Treatment Option Overview
Note: Some citations in the text of this section are followed by a level of
evidence. The PDQ editorial boards use a formal ranking system to help the
reader judge the strength of evidence linked to the reported results of a
therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more
information.)
Small superficial cancers without laryngeal fixation or lymph node involvement
are successfully treated by radiation therapy or surgery alone, including laser
excision surgery. Radiation therapy may be selected to preserve the voice
and to reserve surgery for salvaging failures. The radiation field and dose are
determined by the location and size of the primary tumor. A variety of
curative surgical procedures are also recommended for laryngeal cancers, some
of which preserve vocal function. An appropriate surgical procedure must be
considered for each patient, given the anatomic problem, performance status,
and clinical expertise of the treatment team. Advanced laryngeal cancers are
often treated by combining radiation and surgery.[1-4] A review of published clinical
results of radical radiation therapy for head and neck cancer suggests a
significant loss of local control when the administration of radiation therapy
was prolonged; therefore, lengthening of standard treatment schedules should be
avoided whenever possible.[5,6] Because the cure rate
for advanced lesions is low, clinical trials exploring chemotherapy,
hyperfractionated radiation therapy,[7] radiation sensitizers, or particle-beam
radiation therapy should be considered.[8,9] Although cure rates are not changed with chemoradiation administered in a neoadjuvant setting, organ preservation is increased.[10]
A multi-institutional trial randomized patients to induction cisplatin plus fluorouracil (5-FU) followed by radiation therapy, radiation therapy administered concurrently with cisplatin, or radiation therapy alone.[10] Concurrent radiation therapy plus cisplatin resulted in a statistically significantly higher percentage of patients with an intact larynx at 2 years (i.e., 88% vs. 75% and 70% for concurrent chemotherapy, induction chemotherapy, and radiation alone, respectively) and higher locoregional control (i.e., 78% vs. 61% and 56%, respectively) than the other two regimens. Both chemotherapy regimens had a lower incidence of distant metastases and better relapse-free survivals than radiation therapy alone, but they also had a higher rate of high-grade toxic effects. Overall survival rates were not significantly different between the different groups.[10][Level of evidence: 1iiC]
The risk of lymph node metastases in patients with stage I glottic cancer
ranges from 0% to 2%, and for more advanced disease, such as stage II and stage
III glottic, the incidence is only 10% and 15%, respectively. Thus, there is
no need to treat glottic cancer cervical lymph nodes electively in patients
with stage I tumors and small stage II tumors. Consideration should be given
to using elective neck radiation for larger or supraglottic tumors.[11]
For patients with cancer of the subglottis, combined modality therapy is
generally preferred though for the uncommon small lesions (i.e., stage I or stage
II), radiation therapy alone may be used.
Patients who smoke during radiation therapy appear to have lower response rates
and shorter survival durations than those who do not;[12] therefore, patients
should be counseled to stop smoking before beginning radiation therapy.
Accumulating evidence has demonstrated a high incidence (i.e., >30%–40%) of
hypothyroidism in patients who have received external-beam radiation to the
entire thyroid gland or to the pituitary gland. Thyroid-junction testing of
patients should be considered prior to therapy and as part of posttreatment
follow-up.[13,14]
References
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Silver CE, Ferlito A: Surgery for Cancer of the Larynx and Related Structures. 2nd ed. Philadelphia, Pa: Saunders, 1996.
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Wang CC, ed.: Radiation Therapy for Head and Neck Neoplasms. 3rd ed. New York: Wiley-Liss, 1997.
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Thawley SE, Panje WR, Batsakis JG, et al., eds.: Comprehensive Management of Head and Neck Tumors. 2nd ed. Philadelphia, Pa: WB Saunders, 1999.
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Mendenhall WM, Riggs CE Jr, Cassisi NJ: Treatment of head and neck cancers. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. 7th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2005, pp 662-732.
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Fowler JF, Lindstrom MJ: Loss of local control with prolongation in radiotherapy. Int J Radiat Oncol Biol Phys 23 (2): 457-67, 1992.
[PUBMED Abstract]
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Hansen O, Overgaard J, Hansen HS, et al.: Importance of overall treatment time for the outcome of radiotherapy of advanced head and neck carcinoma: dependency on tumor differentiation. Radiother Oncol 43 (1): 47-51, 1997.
[PUBMED Abstract]
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Bourhis J, Wibault P, Lusinchi A, et al.: Status of accelerated fractionation radiotherapy in head and neck squamous cell carcinomas. Curr Opin Oncol 9 (3): 262-6, 1997.
[PUBMED Abstract]
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Taylor SG 4th: Integration of chemotherapy into the combined modality therapy of head and neck squamous cancer. Int J Radiat Oncol Biol Phys 13 (5): 779-83, 1987.
[PUBMED Abstract]
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Stupp R, Weichselbaum RR, Vokes EE: Combined modality therapy of head and neck cancer. Semin Oncol 21 (3): 349-58, 1994.
[PUBMED Abstract]
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Forastiere AA, Goepfert H, Maor M, et al.: Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 349 (22): 2091-8, 2003.
[PUBMED Abstract]
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Spaulding CA, Hahn SS, Constable WC: The effectiveness of treatment of lymph nodes in cancers of the pyriform sinus and supraglottis. Int J Radiat Oncol Biol Phys 13 (7): 963-8, 1987.
[PUBMED Abstract]
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Browman GP, Wong G, Hodson I, et al.: Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med 328 (3): 159-63, 1993.
[PUBMED Abstract]
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Turner SL, Tiver KW, Boyages SC: Thyroid dysfunction following radiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys 31 (2): 279-83, 1995.
[PUBMED Abstract]
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Constine LS: What else don't we know about the late effects of radiation in patients treated for head and neck cancer? Int J Radiat Oncol Biol Phys 31 (2): 427-9, 1995.
[PUBMED Abstract]
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