The role of open surgery for management of
laryngeal cancer has been greatly diminished during the past decade. The development of transoral endoscopic
laser microsurgery (TLS), improvements in delivery of
radiation therapy (RT) and the advent of multimodality protocols, particularly
concomitant chemoradiotherapy (CCRT) have supplanted the previously standard techniques of open partial
laryngectomy for early
cancer and total
laryngectomy followed by adjuvant RT for advanced
cancer. A review of the recent literature revealed virtually no new reports of conventional conservation surgery as initial treatment for early stage glottic and supraglottic
cancer. TLS and RT, with or without
laser surgery or CCRT, have become the standard initial treatments for T1, T2 and selected T3
laryngeal cancer.
Photodynamic therapy (
PDT) may have an emerging role in the treatment of early
laryngeal cancer. Anterior commissure involvement presents particular difficulties in application of TLS, although no definitive conclusions have been reached with regard to optimal treatment of these lesions. Results of TLS are equivalent to those obtained by conventional conservation surgery, with considerably less morbidity, less hospital time and better postoperative function. Oncologic results of TLS and RT are equivalent for glottic
cancer, but with better voice results for RT in patients who require more extensive cordectomy. The preferred treatment for early supraglottic
cancer, particularly for bulkier or T3 lesions is TLS, with or without postoperative RT. The Veterans Administration Study published in 1991 established the fact that the response to neoadjuvant CT predicts the response of a
tumor to RT. Patients with advanced
tumors that responded either partially or completely to CT were treated with RT, and total
laryngectomy was reserved for non-responders. This resulted in the ability to preserve the larynx in a significant number of patients with locally advanced
laryngeal cancer, while achieving local control and overall survival results equivalent to those achieved with initial total
laryngectomy. Following this report, similar "organ preservation" protocols were employed in many centers. By 2003, results of the RTOG 93-11 trial, utilizing CCRT as initial treatment, were published, demonstrating a higher rate of laryngeal preservation with this protocol. Surgery was reserved for treatment failures. This concept changed the paradigm for management of advanced
laryngeal cancer, greatly reducing the number of
laryngectomies performed. While supracricoid
laryngectomy has been employed for selected patients, total
laryngectomy is the usual procedure for salvage of failure after non-surgical treatment.