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Laryngeal Cancer Surgical Practice Guidelines

Laryngeal Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative evaluation for extent of disease, and
role of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.

Since the development of treatment protocols was not the specific aim
of the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad clinical experience
residing in the membership of the Society, under the direction of Alfred
M. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer
Center, to produce guidelines that were not likely to result in significant
controversy.

Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.

The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.

This article includes the laryngeal cancer practice guidelines and accompanying
narrative. Guidelines on oropharyngeal and oral cavity, parotid, and thyroid
cancer are also featured in this issue.


Society
of Surgical Oncology Practice Guidelines: Laryngeal Cancer

Symptoms and Signs

Early-stage disease

  • Hoarseness
  • Sore throat
  • Persistent throat irritation

Advanced-stage disease

  • Cervical lymphadenopathy
  • Dysphagia
  • Difficulty in breathing
  • Hemoptysis

Evaluation of the symptomatic patient

Work-up

  • Thorough head and neck examination, including indirect laryngoscopy
    and fiberoptic laryngoscopy
  • CT scan of the larynx or MRI of the larynx and neck in patients with
    advanced laryngeal cancer
  • Direct laryngoscopy with biopsy
  • Micro-laryngoscopy with biopsy

Appropriate timeliness of surgical referral

  • In an elderly person who is a chronic smoker, hoarseness should be
    considered cancer of the larynx unless proven otherwise.
  • A complete head and neck examination with laryngoscopy is essential.
    If an obvious lesion is noted, a biopsy under general anesthesia should
    be considered. If there is minimal disease on the vocal cords, the patient
    should be scheduled for microlaryngoscopy with stripping of the vocal cords
    to evaluate the exact pathology and extent of
    disease.

Pre-operative evaluation for extent of disease

Indirect laryngoscopy

Fiberoptic evaluation

Direct laryngoscopy

CT scan

Role of the surgeon in initial management

Preoperative evaluation and diagnostic procedures

  • Evaluation of the symptomatic patient
  • Evaluation of the exact extent of disease, location of disease, and
    vocal cord mobility should be documented.
  • Diagnostic procedures include indirect and direct laryngoscopy, CT
    scan, or MRI to evaluate the extent of disease involvement of the anterior
    commissure, pre-epiglottic space, paraglottic space, and the subglottic
    extension, especially in advanced lesions.

Surgical considerations

  • Depending on the extent of disease, surgery may include: vocal cord
    stripping, endoscopic laser ablation of the vocal cord tumor,hemi-laryngectomy,
    supraglottic laryngectomy, subtotal laryngectomy with crico-hyoidopexy,
    or total laryngectomy.
  • Chemotherapy, including cisplatin and fluorouracil, may be used for
    two to three cycles to evaluate response.
  • Consideration should be given to radiation therapy and salvage laryngectomy.
  • Primary radiation therapy is used in patients with early stage laryngeal
    cancer (T1 vocal cord lesion with mobile cords).
  • In patients with anterior commissure involvement, subglottic extension,
    or impairment of the vocal cords, total laryngectomy maybe indicated or
    extended partial laryngectomy may be required. Subtotal (supracricoid)
    laryngectomy with crico-hyoido-epiglottopexy is becoming an increasingly
    popular operation. Radiotherapy is an alternative to surgery if any two
    of these criteria are present.
  • A larynx-preserving approach with initial chemotherapy followed by
    radiation therapy has shown encouraging results.

These guidelines are copyrighted by the Society of Surgical Oncology
(SSO). All rights reserved. These guidelines may not be reproduced in any
form without the express written permission of SSO. Requests for reprints
should be sent to: James R. Slawny, Executive Director, Society of Surgical
Oncology, 85 West Algonquin Road, Arlington Heights, IL 60005.


Approximately 10,900 cases of laryngeal cancer are diagnosed
every year, and the annual death toll from this cancer is approximately
4,230. The early diagnosis of laryngeal cancer is very critical since cure
rates are excellent for stage I and II disease. The most common risk factors
are smoking, alcohol consumption, and laryngeal papillomatosis.

The most frequent symptom of laryngeal cancer is hoarseness. Other possible
symptoms include sore throat and persistent throat irritation. Patients
with advanced-stage disease may present with cervical lymphadenopathy,
difficulty in breathing, hemoptysis, or, occasionally, dysphagia, although
hoarseness still remains the most common presentation.

Hoarseness in an elderly, chronic smoker should be considered cancer
of the larynx unless proven otherwise. Hoarseness in any elderly
person should prompt an appropriate evaluation to rule out early laryngeal
cancer.

Occasionally, the laryngeal pathology may include vocal cord polyps
or hyperkeratotic lesions. Patients with dysplastic pathology should be
followed very carefully to rule out progression into carcinoma.

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