Larynx

|||||| **Incidence Rates by Race ** ||
 * < **Epidemiolgy:** ||< * Larynx connects the pharynx with the trachea housing the vocal tract.
 * Account for one quarter of all head and neck cancers (mostly affecting true vocal cords (TVC)).
 * Larynx cancer accounts for 2% of all diagnosed cases.
 * Typically seen in patients over the age of 50.
 * Male to female incidence is 4:1.
 * Squamous cell carcinoma is the most common histological type of laryngeal cancer, about 95% of cases. [1]
 * It is estimated that 12,360 men and women (9,840 men and 2,520 women) will be diagnosed with cancer of the larynx. [2]
 * Chance of developing larynx cancer is 0.36% based on rates from 2007-2009. [2]
 * Incidence rate is higher in black males vs. white males. ||
 * **Race/Ethnicity ** || **Male ** || **Female ** ||
 * All Races || 6.2 per 100,000 men || 1.3 per 100,000 women ||
 * White || 6.1 per 100,000 men || 1.3 per 100,000 women ||
 * Black || 9.9 per 100,000 men || 1.8 per 100,000 women ||
 * Asian/Pacific Islander || 2.3 per 100,000 men || 0.3 per 100,000 women ||
 * <span style="font-family: 'Arial','sans-serif'; font-size: 12px;">American Indian/Alaska Native [|a] || <span style="font-family: 'Arial','sans-serif'; font-size: 12px;">4.2 per 100,000 men || <span style="color: #008000; display: block; font-family: arial,sans-serif; font-size: 12px; text-align: right; text-decoration: none;">[|^] ||
 * <span style="font-family: 'Arial','sans-serif'; font-size: 12px;">Hispanic [|b] || <span style="font-family: 'Arial','sans-serif'; font-size: 12px;">4.7 per 100,000 men || <span style="font-family: 'Arial','sans-serif'; font-size: 12px;">0.6 per 100,000 wome ||
 * Smokers are 20 times more likely to be diagnosed with cancer of the larynx.
 * Most larynx cancers arise from mucosal lining. [3]

These symptoms or signs should be discussed with a doctor, especially if they are persistent or get worse[1]. When detected early, laryngeal cancer can often be treated successfully while preserving the function of the larynx. A specific blood test will be given that detects laryngeal several tests, including blood and urine tests, may be done to help determine the diagnosis and learn more about the disease.[1] || <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;">The **glottic** area of the larynx has almost no lymphatic drainage. [4] <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;">The **subglottic** area has little very little lymph drainage to pretracheal lymph nodes and posteriorly to paratracheal lymph nodes, and onto the inferior jugular chain. [4] || // When describing a T1-T4 tumor, doctors divide the larynx into 3 regions: the glottis, the supraglottis, and the subglottis. //
 * **Etiology:** || Due to the number and complexity of tissues with in the head and neck region, specific etiology is difficult to pinpoint and often are associated with structures of similar histological make up and function.
 * Major risk factors include smoking and alcohol use.
 * Alcohol has as a synergetic affect to the use of tobacco and its carcinogenic potential when examined together.
 * Environmental factors that include smoke, dust or wood fibers have been linked to risk factors of cancer of the larynx.
 * HPV-16 is a growing risk factor. [3]
 * Heavy smokers are at greater risk of developing cancer of the larynx. [3] ||
 * **Signs & Symptoms:** || There are several signs and symptoms that are presented for laryngeal cancer; however most of these symptoms do not always show in the patients. Some of the signs and symptoms that are presented are [1]:
 * Hoarseness or change in voice (often an early symptom) that does not go away within two weeks[6]
 * An enlarged lymph node or a lump in the neck
 * Airway obstruction, difficulty breathing, and noisy breathing
 * Persistent sore throat or a feeling that something is caught in the throat
 * Persistent difficulty in swallowing
 * Ear pain
 * Chronic bad breath
 * Choking
 * Unexplained weight loss
 * Fatigue
 * Dyspnea and stridor
 * Ipsilateral otalgia
 * Dysphagia
 * Odynophagia
 * Chronic cough
 * Hemoptysis [1]
 * **Diagnostic Procedures:** || Diagnostic procedures that are done to conclude laryngeal cancer are through a larngoscopy, which the test is preformed in multiple ways.[1] Another way is through X-ray/barium swallow.[1] An x-ray is a way to create a picture of the structures inside of your body, using a small amount of radiation. Sometimes, the patient will be asked to swallow barium, which coats the mouth and throat, to enhance the image on the x-ray (called a barium swallow).[6] A barium swallow is used to identify abnormalities along the throat and esophagus.[1] A special type of barium swallow, called a modified barium swallow, may be needed to evaluate difficulties with swallowing.[1] Furthermore, a dentist may also take extensive x-rays of the teeth, mandible (jawbone), and maxilla (upper jaw), including a panorex (panoramic view) if needed. If there are signs of cancer, the doctor may recommend a computed tomography (CT) scan.[1] Furthermore, magnetic resonance imaging (MRI) is also used as a way to diagnosis laryngeal cancer. [1] An MRI uses magnetic fields, not x-rays, to produce detailed images of soft tissue, such as the tonsils and the base of the tongue. Last but not least, a bone scan can also be used.[1] A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein then it collects in areas of the bone and is detected by a special camera.[1] Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark.[1] In head and neck cancer, bone scans are recommended if there are signs of bone metastasis. After these diagnostic tests are done, the doctor will review all of the results with the patient. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called first steps to take after a diagnosis of cancer.[1] ||
 * **Histology:** || <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;">95% or more of hypopharyngeal tumors are squamous cell carcinoma.[4] ||
 * **Lymph node drainage:** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;">Supraglottic **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;">drainage, which has the best capillary lymphatic drainage in the larynx, flows through the pre-epiglottic space and thyroid membrane to the subdigastric lymph nodes mostly. The supraglottic area has minimal drainage to the middle internal jugular lymph node chain. [4]
 * **Metastatic spread:** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;">Supraglottic **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;"> lesions tend to spread more than glottic and subglottic due to more lymph drainage spreading most commonly to the subdigastric nodes. These allow more access to soft tissues including deep muscles of the neck, tongue, thyroid and esophagus. [4]
 * <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;">Glottic **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;"> lesions are usually localized but can penetrate the thyroid cartilage and in larger more advanced tumors can advance to the supra and subglottic areas and spread to tissues including deep muscles of the neck, tongue, thyroid and esophagus. [4]
 * <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;">Subglottic **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px;">lesions spread to tissues including deep muscles of the neck, tongue, thyroid, trachea, and esophagus are at risk of metastasis due to lymph drainage and proccimety to the subglottic area. [4] ||
 * **Grading:** || **GX**: The grade cannot be evaluated.
 * G1 ** : The cells look more like normal tissue (well differentiated).
 * G2 ** : The cells are only moderately differentiated.
 * G3 ** : The cells don't resemble normal tissue (poorly differentiated).
 * Recurrent ** : Cancer that comes back after treatment. If there is a recurrence, they may need to re-stage. [7] ||
 * **Staging:** || //** PRIMARY TUMOR: **//
 * TX: ** The primary tumor cannot be evaluated.
 * TO: ** No evidence of a tumor is found.
 * TIS: ** Carcinoma in situ. An early cancer where the cancer cells are only in one layer of tissue.


 * Glottis tumor of the larynx: **
 * T1: ** The tumor is limited to the vocal folds, but it does not affect movement of the folds.
 * T1a: ** The tumor is in just the right or left vocal fold.
 * T1b: ** The tumor is in both vocal folds.
 * T2: ** The tumor has spread to the supraglottis and/or the subglottis. T2 also describes a tumor that affects the movement of the vocal fold, without paralyzing the fold.
 * T3: ** The tumor is limited to the larynx and paralyzes at least one of the vocal folds.
 * T4a: ** The tumor has spread to the thyroid cartilage and/or the tissue beyond the larynx.
 * T4b: ** The tumor has spread to the prevertebral space, chest area, or encases the arteries.


 * Supraglottis tumor of the larynx: **
 * T1: ** The tumor is located in a single area above the vocal folds that does not affect the movement of the folds.
 * T2: ** The tumor started in the supraglottis but has spread to the mucus membranes that line other areas, such as the base of tongue.
 * T3: ** The tumor is limited to the larynx with vocal fold involvement and/or has spread to surrounding tissue.
 * T4a: ** The tumor has spread through the thyroid cartilage and/or the tissue beyond the larynx.
 * T4b: ** The tumor has spread to the prevertebral space, chest area, or encases the arteries.


 * Subglottis tumor of the larynx: **
 * T1: ** The tumor is limited to the subglottis.
 * T2: ** The tumor has spread to the vocal folds, and may or may not affect the movement of the folds.
 * T3: ** The tumor is limited to the larynx and affects the vocal folds.
 * T4a: ** The tumor has spread to the cricoids or thyroid cartilage and/or the tissue beyond the larynx.
 * T4b: ** The tumor has spread to the prevertebral space, chest area, or encases the arteries.

//** NODES: **//
 * NX: ** The regional lymph nodes cannot be evaluated.
 * NO: ** There is no evidence of cancer in the regional nodes.
 * N1: ** The cancer has spread to a single node on the same side as the primary tumor, and the cancer found in the node is 3cm. or smaller.
 * N2: ** Describes any of the following conditions:
 * N2a: ** The cancer has spread to a single lymph node on the same side as the primary tumor and is largerthan 3 cm, but not larger than 6 cm.
 * N2b: ** The cancer has spread to more than 1 lymph node on the same side as the primary tumor, and none measure larger than 6 cm.
 * N2c: ** The cancer has spread to more than 1 lymph node on either side of the body, and none measure larger than 6 cm.
 * N3: ** The cancer found in the lymph nodes is larger than 6 cm.

//** METASTATIC SPREAD: **//
 * MX: ** Distant metastasis cannot be evaluated.
 * MO: ** The cancer has not spread to other parts of the body.
 * M1: ** The cancer has spread to other parts of the body.

//** STAGING: **// -redness or skin irritation -swelling -dry mouth -thickened saliva from damage to salivary glands (can be temporary or permanent) -bone pain -fatigue -mouth sores -sore throat -dental problems if not taken care of before treatment -change in voice -taste changes [7] || Image 1: Radiation treatment portals for true vocal cord.
 * Stage 0: ** Describes a carcinoma in situ (Tis), with no spread to lymph nodes (NO) or distant metastasis (MO).
 * Stage I: ** Describes a small tumor (T1), with no spread to lymph nodes (NO) or distant metastasis (M0).
 * Stage II: ** Describes a tumor with some spread to nearby areas (T2), but has no spread to lymph nodes (N0) or to distant parts of the body (M0).
 * Stage III: ** Describes any larger tumor (T3), with no spread to reagional lymph nodes (N0) or metastasis (M0), or a smaller tumor (T1, T2) that has spread to regional lymph nodes (N1) but has no sign of distant metastasis (M0).
 * Stage IVA: ** Describes any invasive tumor (T4a), with either no lymph node involvement (N0) or spread to only a single same-sided lymph node (N1), but no metastasis (M0). It is also used for any tumor (any T) with more significant spread to the lymph nodes (N2), but no metastasis (M0).
 * Stage IVB: ** Describes any cancer (any T) with extensive spread to lymph nodes (N3), but no metastasis (M0). For laryngeal cancer, it is also used for a very advanced localized tumor (T4b), with or without lymph node involvement (any N), but no metastasis (M0).
 * Stage IVC: ** Indicates there is evidence of distant spread (any T, any N, M1). [7] ||
 * **Radiation side effects:** || Some side effects after radiation therapy are:
 * **Prognosis:** || The larynx has a sparse lymphatic supply; therefore, the prognosis is more favorable. Tumors of the larynx staged T1and T2 have a prognosis of 80-90% of patients show no evidence of disease after 5 years. Stages T3 and T4 have a prognosis of 55% of patient show no evidence of disease after 5 years. [3] ||
 * ** Treatments: ** || Treatment of the larynx varies depending of the stage of the disease. Early stage vocal cord carcinoma is usually treated with radiation alone for T1 and T2 lesions. The treatment of choice for advanced stage vocal cord carcinoma is total laryngectomy, with or without adjuvant radiation treatment. Supraglottic early stage treatment of choice is either radiation alone or supraglottic laryngectomy, with or without adjuvant radiation therapy. If neck disease is present, combined treatment is necessary. Advanced stage patients may be treated with a trial of radiation to 45 or 50 Gy. With good response, the radiation continues. If not, they may stop the radiation treatments and have a total laryngectomy performed. Supraglottic laryngectomy is a voice-sparing surgery. Treatment portals are similar to the vocal cord treatment, however the lymphatics must also be treated. [4]

__ Radiation Treatment Techniques __

Superior border - Thyroid notch Inferior border – Cricoid cartilage Anterior border – fall off with flash Posterior border – depends on the tumor extension Dose commonly used is 66 Gy [4]
 * T1 vocal cord (glottic) larynx **

Field is extended. Field sizes range from 4 cm x 4 cm to 6 cm x 6 cm, plus flash anteriorly. Dose commonly used is 70 Gy. [4]
 * T2 vocal cord (glottic) larynx **

Require larger portals to include the jugulodigastric and middle jugular nodes Inferior jugular nodes included in a separate lower neck portal Dose commonly used is 72 Gy once a day (36 fractions) or 74.4 to 76.8 Gy twice a day.[4] Figure 2: Fields can be reduced after 45 Gy A: Left lateral portal for T3N0M0 squamous cell carcimona B: Left lateral radiation field C: Anterior lower neck portal [4]
 * T3 and T4 vocal cord (glottic) larynx **

Treatment portals are similar to glottic tumors, however regional lymph nodes must be included with tumors > T2. For clinically positive nodes, electrons may be used to increase dose to the posterior cervical nodes. Used postoperatively for: Dose commonly used: Whole organ: 70 Gy 2/3 organ: 70 Gy  1/3 organ: 79 Gy  [5] [6] ||||||||   ||
 * Supraglottic larynx **
 * Close or positive margins or nodes
 * Invasion of soft tissues of the neck or thyroid cartilage
 * Subglottic extension > 1cm
 * Extracapsular extension
 * Negative margins: 60 Gy in 30 fractions
 * Positive margins: 66 Gy in 33 fractions
 * Gross residual disease: 70 Gy in 35 fractions [4] ||
 * < **TD 5/5:** |||| Larynx

2. Surveillance Epidemiology and End Results. Fact sheet larynx. [date] Available at: [] Accessed: May 22, 2012 3. Lenhard RE, Osteen R, Gansler T. //The American Cancer Society’s Clinical Oncology//. Williston, VT: Blackwell Publishing, Inc; 2001. 4. Chao KS, Perez CA, Brady LW. //Radiation Oncology: Management Decisions//. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. 5. Marks LB, Yorke ED, Jackson A, et al. Use of Normal Tissue Complication Probability Models in the Clinic. //Int J Radiat Oncol Biol Phys//. 2010;76(3):S10-S19. doi: 10.1016/j.ijrobp.2009.07.1754. 6. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. //Int J Radiat Oncol Biol Phys//. 1991;21(1):109-122. http://www.ncbi.nlm.nih.gov/pubmed/2032882?dopt. 7.Laryngeal and Hypopharyngeal Cancer. Oncologist-approved cancer information from the American Society of Clinical Oncology. December 2011. Available at: []. Accessed: May 22, 2012. ||
 * **References:** || 1. Laryngeal Cancer Best Practices. August 2011. Available at: []. Accessed: May 20, 2012

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