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Laryngeal Cancer

Deciding on a Treatment Plan

Your doctors will typically use National Comprehensive Cancer Network® (NCCN®) Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers to decide on the appropriate treatment course.12Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org. If these guidelines are not followed, they will discuss it with you and explain why your situation might be special.

Before starting treatment, your doctor will make sure that the following steps are completed.

Pretreatment Evaluation

  • A full history and physical examination, including a complete head and neck exam (mirror and fiberoptic exam if needed)
  • An evaluation by the members of a head and neck cancer team
  • A biopsy of primary site or FNA of the neck to to confirm a diagnosis of cancer
  • Imaging of the lungs to check for spread, if needed
  • Imaging of the primary tumor and the neck with CT and/or MRI
  • Maybe a PET-CT for advanced cancers
  • Examination under anesthesia with endoscopy
  • Pretreatment medical clearance and evaluation of the risks of anesthesia
  • A dental evaluation
  • Pulmonary function test may be considered for conservation surgery candidates
  • Maybe a videostrobe voice evaluation for select patients
  • Nutrition, speech and swallowing evaluation and maybe even a hearing evaluation

Then your doctor will recommend a course of treatment for you, depending on a number of factors. As with all cancers in the head and neck, there are three general options to consider:

For larynx cancer, there is not one clear treatment method. You should have an extensive discussion with your cancer team to decide upon the best treatment course for you personally. The options that your doctor will recommend will likely be as follows, depending on the site and stage of cancer you have.

The latest NCCN Guidelines® for Head and Neck Cancers will help your doctor recommend the best course of action based on the evidence.12Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org. Notice that for laryngeal cancer, the treatment recommendation might be slightly different, depending on if the cancer is in the glottis or the supraglottis.

CANCER IN THE GLOTTIS12, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.13 Mantravadi RV, Liebner EJ, Haas RE, Skolnik EM, Applebaum EL. Cancer of the glottis: prognostic factors in radiation therapy. Radiology. Oct 1983;149(1):311-314.:

Larynx cancer within the glottis 

Carcinoma in situ

For these small cancers that have not invaded deeply, either surgical removal (preferred) in the operating room through the mouth (using an endoscope) or radiation is recommended.
Larynx cancer within the glottis 

Total laryngectomy not required (conservation surgery)

(T1-2, selected T3)

There are two options for cancers that fit this profile:

  • Radiation alone
  • A partial laryngectomy with neck dissection as needed with no additional treatment if there are no adverse features. For adverse features, additional treatment may include radiation alone, chemotherapy plus radiation, or surgery depending on the pathologic features
Larynx cancer within the glottis 

T3 that requires total laryngectomy, N0-1 

For these tumors that require removal of the entire voice box if surgery was chosen, there are a few options:

  • Chemotherapy along with radiation. This would be followed by surgery if there is any persistent or recurrent cancer.
  • Radiation alone if you are not able to tolerate chemotherapy plus radiation. This would be followed by surgery if there is any persistent or recurrent cancer.
  • Surgical removal of the voice box (total laryngectomy) and partial thyroidectomy with or without neck dissection as indicated. Then, either no additional treatment, radiation, or radiation with chemotherapy, depending on what the doctors see under the microscope.
  • Induction chemotherapy. Then, depending on the response to the initial chemotherapy, either radiation alone, radiation with chemotherapy or surgery (with radiation or chemotherapy plus radiation.)
  • A clinical trial
Larynx cancer within the glottis 

T3 that requires total laryngectomy, N2-3 

For these tumors that require removal of the entire voice box if surgery was chosen, there are a few options:

  • Chemotherapy along with radiation. This would be followed by surgery if there is any persistent or recurrent cancer.
  • Surgical removal of the voice box (total laryngectomy), partial thyroidectomy (as indicated) and neck dissection. Then, either no additional treatment, radiation, or radiation with chemotherapy depending on what the doctors see under the microscope.
  • Induction chemotherapy. Then, depending on the response to the initial chemotherapy, ether radiation alone, radiation with chemotherapy or surgery (with radiation or chemotherapy plus radiation).
  • A clinical trial
Larynx cancer within the glottis 

T4a, Any N 

The recommended treatment for these tumors is a total laryngectomy, thyroidectomy as needed and neck dissection(s) as needed. This is then followed by either radiation or chemotherapy plus radiation (or in rare cases, no additional treatment). If such a patient chooses not to have surgery, then either chemotherapy along with radiation may be considered, or induction chemotherapy followed by additional therapy depending on the response, or a clinical trial are the only options.

Your physician may also consider a clinical trial in addition to other treatment.

T4b,any N 

Unresectable neck disease 

Unfit for surgery 

In cases that are very advanced, or in patients who are extremely sick, an extensive discussion with your doctors should be undertaken.

CANCER IN THE SUPRAGLOTTIS12, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.14 Bocca E. Supraglottic cancer. Laryngoscope. Aug 1975;85(8):1318-1326.:

Larynx cancer within the supraglottis 

Not requiring a total laryngectomy (conservation surgery)

Most T1-2, Selected T3, with N0

For these tumors, the options are as follows:

  • Endoscopic resection of the primary cancer with or without neck dissection, or open resection of the primary cancer (partial laryngectomy) with or without a neck dissection.
  • Then, either no additional therapy, a second surgery to remove leftover tumor, radiation alone or radiation with chemotherapy, depending on the findings in surgery.
  • Definitive radiation therapy
Larynx cancer within the supraglottis 

Requiring total laryngectomy T3, N0

For these tumors that require removal of the entire voice box if surgery was chosen, there are a few options:

  • Chemotherapy along with radiation. This would be followed by surgery if there is any left over or recurrent cancer.
  • Surgical removal of the voice box (total laryngectomy), partial thyroidectomy, and neck dissection. Then, either radiation alone may be considered or radiation with chemotherapy, depending on what the doctors see under the microscope.
  • Radiation alone if you can’t tolerate chemotherapy with radiation or surgery.
  • Induction chemotherapy, followed by additional treatment, depending on the response. The additional treatment could be either radiation, chemotherapy with radiation or surgery with chemotherapy and/or radiation.
  • A clinical trial
Larynx cancer within the supraglottis


T1-2, N+


Selected T3, N1

Total laryngectomy not required

For cancers in this stage, the recommended options are:

  • Chemotherapy along with radiation. This would be followed by surgery only if there is any leftover or recurrent cancer.
  • Radiation alone followed by surgery, only if there is any leftover or recurrent cancer.
  • Partial laryngectomy with neck dissection(s), followed by no additional treatment, radiation alone or chemotherapy with radiation, depending on what the doctors see under the microscope.
  • Induction chemotherapy, followed by additional treatment, depending on the response. The additional treatment could be either radiation, chemotherapy with radiation, or surgery. Surgery could be followed by chemotherapy and/or radiation.
  • A clinical trial
Larynx cancer within the supraglottis


Most T3, N2-3


Total laryngectomy required

For cancers in this stage, the recommended options are:

  • Chemotherapy along with radiation. This would be followed by surgery if there is any persistent or recurrent cancer.
  • Total laryngectomy, partial thyroidectomy and neck dissection(s), followed by radiation alone or chemotherapy with radiation, depending on what the doctors see under the microscope.
  • Induction chemotherapy, followed by additional treatment depending on the response. The additional treatment could be either radiation, chemotherapy with radiation, or surgery. Surgery could be followed by chemotherapy and/or radiation.

 

Larynx cancer within the supraglottis 

T4a, Any N 

The recommended treatment for these tumors is a total laryngectomy, thyroidectomy as needed and neck dissection(s) as needed. Surgery is then followed by either radiation, or chemotherapy plus radiation depending on the presence of remaining cancer tissue.

If such a patient chooses not to have surgery, then either chemotherapy along with radiation, clinical trial or chemotherapy followed by additional therapy depending on the response are the only options. After induction chemotherapy, the additional therapy could be either radiation, chemotherapy with radiation or surgery with chemotherapy and/or radiation.

T4b, Any N 

Unresectable neck disease 

Unfit for surgery 

In cases that are very advanced, or in patients who are extremely sick, an extensive discussion with your doctors should be undertaken.
References

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2 Lewin F, Norell SE, Johansson H, et al. Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck: a population-based case-referent study in Sweden. Cancer. Apr 1 1998;82(7):1367-1375.

3 Lynch HT, Mulcahy GM, Harris RE, Guirgis HA, Lynch JF. Genetic and pathologic findings in a kindred with hereditary sarcoma, breast cancer, brain tumors, leukemia, lung, laryngeal, and adrenal cortical carcinoma. Cancer. May 1978;41(5):2055-2064.

4 Katsenos S, Becker HD. Recurrent respiratory papillomatosis: a rare chronic disease, difficult to treat, with potential to lung cancer transformation: apropos of two cases and a brief literature review. Case Rep Oncol. 2011 Mar 23;4(1):162-71.

5 Burch JD, Howe GR, Miller AB, Semenciw R. Tobacco, alcohol, asbestos, and nickel in the etiology of cancer of the larynx: a case-control study. Journal of the National Cancer Institute. Dec 1981;67(6):1219-1224.

6 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Esophageal and Esophagogastric Junction Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.

7 El-Serag HB, Hepworth EJ, Lee P, Sonnenberg A. Gastroesophageal reflux disease is a risk factor for laryngeal and pharyngeal cancer. Am J Gastroenterol. Jul 2001;96(7):2013-8.

8 Vaezi MF, Qadeer MA, Lopez R, Colabianchi N. Laryngeal cancer and gastroesophageal reflux disease: a case-control study. Am J Med. Sep 2006;119(9):768-76.

9 Hoare TJ, Thomson HG, Proops DW. Detection of laryngeal cancer--the case for early specialist assessment. Journal of the Royal Society of Medicine. Jul 1993;86(7):390-392.

10 Spiro RH, Thaler HT, Hicks WF, Kher UA, Huvos AH, Strong EW. The importance of clinical staging of minor salivary gland carcinoma. Am J Surg. 1991 Oct;162(4):330-6.

11 Krause CJ, Carey TE, Ott RW, Hurbis C, McClatchey KD, Regezi JA. Human squamous cell carcinoma. Establishment and characterization of new permanent cell lines. Arch Otolaryngol. Nov 1981;107(11):703-710.

12 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.

13 Mantravadi RV, Liebner EJ, Haas RE, Skolnik EM, Applebaum EL. Cancer of the glottis: prognostic factors in radiation therapy. Radiology. Oct 1983;149(1):311-314.

14 Bocca E. Supraglottic cancer. Laryngoscope. Aug 1975;85(8):1318-1326.

15 Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010.

16 Piccirillo JF, Costas I. Chapter 8: Cancer of the Larynx. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.