Larynx

1) Supraglottic region contains: A) Epiglottis B) False vocal cords C) Ventricles D) Aryepiglottic folds E) Arytenoids 2) Glottic region contains: A) True vocal cords B) Anterior commissure 3) Subglottic region is located below the vocal cords and contains: A) Cricoid Cartilage ﻿ ﻿ || __ Endoscopic image of the Larynx: __ || 2)Subglottis – into the peritracheal and low cervical nodes 3)Supraglottis into the peritracheal, cervical submental, and submaxillary nodes || T0 No evidence of primary tumor Tis Carcinoma in situ  (Supraglottis)  T1 Tumor limited to one subsite of the supraglottis with normal vocal cord mobility  T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis without fixation of the larynx  T3 Tumor limited to the larynx with vocal cord fixation and/or invades any of the following: post cricoid area, preepiglottic tissues  T4 Tumor invades through the thyroid cartilage and/or extends into soft tissues of neck, thyroid, and/or esophagus  (Glottis)  T1 Tumor limited to vocal cords (may involve anterior or posterior commissures) with normal mobility  T1a Tumor limited to one vocal cord  T1b Tumor involves both vocal cords  T2 Tumor extends to the supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3 Tumor limited to the larynx with vocal cord fixation T4 Tumor invades through the thyroid cartilage and/or to the other tissues beyond the larynx || Changes in your voice: Your voice may become hoarse or weak during radiation therapy. Your larynx may swell, causing voice changes. Skin changes in the neck area: The skin on your neck may become red or dry. These skin changes usually go away when treatment ends. Mouth sores and taste change are results of radiation treatments. changes in the thyroid: Radiation therapy can harm your thyroid. If your thyroid doesn’t make enough thyroid hormone, you may feel tired, gain weight, feel cold, and have dry skin and hair. Fatigue: You may become very tired, especially in the later weeks of radiation therapy. Resting is important, but doctors usually advise people to stay as active as they can. You will get back you energy a few weeks after completion of treatment. Weight loss: You may lose weight if you have eating problems from a sore throat and trouble swallowing. Some people may need a temporary feeding tube. [1] || 0 Stage Tis/N0/M0 has 5 year survival of 98% I Stage T1/N0/M0 has 5 year survival of 90% II Stage T2/N0/M0 has 5 year survival of 75% III Stage T3/N0/M0 & T3/N1/M0 has 5 year survival of 60% IV Stage AnyT/AnyN/M1 has 5 year survival of 25% [2] Supraglottic carcinoma: I stage T1/n0/m0 has 5 year survival of 90-95% II Stage T2/N0/M0 has 5 year survival of 75-80% III Stage T3/N0/M0 & T3/N1/M0 has 5 year survival of 50% IV Stage AnyT/AnyN/M1 has 5 year survival of 20-40% [3] || <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">In Situ: controlled with stripping of the cord, but its hard to not have microinvasion in te specimens. Recurrance is prevalent and repeated stripping procedures may result in permentent voice hoarseness along with thickined vocal cords. Radiation used earlier in a treatment usually results in better retention of the patients voice. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Surgical treatment in men is hemilaryngectomy where one full cord and one third opposite can be involved. women have smaller larynx so only removal of one cord is acceptable due to the posible airway complications. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Radiation treatment: T1 lesion field borders are thyroid notch superiorly to inferior border of cricoid and flash anteriorly. Posterior border depends on extent of the disease. T2 lesions are treated with opposed lateral fields with 1 cm of flash anteriorly. Typical field sizes are 4 x4 centimeter (cm), 5x5 cm and 6x6 cm fields for larger T2 lesions. T1 will have a total dose of 66 Gy with 2 Gray (Gy) per fraction while T2 tumors will have total dose of 70 Gy at 2 Gy per fraction. T3-T4 lesions have larger field sizes to include jugulodigastric and middle jugular lymphatic regions. A low neck field is also needed for proper coverage of the inferior jugular lymph nodes. T3-T4 treatment doses are 72 Gy in 36 fractions or a twice a day treatment (BID) at a 74.4-76.8 Gy total dose delivered with 1.2 Gy per fraction.[4] <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Supraglottic: <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Surgical treatment is supraglottic laryngectomy, the voice is retained with this procedure. Radiation treatment is similar to glottic area except in tumors larger that T2 size. If node disease is present then electron beam post cervical fields will be needed to spare the spinal cord while adequate coverage of cervical nodes is maintained. Offcord field modification should occur at 45 Gy. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Post operative radiation treatment: Used if close margins, soft tissue invasion, subglottic involvment, extra capsular involvment, thyroid catilage invasion, and multipule positive nodes. Base of tongue and stoma regions are high risk for failure. Doses of post operative cases are clear margins, 60 Gy in 30 fractions; microscopically positive margins, 66 Gy in 33 fractions; Gross residual disease 70 Gy in 35 fractions. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Chemotherapy is still investigational in the treatment of laryngeal cancers.[4] || <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif;"> Spinal cord has a tissue tolerence of 10 cm 2 can get 50 Gy before necrosis will occur. 20cm 2 of spinal cord can get 47 Gy. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 15px; line-height: 150%;">Thyroid gland can recieve 45 Gy to the whole gland before clinical thyroiditis will occur. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 15px; line-height: 150%;">Brachial plexis has a tissue tolerance of 60 Gy going above will result in nerve damage. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; line-height: 150%;"> Skin has a tolerance of 30cm ﻿2 ﻿to recieve 60 Gy, if the dose is above then ulceration and necrosis will occur.[5] || <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 15px; line-height: 150%;">[1] Novant Medical Group. //Potential Effects from Radiation Therapy for Laryngeal cancer.// [] Accessed May 24,2011. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 15px; line-height: 150%;">[2] Buzzle.com intelligent life on the web. //Throat cancer survival rate//. available at: [] Accessed May 23, 2011. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif;">[3] American Medical Network. //Laryngeal Cancer//. available at: [] Accessed May 23, 2011. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">[4] Chao C, Perez C, Brandy L. Radiation Oncology Management Decisions. 2nd ed. Lippincott Williams & Wilkins, Philadelphia, PA. 2002:267-273. <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">[5] Kehwar TS. Use of Normal Tissue Tolerance Doses into Linear Quadratic Equation to Estimate Tissue Complication Probability//.J Cancer Res Ther. 2005 July-Sept;1(3):168-79// <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">
 * Epidemiology: || Larynx cancer is the most common head and neck cancer. The larynx is often referred to as the “voice box”. It is a tubular structure connected to the top of the trachea and is located in the anterior neck at C3-C6 vertebrae. The larynx has three important functions that consist of controlling the airflow during breathing, protecting the airway, and producing sound for speech. The larynx is divided into three regions: the supraglottic, glottic, and subglottic. Please see larynx picture below.
 * Etiology: || Risk factors for larynx cancer involve the excessiove use of tobacco, alcohol, betel and areca nuts, excessive use of your voice, occupational inhalants, and deficiencies of iron, B12, and vitamin C. Supraglottic cancers are seen more than glottic cancers when excessive alcohol is involved. It has been reported that the use of black smoke shows a more increased risk when compared with other tobacco products. ||
 * Signs & Symptoms: || Signs and symptoms of larynx cancer can include the following: voice changes, hoarseness, lump in the neck, sore throat, a feeling that something is stuck in the throat, choking, chronic cough that doesn’t go away, problems breathing, chronic bad breath, earache, fatigue and weight loss. ||
 * Diagnostic Procedures: || A history and physical of the patient begins the work-up of diagnosing larynx cancer. Diagnostic work-up includes a chest x-ray, rigid and flexible endoscope (see photo below), a cat scan to rule out any abnormalities that could be confused with tumor, laryngoscopy, bronchoscopy if clinically indicated, ultrasound, MRI, bone scan, biopsy of tumor and lymph nodes. PET scans are usually used for diagnosis of stages III-IV. Prior to the beginning of radiation treatments (normally 10-14 days) all preventative dental care and extractions should be taken care of by the patient.
 * Histology: || Larynx cancer only represents approximately 2% of the total cancer risk. Squamous cell carcinoma accounts for about 95% of all larynx cancers. This type of cancer is mostly seen in people over the age of 55, although it should also be noted that younger people can also develop this form of cancer. People who stop smoking can greatly reduce their risk of cancer of the larynx. Men are four to five times more likely than women to develop laryngeal cancer. ||
 * Lymph Node Drainage: || 1)Glottis – extremely rare nodal involvement
 * Metastatic Spread: || The disease spreads mainly to the subdigastric nodes. The incidence of clinically positive nodes is 55% at the time of diagnosis, where 16% are bilateral. The elective neck dissection reveals pathologically positive nodes in 16% of all cases. Observation of initially node-negative necks eventually identifies the appearance of positive nodes in 33% of cases. The risk of late-appearing contralateral lymph node metastasis is 37% if the ipsilateral neck is pathologically positive. The incidence of clinically positive lymph nodes at diagnosis of carcinoma of the vocal cord approaches zero for T1 lesions and 1.7% for T2 lesions. The incidence of neck metastases increases to 20% to 30% for T3 and T4 lesions. ||
 * Grading: || * Grade 1 (well differentiated or low grade). The cancer cells look very like the normal cells of the larynx.
 * Grade 2 (moderately differentiated or intermediate grade). The cancer cells look less like the normal cells of the larynx
 * Grade 3 (poorly differentiated or high grade). The cancer cells look abnormal and different from normal cells in the larynx. ||
 * Staging: || TX Primary tumor cannot be assessed
 * Radiation Side Effects: || <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 15px; line-height: 150%;">Sore throat and difficulty swallowing: starts to occur in the end of the first two weeks.
 * <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif;">Prognosis: || <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif;">True vocal cord carcinoma:
 * <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif;">Treatments: || <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">True vocal cord:
 * <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif;">TD5/5: || <span style="color: #ff6300; font-family: Arial,Helvetica,sans-serif; font-size: 15px; line-height: 150%;">National Cancer Institute Task force released the TD5/5 for the larynx. The organ has a limit of 7000 centigray. If only a third of the organ is treated the maximum dose goes up to 7900 centigray. Laryngeal edema occurs at 45 Gy.
 * 1)  Website Article, Larynx Cancer: found at []. Accessed 5-26-2011.
 * 2)  Website Article, Larynx Cancer: found at [|www.cancer.net/patient/cancer+types/Laryngeal]. Accessed 5-27-2011
 * 3)  Website Article, Larynx Cancer: found at [|www.medicineNet.com]. Accessed 5-26-2011
 * 4)  Chao C, Perez C, Brady L .//Radiation Oncology.2nd ed//. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:255-273.
 * 5)  Hansen E., Roach M. //Handbook of Evidence-based Radiation Oncology//. Springer+Business Media, LLC, New York, NY. 2007:112-124.
 * 1) Cancer.net. (n.d.). // Laryngeal and Hypopharyngeal Cancer. // [|http://www.cancer.net/patient/Cancer+Types/Laryngeal+and+Hypopharyngeal+Cancer?sectionTitle=Staging%20With%20Illustrations#] // . //// Accessed May 25, 2011. //
 * 2) Chao C, Perez C, Brady L .//Radiation Oncology.2nd ed//. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:255-273.