The management of cancer of the larynx has arguably become the most complicated task in the field of head and neck oncology. Both physicians and patients struggle to decide how initial treatment should be delivered. Treatment decisions usually are, and, should be, made by a multidisciplinary team. Surgeons sometimes feel that the surgical options are not viewed as conservative or, in many instances, as voice and function preserving. Dr. Weinstein does an excellent job of discussing surgical considerations and how these procedures should be used.
Evolution of Treatments
Treatment of cancer of the larynx has undergone tremendous change over the years. Theodor Billroth performed the first laryngectomy in 1873. Although the morbidity associated with this early procedure was great, it did provide an effective treatment for cancer of the larynx. The introduction of radiation therapy allowed early-stage cancer to be irradiated, while larger tumors still required total laryngectomy. Removal of the oncologically involved portion of the larynx dates back to the 19th century, but the partial laryngectomy was not widely used until the 1960s, when it was popularized by Ogura.[2,3]
Supraglottic and vertical partial laryngectomies have become popular procedures for certain subsets of patients with laryngeal cancers.[2,3] The more limited endoscopic removal of the larynx has also been introduced into practice. Modifications in surgical and radiation techniques and the introduction of chemotherapy have led to the development of effective radiation protocols, combined surgery and radiation therapy, and combined chemotherapy and radiation protocols. The evolution of these treatment modalities provides the clinician with more options and treatment considerations than ever before. At times, these options seem to be in competition or outright conflict with one another.
The Multidisciplinary Approach
A team approach is absolutely imperative for arriving at the best treatment options for patients with laryngeal carcinoma. Dr. Weinstein emphasizes that accurate staging is essential and usually requires careful mapping of the tumor in the operating room as well as radiologic imaging. Once this has been accomplished, a team conversant in the entire spectrum of treatment modalities, including conservative surgical approaches, must decide on the possible treatment options. To make an informed decision, the patient must be presented with these options in a thoughtful and even-handed manner.
Dr. Weinstein provides an excellent discussion of the surgical considerations that should be taken into account by head and neck surgical oncologists when recommending various surgical approaches. He also emphasizes the fact that any clinician treating these patients must have a thorough understanding of the surgical and nonsurgical alternatives in order to counsel a patient appropriately.
Surgical treatment requires removal of part or all of the larynx and, as such, has stirred great emotional response from physicians and patients. All laryngectomies, including the total laryngectomy, attempt to preserve as much function as possible. Retaining the ability to swallow, protecting the airway, and controlling the cancer are important factors when assessing the quality of life of the patient.
End Point of Success
The factors that influence the choice of initial treatment are derived from an analysis of three major categories: patient characteristics, tumor characteristics, and available health-care resources. Important end points for judging success are locoregional control rates, survival rates, and functional results. Voice preservation, swallowing function, complications, and the cost of treatment are all crucial considerations.
Dr. Weinstein points out that the surgeon must accurately determine whether a partial laryngectomy is technically feasible preoperatively, because the need to convert the operation to a total laryngectomy may arise. If, on the other hand, patients who could have been treated with a partial laryngectomy are initially treated with radiation therapy and that strategy fails, they may no longer be candidates for partial laryngectomy and may need to undergo total laryngectomy for salvage. In this sense, partial laryngectomy can truly be considered voice preserving.
The ability to retain the voice, reserve radiation therapy for second primary cancers, and return to work in several weeks all make the partial layngectomy an attractive option for some patients. Bulky neck disease is also better treated with surgery. The patient’s medical fitness and pulmonary reserve must be assessed to determine if he or she can tolerate a partial laryngectomy. Although usually directed by a surgeon versed in the whole range of surgical and nonsurgical alternatives, these decisions are best handled by a multidisciplinary team.
Dr. Weinstein discusses the spectrum of laryngeal carcinoma and of laryngeal cancer surgery. Each tumor and each patient requires a completely individualized approach. Patient choices are extremely important in this situation, and patients do not always choose the treatment modalities that we think they should. This further underscores the importance of thoroughly explaining the options, and how those decisions will affect future treatment.
Dr. Weinstein also addresses the issue of induction chemotherapy followed by radiation or surgery, depending on response. The use of concomitant chemotherapy and radiation is also increasing in popularity, and although these approaches are extremely useful, the fact that conservative surgical approaches may not be possible if initial treatment fails must be emphasized. An initially conservative approach may be associated with a better long-term probability of preserving function in selected patient groups. This again underscores the benefits of a team approach for these patients.
Dr. Weinstein discusses numerous surgical options that continue to evolve and to be debated in the surgical literature. No consensus on where they all fit in has been reached, but this article does an excellent job of highlighting such considerations for the nonsurgical members of the team.