What is the recommended treatment for squamous cell carcinoma of the vocal cord?

Treatment of Squamous Cell Carcinoma of the Vocal Cord

The treatment of squamous cell carcinoma of the vocal cord should be based on disease stage, with early disease (T1-2N0) treated with single-modality therapy (either radiotherapy or conservative surgery) and advanced disease (T3-4) treated with combined modalities. 1

Treatment Algorithm Based on Stage

Early Stage Disease (T1-2N0)

• Single-modality treatment is preferred 1
  • Radiotherapy (RT): Standard option with 80-90% local control rates for T1 and 52-70% for T2 lesions 1, 2, 3
    • Dose: Typically 62-66.5 Gy in 180-250 cGy fractions 4, 5
    • Technique: Intensity-modulated radiation therapy (IMRT) or 3D conformal RT (both show similar outcomes) 6
  • Conservative surgery: Alternative option with comparable control rates
    • Transoral laser microsurgery (TLM)
    • Transoral robotic surgery (TORS)

Advanced Disease (T3-4)

• T3 lesions not requiring total laryngectomy:

  • Concomitant chemoradiotherapy (CRT) 1
  • For larynx preservation: Induction chemotherapy with TPF (docetaxel, cisplatin, 5-FU) followed by RT alone 1

• T4 laryngeal cancers:

  • Primary surgical treatment (total laryngectomy) followed by adjuvant RT or CRT 1

Specific Treatment Recommendations

Chemotherapy Protocols

• Standard concurrent chemotherapy: Cisplatin 100 mg/m² on days 1,22, and 43 of RT 1
• For patients unfit for cisplatin:
  • Carboplatin combined with 5-FU
  • Cetuximab with RT
  • Hyperfractionated or accelerated RT without chemotherapy 1

Post-Treatment Considerations

• Post-operative RT indications:

  • pT3-4 tumors
  • Positive margins (R1/R2)
  • Perineural or lymphatic infiltration
  • Multiple positive lymph nodes
  • Extracapsular extension 1

• Post-operative CRT indications:

  • R1 resection
  • Extracapsular rupture 1
  • Should start within 6-7 weeks of surgery 1

Voice Preservation and Quality of Life

• Voice quality is good-to-excellent in 90% of patients treated with RT for early disease 4
• 75-95% of patients maintain normal voice after RT 4, 5
• Voice preservation should be a key consideration in treatment selection, especially for professional voice users

Recurrent/Metastatic Disease

• For PD-L1 expressing tumors (CPS ≥1):

  • Pembrolizumab plus platinum/5-FU
  • Pembrolizumab monotherapy 1

• For PD-L1 negative tumors:

  • Platinum/5-FU/cetuximab 1

Follow-up Recommendations

• Close monitoring for recurrence and second primaries
• Multidisciplinary team approach including speech/swallowing specialists
• Most recurrences occur within first 2 years after diagnosis 1

Important Considerations and Pitfalls

• Treatment decisions should consider functional outcomes: Voice quality, swallowing function, and quality of life 1
• Surgical salvage rates are high for radiation failures in early disease: 86% salvage rate allows for high ultimate control rates even when initial RT fails 2
• Second primary malignancies are common: 11% actuarial risk at 10 years, particularly in the aerodigestive tract 4
• Treatment duration matters: Increasing duration of RT treatment is associated with increased recurrence rates, particularly for T2 tumors 3
• Field size considerations: Large field sizes (e.g., 7x6 cm) may increase risk of laryngeal edema requiring salvage laryngectomy 3

By following this evidence-based approach to treatment selection, optimal oncologic outcomes can be achieved while preserving laryngeal function whenever possible.