Block 1C - H+N Cancers (Laryngeal, Nasal Cavity, Paranasal Sinuses)

ONCOL 310 - Clinical Oncology II. University of Alberta

what is the most common H+N tumor?

laryngeal cancer

what are the three anatomical regions of the larynx

1. supraglottic larynx

2. glottic larynx

3. subglottic larynx

what is contained in the supraglottic larynx

epiglottis, false vocal cords, ventricles, aryepiglottic folds, arytenoids

why does the supraglottic larynx have the most risk of spread?

there is rich lymphatic drainage from the jugulodigastric and mid-jugular

what is contained in the glottic larynx

the true vocal cords and ant/post commissures

are there any LN in the true vocal cords?

no

what is the most common site of laryngeal cancer

the glottic larynx

what is contained in the subglottic larynx

it is the area 1 cm inf to true vocal cords to the lower border of the cricoid cartilage or first tracheal ring (1 cm long)

• primary cancers here are rare

larynx cancer epidemiology

• M:F ratio

• age range

• what percent are diagnosed in early stage

M:F = 5.5:1

age: > 65 years

50% are diagnosed as early stage

etiological factors of laryngeal cancers

• smoking and excessive alcohol consumption

• HPV +

• occupational exposure (woodworking, metal, leather)

• lower socioeconomic status

• poor nutrition and vitamin status

clinical presentation of supraglottic laryngeal cancer

pharyngitis, odynophagia, dysphagia, otalgia, enlarged LN’s

clinical presentation of glottic laryngeal cancer

hoarseness of voice, pharyngitis

clinical presentation of subglottic laryngeal cancer

no symptoms until locally extensive - hoarseness of voice

describe the natural history of laryngeal cancer

arises from the epithelial lining of the mucous membrane that can spread by local invasion to supra or subglottic regions

• mobility impairment of vocal cords may be caused by direct invasion of tumor into thyroarytenoid muscle

what lymphatic levels are involved in supraglottic pharyn(midline rich lymphatics)

levels II, III, and IV

what lymphatic levels are involved in the glottic laryngeal cancer

rare since devoid of lymphatics but levels II, III, IV, and VI are possible

what lymphatic levels are involved in subglottic laryngeal cancer

also rare but level VI is possible

what is the most common site of mets of laryngeal cancer

lung is most common

• mediastinal LN’s, bone, and liver

good prognostic indicator of laryngeal cancer

lack of LN involvement (75-95%)

• depends on site, bulk, and degree of infiltration

poor prognostic indicator of laryngeal cancer

vocal cord immobility

what indicators have the highest risk of recurrence in 2-3 years

stages III and IV

close or positive surgical margins

perineural, lymphovascular or extracapsular (nodal) spread

primary tumor in oral cavity

what imaging investigations can be done to diagnose laryngeal cancer

laryngoscopy, encoscopy, barium swallow, CXR (for lung mets), CT or MRI with contrast, PET

what two types of biopsies can be used for larryngeal cancer

endoscopic or FNA

what is the most common pathology of laryngeal cancer

squamous cell carcinoma (95%)

• Non-SCC: adenocarcinoma and very rare sarcomas

what are the two different subtypes of SCC laryngeal

keratinzing (HPV unrelated)

non-keratinizing (HPV related)

what are the general staging categories for laryngeal cancer

stage 0 = carcinoma in situ

early = stages 1 & 2

locally advanced = stage 3

advancec = stage 4

Staging (T) for supraglottic cancer

Staging (T) for glottic cancer

Staging (T) for subglottic cancer

Stage IV for all larynx cancers

larynx cancer TNM Staging - N and M

management strategy for laryngeal cancer is dependent on what two things

LN status of neck

prescence of distant mets

what surgeries can be done for smaller early stage laryngeal tumors

laser surgery, vocal cord stripping or coredectomy

what type of surgeries can be done for larger more advanced-stage tumors

partial laryngectomy or total laryngectomy + LN dissection

why is EBRT done for laryngeal cancers

to preserve voice and allows surgery to be reserved for salvaging failures

when is PORT done for laryngeal cancers

positive margins, subglottic extension > 1 cm, cartilage, extracapsular or perineural invasion, multiple positive neck nodes

what chemos are used in the treatment of laryngeal cancer (done pretty much anytime alongside Sx or RT)

cisplatin + 5FU

what biological therapy can be used to treat laryngeal cancers alongside RT and surgery

cetuximab

• EGFR inhibitor

Stage I Laryngeal cancer management

• supraglottis

• glottis

• subglottis

supraglottis: EBRT (66-74 Gy) or laryngectomy

glottis: EBRT or Surgery (laryngectomy, laser excision, cordectomy)

subglottis: EBRT for voice preservation ± Sx

Stage II Laryngeal cancer management

• supraglottis

• glottis

• subglottis

Stage III Laryngeal cancer management

• supraglottis + glottis

• subglottis

Stage IV Laryngeal cancer management

• supraglottis + glottis

• subglottis

what are some of the various treatments of metastatic or recurrent laryngeal cancer

Surgery ± EBRT, EBRT, chemo, immunotherapy, clinical trials

what is the mainstay of treatment for early stage glottis cancer

radiation therapy

RT glottis set-up

supine on AIO board, 4-point shell, arms by sides with knee and ankle rests

RT glottis

• energy

• technique

• collimator angle

• D/F accelerated conccurent boost

• D/F Post-op

6 MV

lat POP with fields centered on vocal cords (5×5 fs)

angle follows vertebral bodies

70 Gy / 35 fraction

64-60 Gy / 27-30 fraction

what are the sup, inf, ant, and post RT borders for glottic cancer

sup = thyroid notch or hyoid bone

inf = border of cricoid cartilage (c6)

ant = clear skin 1-1.5 cm at level of vocal cords (FLASH) + 1 cm bolus for nodal treatment

post = between ant edge and middle of vertebral body, including anterior portion of pharyngeal wall

are fieds larger for supraglottic or glottic lesions

supraglottic lesions

sup, inf, ant, post fields for supraglottic lesions

sup = extends along mandible (to include jugulodigastric and middle jugular LN’s if advanced dx)

inf = inf of cricoid cartilage

ant = clear skin surface/flash

post = spinal accessory chain / spinous process

supraglottic cancer RT

• energy

• technique

• shielding

• D/F

6 MV

IMRT, VMAT, or shrinking field conventional

shielding = trachea and spinal cord

66-70 Gy / 33-35 fractions

advantages of supraglottic cancer RT vs surgery

increased voice preservation, decreased carotid damage, better for patients with short thick necks

subglottic lesions are rare but …

very aggressive

• can cause airway obstruction if advanced

with T3 laryngeal lesions, are larger or smaller fields used to treat it?

larger portals to cover level II-IV lymph nodes

dose to T3 laryngeal lesions

54-60 Gy

what is the goal of treatment of T3 lesions

larynx preservation

with T4 laryngeal lesions, are larger or smaller fields used to treat it?

larger fields than T3, to cover LN levels II-IV + VI

is larynx preservation acheivable with T4 lesions

no, it is rarely acheivable

what are three organs at risk for laryngeal cancer treatment and their TD5/5 for 1/3 of the organ

spinal cord: 50 Gy for 5 cm

Vocal cords: 45 Gy

thyroid: 45 Gy

list 4 acute reactions to laryngeal RT and management of the side effects

• mucositis

  • gargle/rinse of crushed aspirin

• hoarseness

  • rest voice

• erythema/dry desquamation/moist

  • skin care

• dysphagia

  • maintain fluid and nutrition via IV, gargles

• additional: ageusia, fatigue, hearing issues

what are some chronic reactions to laryngeal RT

otalgia, fetid odor, severe hemorrhage/stroke due to carotids in RT field, telangietasia, hypothyroidism, malnutrition

what rehab can be done for significant dysphagia

esophageal dialation, swallowing therapy, surgical replacement of larynx

what rehab can be done to maximize speech post laryngectomy

esophageal speech, electrolarynx, tracheoesophageal puncture

survival rates of laryngeal cancer

subglottis has the lowest 5YS while glottis has the best

hoarseness is a early common symptom in ___ cancer while it is a late symptom for ____ and _____ cancers

early: glottic

late: subglottic and supraglottic (needs to spread)

Early stage laryngeal cancer (T1-T2) is treated with …

surgery or radiation therapy

T3 laryngeal cancer is treated with …

RT ± chemo

advanced laryngeal cancer (T4) extending outside the larynx is treated with …

surgery then post-op chemoRT

What bones form the walls of the nasal cavity?

anteriorly = frontal bone and nasal bone

posteriorly = sphenoid bone

inferiororly = vomer and palatine bone

superiorly = frontal bone

lateral = ethmoid bone

are the maxillary sinuses paired or unpaired

paired: one on each side

what type of epithleium lines the maxillary sinsues, and where to the secretions drain

the maxillary sinus is lined by pseudostratified columnar epithelium and the secretions drain into the middle nasal meatus

what are the sup, inf, post, and medial borders of the maxillary sinus

sup = infraorbital rim

inf = hard palate (roots of teeth penetrate cavity(

post = nasopharynx

medial = nasal wall

what are the functions of the maxillary sinus

decrease skull weight, impact resonance of voice, humidify and warm inhaled air, filter debris, immunodefensive action

nasal cavity cancer epidemiology

• where to most tumors occur

• where do least tumors form

• M:F

• age

• countries where most common

uncommon cancer

• most commonly in maxillary sinus or nasal cavity

• least common in frontal and sphenoid sinus

• M:F = 2:1

• > 55

• more common in south africa and japan

5 etiological factors of nasal cavity cancer

• smoking

• exposure to leather dust, nickel, chromium

• HPV (SCC)

• Epstein-Barr Virus (NHL)

• RT for retinoblastoma

describe the natural history of nasal cavity cancers

most lesions are advanced on presentation and have ability to invade into the orbit from the maxillary sinus

• rare nodal involvement and hematogenous spread

how does cancer get from ethmoid sinus get into the cranial fossa

through the orbit and into the cribriform to get into the cranial fossa

what are the two categories of maxillary sinus cancer

• suprastructure tumors

  • nasal cavity, ethmoid cells, orbit, infratemporal fossa, base of skull

    • poor prognosis as it can invade into skull

• infrastructure tumors

  • palate, alveolar process, gingivobuccal sulcus, soft tissue of cheek, nasal cavity

lymphatic spread from maxillary sinus cancer is rare, but what nodes would if go to first?

subdigastric and submandibular nodes

lymphatic spread from ethmoid and frontal sinus cancer would go to …

submaxillary nodes

lymphatic spread from sphenoid sinus cancer would go to …

jugulodigastric nodes

lymphatic spread from lesions involving oral cavity and cheek would go to …

submandibuar and upper jugular nodes

lymphatic spread from lesions involving nasal cavity and nasopharynx would go to …

retropharyngeal and upper jugular nodes

is hematogenous spread common for maxillary sinus cancer

no

early and advanced presentation of nasal vestibule cancer

early: asymptomatic plaques or nodules (crusting and scabbing)

advanced: pain, bleeding, ulceration

early and advanced presentation of nasal cavity cancer

early: chronic unilateral discharge, ulcer, obstruction, headache

advanced: proptosis, expansion nasal bridge, diplopia, anosmia

presentation of ethmoid sinus cancer

central or facial headaches, referred pain to nasal region, proptosis, diplopia

early and advanced presentation of maxillary sinus cancer

early: vague, mimics sinusitis or inflammation

advanced: facial swelling, epistaxis, orbital pain, unhealed tooth socket

early and advanced presentation of sphenoid sinus cancer

early: vague headache

advanced: CN III, IV, V, VI neuropathy

what imaging tests can be done to diagnose nasal cavity/sinus cancers

CT (cortical bone erosion through cribriform plate)

MR (direct intracranial/leptomeningeal spread)

PET or bone scan

what biopsy is done to diagnose nasal cavity/sinus cancer

transnasal biopsy paired with a fiber optic nasal endoscopy

what would be the diagnosis from this scan

left paranasal sinus invaded with tumor

what would be the diagnosis from this scan

right maxillary bone has been fractured/destroyed by a tumor

three patient prognostic indicators of cancer of nasal cavity/sinus

age (younger is better)

sex (female has better prognosis)

performance status (higher is better)

4 disease prognostic indicators of nasal cavity/sinus cancer

• location (below Ohngren’s line is better, higher in skull is worse)

• histology

• locoregional extent

• perineural

what do most patients die of from when diagnosied with nasal cavity/sinus cancer

direct extension into vital skull areas

what is the most common pathology of nasal cavity/sinus cancers

squamous cell carcinomas (70-80%)

three lesser pathologies of maxillary antrum cancers

• adenocarcinomas

• melanoma

• sarcoma

three lesser pathologies of nasal cavity/sinus cancers

salivary gland

lymphomas

some osteogenic sarcomas

maxillary sinus TNM staging - T

Tx: primary tumor cannot be assessed

Tis: carcinoma in situ

T1:  Mucosa

T2:  Bone erosion/destruction, hard palate, middle nasal meatus

T3:  Posterior bony wall maxillary sinus, subcutaneous tissues, floor/medial wall of orbit, pterygoid fossa, ethmoid sinus

T4a: moderately advanced local dx: (Anterior orbit, cheek skin, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid/frontal sinus)

T4b: very advanced local dx (Orbital apex, dura, brain, middle cranial fossa, cranial nerves other than V2, nasopharynx, clivus)

Nasal cavity / ethmoid sinus cancer TNM staging - T

Tx: primary tumor cannot be assessed

Tis: carcinoma in situ

T1:  One subsite +/- bony invasion

T2:  Two subsites or adjacent nasoethmoidal site

T3:  Medial wall/floor orbit, maxillary sinus, palate, cribriform plate

T4a: moderately advanced local dx (Anterior orbit, skin of nose/cheek, anterior cranial fossa (minimal), pterygoid plates, sphenoid/frontal sinuses)

T4b: very advanced local dx (Orbital apex, dura, brain, middle cranial fossa, cranial nerves other than V2, nasopharynx, clivus)