Larynx Flashcards
Larynx T1N0
63 Gy in 28 fx
“Supine with chin extended, no shoulder pull, aquaplast mask, CT sim. consider bolus over anterior neck if anterior commisure involvement”
2D traditional: (in context of new CTV guidelines, traditional fields may be anachronistic)
Opposed laterals, bolus if lesion is anterior
sup=thyroid notch
inf=bottom of cricoid
ant=flash
post=ant vertebral bodies
Some rotate gantry to make posterior border non-divergent or place isocenter at anterior edge of vertebral body”
“3D
wedges with heel anteriorly (15-30 degrees), 6MV photons, 95% isodose line to cover the entire cords, no hotspot over 110%
IMRT carotid sparing
Mean carotids <25 Gy
V35<20%
V35 ALARA”
“treatment time <44 days improves outcome. Better outcome with lower T-stage, lower grade.
Cerebrovascular events 3% with 3D vs. 0% with IMRT (MDACC retrospective)”
“5yr LC 90%
5-yr CSS 100%
(Yamazaki 2006)”
initial improvement in hoarseness, that then worsens at 3-4 weeks, dysphagia, odynophagia; long term risk of laryngeal edema, soft tissue necrosis, cartilage necrosis.
Larynx T2N0, only small supraglottic involvement
65.25 in 29 fx, finish in <44 days
“Contouring: Contour GTV, 5 mm CTV-P1, and 10 mm CTV-P2. CTV-P2 may or may not pass through a portion of the thyroid cartilage but not muscle beyond.
CTV-P Consensus guidelines, Radiother Oncol, 2018
2D traditional: (in context of new CTV guidelines, traditional fields may be anachronistic)
Same as above 3D, but lower border is below 1st tracheal ring if subglottic and top of hyoid if supraglottic”
“5yr LC 75%, 5yr OS 60%
salvage LC 90-95%, successful surgical salvage in ~75% of patients who fail, LC best if time <44 days (70% vs 100% LC), if subglottic extension LC 77% vs 58%)”
1-4% laryngeal edema, chondronecrosis, tracheostomy, fistula; transolral 1% bleeding risk, partial laryngectomy - 4-10% bleeding, infection, aspiration, laryngeal stenosis, edema, permanent PEG
Larynx T3 or N+
“For laryngeal preservation, first take history to assess if speech and swallowing ability can be preserved
Contraindications: T4 extension of 1 cm to BOT Bulky tumor: 3.5 cm3 for glottic and 6cm3 for supraglottic Poor swallowing Poor speech left to preserve"
“laryngeal preservation
Three volume: 6996 Gy in 33 fx (2.12)/5940 (1.8)/5412 (1.64)
Two volume: 70 and 56 Gy SIB
Cisplatin 100mg/m2 q 3 wk
No neck dissection. PET at 3 months then elective neck dissection if incomplete response”
“CTV neck: bilateral levels II-V and SCV (include level VI for transglottic, subglottic, postcridoid, or esophageal extension, or apex of piriform sinus )
5 mm CTV-P1 and 10 mm CTV-P2. CTV-P2 passes through part of thyroid cartilage but not muscle beyond.
Include stoma in low risk
“10-yr larynx pres 82%, 10-yr OS 30%, 10-yr LC 70%, 10-yr DM 15%
5yr larynx pres 84%, 5yr OS 45% stage III and 35% stage IV (VA study alive with larynx 31%, larynx preservation 62%, of T4 pt 56% req salvage laryngectomy)”
Larynx postop
Surgery preferred for T4 since with chemoRT LC is low and there is poor function at presentation
“66 Gy for positive margin or ECE (SIB to 1.6-1.8 daily to low risk)
60 Gy for intermediate risk (PNI, LVI, T4, close margin in 30 fx (SIB 1.6-1.8 Gy daily to low risk)
Lower risk area to 50-56 Gy”
“CTV neck: levels II-IV to uninvolved undissected neck. Include V for N2-3. Include RSS and SCV in dissected neck. Include level VI for transglottic, subglottic, postcridoid, or esophageal extension, or apex of piriform sinus.
CTV-P: post-op bed (see post-op section)
When considering borders, recognize that the hyoid and cricoid are removed after larygectomy. Use preop scan as reference for node borders.
Supraglottic T1-2N0, select T3 per NCCN not requiring total laryngectomy, T1N0 hypopharynx or select T2 per NCCN
“definitive, laryngeal preservation
70/63/56 (2/1.8/1.6) 35 fx DAHANCA (use DAHANCA, which does BID fx one day a week, if no chemo or cetuximab)
Two volume: 70 Gy with 56 Gy SIB
“CTV neck: II-IV. Always treat nodes if primary supraglottic and hypopharynx tumor, even if T1. Include level IV for transglottic, subglottic, postcridoid, or esophageal extension, or apex of piriform sinus
5 mm CTV-P1, and 10 mm CTV-P2. For T2 and above, CTV-P2 passes through part of thyroid cartilage. PTV 3-5 mm.
5yr OS stage I/II/III/IV supraglottis - 50/50/45/29%, DAHANCA regimen improves local control (60% vs 70%) and DSS (73% vs 66%), but not OS
supraglottic - requires supraglottic laryngectomy with B MRND (hyoid, epiglottis, pre-epiglottic space, thyrohyoid membrane, bilateral false cords, one arytenoid, bilateral AE folds, superior half of thyroid cartilage (can’t do if bilateral arytenoids, fixed cords, ext to true cord, ant comissure involvement, thyroid or cricoid invasion, subglottic ext)
Supraglottic larynx >T2N0
“Three volume: 70/63/56 in 35 fx with chemo
Two volume: 70 Gy and 56 Gy SIB
PET at 3 months then elective neck dissection if incomplete response”
“CTV neck: II-IV. Include V for N2-3. Always treat nodes if primary supraglottic and hypopharynx tumor, even if T1. Include level IV for transglottic, subglottic, postcridoid, or esophageal extension, or apex of piriform sinus
5 mm CTV-P1, and 10 mm CTV-P2. CTV-P2 passes through part of thyroid cartilage. 3-5mm PTV.
“Overall supraglottic tumors with 55% LN positive, 16% bilateral.
Hypopharynx T3/4 or N2
“Three volume: 6996/5940/5412 (2.12/1.8/1.64) 33 fx with chemo
Two volume: 70/56 SIB
PET at 3 months then elective neck dissection if incomplete response
“CTV neck: bilateral levels II-IV. RP nodes for posterior pharygeal wall. Include level V for node positive. Include VI for transglottic, subglottic, postcridoid, or esophageal extension, or apex of piriform sinus
5 mm CTV-P1, 10-15 mm CTV-P2.
T1: CTVs do not include thyroid, cricoid, or hyoid. Could include esophagus.
≥T2: CTV-P2 passes through part of thyroid cartilage, part of cricoid, part of hyoid, and may extend into the esophagus. CTV-P2 may be extended 15 mm vertically
75% ipsi and 30% contra LN +
If gross nodes were treated, perform PET at 3 months. If disease is still active, recommend neck dissection
“5-yr larynx preservation and 5-yr OS both 35%
LC 90/90/70/50 for T1-4”
