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Larynx Flashcards

1
Q

how common is larynx cancers among H&N cancer as a whole

A

it is the most common H&N cancer

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2
Q

most common place that larynx cancer occurs

A

most common in the glottis 3:1 glottis to supraglottic cancers
more specifically in the anterior 2/3 of the true vocal cords (75%) then the anterior commissure (15%)

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3
Q

what is larynx cancer most commonly caused by?

A

cigarette smoking

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4
Q

what T level is the larynx located between

A

between C3-C6

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5
Q

Larynx is sup to the _____and ant to the _____.

A

sup to the trachea

ant to the hypopharynx

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6
Q

cartilages of the larynx

A 
there is 3 unpaired cartilages (epiglottis, thyroid and cricoid cartilage)
paired cartilages (arytenoids, corniculate and cuneiform)
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7
Q

functions of the larynx

A

acts as an instrument to produce sound and acts as a valve to close the lower respiratory tract

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8
Q

3 regions of the larynx

A

suoraglottis (Epiglottis, false vocal cords, ventricles, aryepiglottic folds, arytenoids)
glottis (true vocal cords and anterior commissure)
subglottis (located below the vocal cords)

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9
Q

lymphatics of the larynx

A

there is no LN in the glottis therefore there is only LN involvement in the supra and sub glottic areas and the LN mostly involved is the subdigastric LN

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10
Q

Larynx cancer usually presents _____.

A

early

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11
Q

most common site of disease recurrence

A

anterior commisure

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12
Q

most common site of distant mets

A

lungs

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13
Q

most common presentation of the true vocal cords

A

hoarseness

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14
Q

lymphatic drainage of the supra glottis , glottis and subglottis

A

supra glottis : peritracheal, cervical submittal and submaxillary LN

glottis: LN involvement is very rare
subglottis: peritracheal and low cervical LN

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15
Q

expected direct spread of the larynx

A
  1. true vocal cords
  2. false vocal cords
  3. arytenoid muscles
  4. epiglottis
  5. hypopharynx
  6. aryepiglottic folds
  7. ventricles
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16
Q

supraglottic S&S

A

neck mass may be the first sign of supraglottic involvement but the most common s&s is mild odonophagia

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17
Q

s&s of advanced laryngeal lesions

A 
sore throat 
referred pain through the vagus nerve to the auricular nerve of Arnold
pain localized to thyroid cartilage 
airway obstruction
stridor -high pitched wheezing
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18
Q

diagnostic methods of larynx cancers

A

fibre optic illuminated endoscope

CT followed by biopsy so that abnormalities from the biopsy are not confused with the tumour itself

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19
Q

most common pathology o larynx cancer

A

SCC

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20
Q

Carcinoma in stu is common for what area of the larynx

A

of the vocal cords

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21
Q

T1-T4 for the supraglottis

A

T1-limited to 1 site if the supra glottis with normal vocal cord mobility
t2-Invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis without fixation of the larynx
T3-Tumour is limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space and/or inner cortex of thyroid cartilage
T4-(a) Tumour invades through the thyroid cartilage and/or invades tissues beyond the larynx or (b) invades prevertebral space or mediastinal structures

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22
Q

T1-T4 for the glottis

A

T1A-limited to one vocal cord or T1B-to both vocal cords but with limited mobility
T2-extends to supra glottis or subglottis or with impaired vocal cord mobility
T3-limited to the larynx with vocal cord fixation
T4a- invades outer cortex of the thyroid cartilage or invades tissues beyond the larynx
T4b-tumour invades pre vertebral space encases carotid artery or invades mediastinal structures

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23
Q

subglottis T1-T4

A

T1-tunour limited to the sub glottis
T2-tunour extends to the vocal cords with normal or impaired mobility
T3-tunour limited to larynx with vocal cord fixation
T4a- tumour extends to third and cricoid cartilage with or without invading tissues beyond the larynx
T4b-tunour invades qprevertebral space encases carotid artery or invades mediastinum

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24
Q

N1-N3 for larynx cancers

A

N1-mets in 1 ipsilateral LN <3cm
N2-mets in single or bilateral LN 3-6cm
N3- mets >6cm

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25
staging larynx cancer
``` same for all H&N cancers except for nasopharynx cancers stage 1- T1 N0 Stage 2 T2 N0 Stage 3- T1-T3 N1 T3 N0 stage4-T4, N0 any T, any N, m1 any T N2,n3, M0 ```
26
prognostic indicators of larynx cancer
T Stage predicts local control N stage predicts mets females have better survival subglottic extension usually has worse control HPV status usually found in laryngeal SCC
27
Use of chemo in larynx cancer what agent is used?
used concurrently with XRT for late stage larynx cancer | cisplatinum is the agent used
28
surgery for early stage larynx cancer
primary treatment for early stage supra and subglottic lesions but not for glottis cancer XRT could also be used for early stage lesions with the advantage of having better voice preservation than surgery surgeries include a hemilaryngectomy or a total laryngectomy
29
contraindications for a hemilaryngectomy
Tumour extension to the epiglottis, false cord, or both arytenoids is a contraindication to hemilaryngectomy
30
what is a supraglottic laryngectomy
A voice sparing surgery that can be successfully for selected lesions involving the epiglottis, a single arytenoid, the aryepiglottic fold or the false vocal cord
31
XRT in larynx cancer | indications and advantages
the advantage of XRT to surgery is that there is better voice preservation and cosmetic outcome with XRT than with surgery can be used as primary treatment for early stage disease or in late disease when combined with chemo XRT alone or with chemo is also the treatment of choice for poorly differentiated disease
32
treatment for vocal cord carcinoma in situ
stripping the cord micro excision or laser ablation may be used early XRT is also recommended and is used in most patients to conserve the patients voice
33
treatment for T1-T2 vocal cord cancer
``` vocal cord (glottic cancer) XRT is initial treatment for these tumours and Surgery is used as a salvage therapy after XRT failure ```
34
treatment for T3 vocal cord cancer
mid grade glottic cancer is subdivided into 2 categoriesL relatively favourable or unfavourable prognosis the favourable prognosis is given non-XRT treatments with surgical salvage or immediate laryngectomy the unfavourable prognosis is given XRT
35
Treatment for T4 vocal cord cancer
given surgery (TOTAL laryngectomy ) sometimes followed by XRT XRT is given in the following situations: -close or +margins -subglottic extension >1cm -cartilage invasion -perineural invasion -extension of primary tumour into the soft tissues of the neck -multiple +LN of the neck -extra capsular extension
36
XRT borders and doses and energy for T1 glottic cancer
sup:thyroid notch inf:cricoid cartilage post: depends on the extension of the lesion ant: fall off ant to the skin 4-6MV is used 52/20 or 66/33 =weighted lateral POP
37
XRT borders doses and energy for T2 glottic cancer
fields size can range from 4x4cm- 6x6cm 70/35 =weighted POP 4-6MV used
38
XRT borders doses and energy for T3-T4 glottic cancer
Portals include jugulodigastric and middle jugular l/n Inferior jugular l/n are included in separate low-neck portal 72 Gy/36 fx or BID at 1.2 Gy /fx to total doses of 74.4-76.8 Gy Portals are reduced after 45.6 Gy in 38 fx; the reduced portals cover only the primary lesion
39
early and mid supraglottic cancer treatment
XRT is primary treatment early staged lesions with Nodal disease (N2B-N3), combined treatment is needed (XRT +Sx is used) For early stage resectable disease (N1-N2) Surgery is used alone unless something unexpected is found during the surgery then adjuvant XRT is added (unexpected findings being multiple +LN, +margins etc.)
40
advanced supraglottic lesions treatments
some lesions may be treated with XRT and surgery is saved for XRT failure neoadjuvant chemo followed by XRT is used for some patients total laryngectomy is used for some patients borderline lesions are given 45Gy and if response is seen then the full course of XRT
41
contraindications for supraglottic laryngectomy
extension to true vocal cord, ant commissure and atenyoids | fixation of vocal cord, thyroid or cricoid cartilage extension
42
radiation in supraglottic cancer
LN must be irradiated in tumours larger than T2 as there is more rich lymphatics in the supra glottis XRT is used adjuvantly after surgery in the following situations: -XRT is added for close + margins, invasion of soft tissues of the neck, significant subglottic extension , thyroid cartilage expansion, multiple + LN, extra capsular extension
43
doses for supagloottic XRT
- MARGINS 60/30 Microscopically + margins 66/33 gross residual disease 70/35 if there is subglottic extension the storma is boosted with electrons (10-14MEV) with an extra dose of 10Gy/5fx
44
lateral POP for supraglottic cancers
Used for small, early stage tumours that arise near the midline and do not involve nodes Most common for glottic tumours Can be used for laterally located lesions where there is evidence or risk of involvement of disease across midline Typically compensated for the ant-post slope of the neck contour (wedges, segments) or more commonly subfields or IMRT
45
angled down techniqueue for supraglottic cancers
Used when shoulders would be in the way of lateral POP beams (ie. short neck or disease at level of shoulders) Used to get better dose distribution (ie shoulders would not be attenuating the beam as much) Gantry 90 and 270 Couch rotated 15 degrees away from the gantry wedges , thick end sup, to compensate for the Sup-Inf dose gradient due to the couch rotation *wedge typically 30deg Rarely used due to IMRT Bolus can be placed on the anterior surface of the larynx (only a couple cm wide so that the dose to the side of the neck is not increased) The bolus generates scatter which projects posteriorly and increases the coverage of vocal cords and anterior commissure
46
complications of semi laryngectomy
chondritis wound slough, inadequate glottic closure and anterior commissure webs
47
complications of supraglottic laryngectomy and total laryngectomy
fistula, carotid artery exposure, infection and wound sloughing and fatal complications s
48
complications of XRT
Voice may improve after tumours regress after 2-3 weeks and it will plateau after 2-3 months edema occurs after XRT and is MOST COMMON LATE effect is will usually subside within 6 months -1 year
49
what is the 3 divisions of thed larynx
glottis, subglottis and supraglottis
50
what part of the larynx has best prognosis
glottis (true vocal cord)
51
what age is most common
50-60 yo
52
what subsitev is most common
glottis
53
what is a risk factor for supraglottic cancer but not glottic cancer
alcohol
54
what is the true vocal cords vs false vocal cords locsted
false- in the supraglottis | true- in the glottis
55
3 unpaired cartilages
epiglottis | thyroid and cricoid
56
3 paired cartilages
arteynoids, corniculate and cunieform
57
what are the parts of the supraglottis
epiglottis, false vocal cord, areyepiglottis fold and arytenoids
58
what are the portions of the glottis
true vocal cords and ant commisure
59
what are the portions of the subglottis
below vocal cords
60
LN spread occurs when what structure is invaded
Sub or Supra glottis
61
LN spread is most commonly to what LN
subdigastric
62
what subsites ar well differentiated, poorly differentiated?
glottic are well differentiated, supraglottic is less differentited and + aggresive
63
most common subsite... ant more specifically....?
most common subsite is the glottis | 65-75% occur on the ant 2/3 of 1 vocal cord
64
what happens if a glottic lesion is left untreated
if untreated, it can cause vocal cord fixation, exophytic lesions can cause obstruction, in this case tracheostomy is put in before tx starts
65
what subsites commonly have LN involved, which dont?
LN most commonly involved in the supraglottis -> rich LN network 55% + at dx compared to sub and regular glottis
66
how common is distant mets? where does it occur?
distant mets is Very rare about 1% of all vocal cord cancers the most common site is the lung followed by bone
67
S&S of the supraglottis
Is associated with voice changes - false vocal cords- hoarseness - epiglottis- hot potato voice
68
classic presentation of the glottis
hoarseness and sore throat
69
what is the treatment f choice for T1-2 glottic cancers and why
XRT is treatment of choice as it is better at sparing voice c/t SX
70
what stage is LN included in the Tx volume, what LN are tx
stage3 | midjugular & Jd are in the TX FIELD and a separate low neck field for inf jugular LN
71
typical treatment for subglottis
Sx- total laryngectomy is tx of choice XRT added for + margins after Sx
72
when would a lat POP be used?
lat POP may be used for early stage disease near M/L if LN are not involved, most frequently in glottic cases
73
when would angled down technique be used?
its used when shoulders are in the way of lat POP bams
74
what is the margins in IMRT
1-1.5cm for all subsites

Skin Radiation therapy (40 decks)

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