H&N Evaluation and management of laryngeal cancer Flashcards
What patient demographic is at highest risk for
laryngeal cancer?
● Males (3.8:1)
● Associated with tobacco exposure
● Age younger than 40 years
What are the strongest risk factors for laryngeal
carcinoma?
● Tobacco smoking (packs per day and years of use)
● Alcohol use (amount consumed and duration of use)
What is the role of laryngopharyngeal reflux in
laryngeal cancer?
Controversial. It is unclear whether it is an independent or
associated risk factor.
What percentage of laryngeal cancers have been
associated with high-risk HPV (HPV 16 > HPV 18)?
~ 25%. Clinical significance is unclear.
What are four primary premalignant laryngeal
lesions as defined by the WHO?
● Hyperplasia
● Keratosis
● Dysplasia: Mild, moderate, severe
● Carcinoma in situ
What significance does laryngeal leukoplakia have?
Leukoplakia means “white plaque” and without a biopsy
gives no information relevant to management.
What is the approximate rate of dysplasia in
laryngeal leukoplakia?
40%
What is the approximate rate of malignant trans-
formation of mild dysplasia? Severe dysplasia or
carcinoma in situ?
● 11%
● 30%
Note: It may take up to 10 years for malignant conversion
(average 3 years).
What percentage of laryngeal tumors are squamous cell carcinomas?
85 to 95%
According to WHO, what are the possible subtypes
of squamous cell carcinoma found in the larynx?
● Verrucous
● Spindle cell carcinoma (also called sarcomatoid carcinoma, carcinosarcoma, pseudosarcoma)
● Adenoid (acantholytic) Basaloid squamous cell carcinoma
● Clear cell carcinoma
● Adenosquamous carcinoma
● Giant cell carcinoma
● Lymphoepithelial carcinoma
What laryngeal lesion is characterized by prolifer-
ation of the squamous mucosa, elongated rete
ridges that appear worrisome for carcinoma and
show no evidence of cytologic abnormalities
consistent with malignancy?
Pseudoepitheliomatous hyperplasia. It can be associated with
infection (e.g., tuberculosis, syphilis, blastomycosis), trauma,
granular cell tumor, and chronic irritation. It is easily mistaken
for squamous cell carcinoma and requires proper orientation
of specimens and periodic-acid Schiff stain.
What pathology in the larynx is associated with
trauma and infarction of salivary gland tissue
(ducts and acini of seromucinous glands), is often
misdiagnosed as squamous cell carcinoma or
mucoepidermoid carcinoma, and requires immu-
nohistochemistry for diagnosis?
Necrotizing sialometaplasia
What subtype of squamous cell carcinoma results
in largely exophytic growth, pushing margins,
does not metastasize, is associated with HPV-16
and -18, and has an indolent course?
Verrucous carcinoma. It is the second most common site in
the head and neck (to oral cavity).
What epithelial laryngeal cancer contains both
basaloid and squamous components (biphasic),
cystic spaces, results in frequent regional and
distant metastases, occurs most commonly in the
supraglottis, and has a worse prognosis than
standard squamous cell carcinoma?
Basaloid squamous cell carcinoma
What epithelial laryngeal cancer contains malignant squamous epithelium on its surface associated with a deeper malignant spindle cell
carcinoma (biphasic), is associated with tobacco
and alcohol use, results in common regional
metastases, and is relatively radioresistant?
Spindle cell carcinoma
What is the most common location for adenosquamous carcinoma, a biphasic tumor arising
from the basal layer of the epithelium and
demonstrating behavior more aggressive than
conventional squamous cell carcinoma, in the
upper aerodigestive tract?
Larynx
What is the key pathologic difference between laryngeal verrucous carcinoma and papillary
squamous cell carcinoma, which demonstrates
exophytic papillary growth with cores of fibrovas-
cular stroma?
Significantly abnormal cytology
According to the WHO, what are the possible
subtypes of malignant salivary gland tumors found
in the larynx, which make up less than 1% of all
laryngeal tumors?
● Mucoepidermoid carcinoma ● Adenoid cystic carcinoma ● Adenocarcinoma ● Acinic cell carcinoma ● Carcinoma ex-pleomorphic adenoma ● Epithelial-myoepithelial cell carcinoma ● Salivary duct carcinoma
What are the cells of origin for supraglottic
adenocarcinoma?
Minor salivary glands
Are salivary gland carcinomas of the larynx more
common in men or women?
Men (2:1). However, adenoid cystic carcinoma has no
gender bias.
What are the two most common laryngeal
malignant salivary gland cancers?
Mucoepidermoid carcinoma and adenoid cystic carcinoma,
constituting one-third of malignant laryngeal salivary gland
tumors
What laryngeal tumor is composed of squamous,
mucin-secreting, and intermediate-type cells and likely forms in the intercalated ducts of seromucinous glands?
Mucoepidermoid carcinoma
What percentage of supraglottic cancers arising from minor salivary glands will be mucoepidermoid carcinoma on pathological analysis?
35%. They are less common than adenoid cystic (46%),
more common than adenocarcinoma (12%).
Adenoid cystic carcinoma is defined by uniform
basaloid cells that grow in what three distinct
patterns?
● Cribriform
● Tubular
● Solid
According to the WHO, what are the possible
subtypes of neuroendocrine tumors found in the
larynx, which are the second most common
tumors of the larynx next to squamous cell
carcinoma?
● Atypical carcinoid tumor (54%)
● Small cell carcinoma (28%)
● Malignant paraganglioma (12%)
● (Typical) carcinoid tumor (7%)
What is the relative occurrence of supraglottic
neuroendocrine tumors in men and women?
They occur three times more commonly in women than in
men.
What is the 5-year survival rate for laryngeal
neuroendocrine carcinoma?
Although it is one of the most common extrapulmonary sites for neuroendocrine carcinoma, laryngeal neuroendocrine carcinoma is extremely rare. It is also most often lethal, with 2- and 5-year survival rates of 16% and 5%,
respectively.
What subsite of the larynx is most commonly
involved by both typical and atypical carcinoid tumors, which present as submucosal and polypoid masses?
Supraglottis
To what unusual locations do atypical carcinoids
commonly metastasize?
Skin and subcutaneous tissue
What percentage of patients with laryngeal small
cell carcinoma will develop distant metastases?
90%
According to the WHO, what are the possible
subtypes of malignant soft tissue tumors found in
the larynx?
● Fibrosarcoma ● Malignant fibrous histiocytoma ● Liposarcoma ● Leiomyosarcoma ● Rhabdomyosarcoma ● Angiosarcoma ● Kaposi sarcoma ● Malignant hemangiopericytoma ● Malignant nerve sheath tumor ● Alveolar soft part sarcoma ● Synovial sarcoma ● Ewing sarcoma
According to the WHO, what are the possible
subtypes of malignant bone and cartilage tumors
in the larynx?
● Chondrosarcoma (most common)
● Osteosarcoma
What laryngeal tumors arise from ossified hyaline cartilage, most commonly from the cricoid cartilage?
Chondrosarcomas
What is the distant metastasis rate in laryngeal
chondrosarcoma?
8.5%
According to the WHO, what are the possible
subtypes of malignant hematolymphoid tumors
found in the larynx?
● Extramedullary plasmacytoma (most common)
● Lymphoma
According to the WHO, what tumors most
commonly metastasize from a distant site to the
larynx?
● Kidney ● Skin (melanoma) ● Breast ● Lung ● Prostate ● Gastrointestinal tract
What is the most common site of second
primaries in patients with larynx cancer?
Lung. Consider a pulmonary lesion a second primary tumor
until proven otherwise.
What are the clinical risk factors that may increase
the likelihood of stomal recurrence?
● Primary subglottic tumor
● Glottic tumor invading subglottis by > 1 cm
● T4 glottic primary tumor
What are the proposed causes of stomal recurrence after total laryngectomy for laryngeal cancer?
● Positive tracheal margin
● Paratracheal nodal metastases
● Thyroid gland invasion
● Seeding of the stoma at initial operation
What is the most common initial symptom
associated with supraglottic carcinoma?
Dysphagia. It can also manifest with dysphonia, odynophagia, otalgia, stridor, dyspnea, hemoptysis, and neck mass.
What is the most common initial symptom
associated with early versus late glottic carcinoma?
● Early disease: Dysphonia
● Advanced disease: Stridor, dyspnea
What are the most common initial symptoms
associated with subglottic carcinoma?
Dyspnea and stridor
Patients with what symptoms may require urgent
or emergent management of their laryngeal
tumor?
Dyspnea and stridor
On endoscopy, which of the following lesions may
be suspicious for a laryngeal carcinoma: ulceration, sessile lesion, polypoid lesion, submucosal fullness, or exophytic friable mass?
All should suggest possible malignant process.
What laryngoscopy adjunct should be used in the
clinic to evaluate a patient in whom you are
concerned about a laryngeal malignancy?
Flexible fiberoptic laryngoscopy and/or video stroboscopy
To evaluate a patient with laryngeal carcinoma for posterior invasion of the prevertebral fascia, you grasp the larynx and rock it back and forth.
Inability to rock the larynx and lack of what sound/tactile feedback suggest invasion?
Laryngeal crepitus (movement of laryngopharyngeal framework across the prevertebral and vertebral structures)
What is the most commonly used imaging
modality for the initial workup of laryngeal
cancer?
CT with contrast using fine cuts through the larynx
~ 1 mm
Which offers better evaluation of cartilage invasion: CT or MRI?
MRI
When using MRI for the evaluation of a patient
with laryngeal cancer, what modality or sequences
would be most useful to determine invasion of the
preepiglottic and/or paraglottic spaces?
T1-weighted gadolinium enhanced MRI with fat suppres-
sion. High negative predictive value. False-positive results are caused by inflammation.
During direct endoscopic examination of the
upper aerodigestive tract in the operating room
for laryngeal cancer, what maneuver should be
performed if there is concern for fixation of the
larynx or immobility of a vocal cord?
Palpation of the laryngeal structures
Describe microflap excision for laryngeal biopsy.
Microflap surgery requires dissection of the superficial
lamina propria as opposed to excision. This allows for
sparing of the vocal ligament and affords a better
postoperative mucosal wave.
Why is detection of recurrence after radiation
more difficult in laryngeal cancer?
Persistent edema and fibrosis are common post-treatment
sequelae that obscure visualization of (often submucosal)
tumor growth.
Although deep biopsies are often necessary to
diagnose a recurrent laryngeal tumor after radiation therapy, what adverse outcomes are associated with biopsy in this setting?
Increased risk of infection, perichondritis, and chondroradionecrosis
Describe the “T” staging system for epithelial
supraglottic malignancies according to the AJCC.
● T1: Tumor limited to one supraglottic subsite, normal
vocal cord mobility.
● T2: Tumor invasion of more than one subsite of the
supraglottis or glottis or region outside the supraglottis
(e.g., mucosa of base of tongue, vallecula, medial wall of
pyriform sinus) without fixation of the larynx
● T3: Tumor limited to the larynx with vocal cord fixation
and/or invades any of the following: postcricoid area, pre-
epiglottic tissues, paraglottic space, and/or minor thyroid
cartilage erosion (e.g., inner cortex).
● T4a: Moderately advanced local disease: tumor invades
through the thyroid cartilage and/or invades tissue
beyond the larynx (e.g., trachea, soft tissues of neck
including deep extrinsic muscles of the tongue, strap
muscles, thyroid, or esophagus).
● T4b: Very advanced local disease: Tumor invades pre-
vertebral space, encases carotid artery, or invades mediastinal structures.
What differentiates T2 from T3 supraglottic
tumors?
T2 tumors do not invade the parilaryngeal spaces; T3
tumors present with vocal cord fixation.
What differentiates T1 from T2 supraglottic
tumors?
● T1 tumors are limited to one subsite with normal vocal
cord mobility.
● T2 tumors may involve multiple supraglottic subsites or
adjacent regions (tongue base, glottis).
Describe the “T” staging system for epithelial
glottic malignancies according to the AJCC).
● T1: Tumor is limited to the vocal cord(s); may involve anterior or posterior commissure; normal vocal cord
mobility.
● T1a: Tumor is limited to one vocal cord.
● T1b: Tumor involves both vocal cords.
● T2: Tumor extends to supraglottis and/or subglottis or
with impaired vocal cord mobility (some authors divide
T2 into T2a and T2b; see below).
● T3: Tumor is limited to the larynx with vocal cord fixation
and/or invades the paraglottic space, and/or minor
thyroid cartilage erosion (e.g., inner cortex).
● T4a: Moderately advanced local disease: Tumor invades
through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck
including deep extrinsic muscle of the tongue, strap muscles, thyroid or esophagus).
● T4b: Very advanced local disease: Tumor invades pre-
vertebral space, encases carotid artery, or invades mediastinal structures.
Although the AJCC, (7th edition) does not differentiate T2 into T2a and T2b, some authorities do. How are these stages defined?
Tumor extends to the supraglottis and/or subglottis:
● T2a: Without impaired vocal cord mobility
● T2b: With impaired vocal cord mobility
What is the rate of nodal metastases in T1 glottic
carcinoma?
5%
What differentiates T3 from T4 glottic tumors?
T3 tumors are confined to the larynx, whereas T4 have
spread extralaryngeally (into strap musculature, thyroid
gland, trachea, esophagus).
Describe the “T” staging system for epithelial
subglottic malignancies according to the AJCC.
● T1: Tumor is limited to the subglottics.
● T2: Tumor extends to vocal cord(s) with normal or
impaired mobility.
● T3: Tumor is limited to the larynx with vocal cord fixation.
● T4a: Moderately advanced local disease. Tumor invades
cricoid or thyroid cartilage and/or invades tissues beyond
the larynx (e.g., trachea, soft tissues of the neck including
deep extrinsic muscles of the tongue, strap muscles,
thyroid or esophagus)
● T4b: Very advanced local disease: Tumor invades pre-
vertebral space, encases carotid artery, or invades mediastinal structures.
Describe the stages of stomal recurrence after
total laryngectomy for laryngeal cancer (Sisson,
1989).
● Stage I: Superior to the stoma, at 9 to 3 o’clock position.
Normal swallowing and esophagoscopy
● Stage II: Above or below the stoma, 9 to 3 o’clock. Most
have dysphagia and esophageal invasion.
● Stage III: Below the stoma, at 9 to 3 o’clock. Esophagus is
always involved. High risk of upper mediastinal disease
● Stage IV: Lateral extension of the tumor under the
clavicle, dysphagia, and esophageal invasion
What is the overall 5-year survival rate for
laryngeal cancer, and what subsite has the best overall survival?
● 64%
● Glottic (79%) > supraglottic (47%) > subglottic (30 to 50%)
During the initial workup of a patient with
laryngeal cancer, you identify cartilage invasion.
How does this impact prognosis and manage-
ment?
● Upstages tumor (T3 or T4a)
● Poorer response to radiation therapy
● Decreased local control rates
● Higher risk of chondroradionecrosis
What is the incidence of distant metastasis in
glottic carcinoma?
4%
What are the most important clinical prognostic
factors in order of importance?
● Clinical stage (most important to least: M > N > T)
● Location of the primary (best to worst: glottic > supra-
glottic > subglottic)
Why does involvement of the anterior commissure decrease prognosis (local control rates) for both surgery and radiation therapy?
Inadequate recognition of deep extension
What factors increase the risk of peristomal
recurrence after laryngectomy for laryngeal cancer?
● T3 or T4 tumors
● Subglottic tumor extension
What histologic characteristics decrease local
control and overall survival?
● Extracapsular spread*
● Positive surgical margins*
● Histologic subtype
● Histologic grade (well, moderate, poor)
● Pattern of invasion (pushing vs infiltrative)
● Perineural invasion*
● Vascular embolus (invasion)*
*Considered adverse features impacting management
decisions by the NCCN (2013)
In addition to primary oncologic management,
what behavioral modifications should be recommended to maximize treatment benefit and decrease the risk of recurrence for premalignant
and malignant laryngeal cancer?
● Tobacco and alcohol cessation
● Reflux control
What is the wavelength and chromophore of the
CO2 laser?
● Wavelength: 10,600 nm
● Chromophore: water
What is the wavelength and chromophore of the
potassium-titalyl-phosphate (KTP) laser?
● Wavelength: 532 nm
● Chromophore: Oxyhemoglobin
What treatment modality makes use of photo- reactive chemicals (5-aminolevulinic acid, Photofrin, hematoporphyrin, foscan), which are preferentially absorbed by premalignant or malignant cells and then subsequently activated by light of a specific frequency?
Photodynamic therapy
What is the treatment of choice for premalignant
laryngeal lesions?
● Complete excision with pathologic analysis (microflap,
vocal cord stripping; higher risk for poor voice outcomes,
laser resection)
● Close follow-up
● Can consider laser ablation (pulsed dye laser or KTP) once
pathologic diagnosis is established
What are the management options for carcinoma
in situ?
Complete surgical excision or radiation therapy.
Note: Recurrence is higher after surgical excision than after
radiation therapy, but local control is equivalent with repeat
excision.
For a patient with significant airway obstruction
from a laryngeal tumor, should you perform an
emergent laryngectomy or tracheostomy?
High tracheostomy. No evidence has been established that
tracheostomy increases the risk of peristomal recurrence,
and emergent laryngectomy does not allow time for
complete workup and counseling.
In the Veterans Affairs’ (VA) laryngeal cancer
study, what groups were compared?
● Induction chemotherapy and radiation for responders
and surgery followed by postoperative radiation therapy
for responders
● Surgery and postoperative radiation
What were the laryngeal preservation rates and
overall survival figures in the VA laryngeal cancer
study?
For patients with advanced resectable laryngeal cancer
(stage III or IV, excluding T1N1), induction chemotherapy
and radiation allow for laryngeal preservation in 64% of
patients and a similar 2-year overall survival (68%)
compared with total laryngectomy and postoperative
radiation therapy.
What proportion of patients in the VA laryngeal
cancer study preoperatively had mobile vocal
cords? Cartilage invasion?
44% and 9%, respectively
In the RTOG 91–11 organ preservation in advanced laryngeal cancer study, what groups were compared?
● Concurrent cisplatin and radiation
● Induction cisplatin/5-FU followed by radiation therapy for
complete and partial responders or surgery and adjuvant
radiation therapy for non responders
● Radiation alone
What was the laryngeal preservation rate for concurrent chemoradiation, induction chemotherapy/radiation, and radiation alone in RTOG 91–11?
● CRT: 88%
● Induction chemotherapy/radiation + radiotherapy: 75%
● Radiotherapy alone: 70%
What was the grade 3/4 mucositis rate for concurrent chemoradiation, induction chemotherapy/radiation, and radiation alone in RTOG 91–11?
● CRT: 43%
● Induction chemotherapy + radiotherapy: 24%
● Radiotherapy: 24%
What patients with advanced laryngeal cancer
were excluded from RTOG 91–11?
Patients were excluded if they were not eligible for total
laryngectomy with curative intent, T1 primary tumors, and
large-volume T4 disease (transcartilaginous or > 1-cm
tongue base invasion).
What are the contraindications to transoral re-
section of laryngeal carcinoma?
● Subglottic extension (> 5 mm)
● Postcricoid extension
● Pyriform sinus invasion
● Cartilage invasion
● Tongue base involvemen
Note: Restricted vocal cord mobility and extension onto the
arytenoid are relative contraindications.
What factors are critical to transoral resection of
laryngeal carcinoma?
Adequate exposure, accurate assessment of tumor extension, complete resection
Name the open conservation laryngeal procedure
in which one vocal cord or one and a portion of
the other vocal cord are removed in continuity
with the adjacent paraglottic space and overlying
thyroid cartilage.
Vertical partial laryngectomy. The vertical height of the
larynx is maintained by the retained contralateral thyroid
ala.
What contraindicates vertical partial laryngectomy?
● Cricoid cartilage involvement (1-cm subglottic extension
anteriorly and 5 mm posteriorly)
● Thyroid cartilage involvement (often the case for trans-
glottic tumors because mucosal spread from the supra-
glottis to glottis across the ventricle brings tumor into close proximity to the inner thyroid perichondrium)
● Poor pulmonary function
Name the operation and its subtypes in which the
entire superior portion of the thyroid cartilage is
removed along with the underlying laryngeal
structures, reducing the vertical height of the
larynx by the subsequent reconstruction.
Horizontal partial laryngectomy: ● Supraglottic ● Extended supraglottic ● Supracricoid (with cricohyoidopexy or cricohyoiodoepi- glottopexy)
What is the embryologic rationale behind horizontal hemilaryngectomy?
An embryologic boundary exists between the false and true
vocal folds, resulting in independent lymphatic drainage
from each. Therefore, in select (T1/T2) supraglottic tumors
that do not extend into neighboring structures, horizontal
supraglottic hemilaryngectomy may be considered an
oncologically sound resection strategy.
What are the contraindications for supracricoid
horizontal partial laryngectomy?
● Arytenoid fixation ● Cricoid/thyroid cartilage involvement ● Hyoid involvement ● Significant pre-epiglottic space disease ● Poor pulmonary function
What patient factors are critical to conservation
laryngeal operations?
Excellent cardiopulmonary reserve and motivation to retain
larynx
What tumor factors contraindicate conservation
laryngeal surgery?
● Cartilage invasion ● Extralaryngeal spread ● Interarytenoid involvement ● Postcricoid spread ● Invasion to pyriform apex
What factors reduce the efficacy of radiation in
laryngeal cancer?
● Cartilage invasion
● T4 stage
● Extralaryngeal spread
What site(s) are most commonly involved by distant metastases from the larynx?
Lung and mediastinum (not including level VII)
What subsite of the larynx has the highest risk for
distant metastasis?
Supraglottis (up to 15%)
What factors increase the risk of distant metastasis
for laryngeal cancer?
History of nodal metastasis
What is the management of choice for supra-
glottic carcinoma not requiring a total laryngec-
tomy (mostly cT1–2, N0) according to the NCCN
(2011)?
● Endoscopic resection → neck dissection
● Open partial supraglottic laryngectomy → neck dissec-
tion
● Definitive radiation therapy
For patients undergoing primary surgical man-
agement of cT1–2N0 supraglottic carcinoma not
requiring a total laryngectomy, what are the adjuvant treatment recommendations according to the NCCN (2011)?
● N0 → observation
● One positive node, no adverse features → consider
radiation therapy
● N + , positive margin → re-excision, radiation therapy, or
chemoradiation therapy
● N + , extracapsular spread → chemoradiation therapy or
radiation alone
What is the treatment of choice for cT1–2N + and
select cT3N1 supraglottic carcinomas not requir-
ing a total laryngectomy according to the NCCN
(2011)?
● Concurrent chemoradiation therapy with cisplatin (pre-
ferred) → additional therapy dictated by response to therapy
● Definitive radiation therapy → additional therapy dictated
by response to therapy
● Partial supraglottic laryngectomy and neck dissection(s)
→ adjuvant therapy as dictated by pathologic findings
● Induction chemotherapy
What is the treatment of choice for a cT3N0
supraglottic carcinoma requiring a total laryngec-
tomy according to the NCCN (2011)?
● Concurrent chemoradiation therapy with cisplatin (pre-
ferred)
● Laryngectomy, ipsilateral thyroidectomy, with ipsilateral
or bilateral neck dissection
● Radiation therapy (if not a candidate for concurrent
chemotherapy)
● Induction chemotherapy
For patients undergoing primary surgical man-
agement of cT3N0 supraglottic carcinoma, what are the adjuvant treatment recommendations
according to the NCCN (2011)?
● N0 or 1 positive node without adverse features →
consider radiation therapy
● Extracapsular spread or positive margin → chemoradiation
● Other risk features → radiation therapy with or without
chemotherapy
What is the management of choice for a cT3N2–3
supraglottic carcinoma requiring a total laryngec-
tomy according to the NCCN (2011)?
● Concurrent chemoradiation therapy with cisplatin (pre-
ferred) → surgical salvage based on response to therapy
● Laryngectomy, ipsilateral thyroidectomy with neck dis-
section(s) → radiation therapy → chemotherapy based on
the presence of pathologic adverse features
● Induction chemotherapy followed by chemoradiation
therapy
What is the management of choice for a cT4aN0–
3 supraglottic carcinoma requiring according to
the NCCN (2011)?
● Laryngectomy, ipsilateral thyroidectomy, with ipsilateral
or bilateral neck dissection:
● N0, no risk features → radiation therapy
● Extracapsular spread and/or positive margin → hcemo-
radiation therapy
● Other risk features → radiation therapy → chemotherapy
● Note: For those who decline surgery, concurrent chemo-
radiation therapy, enrollment in a clinical trial, or induction chemotherapy followed by primary chemo-
radiation therapy can be considered.
For patients undergoing primary induction che-
motherapy for supraglottic carcinoma, what are the treatment recommendations based on response to induction according to the NCCN (2011)?
● Primary site: Complete response → radiation therapy with
or without chemotherapy
● Primary site: Partial response → chemoradiation therapy
→ if partial response → salvage surgery
● Primary site < partial response → surgery → radiation therapy with or without chemotherapy based on presence of pathological adverse features
What dose of definitive radiation therapy is
recommended by the NCCN (2011) for patients
with T1–2N0 supraglottic squamous cell carcino-
ma?
● ≥ 66 Gy
What dose of definitive radiation therapy is
recommended by the NCCN (2011) for patients
with T2–3N0–1 supraglottic squamous cell carcinoma?
● Primary and cN + ≥ 70 Gy, conventional fractionation
(Monday through Friday for 7 weeks), high-risk nodal
basins 44 to 64 Gy
● Accelerated fractionation: 66 to 74 Gy to gross disease,
44 to 64 Gy to high-risk regions for 6 weeks
● Concomitant boost accelerated radiation therapy: 72 Gy/
6 weeks, second daily dose for the last 12 days
● Hyperfractionation: 81.6 Gy for 7 weeks
What dose of radiation therapy is recommended
by the NCCN (2011) for patients undergoing
concomitant chemoradiation therapy for supraglottic squamous cell carcinoma?
70 Gy for 7 weeks, conventional fractionation
What dose of radiation therapy is recommended
by the NCCN (2011) for patients undergoing
postoperative radiation therapy for supraglottic
squamous cell carcinoma?
● Primary 60 to 66 Gy, conventional fractionation (Monday
through Friday for 7 weeks), high-risk nodal basins 44 to
64 Gy
● N + neck: 60 to 66 Gy
● N0, high-risk neck: 44 to 64 Gy
What chemotherapeutic agent and dose are
recommended by the NCCN (2011) for patients
undergoing concomitant chemoradiation therapy
for supraglottic squamous cell carcinoma?
Cisplatin 100 mg/m2 every 3 weeks during radiation
What levels of the neck should be addressed
during an elective neck dissection for an N0
supraglottic cancer according to the NCCN
(2011)?
Level II-IV, level VI when appropriate
What is the initial local control achieved by
radiation alone for T1 and T2 supraglottic carcinoma?
92 to 100%
What percentage of patients who undergo supracricoid partial laryngectomy with cricohyoidopexy for supraglottic cancer will never achieve decannulation?
1.5%
Which of the following has more influence on
survival in supraglottic malignancies: histology of tumor (squamous vs. nonsquamous) or T/N-
staging?
T and N staging
What is the management of choice for glottic
carcinoma not requiring a total laryngectomy
according to the NCCN (2011)?
● Radiation therapy
● Partial laryngectomy/open or endoscopic resection as
indicated
● N0 → observe
What is the management of choice for T3 glottic
carcinoma requiring total laryngectomy (N0–1)
according to the NCCN (2011)?
● Concurrent chemoradiation therapy with cisplatin (pre-
ferred)
● Radiation (if not a candidate for surgery)
● Surgery
If a patient with T3 glottic cancer requiring a total
laryngectomy (N0–1) undergoes concurrent chemoradiation therapy with cisplatin or primary
radiation therapy alone, what are the recom-
mended management steps based on the pa-
tient’s response to therapy at the primary site?
● Complete response (N0 at initial staging) → observe
● Complete response (N + at initial staging)
● Residual nodal disease → neck dissection
● Complete clinical response in neck → evaluation → if
N + → neck dissection, if N0 → observe
● Residual tumor at the primary site → salvage surgery +
neck dissection as indicated
If a patient with T3 glottic cancer requiring a total
laryngectomy (N0–1) elects to undergo primary
surgical intervention, what are the recommended
management steps based on the patient’s nodal
status?
● N0 → Laryngectomy with ipsilateral thyroidectomy
● N1 → Laryngectomy with ipsilateral thyroidectomy,
ipsilateral or bilateral neck dissection
● No adverse features → observe
● Extracapsular spread or positive margins → chemoradiation therapy
● Other risk features → radiation therapy → chemotherapy
What is the treatment of choice for T3 glottic
carcinoma requiring total laryngectomy (N2–3)
according to the NCCN (2011)?
● Concurrent chemoradiation therapy with cisplatin (pre-
ferred)
● Laryngectomy with ipsilateral thyroidectomy and ipsilateral or bilateral neck dissection
● Induction chemotherapy
If a patient with T3N2–3 glottic carcinoma
requiring a total laryngectomy undergoes concurrent chemoradiation therapy with cisplatin,
what are the treatment options based on response
to therapy?
● Primary site: complete response
● Residual tumor in neck → neck dissection
● Complete clinical response in neck → evaluation → if N0,
observe, if N + then neck dissection
● Primary site: residual tumor
● Salvage surgery + neck dissection as indicated
If a patient with T3N2–3 glottic carcinoma
requiring a total laryngectomy undergoes primary surgical treatment, what are the treatment options based on pathologic analysis?
● No adverse features → observe
● Extracapsular spread and/or positive margins → chemo-
radiation therapy
● Other risk features → radiation therapy → chemotherapy
If a patient with T3N2–3 glottic carcinoma requiring a total laryngectomy undergoes induction chemotherapy, what are the treatment options based on clinical response of the primary
site?
● Complete response → definitive radiation therapy or
chemoradiation therapy
● N + → neck dissection
● N0 → evaluation, if N + → neck dissection
● Partial response → chemoradiation therapy
● Complete response → observe
● Residual disease → Salvage surgery
● < Partial/no response → surgery
● No adverse features → radiation therapy
● Extracapsular spread and/or positive margin →chemo-
radiation therapy
● Other risk features → radiation therapy → chemotherapy
What is the treatment of choice for T4aN0 glottic
carcinoma according to the NCCN (2011)?
Laryngectomy with ipsilateral thyroidectomy → unilateral/
bilateral neck dissection → chemoradiation therapy
What is the treatment of choice for T4aN1 glottic
carcinoma according to the NCCN (2011)?
Laryngectomy with ipsilateral thyroidectomy and ipsilateral neck dissection → contralateral neck dissection → chemo-
radiation therapy
What is the treatment of choice for T4aN2–3
glottic carcinoma according to the NCCN (2011)?
Laryngectomy with ipsilateral thyroidectomy and ipsilateral
or bilateral neck dissection → chemoradiation therapy
What is the definitive radiation therapy for T1N0
glottic carcinoma recommended by the NCCN
(2011)?
63 to 66 Gy, conventional fractionation
What is the definitive radiation therapy for T1–2
glottic carcinoma recommended by the NCCN
(2011)?
> 66 Gy, conventional fractionation
What is the definitive radiation therapy for >
T2N + glottic carcinoma recommended by the
NCCN (2011)?
66 to 74 Gy, conventional fractionation (accelerated frac-
tionation schedules may be considered)Nodal levels at risk for disease: 44 to 64 Gy
What is the radiation dose for primary concurrent
chemoradiation therapy for glottic carcinoma
recommended by the NCCN (2011)?
● Primary and N + disease: ≥ 70 Gy
● Nodal levels at high risk: 44 to 64 Gy
What is the radiation dose for adjuvant radiation therapy for glottic carcinoma recommended by the NCCN (2011)?
● Primary: 60 to 66 Gy
● N + : 60 to 66 Gy
● N0: 44 to 64 Gy
What is the chemotherapeutic agent and dose of
choice for chemoradiation therapy for glottic
carcinoma recommended by the NCCN (2013)?
Cisplatin 100 mg/m2 every 3 weeks (generally for three
cycles)
Describe vestibulotomy as a component of trans-
oral laser resection of glottic carcinoma.
Vestibulotomy refers to removing those portions of the false
cord that overlie the tumor. It affords lateral exposure and
may facilitate postoperative surveillance.
What is the initial treatment of an airway fire?
First remove the endotracheal tube because it is providing the fuel (oxygen) for the fire. Irrigate with water, reintubate, and perform bronchoscopy to survey the injury.
What is the point of entrance into the larynx
during laryngofissure?
The larynx is divided in the midline, with entry at the
anterior commissure.
What are the benefits of transoral approach for
cordectomy?
Avoidance of initial tracheostomy and external scar. The
main disadvantage, of course, is poorer access.
What are the indications for cordectomy via
transoral access or laryngofissure?
● Cordectomy can be considered for T1 tumors limited to
the middle third of the vocal fold.
● Contraindications include extension of tumor to vocal
process or anterior commissure, subglottis, ventricle, or
false cord.
What is the standard treatment for subglottic
carcinoma?
Total laryngectomy with paratracheal node dissection
followed by radiation therapy (including the mediastinum)
± chemotherapy
For carcinoma with unilateral subglottic extension,
what additional surgery should be considered
during total laryngectomy?
Ipsilateral thyroid lobectomy and paratracheal node dis-
section
What are the surgical options for primary sub-
glottic squamous cell carcinoma?
When treated surgically, all require total laryngectomy with
paratracheal node dissection.
What proportion of patients for whom radiation
for advanced larynx cancer fails would be suitable
candidates for salvage surgery?
Two-thirds
What are some of the common indications for
salvage surgery after nonoperative primary management of laryngeal cancer?
● Residual or recurrent locoregional disease ● Chondroradionecrosis ● Severe aspiration ● Laryngeal stenosis ● Pharyngoesophageal stenosis
What are the contraindications to partial laryngectomy in the salvage situation for patients with
recurrent laryngeal cancer (Biller et al, 1970)?
● Subglottic extension > 5 mm
● Cartilage invasion
● Contralateral vocal cord invasion
● Arytenoid cartilage invasion (other than vocal process)
● Vocal cord fixation
● Recurrence not associated with the primary lesion
What complications are frequently associated with
management of stomal recurrences?
● Vascular injury
● Hypocalcaemia
● Mediastinitis
● Fistula
What laryngeal reconstructive technique used for
supracricoid partial laryngectomy preserves the
epiglottis?
Cricohyoidoepiglottopexy
What laryngeal reconstructive technique is used
after horizontal partial laryngectomy and requires
resection of the epiglottis?
Cricohyoidopexy
In a patient undergoing laryngopharyngectomy with
primary closure, what additional procedure should
be performed to decrease postoperative dysphagia?
Cricopharyngeal myotomy
What type of stitch is most frequently used for
closure of laryngopharyngectomy?
Running modified Connell stitch, followed by one or two
layers of interrupted 3–0 Vicryl to imbricate overlying
layers. Flood the mouth to ensure closure is water tight.
What are the benefits of the artificial larynx for
speech after total laryngectomy?
Inexpensive, relatively easy to learn, provides loud voice
After laryngectomy, what type of speech is being
used if a patient injects (swallows) air into the
esophagus, which acts as a reservoir for the
expelled air used for voicing?
Esophageal speech. This produces a characteristic belching
sound. Patients are usually limited to soft volume and short
duration of utterance.
Name the one-way valve placed across the wall
between the trachea and esophagus that allows
exhaled air to pass through the neopharynx for voicing.
Tracheoesophageal prosthesis
Describe primary tracheoesophageal puncture (pri-
mary TEP).
Before closing the pharyngeal defect, a hemostat is passed
into the esophagus to the posterior tracheal wall, where a
blade is used to create a small fistula. A catheter is placed
through this to maintain patency until a prosthesis is fitted.
Describe the esophageal insufflation test in
evaluating candidates for secondary TEP.
A catheter is placed transnasally into the esophagus, air is
insufflated, and the patient is asked to count.
Describe two anatomical relative contraindications
to TEP voice rehabilitation.
● Microstomia (< 1 cm)
● Pharyngeal stricture
Why is a cricopharyngeal myotomy critical to total
laryngectomy voice rehabilitation?
Cricopharyngeal muscle spasm diverts air passing through
the TEP into the distal esophagus (instead of through the
mouth), which prevents acquisition of alaryngeal speech.
What is the most common reason for TEP valve
failure?
Candida fungal colonization
What is the definitive treatment for aspiration
through the TEP site in the setting of a properly-
functioning TEP valve?
A SCM flap or pectoralis major myofascial flap interposition
(between the trachealis and esophagus) to reconstruct the
party wall
How should a dislodged TEP temporary catheter
be triaged?
Urgently. If not replaced within 24 hours, the fistula is likely
to close, and the TEP would require surgical revision.
When factors imply that a patient has a functional
larynx?
● Intelligible voice
● Able to take in adequate calories by mouth with no/
minimal aspiration
● Avoidance of a stoma
What tumor factors most notably influence voice
outcomes after surgery or radiation therapy?
Tumor extent and depth of invasion
What patient factors affect the functional out-
come of total laryngectomy?
● Motivation for alaryngeal speech
● Ability to communicate by writing
● Manual dexterity for using voice prostheses
● Family and social support
What are the functional effects after total laryn-
gectomy?
● Loss of normal speech (not aphonia)
● Inability to develop positive airway pressure (straining,
coughing)
● Loss of nasal airflow (anosmia, air filtration)
● Presence of stoma (water precautions, body image)
True or False. Aggressive tumor surveillance with
imaging and examinations improves the detection of asymptomatic recurrences and second primaries and therefore improves oncologic outcomes after primary management of laryngeal cancer.
False
What are the early complications of conservation
laryngectomy?
● Tracheotomy tube obstruction
● Hemorrhage
● Aspiration pneumonia
● Subcutaneous emphysema
What is the long-term incidence of hypothyroid-
ism in patients treated primarily with radiation for laryngeal cancer?
70%
What is the appropriate sequence of actions in the
event of an airway fire?
Extubation, then removal of supplemental oxygen and instillation of saline into the airway, then reintubation
What are the main risk factors for developing a
pharyngocutaneous fistula after laryngectomy?
Comment: Does history of neck radiation need
to be included in the risk factors for fistula
formation (or at least should we specify in
patients who are not undergoing salvage)?
● Postoperative hemoglobin < 12.5
● Congestive heart failure
● Extended laryngectomy
● History of head and neck radiation
What is the best initial treatment for pharyngo-
cutaneous fistula?
● Debridement
● Wound dressing with antiseptic packing material
● Nothing taken orally (NPO)
● Antibiotics (if infected)
● Consideration of hyperbaric oxygen therapy if initial
measures are not successful
What complications are associated with tracheot-
omy placement during total laryngectomy?
● Pneumothorax
● Hemorrhage via tracheoinnominate fistula
● Subcutaneous emphysema.
What medical therapy would be most effective for a patient with persistent gastric inflation when attempting to use a transesophageal prosthesis?
Botulinum toxin injections to the cricopharyngeus muscle
