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Oto Board Pearls of Wisdom - Section III Diseases, Disorders, and Conditions > 24 Neoplastic - Larynx > Flashcards

24 Neoplastic - Larynx Flashcards

1
Q

M/c site of laryngeal CA

A

glottis

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2
Q

What are the 7 different types of squamous cell aberrations occurring in the larynx?

A
  1. benign hyperplasia
  2. benign keratosis (no atypia)
  3. atypical hyperplasia
  4. keratosis with atypia or dysplasia
  5. intraepithelial carcinoma
  6. microinvasive SCCa
  7. invasive SCCa
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3
Q

What percent of pts with CIS of the VF will develop invasive SCCa after a single excisional bx?

A

1 in 6 (16.7%)

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4
Q

What is microinvasive SCCa of the VF

A

invades through BM but not into vocalis muscle

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5
Q

What is Ackerman’s tumor

A

Verrucous carcinoma, thought to be less radiosensitive and less likely to metastasize than SCCa

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6
Q

2 most imp factors predicting LN mets in laryngeal CA

A

tumor size and location

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7
Q

T/F: Once invasion of the laryngeal framework occurs, the ossified portions of cartilage have the least resistance to tumor spread

A

True

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8
Q

What percent of glottic tumors display perineural and vascular invasion

A

25%

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9
Q

What percent of pts w/ primary laryngeal CA will eventually develop a 2nd primary

A

10-20%

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10
Q

What is the stage of a transglottic tumor w/o VF fixation, cartilage invasion, or extension beyond the larynx

A

T2

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11
Q

What parts of the glottis are most difficult to treat with RT

A

Anterior commissure, posterior 1/3 of the VF

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12
Q

What percent of tumors at ant commissure and posterior 1/3 of VF will met to cervical LNs

A

25%

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13
Q

What are the 2 m/c reasons for tumor recurrence after hemilaryngectomy?

A

Inability to recognize the inferior tumor margin and spread of tumor through the cricothyroid membrane

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14
Q

What is the incidence of positive cervical nodes in pts with T3 glottic tumors

A

30-40%

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15
Q

Which type of laryngeal CA is most likely to met distally

A

Supraglottic

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16
Q

What is the m/c site of distant met from laryngeal CA

A

lungs

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17
Q

How does mets to lungs normally present

A

Multiple small lesions <3 mm that are difficult to detect on x-ray

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18
Q

Where does supraglottic CA most often begin

A

junction of epiglottis and false fold

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19
Q

What anatomic structure serves as a natural barrier to the inferior extension of supraglottic CA

A

Ventricle (embryologic development is completely separate from false cord)

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20
Q

Which kinds of supraglottic CA are more likely to extend inferiorly to the anterior commissure or ventricle – ulcerative or exophytic?

A

ulcerative

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21
Q

T/F: Stage I lesions of the supraglottis can be controlled equally well with RT or surgery

A

True

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22
Q

What is the risk of cervical mets in pts w/ T1, T2, T3, and T4 supraglottic tumors

A

20, 40, 60, 80%

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23
Q

What percent of pts undergoing supraglottic laryngectomy and u/l neck dissection will fail in the CONTRA neck

A

16% despite receiving RT to the area

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24
Q

What percent will fail if b/l neck dissections are performed

A

9%

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25
Q

What percent of laryngeal tumors are primarily subglottic

A

5%

26
Q

What are the differences b/w primary and secondary subglottic tumors?

A

Primary tumors are less common, usually present with stridor or dyspnea and at a more advanced stage, and have a worse survival time than secondary tumors.

27
Q

What is the primary site of lymph drainage for subglottic tumors

A

paratracheal nodes

28
Q

Compared with supraglottic and glottic tumors, subglottic tumors are at a much higher risk for developing what?

A

Stomal recurrence

29
Q

What is the tx of choice for primary subglottic CA?

A

TL, b/l ND, near total thyroid, paratracheal ND, postop RT to superior mediastinum and stoma; if the anterior cervical esophageal wall is involved, then laryngopharyngectomy with cervical esophagectomy instead of TL

30
Q

What was the 1st published RCT for organ preservation in H&N CA

A

The VA trial for SCCa of the larynx

31
Q

What were the VA tx arms and outcomes

A
  1. Surgery
  2. 2 cycles of cisplatinum and 5-FU
    a. responders received a 3rd cycle followed by RT
    b. Nonresponders had surgery +/- RT

No significant difference in survival among the 3 arms

32
Q

What were the 3 major RCT on organ preservation as tx for laryngeal CA

A

VA, GETTEC, EORTC

33
Q

What conclusions can be made based on meta-analysis of these 3 studies

A

The surgical patients had slightly higher (but not significant) survival advantage (6%). Among patients receiving chemotherapy, 58% were able to keep their larynx. Better outcomes were seen in patients with hypopharyngeal cancer who underwent chemotherapy than in those with laryngeal cancer.

34
Q

What is the best organ-sparing tx for a pt with stage III SCCa of the supraglottis

A

Induction chemo followed by RT

35
Q

What are the indications for postop RT after ND

A

multiple nodes or ECS

36
Q

What is the significance of the number of pathologically + nodes on prognosis

A

Greater than 3 nodes is a neg prognostic indicator

37
Q

T/F: chemosensitive tumors are usu radiosensitive

A

True

38
Q

Which types of RT beams are used for superficial tumors and why

A

electrons; finite range spares deeper tissue

39
Q

T/F: The dose of RT necessary to kill hypoxic cells is 2.5-3.0 times greater than than required to kill well-oxygenated cells

A

True, as free radical formation requires O2

40
Q

T/F: Cells undergoing DNA synthesis in the S phase are much more radiosensitive than cells in other phases of cell cycle

A

False; they are much more radioresistant in the S phase

41
Q

Which type of CA is most sensitive to RT: exophytic, infiltrative, or ulcerated?

A

Exophytic

42
Q

When, after RT is a + bx a reliable indicator of persistent dz

A

3 mo post-tx

43
Q

How do RT failures differ from surgical failures in site of recurrence

A

RT failures often occur in the center of areas that were grossly involved w/ CA initially, whereas surgical failures often occur at periphery of the original tumor

44
Q

What is the conventional fractionated RT

A

1.8-2.5 Gy every day, five fractions every week, for 4-8 weeks (total 60-65 Gy for small tumors, 65-70 Gy for larger tumors)

45
Q

How is altered fractionated schedule different?

A

Lower dose per fraction, 2 or more fractions every day, decreased overall tx time, with total dose same or higher

46
Q

What are the 2 categories of altered fractionation

A

accelerated and hyperfractionated

47
Q

What is the difference

A

Accelerated: Total dose is the same as conventional treatment, but overall treatment time is decreased.

Hyperfractionated: Overall treatment time is the same as conventional treatment, but total dose is increased, dose per fraction is decreased, and the number of fractions is increased.

48
Q

What impact does hyperfractionation have on locoregional control and survival rates compared with conventional therapy

A

significantly higher locoregional control and survival rates

49
Q

What were the results from the EORTC 22851 study comparing accelerated split-course XRT with conventional XRT

A

Accelerated course resulted in significantly higher late SE w/o significant locoregional control or survival advantage

50
Q

What were results of RTOG 9003 study evaluating acclerated tx w/ concomitant boost

A

Significantly higher locoregional control and survival rates w/ somewhat higher rate of late SE compared w/ conventional RT

51
Q

RT is not as effective for tumors with which characteristics

A

High volume, cartilage destroying, with bulky LN dz

52
Q

What is the max dose of RT to spinal cord

A

45 Gy (or inc risk of radiation myelitis)

53
Q

Advantages of planned preop RT

A
  • Unresectable tumors may be made resectable
  • Extent of surgical resection may be diminished
  • Tx portals preop are usu smaller than those used postop
  • Microscopic dz is more radiosensitive preop due to better blood supply
  • Viability of tumor cells that may be disseminated by surgical manipulation is diminished
54
Q

Disadvantages of planned preop RT

A
  • Wound healing is more difficult

- Dose that can be safelly delivered preop is less than that which can be given postop

55
Q

Advantages of postop RT

A
  • Anatomic extent of tumor can be determined surgically making it easier to define the tx portals required
  • Greater dose can be given postop
  • Total dose can be determined on basis of residual tumor burden after surgery
  • Surgical resection is easier and healing is better in nonirradiated tissue
56
Q

T/F: RT should not be delayed in the presence of a fistula, open wound, or bony exposure

A

True: as long as carotid artery is not exposed, RT should never be delayed

57
Q

What is the primary role of concomitant CRT in tx of H&N CA

A

Improve local and regional control in pts w/ unresectable dz

58
Q

What is the primary problem with concomitant CRT

A

Acute toxicities are markedly increased and result in pt noncompliance

59
Q

Which pts are more likely to benefit from adjuvant chemo

A

Those with high risk tumors (ECS, CIS, close surgical margins) and those with locally advanced NP CA

60
Q

What were the 3 tx arms in H&N Intergroup R91-11 trial

Which arm had best outcome

A
  • Induction chemo (cisplatin and 5-FU) vs
  • RT alone vs
  • Concomitant cisplatin and RT

for tx of potentially resectable stage III and IV CA of the larynx

Concomitant CRT significantly increased the time to TL

61
Q

What can be said of presence of level V cervical mets from SCCa of the upper aerodigestive tract?

A

Uncommon (7%) and if present most likely to occur in presence of level IV mets

Oto Board Pearls of Wisdom - Section III Diseases, Disorders, and Conditions (14 decks)

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