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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4505_Библиотеки_им_академика_М_И_Перельмана
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154
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Part 2 Site-Specifi c Indications and Techniques
Case
Study
9-3
epiglottis and le aryepiglottic fold. ere was a small le
subdigastric node noted. Biopsy of the primary tumor was
positive for squamous cell carcinoma, and the patient was
staged as having a T2 N1 carcinoma.
e patient was treated with IMRT using a concomitant
boost schedule. Figure 9.3B shows CTVHD ( red) encompassing
A 63-year-old man, long-time smoker, presented to an otolaryngologist for a benign
problem and was incidentally found to have a
supraglottic tumor (Fig. 9.3A). e lesion was
relatively small and involved the suprahyoid
the primary tumor (T) with generous margin, CTVID (blue)
the nodal region immediately below the involved node, and
CTVED (yellow) the remaining uninvolved neck nodes. More
superiorly (Fig. 9.3C) CTV
margin and the inferior base of tongue (superior margin on
the primary tumor). CTV
erally (Fig. 9.3D). Isodose distributions are shown on axial
(Fig. 9.3E), sagittal (Fig. 9.3F), and coronal (Fig. 9.3G) views.
He remains free of disease 2 years later and has an asymptomatic le paramedian epiglottis defect (Fig. 9.3H), approximately at the epicenter of the original tumor.
covers the involved node with
HD
covers level IV neck nodes bilat-
ED
A
C
Figure 9.3A-D
B
D
Chapter 9 Larynx
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155
E
G
Figure 9.3E-H
Background Data
Table 9.1
Squamous Cell Carcinoma of the Supraglottic Larynx: Control of Primary Lesion by Radiotherapy
F
H
Stage
1954–1963 1964–1972
Site
Suprahyoid epiglottis 6/6 3/4 9/13 9/15 3/4 7/7 13/15 3/5
Infrahyoid epiglottis 3/5 5/8 0/0 1/4 5/5 11/12 3/4 1/1
Aryepiglottic folds 2/2 9/11 4/7 1/1 5/5 6/7 3/4 3/6
False cords 3/3 5/6 1/1 0/0 2/2 8/10 0/0 1/1
Arytenoids 0/0 2/3 0/1 0/0 2/2 1/1 0/0 0/0
Total 14/16 24/32
Note: Approximately 500 rad higher dose in second period.
a
T2 + T3: 1954–1963, 30% failure rate; 1964–1972, 13% failure rate.
2
= 4.9386; P < 0.05.
c
Data from the M.D. Anderson Cancer Center. Analysis: August 1976.
Modifi ed from Fletcher GH, Goepfert H. Larynx and pyriform sinus. In: Fletcher GH, ed. Textbook of radiotherapy, 3rd ed. Philadelphia, PA: Lea & Febiger,
1980:330–363, with permission.
T1 T2 T3 T4 T1 T2 T3 T4
a
14/22
a
11/20 17/18 33/37
a
19/23
a
8/13
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Part 2 Site-Specifi c Indications and Techniques
Table 9.2
Radiation Schedules
Hyperfractionationb (1984–1991) 77 87% 80% 2.7
Standard fractionation
Note: Patients treated in 1982 and 1983 were excluded because some received treatment with conventional fractionation and others with hyperfractionation.
a
Requiring tracheotomy or laryngectomy.
b
P = 0.04.
Data from the M.D. Anderson Cancer Center. Analysis, July 1992.
Table 9.3
Stage
T2 35/41 (85%) 14/16 (88%) 49/57 (86%) 44/52 (85%)
T3 9/13 (69%) 8/13 (62%) 17/26 (66%) 17/26 (65%)
Total 44/54 (81%) 22/29 (76%) 66/83 (80%) 61/78 (78%)
Note: Local control following radiotherapy according to medical and anatomic suitability for surgery in 83 patients treated at the University of Florida. This
excludes patients who died within 2 yr of radiotherapy with primary site continuously disease free.
Modifi ed from Hinerman RW, Mendenhall WM, Amdur RJ, et al. Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned
neck dissection. Head Neck 2002;24:456–467.
Local Control and Complication Rates Following Radical Radiation of T2–T3, N0 N3 Carcinoma of the
Supraglottic Larynx
Local Control
No. of Patients 2 yr 5 yr Severe Complicationa(%)
b
(1970–1981) 98 78% 70% 3.0
T2 to T3 Carcinoma of Supraglottic Larynx
Anatomically Suitable for Supraglottic Laryngectomy
Medically Suitable Medically Unsuitable Total
Anatomically Unsuitable
GLOTTIS CARCINOMA: EARLY STAGE
Treatment Strategy
Primary radiotherapy is preferred for most T1 to T2 tumors.
Primary Radiotherapy
Target Volume
e target volume encompasses the larynx proper (sparing
suprahyoid epiglottis) (Case Studies 9-4 and 9-5).
Setup and Field Arrangement for Conventional
Radiotherapy Technique
e patient is immobilized in a supine position with a thermoplastic mask. Lateral parallel–opposed photon elds are
used. In patients with a short neck, a 5- to 10-degree inferior
tilt may be necessary to avoid irradiation through the wider
part of the shoulder.
• Superior border: top of thyroid cartilage for T1 or higher
for T2 tumor with supraglottic extension.
• Anterior border: approximate 1 cm fallo .
• Posterior border: anterior margin of the vertebral bodies.
• Inferior border: lower edge of the cricoid cartilage for T1 or
lower for T2 tumor with subglottic extension.
Dose
For microscopic disease (e.g., a er “stripping” or excisional
biopsy of T1 tumors): 60 Gy in 30 fractions.
Other T1 tumors: Several dose fractionation schedules
have been described. e key element is that the dose per
fraction should be ≥ 2 Gy. Options are 66 Gy in 33 daily fractions or 63 Gy in 28 daily fractions.
T2 tumors: Altered fractionation schedules are preferred. Hyperfractionation to a dose of 76.6 to 79.2 Gy at
1.2 Gy per fraction delivered twice daily (with at least 6 hours
between fractions) is an option. An alternative is 70 Gy in
35 fractions over 6 weeks by treating twice daily once per
week (6 fractions per week) for 5 weeks.
Bulky T2 tumors: 70 Gy in 35 fractions over 7 weeks
with concurrent cisplatin (see T3 tumors below).
e radiation dose is speci ed at an isodose line. For
patients treated with conventional techniques, treatment
is usually given with 15- or 30-degree wedges. Di erential
loading (2:1 or 3:2) may be used for unilateral lesions.
Intensity-Modulated Radiation Therapy Planning
IMRT is being investigated for carotid artery sparing (Case
Study 9-6). e CTV is the entire larynx excluding the
suprahyoid epiglottis. e superior and inferior borders are
similar to those used for conventional therapy.
Chapter 9 Larynx
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157
Case
Study
9-4
supraglottic or subglottic spread, and vocal cord mobility
was normal. No lymph nodes were palpated in the neck.
Biopsies showed microinvasive squamous cell carcinoma on both true vocal cords. Stage: T1 N0 M0. e
patient was treated with lateral parallel–opposed elds
(Fig.9.4). A dose of 64 Gy speci ed in the isocenter was
delivered in 2-Gy fractions. A er a dose of 50 Gy, the posterior border was moved 1 cm anteriorly to reduce the dose
to the arytenoids. A 15-degree wedge was used to produce a
slight dose gradient delivering a higher dose to the thickest
part of the lesion at the anterior third of the cords. He had
no evidence of disease and had good voice quality 4 years
a er therapy.
A 66-year-old man presented with a 6-month
history of progressive hoarseness. Examination showed mild edema and leukoplakia of
the anterior commissure and the anterior one
third of both true vocal cords. ere was no
Figure 9.4
Case
Study
9-5
did not extend into the supraglottic or subglottic larynx.
Abiopsy was positive for invasive squamous cell carcinoma.
A 52-year-old woman who smoked cigarettes presented with hoarseness. Examination revealed a tumor involving the entire
length of the right true vocal cord. e vocal
cord mobility was normal, and the tumor
A B
Figure 9.5A,B
Stage: T1 N0 M0. She was treated with primary radiation to
the larynx only. Parallel–opposed elds were used to deliver
a dose of 66 Gy in 33 fractions. Figure 9.5 shows the digitally
reconstructed portal radiograph (Fig. 9.5A) and the isodose
distribution through the larynx (Fig. 9.5B). A combination
of 30- and 45-degree wedges was used to modify the beam,
and the dose was delivered preferentially from the right side.
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Part 2 Site-Specifi c Indications and Techniques
Case
Study
9-6
A
is 66-year-old patient was diagnosed with
squamous cell carcinoma of the larynx, stage T1
N0, and was treated with IMRT.
Figure 9.6 shows an axial CT slice with
the CTVHD outlined in red (Fig. 9.6A), a
sagittal image outlining the superior and inferior borders
of the CTVHD (Fig. 9.6B), and an axial isodose distribution
at thelevel of the glottis (Fig. 9.6C). e dose prescribed
to the CTV
carotid vessels are outside the 40-Gy line (blue).
C
was 63 Gy (in 28 fractions). Note that the
HD
B
Figure 9.6A-C
Background Data
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Chapter 9 Larynx
159
Table 9.4
Results of Radiation for T1 Carcinomas
of the True Vocal Cords (Review)
No. of
Series
Patients Local Control
Harwood et al. (1979) 333 86% (5-yr A)
Fletcher and
332 89% (C)
Goepfert (1980)
Lustig et al. (1984) 342 90% (3-yr A)
Hendrickson (1985) 364 90% (C)
Wang (1997) 665 93% (5-yr A)
Le et al. (1997) 315 84% (C)
Warde et al. (1998) 449 91% (T1a, 5-yr A)
82% (T1b, 5-yr A)
Cellai et al. (2005) 831 84% (5-yr A)
Chera et al. (2010) 325 94% (T1a, 5-yr A)
83% (T1b, 5-yr A)
A, actuarial; C, crude.
Table 9.5
Results of Radiation for T2 Carcinomas
of the True Vocal Cords (Review)
No. of
Series
Patients Local Control
Lustig et al. (1984) 109 78% (3-yr A)
Karim et al. (1987) 156 78% (5-yr A)
Barton et al. (1992) 327 69% (5-yr A)
Wang (1996) 237 77% (T2a, 5-yr A)
71% (T2b, 5-yr A)
Warde et al. (1998) 230 69% (C)
Garden et al. (2003) 230 72% (5-yr A)
Frata et al. (2005) 256 73% (5-yr A)
Chera et al. (2010) 260 80% (T2a, 5-yr A)
70% (T2b, 5-yr A)
A, actuarial; C, crude.
Table 9.6
Control Probability of T2 Glottic Cancer as a Function of Cord Mobility (Review)
Local Control (%) After
No. of Patients
Radiotherapy (3 or 5 yr)
Ultimate Control
(%) (3 or 5 yr)
Series T2a T2b T2a (%) T2b (%) T2a (%) T2b (%)
Martensson et al. 30 19 70 47 — —
Kun et al. 12 43 75 58 — —
Fletcher 108 67 77 69 97 90
Harwood et al. 156 80 80 52 — —
Van den Bogaert et al. 33 28 62 65 81 68
Wang 102 88 79 61 — —
Karim et al. 111 45 78 80 90 95
Mendenhall et al. 65 43 77 72 97 88
Wiggenraad et al. 50 21 78 71 98 76
Howell-Burke et al. 40 74 73 72 95 97
From Ang KK, Peters LJ. Vocal cord cancer: 2b worse than not 2b? Radiother Oncol 1990;18:365–366, with permission.
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Part 2 Site-Specifi c Indications and Techniques
Table 9.7
Five-Year Local Control Rates in 230 Patients with T2 N0 Glottic Carcinoma: Prognostic Variables
No. of Patients 5-yr Control Rate (%) P-value
No subglottic extension 111 81 0.004
Subglottic extension 119 63
T2a 114 74 0.37
T2b 116 70
Daily dose >2 Gy
a
138 80 <0.001
Daily dose ≤2 Gy 90 59
Once-daily fractionation
a
147 67 0.06
Twice-daily fractionation 81 79
Total 230 72
a
Two patients with compliance diffi culties had fractionation schedule changes during their treatments and are excluded.
Data from M.D. Anderson Cancer Center. Modifi ed from Garden. AS, Forster.K, Wong. PF, et al. Results of radiotherapy for T2 N0 glottic carcinoma: does the
“2” stand for twice-daily treatment? Int J Radiat Oncol Biol Phys 2003;55:322–328.
Table 9.8
Outcome of Treatment of First Recurrences After Primary Radiotherapy in 37 Patientsa Treated at the
M.D. Anderson Cancer Center
Local–Regional Control by Treatment Modality
Site of
Recurrence
Laryngectomy
Only
and Neck
Dissection
Neck
Dissection
Larynx 23/28 — — — 1/1 1/3
Laryngectomy
Neck and
Dissection
Radiotherapy Hemilaryngectomy Laser
b
Neck — — 1/1 2/2 — —
Larynx and
— 0/2 — — — —
neck
a
Entries indicate number of patients whose fi rst recurrence was controlled over the number of patients treated.
b
Although disease recurred in two patients treated by laser therapy, both recurrences were controlled by subsequent laser ablations.
From Howell-Burke D, Peters LK, Goepfert H, et al. T2 glottic cancer. Recurrence, salvage, and survival after defi nitive radiotherapy. Arch Otolaryngol Head
Neck Surg 1990;116:830–835, with permission.
Table 9.9
Causes of Death After Treatment of T2 Glottic Carcinoma in 230 Patients Treated at the M.D. Anderson
Cancer Center
Causes No. of Patients
Index cancer
Recurrence above clavicles 15
Distant metastases 15
Surgical complications 3
Second cancers 32
Other intercurrent disease (or unknown) 55
Total 119
a
One patient died with both local recurrence and distant disease.
Adapted from Garden AS, Forster K, Wong PF, et al. Results of radiotherapy for T2 N0 glottic carcinoma: does the “2” stand for twice-daily treatment? Int J
Radiat Oncol Biol Phys 2003;55:322–328.
a
Chapter 9 Larynx
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161
LOCALLY ADVANCED CARCINOMA
OF THE LARYNX
Treatment Strategy
Radiation with concurrent cisplatin (100 mg/m2, q3 wk) is
the preferred larynx-preserving treatment for T2 N2 to N3
and the vast majority of T3 tumors. An alternative option is
three cycles of induction chemotherapy, consisting of docetaxel, cisplatin, and uorouracil, followed by radiotherapy
in responders or total laryngectomy in nonresponders.
e standard treatment for resectable T4 tumors is total
laryngectomy, usually with postoperative radiotherapy and,
in the presence of high-risk features such as positive extracapsular nodal extension or positive margin, with concurrent
cisplatin. Selected patients may be enrolled in ongoing trials.
Primary Radiotherapy for T3 or
N+ Tumors
Target Volume
For patients without nodal involvement, the initial target volume
encompasses the larynx and levels II, III, and IV (subdigastric,
midjugular, and lower neck) nodes (Case Study 9-7). For patients
with involved node(s), the initial target volume includes ipsilateral levels IB and/or V nodes. e boost volume encompasses
the primary tumor and involved nodes with 1- to 2-cm margins.
Setup and Field Arrangement for Conventional
Radiotherapy T
e patient is immobilized in a supine position with a thermoplastic mask. Marking of shoulders and palpable lymph
nodes, when present, facilitates portal design. Lateral
parallel-opposed photon elds are used to treat the primary
tumor and level II to III nodes. Field borders are similar to
those used for supraglottic carcinoma. A matching anterior
portal is used for treatment of the level IV nodes.
It may be necessary to use anterior and inferior tilts for
patients with a short neck. In this case, the supraclavicular
fossae are included in the primary portal (Case Study 9-8).
For boost volume, lateral portals are reduced to encompass gross disease. Nodes overlying the spinal cord can usually receive boost dose through oblique–lateral primary
boost portals and those in the lower neck through an appositional electron portal or glancing photon elds.
Intensity-Modulated Radiation Therapy Planning
Most patients are now treated with IMRT to spare parotid
(Case Studies 9-9 and 9-10). e primary disease
nction
fu
is treated with a minimum of 1-cm margin, though, due
to laryngeal motion, it is prudent to encompass the majority of the larynx in the high dose target (CTVHD or CTV1).
Involved node(s) with 1-cm margin are also encompassed in
CTVHD. e neck compartments outside CTVHD with a 2-cm
echnique
Case
Study
9-7
tumor extended into the le ventricle, and there was minimal edema of the le false cord. e right true vocal cord
showed an area of leukoplakia, but the mobility was normal.
ere was no palpable neck lymphadenopathy. Computed
tomography (CT) scan of the larynx con rmed the physical
ndings. Biopsy showed a well-di erentiated squamous cell
carcinoma of the le true vocal cord. Stage: T3 N0 M0. He
was treated with a standard fractionation (70Gy in 35fractions over 7 weeks with concurrent cisplatin).
e lateral portals (Fig. 9.7) were designed to encompass the primary tumor and level II and III lymph nodes.
e level IV neck nodes were treated with a matching
anterior appositional eld. e boost dose was delivered
through small lateral elds as used for T1 to T2 vocal cord
tumors. e primary tumor received 70 Gy over 7 weeks,
uninvolved neck nodes 50 Gy in 25 fractions over 5 weeks.
is patient continued to smoke during and a er treatment. Follow-up examination 2.5 years later revealed no
evidence of disease, but the arytenoids were edematous.
A 55-year-old man presented with a long history of persistent hoarseness and recent onset
of le ear pain. Mirror examination showed a
whitish exophytic lesion over the entire length
of the le true vocal cord, which was xed. e
Figure 9.7
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Part 2 Site-Specifi c Indications and Techniques
Case
Study
9-8
eral neck dissection. Histologic examination revealed basaloid squamous cell carcinoma of the right hemilarynx and
pyriform sinus. e tumor invaded the thyroid cartilage,
hyoid bone, and skeletal muscle of the neck. e margins
were negative. Two of 32 right neck nodes were involved
but without extracapsular extension. Le neck nodes were
free of carcinoma. Stage: T4 N2 M0.
Radiation commenced 4 weeks a er surgery. It was
thought that the initial tumor volume extended inferiorly,
and parallel–opposed elds would inadequately cover the
volume at risk. It was elected instead to use oblique portals
A 52-year-old man presented with a transglottic tumor of the larynx and bilateral adenopathy. CT scan revealed a large primary
laryngeal tumor invading the thyroid cartilage.
He underwent a total laryngectomy and bilat-
angled caudally and posteriorly (Fig. 9.8A). ese two elds
encompassed the primary tumor volume at risk as well as
the retropharyngeal nodes and nodal levels II through V.
e stoma was covered in these elds, as well. At 42 Gy, the
elds were reduced o the spinal cord. e caudal angulation was continued, but the elds were placed in true lateral
position (Fig. 9.8B) to facilitate matching the electron elds
for delivering supplemental dose to the posterior cervical
strips. e nal dose was 60 Gy. A reduction was not made
o the superior border because the larger tissue diameter
in this region resulted in a lower dose per fraction to the
retropharyngeal and highest jugular nodes. us the highrisk volume received 60 Gy, while the lower risk subclinical
volume received 54 Gy (all in 30 fractions). Figure 9.8C and
D shows representative isodose distributions through axial
cuts of the mid and low neck.
A B
C
Figure 9.8A-D
D
Chapter 9 Larynx
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163
Case
Study
9-9
for squamous cell carcinoma. She was staged as having a
T3 N0 carcinoma of the vocal cord. She was treated with
A
A 45-year-old woman presented with
hoarseness.
Examination revealed a lesion on the
right vocal cord (Fig. 9.9A), which was xed.
Biopsy of the primary tumor was positive
IMRT and three cycles of concurrent cisplatin (100 mg/
m2, q3wk). e larynx (CTVHD) and bilateral levels II
to IV nodes (CTVED) received 70 Gy and 57 Gy given in
35 fractions, respectively. Figure 9.9 shows axial (Fig. 9.9B),
sagittal (Fig. 9.9C), and coronal (Fig. 9.9D) isodose distributions through the larynx.
B
C
Figure 9.9A-D
D
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