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 This is an original JCO publication from 2006. Please visit the JCO website to access the full article.


Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer


 

 Authors
David G. Pfister, Scott A. Laurie, Gregory S. Weinstein, William M. Mendenhall, David J. Adelstein, K. Kian Ang, Gary L. Clayman, Susan G. Fisher, Arlene A. Forastiere, Louis B. Harrison, Jean-Louis Lefebvre, Nancy Leupold, Marcy A. List, Bernard O. O’Malley, Snehal Patel, Marshall R. Posner, Michael A. Schwartz, and Gregory T. Wolf

This guideline is currently in the process of being updated.

SUMMARY OF RECOMMENDATIONS

Summary of Recommended Strategies for Treatment of the Primary Site for Larynx Preservation
Type of CancerOrgan-Preservation StrategyBasis for RecommendationQuality of Evidence
RecommendedOther Options
T1 cancer of the glottis: T1—tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility T1a—tumor limited to one vocal cord T1b—tumor involves both vocal cordsEndoscopic resection (selected patients) OR radiation therapyOpen organ-preservation surgeryHigh local control rates and quality of voice after endoscopic resection compared with radiation therapy; possible cost savings; ability to reserve radiation for possible second primary cancers of the upper aerodigestive tract; however, not suitable for all patientsComparison of outcomes from case series/ prospective single-arm studies
T2 cancer of the glottis, favorable*:T2—tumor extends to supraglottis and/or subglottis, or with impaired vocal cord mobilityOpen organ-preservation surgery OR radiation therapyEndoscopic resection (selected patients)Open organ-preservation surgery is associated with highest local control rates; however, leads to permanent hoarseness; local control rates after radiation therapy are also high, and functional outcomes may be betterComparison of outcomes from case series/prospective single-arm studies
T2 cancer of the glottis, unfavorable*Open organ-preservation surgery OR concurrent chemoradiation therapy (selected patients with node-positive disease)Radiation therapy Endoscopic resection (selected patients)Higher local control rates after surgery compared with radiation therapy alone; quality of voice after therapy of less concern if vocal cord function is irreversibly compromised by tumor invasion; endoscopic surgery requires careful patient selection For patients with T2 N+ disease, evidence from randomized trials supports concurrent chemoradiation therapy as an organ-preservation optionComparison of outcomes from case series/ prospective single-arm studies; randomized controlled clinical trials comparing concurrent chemoradiation therapy, and/or induction chemotherapy followed by radiation, and/or radiation therapy alone, and/or surgery followed by radiation
T1-T2 cancer of the supraglottis, favorable*:T1—tumor limited to one subsite of 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 (eg, mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynxOpen organ-preservation surgery OR radiation therapyEndoscopic resection (selected patients)Open organ-preservation surgery associated with highest local control rates; however, requires temporary tracheostomy and may lead to increased risk of aspiration after therapy; local control rates after radiation therapy are also high, and functional outcomes may be betterComparison of outcomes from case series/ prospective single-arm studies
T2 cancer of the supraglottis, unfavorable*Open organ-preservation surgery OR concurrent chemoradiation therapy (selected patients with node-positive disease)Radiation therapy Endoscopic resection (selected patients)Open organ-preservation surgery is more likely to yield higher local control rates than radiation therapy; for patients with T2 N+ disease, evidence from randomized trials supports concurrent chemoradiation therapy as an organ-preservation optionComparison of outcomes from case series/ prospective single-arm studies; randomized controlled clinical trials comparing concurrent chemoradiation therapy, and/or induction chemotherapy followed by radiation, and/or radiation therapy alone, and/or surgery followed by radiation
T3-T4 cancers of the glottis or supraglottis:T3 glottis—tumor limited to the larynx with vocal cord fixation, and/or invades paraglottic space, and/or minor thyroid cartilage erosion (eg, inner cortex) T3 supraglottis—tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (eg, inner cortex) T4a glottis or supraglottis—tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) T4b glottis or supraglottis—tumor invades prevertebral space, encases carotid artery, or invades mediastinal structuresConcurrent chemoradiation therapy OR open organ-preservation surgery (in highly selected patients)Radiation therapyHighest rate of larynx preservation is associated with concurrent chemoradiation therapy compared with other radiation-based approaches, at the cost of higher acute toxicities but without more long-term difficulties in speech and swallowing; when salvage total laryngectomy incorporated, no difference in overall survival; organ preservation surgery is an option in highly selected patietns (eg, there are patients with T3 supraglottic cancers that have minimal or moderate pre-epiglottic invasion and are candidates for organ preserving surgery)Randomized controlled clinical trials comparing concurrent chemoradia- tion therapy, and/or induction chemotherapy followed by radiation, and/or radiation therapy alone; and/or surgery followed by radiation; comparison of outcomes from case series/prospective single-arm studies
  • * A favorable T2 glottic lesion is defined as a superficial tumor, on radiographic imaging, with normal cord mobility. An unfavorable T2 glottic lesion is defined as a deeply invasive tumor on radiographic imaging, with or without subglottic extension, with impaired cord mobility (indicating deeper invasion). A favorable supraglottic lesion is defined as a T1 or T2 tumor with superficial invasion on radiographic imaging and preserved cord mobility, and/or tumor of the aryepiglottic fold with minimal involvement of the medial wall of the pyriform sinus. More locally advanced and invasive T2 suproglottic lesions are considered unfavorable.

 

 

 

 

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