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Skin Radiation therapy > Larynx > Flashcards

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
Q

staging larynx cancer

A 
same for all H&amp;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
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26
Q

prognostic indicators of larynx cancer

A

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

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27
Q

Use of chemo in larynx cancer what agent is used?

A

used concurrently with XRT for late stage larynx cancer

cisplatinum is the agent used

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28
Q

surgery for early stage larynx cancer

A

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

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29
Q

contraindications for a hemilaryngectomy

A

Tumour extension to the epiglottis, false cord, or both arytenoids is a contraindication to hemilaryngectomy

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30
Q

what is a supraglottic laryngectomy

A

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
Q

XRT in larynx cancer

indications and advantages

A

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
Q

treatment for vocal cord carcinoma in situ

A

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
Q

treatment for T1-T2 vocal cord cancer

A 
vocal cord (glottic cancer)
XRT is initial treatment for these tumours and Surgery is used as a salvage therapy after XRT failure
34
Q

treatment for T3 vocal cord cancer

A

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
Q

Treatment for T4 vocal cord cancer

A

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
Q

XRT borders and doses and energy for T1 glottic cancer

A

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
Q

XRT borders doses and energy for T2 glottic cancer

A

fields size can range from 4x4cm- 6x6cm
70/35
=weighted POP
4-6MV used

38
Q

XRT borders doses and energy for T3-T4 glottic cancer

A

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
Q

early and mid supraglottic cancer treatment

A

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
Q

advanced supraglottic lesions treatments

A

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
Q

contraindications for supraglottic laryngectomy

A

extension to true vocal cord, ant commissure and atenyoids

fixation of vocal cord, thyroid or cricoid cartilage extension

42
Q

radiation in supraglottic cancer

A

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
Q

doses for supagloottic XRT

A
  • 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
Q

lateral POP for supraglottic cancers

A

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
Q

angled down techniqueue for supraglottic cancers

A

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
Q

complications of semi laryngectomy

A

chondritis wound slough, inadequate glottic closure and anterior commissure webs

47
Q

complications of supraglottic laryngectomy and total laryngectomy

A

fistula, carotid artery exposure, infection and wound sloughing and fatal complications s

48
Q

complications of XRT

A

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
Q

what is the 3 divisions of thed larynx

A

glottis, subglottis and supraglottis

50
Q

what part of the larynx has best prognosis

A

glottis (true vocal cord)

51
Q

what age is most common

A

50-60 yo

52
Q

what subsitev is most common

A

glottis

53
Q

what is a risk factor for supraglottic cancer but not glottic cancer

A

alcohol

54
Q

what is the true vocal cords vs false vocal cords locsted

A

false- in the supraglottis

true- in the glottis

55
Q

3 unpaired cartilages

A

epiglottis

thyroid and cricoid

56
Q

3 paired cartilages

A

arteynoids, corniculate and cunieform

57
Q

what are the parts of the supraglottis

A

epiglottis, false vocal cord, areyepiglottis fold and arytenoids

58
Q

what are the portions of the glottis

A

true vocal cords and ant commisure

59
Q

what are the portions of the subglottis

A

below vocal cords

60
Q

LN spread occurs when what structure is invaded

A

Sub or Supra glottis

61
Q

LN spread is most commonly to what LN

A

subdigastric

62
Q

what subsites ar well differentiated, poorly differentiated?

A

glottic are well differentiated, supraglottic is less differentited and + aggresive

63
Q

most common subsite… ant more specifically….?

A

most common subsite is the glottis

65-75% occur on the ant 2/3 of 1 vocal cord

64
Q

what happens if a glottic lesion is left untreated

A

if untreated, it can cause vocal cord fixation, exophytic lesions can cause obstruction, in this case tracheostomy is put in before tx starts

65
Q

what subsites commonly have LN involved, which dont?

A

LN most commonly involved in the supraglottis -> rich LN network 55% + at dx compared to sub and regular glottis

66
Q

how common is distant mets? where does it occur?

A

distant mets is Very rare about 1% of all vocal cord cancers the most common site is the lung followed by bone

67
Q

S&S of the supraglottis

A

Is associated with voice changes

  • false vocal cords- hoarseness
  • epiglottis- hot potato voice
68
Q

classic presentation of the glottis

A

hoarseness and sore throat

69
Q

what is the treatment f choice for T1-2 glottic cancers and why

A

XRT is treatment of choice as it is better at sparing voice c/t SX

70
Q

what stage is LN included in the Tx volume, what LN are tx

A

stage3

midjugular & Jd are in the TX FIELD and a separate low neck field for inf jugular LN

71
Q

typical treatment for subglottis

A

Sx- total laryngectomy is tx of choice XRT added for + margins after Sx

72
Q

when would a lat POP be used?

A

lat POP may be used for early stage disease near M/L if LN are not involved, most frequently in glottic cases

73
Q

when would angled down technique be used?

A

its used when shoulders are in the way of lat POP bams

74
Q

what is the margins in IMRT

A

1-1.5cm for all subsites

Skin Radiation therapy (40 decks)

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