Controversies in the management of advanced laryngeal squamous cell carcinoma

The consultants agree that the patient requires an initial complete head and neck examination to determine pretreatment laryngeal function and to exclude a synchronous head and neck second primary tumor. A videostroboscopy provides a permanent record of dynamic laryngeal function prior to treatment and can serve as a reference point after treatment; however, Dr. Laccourreye did not believe that video documentation was necessary for assessing the appropriateness of the tumor for partial laryngectomy. The laryngeal imaging modality of choice selected by all three consultants was a high-resolution CT scan with contrast enhancement. Imaging is important to define laryngeal skeleton involvement and regional lymph node status. Dr. Forastiere noted the correlation between tumor volume and local control, although to our knowledge this has not been examined prospectively in patients receiving chemotherapy and radiotherapy. All the consultants agreed that a staging evaluation should include a chest radiograph to exclude a second primary tumor in the lung as opposed to distant metastasis, a rare event at the time of presentation given the site and stage of this patient's tumor. None of the consultants would advocate a total laryngectomy as the initial treatment option. Dr. Rosenthal raised the point that pretreatment laryngeal function may predict posttreatment function. In patients with poor function at the time of presentation (poor voice, aspiration, and tracheostomy), total laryngectomy may be a better alternative than a nonsurgical approach because functional recovery in this situation is unlikely. An agreed-upon goal for this patient is voice preservation, given his occupation and age. Drs. Forastiere and Rosenthal would recommend concomitant chemotherapy and radiotherapy based on the results of the RTOG 91-11 trial, which demonstrated superior laryngeal preservation over radiotherapy alone or chemotherapy followed by radiation. Dr. Laccourreye's organ preservation approach is more controversial. He would advocate multiple courses of chemotherapy alone to avoid the need for radiotherapy and to select patients who may be treated with systemic therapy alone (complete clinical and pathologic response). Incomplete responders would undergo a supracricoid laryngectomy with cricohyoidoepiglottopexy for voice preservation. The consultants agree that patients with recurrent disease after concomitant chemotherapy and radiotherapy would most often require total laryngectomy for salvage. Dr. Laccourreye notes that as a salvage procedure, partial laryngectomy is associated with significant postoperative morbidity and the functional result would be less than optimum after radiotherapy.