Laryngeal Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focuson the signs and symptoms of primary cancer, timely evaluation of the symptomaticpatient, appropriate preoperative evaluation for extent of disease, androle of the surgeon in diagnosis and treatment. Separate sections on adjuvanttherapy, follow-up programs, or management of recurrent cancer have beenintentionally omitted. Where appropriate, perioperative adjuvant combined-modalitytherapy is discussed under surgical management. Each guideline is presentedin minimal outline form as a delineation of therapeutic options.

Since the development of treatment protocols was not the specific aimof the Society, the extensive development cycle necessary to produce evidence-basedpractice guidelines did not apply. We used the broad clinical experienceresiding in the membership of the Society, under the direction of AlfredM. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering CancerCenter, to produce guidelines that were not likely to result in significantcontroversy.

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

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

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

Societyof 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 laryngoscopyand fiberoptic laryngoscopy
• CT scan of the larynx or MRI of the larynx and neck in patients withadvanced 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 beconsidered 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 shouldbe considered. If there is minimal disease on the vocal cords, the patientshould be scheduled for microlaryngoscopy with stripping of the vocal cordsto 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, andvocal cord mobility should be documented.
• Diagnostic procedures include indirect and direct laryngoscopy, CTscan, or MRI to evaluate the extent of disease involvement of the anteriorcommissure, pre-epiglottic space, paraglottic space, and the subglotticextension, especially in advanced lesions.

Surgical considerations

• Depending on the extent of disease, surgery may include: vocal cordstripping, 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 fortwo 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 laryngealcancer (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 orextended partial laryngectomy may be required. Subtotal (supracricoid)laryngectomy with crico-hyoido-epiglottopexy is becoming an increasinglypopular operation. Radiotherapy is an alternative to surgery if any twoof these criteria are present.
• A larynx-preserving approach with initial chemotherapy followed byradiation 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 anyform without the express written permission of SSO. Requests for reprintsshould be sent to: James R. Slawny, Executive Director, Society of SurgicalOncology, 85 West Algonquin Road, Arlington Heights, IL 60005.

Approximately 10,900 cases of laryngeal cancer are diagnosedevery year, and the annual death toll from this cancer is approximately4,230. The early diagnosis of laryngeal cancer is very critical since curerates are excellent for stage I and II disease. The most common risk factorsare smoking, alcohol consumption, and laryngeal papillomatosis.

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

Hoarseness in an elderly, chronic smoker should be considered cancerof the larynx unless proven otherwise. Hoarseness in any elderlyperson should prompt an appropriate evaluation to rule out early laryngealcancer.

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

Screening

Laryngeal cancer patients are at high risk of developing a second primaryin the lung and esophagus. Approximately 30% of patients with head andneck cancer will present with a second primary, either synchronous or metachronous.They should be kept under regular observation for the rest of their lives.

Even though there are no standard screening practices for laryngealcancer, patients with other head and neck cancers should be carefully evaluatedfor any laryngeal pathology. A chronic smoker should be assessed regularlyfor any change in voice, and patients with lung cancer should also be evaluatedto rule out laryngeal pathology.

Staging

Appropriate staging of laryngeal cancer is very important in decision-makingand selecting a definite treatment modality. Vocal cord mobility playsa key role in the staging system (see Table1). In stages I and II, the vocal cords are mobile; fixity of the vocalcords reflects deep infiltration of the tumor, and patients with thesefindings are staged as stage III or IV.

Lymph node metastasis is another important factor. The presence of lymphnode metastasis puts the patient directly in stage III or IV, and alsoconsiderably diminishes overall survival.

T1 tumors are limited to the vocal cord only with normal cord mobility;T2 tumors extend to the supraglottis or subglottis. T3 denotes fixity ofthe vocal cord, while T4 tumors invade through the thyroid cartilage orextend to the tissues beyond the larynx.

Distant metastases are quite rare in laryngeal cancer, although theymay be noted occasionally in the mediastinum or lungs. A nodular lesionin the lung, if single, may be considered a second primary cancer. However,a CT scan is important in such cases to rule out the possibility of multiplepulmonary nodules.

The stage I and II tumors have excellent overall survival (5-year survivalrates of 90% to 95% and 80% to 85%, respectively). Compared to early-stagelaryngeal cancer, stage III and IV tumors generally have a poor prognosis(5-year survival rates of 60% to 70% and 40% to 50%, respectively).

Advanced-stage laryngeal cancer patients who require total laryngectomymay be entered into a larynx-preservation protocol with a combination ofchemotherapy and radiation therapy. However, it should be remembered thatthe presence of cartilage destruction, massive soft-tissue disease, orextensive subglottic tumor generally respond poorly to chemotherapy plusradiation therapy.

Evaluation

The work-up for a patient with suspected laryngeal cancer should includea thorough head and neck examination, including indirect laryngoscopy andfiberoptic laryngoscopy. Photographic documentation of laryngeal pathologycan be performed with fiberoptic endoscopes. CT and MRI of the larynx maybe helpful in cases of advanced laryngeal cancer, especially to evaluatethe depth of tumor in fixed vocal cord or pre-epiglottic and paraglottictumor spread.

Direct laryngoscopy in the operating room with the help of an operatingmicroscope is crucial in making the diagnosis, evaluating the exact extentof disease, and making a decision about the type of surgical procedure.

Treatment

Even though there is considerable controversy over whether radiationtherapy or surgery should be used to treat early laryngeal cancer, thereis general agreement that radiation therapy is preferable because it resultsin better vocal function. Supraglottic laryngectomy may be considered forearly cancers of the supraglottic larynx.

In patients with advanced laryngeal cancer, total laryngectomy generallygives the best results. However, quality of life is a major concern inpatients undergoing total laryngectomy. With the recent advances in post-laryngectomyvoice rehabilitation, especially the advent of tracheo-esophageal puncture,quality of life is quite good. Combination chemotherapy with cisplatin(Platinol) and fluorouracil followed by radiation therapy was shown tobe effective in the Veterans Affairs Cooperative Trial. If total laryngectomyis used as the primary modality in advanced laryngeal cancer, most patientswill require postoperative radiation, especially if multiple lymph nodemetastases are noted at the time of surgery.

In patients whose neck is staged N0, treatment of the neck depends onhow the primary is treated. In those whose neck is staged N1, a modifiedneck dissection is appropriate if the primary is best treated with surgery.If the neck is staged N2 or N3, combined treatment with surgery and radiationis indicated.

References:

Biller HF, Barnhill FR, Ogura JH, et al: Hemilaryngectomy followingradiation failure for carcinoma of the vocal cords. Laryngoscope 80:249-253,1970.

Kirchner JA, Som ML: Clinical and histological observations on supraglotticcancer. Ann Otol Rhinol Laryngol 80:638-645, 1971.

Laccourreye O, Brasnu D, Merite-Drancy A, et al: Cricohyoidopexy inselected infrahyoid epiglottic carcinomas presenting with pathologicalpreepiglottic space invasion. Arch Otolaryngol Head Neck Surg 119:881-886,1993.

Soo KC, Shah JP, Gopinath KS, et al: Analysis of prognostic variablesand results after vertical partial laryngectomy. Am j Surg 156(4):264-268,1988