In the past 10 years, the introduction of combined chemotherapy and radiation as an alternative to total laryngectomy for patients with advanced laryngeal cancer ushered in a new treatment paradigm termed "organ preservation." The adoption of this terminology has been somewhat misleading, because radiation alone and conservation surgical approaches for preserving organ function in patients with early laryngeal cancer flourished for decades prior to the use of chemotherapy. This new emphasis on organ preservation and quality-of-life issues, however, has renewed the debate on optimal treatment approaches for patients with advanced laryngeal cancer. In this debate, some proponents have lost sight of the principle that the combination of chemotherapy and radiation for "organ preservation" is appropriately restricted to patients facing total laryngectomy.
An optimal oncologic treatment that involves less than a total laryngectomy and results in lower morbidity is generally preferred. The appropriate debate would therefore center on rates of salvage surgery (local control), swallowing function, speech and respiration (need for tracheostomy), and ultimately, survival. The patient being considered for organ-preserving treatment must be adequately counseled about all treatment options, sequelae, subsequent therapy, follow-up requirements, and failure rates. Only the most knowledgeable head and neck surgical oncologist has the understanding, tumor-staging skills, and expertise to accurately represent both the surgical and nonsurgical approaches to organ preservation.
Excellent Results Encourage Use of Surgical Approach
Dr. Weinstein’s article, "Surgical Approach to Organ Preservation in the Treatment of Cancer of the Larynx," is an excellent review of the modern rationale for the primary surgical management of early- and intermediate-stage laryngeal cancer. The philosophic argument for a surgical organ-preservation approach is well stated, and the important functional considerations in treatment selection are adequately outlined. A strong argument is made for considering surgical approaches in all patients with early lesions, based on the excellent functional results, local control rates, and infrequent requirement for total laryngectomy as a salvage procedure.
I agree with this opinion. Indeed, the discussion is particularly timely in light of recent reports of the excellent results achieved with two new surgical approaches for organ preservation. The first is endoscopic laser resection for early-stage cancer (T1/T2), and the second, supracricoid partial laryngectomy procedures (pioneered in Europe) for patients with more advanced lesions (T2/T3). The author correctly stresses the importance of adequate tumor staging and thorough discussion of treatment options with each patient. In addition, the article clarifies and summarizes for the general oncologist several quality-of-life issues that should be considered when making treatment decisions.
Points Requiring Greater Emphasis
Perhaps not adequately emphasized in this discussion is the fact that conservation laryngeal surgery (including the newer laser and supracricoid resections) requires utmost precision, detailed analysis of tumor extent, careful patient selection, specialized surgical techniques, and careful follow-up. Errors in technique can lead to surgical misadventures and oncologic disaster. Even the strongest proponents of endoscopic techniques for the treatment of small (T1/T2) or intermediate (T2/T3) lesions acknowledge that there is a steep learning curve.
Furthermore, the author correctly points out that total laryngectomy is the salvage procedure for most failed organ-preservation approaches (both surgical and nonsurgical). Although some surgical approaches can be salvaged with additional conservation techniques and some glottic cancer radiation failures can occasionally be salvaged without total laryngectomy, identifying such cases requires extreme skill and diligent follow-up.
Finally, the author proposes five principles for surgical organ preservation. Although this serves to simplify the complex issues involved in selecting surgical treatment and determining the extent of surgery, a number of important points warrant comment.
Principle 1: Nonsurgical vs Surgical Organ Preservation
The author correctly stresses that both surgical and nonsurgical approaches have a role in preserving the function of the larynx. However, inadequate emphasis is placed on the importance of multidisciplinary evaluation and management (which at a minimum would include surgery and radiation therapy in the decision-making process). Patient desire, logistics, the skill of local practitioners, and quality-of-life issues must all be considered. The author fails to adequately stress the importance of the role of the surgeon as the team member who directs staging, follow-up, and salvage, even in organ-preservation approaches involving radiation alone or radiation and chemotherapy.
This is a critical concept. It is particularly important in patients with early-stage cancers who are eligible for treatment with radiation alone and whose disease might also be amenable to organ-preservation surgery as a salvage procedure. The discussion also fails to emphasize the fact that the number of patients with T3 or T4 cancers who require total laryngectomy as initial treatment has declined as surgical techniques have improved. Thus, more patients are eligible for organ-preserving surgery. Only the surgeon has the experience to determine whether an organ-preservation surgical approach is likely to be successful or result in permanent tracheostomy or life-threatening, chronic aspiration.
Principle 2: Staging
The author misrepresents tumor staging as a fundamental difference between surgical and nonsurgical organ preservation. The notion that nonsurgical organ preservation does not require precise tumor staging, endoscopy under anesthesia, and careful delineation of tumor depth of invasion and arytenoid mobility is naive. Precise delineation of tumor extent and determination of resection margins for potential conservative surgical procedures that could adequately extirpate a cancer are mainstays of all treatment decision-making.
It is crucial that this planning be performed prior to radiation therapy if there is to be any hope of an oncologically adequate organ-preserving salvage procedure. Proponents of nonsurgical organ preservation must respect the importance of a work-up that includes precise endoscopy and appropriate radiologic imaging. These are complementary procedures. One cannot substitute for the other, and together they provide both static and dynamic information.
The author correctly points out important differences between vocal cord and arytenoid mobility. Although invasion of the cricoarytenoid joint is an uncommon cause of vocal cord fixation, it is important to identify because it is a contraindication for most organ-preserving surgical procedures. Such patients would be candidates for nonsurgical organ preservation or total laryngectomy.
Principle 3: Spectrum Concept
The author is to be commended for the considerable effort expended in developing detailed decision-making and staging worksheets to aid the surgeon in selecting an appropriate conservation surgical procedure. These aids will enhance the quality of care and the comparison and reporting of treatment results. However, the spectrum concept suggests a "cookbook" approach to decision-making that omits other important considerations in treatment selection such as patient age, physiology, prior treatment, risk of second malignancy, vocal use, patient desires, cost, logistics, depth of tumor invasion, and risk of regional metastases.
Principle 4: Resection of Normal Tissue
This principle is well stated. The need to resect redundant tissue, restore symmetry, and optimize function is an essential and well-accepted concept in organ-preservation laryngeal surgery.
Principle 5: Importance of Local Control
It is easy to fall prey to the seduction of local control as the ultimate goal in laryngeal cancer. In debates on organ preservation, local control remains an important goal, and the trade-offs of function vs local control must be considered for each treatment option. However, despite tremendous advances in organ-preservation surgery, survival rates remain unchanged. A major cause of death in advanced la-ryngeal cancer is failure to control regional disease. The discussion of organ-preservation surgery is therefore incomplete without some consideration of how optimal management of the neck can be integrated into conservation-surgery treatment schemes.
Although clinical regional metastases are uncommon in early glottic cancers, rates of occult regional metastases approach 30% when the vocal cord is fixed and, therefore, neck treatment must be considered. If histologically positive nodes are found, optimum regional control rates can be achieved with a combination of surgery and adjuvant radiation. Supraglottic cancers (T2-4) are associated with regional metastases rates in excess of 60%. Management of the neck in patients with supraglottic cancers is an issue in nearly every patient. Thus, indications for combining organ-preservation surgery with elective neck dissection and/or adjuvant radiation should be discussed.
In general, the role of neck dissection in patients who are candidates for vertical or horizontal partial laryngectomy is well defined and accepted. The role of neck dissection combined with endoscopic laser resections is less well described. The role of adjuvant radiation after supracricoid resection should also be discussed, since complication rates would be expected to be higher and functional results lower. Is there a role for elective neck irradiation combined with these newer techniques? What are the success rates for laser resection or supracricoid laryngectomy after radiation failure? These questions should be included in the organ-preservation debate.
Finally, there are patients with advanced neck nodes (N2/N3), who undoubtedly require radiation therapy and for whom distant relapse is a significant concern. For these patients, combinations of chemotherapy and radiation may be particularly suitable approaches in an organ-preservation treatment program.
Dr. Weinstein has done an admirable job of describing the latest evolution and rationale for surgical organ preservation in patients with laryngeal cancer. He has touched on some of the complexities involved in deciding on an optimal treatment approach. The message should be that a number of excellent treatment alternatives are available that will preserve laryngeal function. The pros and cons of each approach will continue to be vigorously debated, and the patient will be the ultimate beneficiary of this debate. The patient is also well served by sophisticated, multidisciplinary evaluation and care.
Better methods of selecting treatment are needed to replace crude tumor measurements and radiologic images, and advances in the molecular biology of laryngeal cancer may help in this regard. Until new treatment approaches that improve cure rates are developed, surgical approaches that preserve structure and function will maintain an increasingly important role in laryngeal cancer management. The ultimate role of these newer organ-preservation techniques will depend on further long-term reports and duplication of the results achieved by European surgeons who have had extensive experience with these techniques.