1. CANCER OF LARYNX

6. the larynx is consists of a cartilaginous skeleton with
ligaments,which carries the muscles and mostly is covered
by mucous membrane .
skeleton of the larynx ;-
1)Thyroid cartilage ;- consist of tow lateral laminae which are
fused in front (bow ship). At the tip of bow is a notch (Adam
apple) . The superior and inferior horn arise from the
posterior edge of each laminae
2) Caricoid cartilage ;-it is ship is like signet ring .it is lamina is
2-2.5 cms lies posterior .the upper edage of the lamina has
tow articular surface for the arytenoid cartilage .the lateral
surface on each side has articular surface for the inferior
horn of the thyriod cartilage .

7. Arytenoid cartilage ;-pair of cartilage sited on the
upper edge of the lamina of the cricoid cartilage .it
has the shap of triangular pyramid .
The vocal cord are two thickened uppper end of the
conus attached posterior to the vocal process of
both arytenoids cartilage and interiorly to the inner
surface of the angle of the thyroid
cartilagecricoarytenoid muscles .
Epiglottis ;-lies against the middle of the thyroid
cartilage

8. Laryngeal ligaments ;-is a membrane composed of a
dense elastic fiber net which lies below the mucous
memberane of the larynx and has different
sickness in different region (conus elasticus-vocal
cord –median cricothyroid ligament l-quadrangular
membrane –vestibular ligament …)

10. New case in 2009 is 12,290 with ca larynx .with men
affected four time more than female .deaths from
ca larynx is 3,660 . With modern care the deaths
dropped from 2,97 per 100,000 to 2,24 per 100,000 .
Risk factors ;-
1) Age > 55 yrs .
2)Gender male to female ratio 4:1
3)Cigarette smoking (2-25X increase)

11. 4) Alcohol consumption (2-6 increase ) the .
The combination of cigarette and alcohol ↑(40-100) .
5) Race African –American are more affected .
6) Past medical history of head and neck cancer
↑risk of ca larynx .
7) Genetic factors ;- e.g fanconia anemia and
dyskeratosis congenita (condation→aplastic
anemia ↑ risk of ca larynx .
8) Condition → ↓ immunity (AIDS –organ
transplant ) .↑risk of ca larynx .

12. The majority of ca larynx which arise from the
mucosal surface is squamous cell carcinoma .
The most are well to mode differentiated .
Ca larynx sub site percent
supraglottic 35%
glottic 65%
subglottic 1%

15. spread occur by one of the three ;-
A) Local extension ;- the most common ,spread to
cartilages→ sclerosis then by additional growth
causes cartilage erosion → destruction and
penetration of cartilages .
B) Lymph nodes met- Occur less common .the
lymphatic drainage depend on the origin of the 1ry
sites .
C) Distant mets- ;-the most common site of
hematogenous spread is the bones then less
common to the lungs .

17. ipsilateral nodes contralateral nodes
11 111 1v v 1 11 111 1v v
1su
pr
1% 39% 26% 8% 5% O% 12% 5% 3% 3%
lymph nodes involved in the ca larynx (supraglottic)

18.  Clinical presentation ;-
Early presentation is hoarseness of the voice
Change in the quality of the voice .
While advance presentation is difficulty in the swallowing .
Cervical adenopathy . Weight loss . Throat pain . Referred
pain . Air way obstruction .
Head and neck examination :- inspection of the scalp,ears,
Nose, and mouth . Palpation of the neck, mouth, tongue
Mobility, base of the tongue, and floor of mouth.
Endoscope to nasal cavity,nasopharynx,oropharynx,
Hypopharynx and larynx . Carefully cranial nerve
examination

19. Diagnosis and clinical staging depends on finding from
history ,physical examination ,imaging and lab tests
. Pathological staging depends on finding from
surgical resection and histological examination .
There are American joint committee on cancer (AJCC)
And Tumor, Node, and Metastasis .(TNM)

20. AJCC ,TNM classification of carcinoma
Primary tumor ;-
Tx primary tumor can not be assessed
T0 No evidence of primary tumor
T is Carcinoma insitu

21. supraglottis ;-
T1 Tumor limited to 1 sub site of supraglottis ,with normal
vocal cord mobility
T2 Tumor in more than 1 adjacent sub site of the
supraglottis or glottis .with out fixation of the larynx
T3 tumor limited to larynx with vocal cord fixation, or
invades following postcricoid area preepiglottic space
Or inner cortex of thyroid cartilage
T4a Moderate advanced local disease, tumor invade thyroid
cartilage or pre -larynx tissues
T4b Very advanced local disease ,tumor invade prevertedral
space,carotid artery,or invades mediastinal structure

22. Glottis
T1 Tumor limited to 1 vocal cord with normal mobility
T1b Tumor involve both vocal cord with normal
mobility
T2 Tumor extends to supraglottis or subglottis with
impaired vocal cord mobility.
T3 Tumor limited to the larynx with vocal cord fixation
Or involve paraglottic space ,or inner cortex of
thyroid cartilage .
T4a Moderately advanced local disease ,outer cortex of
thyroid cartilage or tissues surrounding the larynx
T4b Very advanced local disease prevertebral space or
mediastinal structures .

23. Sub glottis ;-
T1 tumor limited to the subglottis
T2 Tumor extend to vocal cord with normal or
impaired mobility
T3 Tumor limited to the larynx with vocal cord fixation
T4 Moderately advanced local disease .invading of the
cricoid or thyroid cartilage or tissue around the
larynx .
T4b Very advanced local disease ,invading the
prevertebral space ,cartoid artery ,meditational
structure .

24. Regional lymph nodes ;-
Nx Can not be assessed
N0 no lymph nodes metastasis
N1 metastasis in the ipsilateral lymph nodes≤3 cm
(greater dimension)
N2a Metastasis in single ipsilateral lymph nodes>3cm
but≤6cm in greater dimension
N2b Metastasis in multiple ipsilateral lymph nodes
none >6 cm
N2c Metastasis in bilateral or contra lateral lymph
nodes none > 6cm
N3 Metastasis in lymph nodes >6cm in greater
dimension

25. Ca larynx suspected
Complete history & physical exam
Endoscopy and biopsy
imaging Lab
interventi
study study
on
Lesion
Advanced Advanced
incapable of LESION
lesion lesion
regional CAPABLE
suitable for beyond
met- OF
organ organ
GLOTTIC T1- REGIONAL
conservation conservation
2N0M0 *Mets-
** ***

26.  The out come of treatment of ca larynx is
varies substantially, from excellent to poor.
The most important prognostic factors
include extent/stage at diagnosis, the exact
site of origin of disease and patient’s
performance status /ability to tolerate the
desired therapy

27. Localized lesion incapable of regional
metastasis ; this include the SCC of glottis (T1 or
T2, N0 ) .this treated by radiation therapy to the
primary site only . Surgery is second option but
radiation is preferable due to subsequent voice
quality .
Radiation therapy ;- is indicated for all early stage .
The techniques ;- small opposed portals (e.g. 5x5 or
6x6 cm ) treating the primary tumor only .the dose
is 63 Gy in 28 fr/ 2.25 CGY/day in 5.6 weeks .

28. Usually the portals extend from hyoid bone to the
bottom of the cricoids cartilage (upper/lower) and
from the flash of the skin to the anterior aspect of
the vertebral body (anterior/posterior) .
Usually we use tow parallel opposed 4-6 MV photon
Beam field .
In recent years arandomized study done concurring
the fraction schaclat for T1N0M0 glottic cancer were
treated either with 2,0 or 2.25 Gy ,the 5yrs local
control rate favored the group that received 2.25 Gy

29. (92 versus 77%) . But the cause specific survival rate
were similar (100 and 97%) .
Localized lesion capable of regional metastasis
Limited extent SCC of the supraglottic larynx
(T1N0-smallN1 and most T2N0 . In treatment of the
these type of the lesion the tow type of the
treatment can be done radiation and surgery but
the radiation is preferable due to less morbid .
Radiation ;- suitable for all case . Specially if the
extend of the disease required total laryngectomy
to repair the surgery .

30. The techniques ;-
For small supraglottic include the primary lesion pulse the
upper and mid cervical (level1&11) .
For more extensive supraglottic lesion also include low,
anterior cervical (level1v) nodes .
If N1 anterior cervical disease the posterior cervical (level
5) should be treated .
Radiation technique ;-usually lateral and parallels op-
Posed fields are used . For T1 supraglottic lesion a dose of
66 GY in 33fr 2fr/day .for T2 supraglottic 70 GY in35 fr .

31. Advanced lesion suitable for organ preservation
T3 –T4 ;- this lesion traditionally treated by
laryngectomy(with or without pharyngectomy)
.now these is larynx sparing therapy these is no
deferent in the cervival between surgery and the
larynx sparing therapy .but not all lesion are suitable
for organ preservation therapy (unreliable
patients,pts contuse smoking during treatment
,hypertensive,pts who cannot tolerate discomfort
of the surgery)

32. The treatment modal which used for organ
preservation;-
Indicated for advanced lesion that have not
penetrated cartilage .(cord fixation is not contra-
Indication).
Techniques ;-the primary tumor and clinical involved
Nodes should receive 70 GY in 35 frs .
All anterior and posterior cervical andsupraclavicular
clinically uninvolved are at risk for sub clinical
involvement and need to receive minimum of 50 GY

33. The chemotherapy ;- include cisplatin I.V on day 1,22
&43 of radiotherapy .
Clinical evidence ;-
Randomized trials ;-
Departmen pts number= 332 ( stage 111 or 1v ca larynx ). Median fallow up 33
t of veteran months
affairs Compared 3 cycles of indication cisplatin + flurouracil chemotherapy
larynx Versus laryngectomy postoperative radiation.
The survival rate is equal in both arm for 2 yrs =68% ( p=0.098)
.there were
More local recurrence (p=0.005)and fewer distant metastases
(p=0.016)
In the chemotherapy group than in the other group

34. EORTC2489 Randomized of patent number202 with ca
1b larynx of the pyriform sinus stage 11-1v follow
up to 51 months .
Compared cycles of inducation cisplatin
chemotherapy and thenradiotherapy verus
larngectomy and postoperative radiotherapy
median cervival was 44months in inducation
chemotherapy arm and 25 months in surgery
arm .
Local and regional recurrence was similar in
both arm

35. RTOG Randomized care of 520 patients who wise
Required laryngectomy .
Comparing inducation cisplatin plus fluoro-
Uracil and then radiotherapy versus radiotherapy
with concurrent administration of cisplatin versus
radiotherapy alone .
The primary end point of preservation of the
larynx significantly favored concurrent
Therapy 2yrs-88% while inducation chemo-
75% and the radiotherapy 70%.
2nd end point of loco regional control significantly
Favored concurrent therapy 78% while with
inducation chemo-61% and 56% with radiotherapy
Alone .overall survival was similar in all groups

36. Resectable advanced lesions not suitable for organ
Preservation ;-the important part in preservation is
the preservation of the function .once function is
Irreparably lost , these is little benefit to preserving
The anatomy .in other cases concurrent chemo-may be
toxic due to other diseases or refuse stop smoking /co-
morbidities /unreliable who cutting medication /patients
who emotionally would prefer
Surgery / cartilage destroyed or extracapssular extension.
2studies show that stage111 loco regional
Control improved by adding cisplatin concurrent with

37. Radiation therapy tech- ;-the fields include the
primary site (tumor +ve LNs) +subclinical LNS
The upper border includes the nodes in the upper
jugular region. both the ipsilateral and contra lateral
Posterior are include in the treatment portals if
anterior chain +ve.
The primary site &area with↑risk(dissected and has
Altered vascular supply)60-66GY 33fr .
While area of low risk(not dissected) will receive
50-54 fr .

38. unresectable advanced lesion not suitable for organ
Preservation ;- in unresectable patients with good
general condition with no heamatogenus spread
can be approached with curative- intent
chemotherapy-enhanced radiation therapy . In very
Fit patients inducation chemotherapy succeeded by
Chemo—enhanced radiation therapy .for patient with
Already distant metastasis role will be palliation

39. Post-operative radiation therapy .
Radiation is indicated for all lesion extent
Tech – 60-66 GY to operative bed and drainage
Nodes .
Chemo- ;-indicated for microscopically involved
mucosal margin /extra capsular extension of nodal
Disease .
Tech- I-V ;-cisplatin 1 on day 1 ,22 and 43 of
radiotherapy treatment .

40. The volume delineation ;-
The primary tumor site,all nodal beds at risk of
subclinical disease and operative bed . The upper
border include the nodes in jugular region .the high
Risk region→ 60-66 GY .low risk→50-54 GY .

41. Supporting clinical evidence
RTOG 9501 459 patients . Who ,after definitive surgery , had
histologic invasion
Of tow or more regional LNs/extra capsular extension
of nodal disease
Or mucosal resection margin.
Randomized to radiotherapy alone o(60-66GY) versus
identical treatment
+concurrent cisplatin on day 1 ,22 &43 .
The primary end point of loco regional control favored
concurrent chemotherapy at 2 yrs 82% ( with
chemotherapy ) versus 72% (no chemotherapy ).
The secondary end point of disease free survival also
favored concurrent
Therapy ( p=0.04) but over all survival not different

42. EORTC Patients number 334 ,who after definitive surgery had
22931 histological
Evidence of extra nodal spread , + ve margin , per neural
involvement
Or vascular tumor embolism (median fallow up 60
months )
Randomized to radiotherapy alone (66 GY in 33 fr)
versus identical treatment +concurrent cisplatin in day
1, 22 &43 .
The primary end point of disease free survival favored
concurrent therapy
At 5 yr s4% with chemotherapy verus36% (no
chemotherapy) p=o.o4
Second end point of overall survival(p=0.02) and loco
regional control
(p=0.007) both significantly favored concurrent therapy

43. schedule frequency
First follow up 2weeks after radiation →for acute reaction
Yrear0-1 Every month
Year 1-2 Every 2 months
Year2-3 Every 3 months
Year 3+ Every 6 months

44. From the previous data of RTOG 9501and EORTC
22931
Which concurring the benefit of chemotherapy.
Were the ECE (extra capsular extenation) or +ve SM.
Involvement of2 more LNs by tumor is not predict
Benefit from chemotherapy .

45. The emis is to controlling thedistressing loco-
Regional signs or symptoms of disease for during the
patient remaining alive .
For who have one or tow non life threatening lesion
.with good response to chemotherapy ,the radiation
Therapy that approaches the intensity of definitive
Treatment. With more advanced metastatic disease
The author tends to favor asplit-course( eg;-30GY in
2weeks the tow weeks rest ,followed by another
30 GY in 2weeksto smaller field never over lap the
spinal cord.for patient live more we can do quad
Shot technique

46. Supporting clinical evidence ;-
For M0tumor Multi-institutional phase 111 trial includeing 295 patient with
unresectable
Nondisseminated ,head and neck cancer.
Randomized to stander radiation therapy alone (70YG in 30 fr ) versus
Identical radiation +concurrent bolus cisplatin on day 1 ,22 ,34 versus
Split-course radiation therapy + bolus cisplatin and continuous –infusion
Fluorourcil . The with concurrent cisplatin is associated with improve of
The survival,at the cost increase the toxicity .the 3yrs overall survival
37% .

47. For M0 166 patients with locally advanced ( 74% operable and 26%
tumor unoperable)laryngeal and hypophyaryngealcancer .
Randomized to to treatment with docetaxel (taxotere) ,cisplatin
And 5-fluorourcil inducation then chemoradiotherapy versus
Cisplatin and fluorourcil (pf) then chemoradiotherapy .
For inoperable 2 yrs overall survival was 55% with TPF AND 41%
In the PF .
for inoperable tumor ,the 2 yrs progression free survival was 42%
In TPF and 30% in the PF .

48. For MI 30 patients who had advanced head and neck nearly stage 1v
TUMOR With performance score of 2-3 .
Quad shot =14 GY in 4fr given twice a day at least 6hours apart
Over 2 consecutive days ahd repeated up to twice more every
4 weeks .
53% objective reponse rate ( complete reponse,2, partial response
,4.) .
Median progression free survival3,1 months . Median overall
survival 57 months .
44% patients had measurable improvement in the quality of life

49. Dose limitation gude line in the ca larynx
Organ at risk Dose limitation (GY)
spinal cord 45
brachial 60
plexus
mandible 70
posterior <35 (astrip of normal tissue should
neck be left to facilitate
Drainge )