown to another area of larynx, may be affecting vocal cords causing hoarseness. No lymphatic spread or spread to other organs. 3: cancer has grown throughout larynx, but no spread to other areas of the body. May involve lymphatic spread. 4: advanced cancer 4a has direct spread through wall of larynx into surrounding tissues with possible lymph involvement of less than 3cm, or spread to a lymph node with a size between 3-6cm, or spread to a single lymph node with a size no greater than 6cm. 4b cancer has spread to at least one lymph node, and greater than 6cm. 4c cancer has spread to another part of the body (such as lungs).

Laryngeal cancer has 3 gradings:

1 low grade cancer cells which appear close to normal larynx cells. 2 intermediate grade cells have a moderate differentiation, and look slightly like normal larynx cells. 3 high grade cells appear very abnormal and have little similarity to healthy larynx cells. Lower grade cancers are normally slower growing and less likely to spread, while higher grade cancers are more aggressive.

Prognosis
1 year survival rate: 80% 5 year survival rate: 63% 10 year survival rate: 47% Women typically have lower survival rates than men. Dependant on stage and site of tumour. Lymphatic spread

Laryngeal technique:
Pre radiotherapy preparation
Advise to avoid/quit smoking and drinking.

Patient preparation
Head, neck and shoulder shell.

Localisation CT
Supine, head tilted up. Thermoplastic shell, 7 point. Arms by sides. No mouth bite.

Planning issues
Dose limiting structures are the spinal cord and the oesophagus. Head and neck SCCs respond well to high dose treatments, but the associated toxicity to surrounding structures limits potential for dose escalation. Acute side effects dominated by effects of radiation on skin and mucous membranes which in the head and neck area often lie close to the target volume. Anatomical position of tumour and related lymph nodes relative to the spinal cord contraindicated use of single phase delivery for conventional RT. Results in need for matching photon and electron fields around the spinal cord. Alternative is IMRT in single phase. In this case, IMRT can often be planned faster as a single phase treatment rather than a 2 or 3 phased treatment as with conventional RT. Extensive disease involves nodes/electrons/cord. Most larynx tumours picked up early, don't involve nodes.

Beam energy
4-6MeV Lat opp pair or oblique pair. Lat opp pair can come off cord and allow for dose escalation.

Fractionation schedule
Depends on nodal involvement. If nodal involvement 50Gy given to nodes, with the tumour site given 66Gy. Can be achieved using phased delivery or IMRT.

Typical IMRT regime:

PTV66 (primary tumour site) PTV60 (high risk nodal sites) PTV54 (elective nodal sites) Delivered in 30 fractions. 1cm margin around lymph nodes to cover any microscopic nodal extension.

Field arrangements and sizes

IMRT, 2 lats and an ant or two oblique fields

Beam modifications
MLCs, wedges to compensate for curvature of neck

Verification
2D 2D kV image matching FSDs

Special considerations
Patient care Speech and language therapy Dietician RRS Will experience erythema, or dry desquamation.

Alternative treatment Surgery is a common treatment for all stages of laryngeal cancer. The following surgical procedures may be used: Cordectomy:

Supraglottic laryngectomy Hemilaryngectomy Partial laryngectomy: Total laryngectomy: Thyroidectomy:. Laser surgery:

Some patients may be given chemotherapy kill any cancer cells that are left.