Green Book Chapter 33 Larynx and Hypopharyngeal Cancers

Question 1

What is the incidence of laryngeal cancer (LCX) in the United State?

Answer 1

~ 12,000 cases/yr of LCX (~20% of all H&N)

Question 2

What are the risk factors for developing LCX?

Answer 2

smoking, alcohol use, and voice abuse

Question 3

What are the subsites of larynx?

Answer 3

supraglottic, glottic, and subglottic

Question 4

What is incidence/distribution of LCX according to subsites?

Answer 4

Glottic: 69%
Supraglottic: 30%
Subglottic: 1%

Question 5

What % of premalignant lesions (leukoplakia/erythroplakia) progress to invasive laryngeal lesions?

Answer 5

20% of premalignant laryngeal lesions ultimately progress to invasive cancer (higher for erythroplakia than leukoplakia).

Question 6

What is the most common LCX histology?

Answer 6

Squamous cell carcinoma (SCC) makes up > 95% of LCX. Other histologies include verrucous carcinoma (1% - 2%), adenocarcinoma, lymphoma, chondrosarcoma, melanoma, carcinoid tumor, and adenoid cystic carcinoma

Question 7

What are the subdivisions of the supraglottic larynx?

Answer 7

Supraglottic larynx: Epiglottis (suprahyoid and infrahyoid), AE (aryepiglottic) folds, arytenoids, ventricles, and false vocal cords (FVCs)

Question 8

What are the subdivisions of the glottic larynx?

Answer 8

Glottis: Ant/Post commissures, true vocal cords (TVCs)

Question 9

What are the anatomic borders of the subglottic larynx?

Answer 9

Subglottis: 0.5 cm below the TVCs to the 1st tracheal ring

Question 10

What are the nodal drainage pathways of the various laryngeal subsites?

Answer 10

Supraglottic: levels II - IV
Glottic: virtually no drainage
Subglottic: pretrracheal and Delphian (level VI)

Question 11

What is the incidence of hypopharyngeal cancer (HPxC) in the US?

Answer 11

There are ~ 2500 cases/yr

Question 12

What is the median age at Dx for HPxC?

Answer 12

The median age at Dx is 60 - 65 yrs for HPxC

Question 13

What are the subsites of the hypopharynx (HPX)?

Answer 13

Pyriform sinus, Postcricoid area, Posterior pharyngeal wall (“3Ps”)

Question 14

What are the anatomic boundaries of the HPX?

Answer 14

The HPX spans from C4-6 or from the hyoid bone to the inf edge of the cricoid cartilage.

Question 15

What is the sex predilection for HPxC based on the different subsites?

Answer 15

The sex predilection is predominantly male for pyriform sinus and post pharynx primaries, but predominantly female for postcricoid area tumors.

Question 16

What are the classic risk factors for the development of HPxC?

Answer 16

Smoking, alcohol, betel nut consumption, nutritional deficiency (vitamin C, Fe [Fe deficiency is associated with 70% of postcricoid cancers in northern European women]), and prior Hx of H&N cancer

Question 17

Is nodal involvement common with HPxC?

Answer 17

Yes. Nodal involvement is common due to abundant submucosal lymphatic plexus drainage to the retropharyngeal nodes, cervical LNs, paratracheal LNs, paraesophageal nodes, and SCV nodes

Question 18

What are the most commonly involved nodal stations in HPxC?

Answer 18

Levels II, III, and the retropharyngeal nodes are most commonly involved in HPxC. Level VI can also be involved and therefore should be covered when planning these cases for RT.

Question 19

What is the name for the most sup of the lat retropharyngeal nodes?

Answer 19

The most sup of the lat retropharyngeal nodes is the node of Rouviere

Question 20

What % of HPxC pts have nodal involvement at Dx?

Answer 20

~75% overall have the nodal involvement at Dx (~60% for T1)

Question 21

What is the typical histology seen in HPxC?

Answer 21

The predominant histology is SCC (>95%) –> adenoid cystic, lymphoma, and sarcoma

Question 22

What are the most common subsites of origin for HPxC?

Answer 22

The pyriform sinus: 70 - 80%
Post pharyngeal wall: 15 - 20%
Postcricoid: 5%

Question 23

At what cervical spine levels are the hyoid bone and the TVCs located?

Answer 23

The hyoid bone is at C3, whereas the TVCs are located near C5-6.

Question 24

How do pts with LCX typically present?

Answer 24

Hoarseness, odynophagia/sore throat, otalgia (via the Arnold nerve / CN X), aspiration/choking, and neck mass

Question 25

What is the typical workup for pts presenting with a possible laryngeal mass?

Answer 25

Possible laryngeal mass workup: H&P (voice change, habits, indirect/direct laryngoscopy), CXR, CT/MRI, PET, basic labs, EUA + triple endoscopy, and Bx of the primary +/- FNA of the neck mass

Question 26

What does the loss of the laryngeal click on palpation of the thyroid cartilage indicate?

Answer 26

Loss of laryngeal click on exam indicates postcricoid extension (or postcricoid tumor).

Question 27

What does pain in the thyroid cartilage indicate on exam?

Answer 27

Pain on palpation of the thyroid cartilage indicates tumor invasion into the thyroid cartilage (T4a disease)

Question 28

What imaging modality is best to assess for bony or cartilage erosion in pts with LCX?

Answer 28

CT scan is best for assessing bony/cartilage erosion (bone window)

Question 29

What is the incidence of nodal involvement for T1, T2, and T3-T4 glottic cancer?

Answer 29

T1: 0-2% T2: 2-7% T3 - T4: 15-30%

Question 30

What is the incidence of nodal involvement for supraglottic lesions according to T stage?

Answer 30

T1 - T2: 27% - 40% T3 - T4: 55% - 65%

Question 31

What does total laryngectomy entail?

Answer 31

removal of the hyoid, thyroid, and cricoid cartilage, epiglottis, and strap muscle with reconstruction of the pharynx as well as a permeant tracheostomy

Question 32

What structures are removed with a supraglottic laryngectomy?

Answer 32

FVCs, epiglottis, and aryepiglottic folds

Question 33

What is the preferred surgical option for dysplastic lesions on the glottic larynx?

Answer 33

Mucosal stripping is typically curative for dysplastic lesions. Close follow-up is needed.

Question 34

What are the Tx options for Tis lesions of the glottic larynx?

Answer 34

Cord stripping/laser excision (need close f/u; cannot r/o microinvasive Dz) or definitive RT

Question 35

What are the ~5 yr LC rates for glottic CIS with the use of stripping vs. laser vs. RT?

Answer 35

Stripping: 72% Laser: 83% RT: 88 - 92%

Question 36

What are the advantages and disadvantages of using RT for early glottic cancer?

Answer 36

Advantages: better voice qulaity, noninvasive, organ preservation Disadvantages: long Tx duration, RT changes could obscure post-Tx surveillance

Question 37

What is the voice quality preservation rate for early glottic tumors/pts treated with laser vs. RT?

Answer 37

The JHH data (Epstein BE et al., Radiology 1990) suggests better voice quality after RT (laser: 31%, RT: 74%, p = 0.012). More recent RCT from Finland (Aaltonen L et al. IJROBP 2014) also suggest better voice quality with RT.

Question 38

What are the currently accepted dose fractionation and total dose Rx for CIS and T1 glottic lesions?

Answer 38

CIS: 60.75 Gy in 27 fx T1: 63 Gy in 28 fx at 2.25 Gy/fx