Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer(beta)
All patients with T1, T2 laryngeal cancer should be treated, at least initially, with intent to preserve the larynx.
T1, T2 laryngeal cancer can be treated with radiation or larynx-preserving surgery with similar survival outcomes. Selection of treatment depends on patient factors, local expertise, and the availability of appropriate support and rehabilitative services. Every effort should be made to avoid combining surgery with radiation therapy because functional outcomes may be compromised by combined-modality therapy; single-modality treatment is effective for limited-stage, invasive cancer of the larynx.
The success of the larynx-preservation approach may be higher with initial larynx-preserving surgery compared with radiation therapy based on retrospective studies; however, this may be subjected to patient selection factors. In experienced hands, endoscopic resections are preferred because of equal or better outcomes compared with open partial laryngectomy, unless there are issues with tumor exposure or safety of the endoscopic approach.
Surgical excision of the primary tumor with intent to preserve the larynx should be undertaken with the aim of achieving tumor-free margins. Surgery that anticipates the need for postoperative radiation therapy to treat close or involved tumor margins or widespread dysplasia is not an acceptable treatment approach.
Local tumor recurrence after radiation therapy may be amenable to salvage by organ-preservation surgery, but total laryngectomy will be necessary for a substantial proportion of patients, especially those with index T2 tumors.
Combined chemotherapy and radiation therapy may be used for larynx preservation for selected patients with limited-stage and (1) unfavorable or deeply invasive T2 cancer, (2) T2 N+ cancer, (3) for whom a total laryngectomy may be the only surgical option, (4) in whom the functional outcome after larynx-preserving surgery is expected to be unsatisfactory, and (5) for whom surgical expertise for such procedures is not available.
Limited-stage laryngeal cancer constitutes a wide spectrum of disease. The clinician must exercise judgment when recommending treatment in this category. For a given patient, factors that may influence the selection of treatment modality include extent and volume of tumor; vocal cord mobility; involvement of the anterior commissure; lymph node metastasis; the patient’s age, occupation, pretreatment voice, and swallowing function; patient preference and compliance; and the availability of expertise in radiation therapy or surgery. Optimal outcomes require specialized skills, judgment, and expertise. Poorly performed open or endoscopic surgery or radiation therapy will raise the risk for recurrence or the need for additional modalities of therapy to achieve disease control.
Organ-preservation surgery, combined chemotherapy and radiation therapy, and radiation therapy alone, all with further surgery reserved for salvage, offer the potential for larynx preservation without compromising overall survival. Anticipated success rates for larynx preservation, associated toxicities, and suitability for a given patient will vary among these approaches. Selection of a treatment option will depend on patient factors, including age, comorbidities, preferences, socioeconomic factors, local expertise, and the availability of appropriate support and rehabilitation services.
For selected patients with extensive T3 or large T4a lesions and/or poor pretreatment laryngeal function, better survival rates and quality of life may be achieved with total laryngectomy rather than with organ-preservation approaches and may be the preferred approach.
All patients should have a multidisciplinary evaluation regarding their suitably for a larynx-preservation approach, and they should be apprised of these treatment options. No larynx-preservation approach offers a survival advantage compared with total laryngectomy and appropriate adjuvant treatment.
A minority of patients with T3, T4 primary site disease will be suitable for specialized organ-preservation surgical procedures, such as a supracricoid partial laryngectomy. The addition of postoperative radiation therapy will compromise functional outcomes. Induction chemotherapy before organ-preservation surgery is not recommended outside a clinical trial.
Concurrent chemoradiotherapy offers a significantly higher chance of larynx preservation than radiation therapy alone or induction chemotherapy followed by radiation therapy, albeit at the cost of higher acute in-field toxicities and without improvement in overall survival. The best available evidence supports the use of cisplatin as the drug of choice in this setting.
There is insufficient evidence to indicate that survival or larynx-preservation outcomes are improved by the addition of induction chemotherapy before concurrent treatment or the use of concurrent treatment with altered fractionation radiation therapy in this setting.
For patients who desire larynx-preservation therapy but are not candidates for organ-preservation surgery or chemoradiotherapy, radiation therapy alone is an appropriate treatment. With this last approach, survival is similar to that associated with chemoradiotherapy when timely salvage surgery is incorporated, but the likelihood of larynx preservation is lower.
Regional Cervical Nodes
Most patients with T1, T2 lesions of the glottis and clinically negative cervical nodes (N0) do not require routine elective treatment of the neck.
Patients with advanced lesions of the glottis and all patients with supraglottic lesions should have elective treatment of the neck, even if clinically N0.
Patients with clinically involved regional cervical nodes (N+) who are treated with definitive radiation therapy or chemotherapy and radiation therapy and who have complete clinical, radiologic, and metabolic imaging (positron emission tomography/computed tomography at 12 weeks or later after therapy) do not require elective neck dissection.
Patients with equivocal [18F]fluorodeoxyglucose uptake should undergo neck dissection. The risks and cost of expectant observation versus surgery should be discussed with the patient
Patient Selection and Evaluation
There are no validated markers that consistently predict outcomes of larynx-preservation therapy. However, patients with a nonfunctional larynx (e.g. extensive T3 or T4a) or tumor penetration through cartilage into surrounding soft tissues are considered poor candidates for a larynx-preservation approach. Primary surgery, usually total laryngectomy, is commonly recommended in this setting.
Selection of therapy for an individual patient requires assessment by the multidisciplinary team as well as consideration of voice and swallowing function; patient comorbidity, psychosocial situation, and preferences; and local therapeutic expertise. The multidisciplinary team should include surgical oncology, medical oncology, radiation oncology, speech pathology, radiology, pathology, nursing, dietetics, psychology, and a variety of rehabilitative services, including dental/prosthodontics, smoking cessation, and other ancillary services as required for such things as pain management and psychosocial support.
As part of a comprehensive pretreatment evaluation, all patients should undergo a baseline assessment of voice and swallowing function, voice (use and requirements), and counseling with regard to the potential effect of treatment options on voice, swallowing, and quality of life.
Pretreatment voice and swallowing assessments should establish the functional impact of tumor volume and extent and stage of disease on voice and swallowing outcomes.
Instrumental, performance status, and quality-of-life measures of voice and swallowing should be used to evaluate pre- and post-treatment function. Multiple assessment tools are available for voice and swallowing. Routine methods of assessment include self-recorded and/or expert-rated voice-quality measures, voice-related quality-of-life tools, videostroboscopy, radiographic (videofluoroscopic) or fiber-optic laryngoscopic evaluation of swallowing, and dietary assessment.
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