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.

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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, hemilaryngectomy, supraglottic laryngectomy, subtotal laryngectomy with crico-hyoidopexy, or total laryngectomy.
• Chemotherapy, including cisplatin(Drug information on cisplatin) and fluorouracil(Drug information on 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.

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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(Drug information on 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.