What are the treatment options for laryngeal cancer?

Treatment of Laryngeal Cancer

All patients with T1 or T2 laryngeal cancer should be treated initially with larynx-preservation strategies using either radiation therapy or larynx-preserving surgery as single-modality treatment, as both achieve similar survival outcomes. 1

Limited-Stage Disease (T1, T2)

Primary Treatment Options

For T1 and T2 laryngeal cancer, choose between three equally effective single-modality approaches: 1

• Endoscopic resection (preferred when technically feasible due to equal or better outcomes compared to open surgery) 1
• Open surgical partial laryngectomy 1
• Radiation therapy alone 1

Critical Treatment Principle

Avoid combining surgery with radiation therapy in limited-stage disease, as functional outcomes are significantly compromised by combined-modality therapy. 1 Single-modality treatment is effective and preserves voice and swallowing function better. 1

Treatment Selection Factors

Choose your approach based on: 1

• Tumor location (glottic vs supraglottic—supraglottic tumors have higher risk of occult regional metastases requiring neck treatment) 1
• Vocal cord mobility (impaired mobility indicates deeper invasion and unfavorable prognosis) 1
• Depth of tissue invasion (deep invasion or involvement of pre-epiglottic/paraglottic spaces makes tumors unfavorable) 1
• Ability to achieve adequate endoscopic visualization 1
• Local surgical expertise and availability of radiation therapy 1
• Patient comorbidities and pretreatment voice/swallowing function 1

Unfavorable T2 Tumors

For unfavorable T2 glottic tumors (deep-tissue invasion, impaired vocal cord mobility, or rare N+ disease): 1

• Supracricoid partial laryngectomy with cricohyoidoepiglottopexy is the organ-preserving surgery of choice 1
• Concurrent chemoradiation may be considered as an alternative 1

For unfavorable T2 supraglottic cancers (deep invasion in laryngeal spaces, larger tumor volumes): 1

• Primary open surgery shows better local control rates in single-arm studies, though patient selection complicates interpretation 1
• Concurrent chemoradiation has shown success in selected patients 1

Advanced-Stage Disease (T3, T4)

For most patients with T3 or T4 disease without tumor invasion through cartilage into soft tissues, concurrent chemoradiotherapy is the most widely applicable larynx-preservation approach and represents standard treatment. 1

Requirements for Optimal Outcomes

Advanced disease requires: 1

• Multidisciplinary team with special expertise 1
• Comprehensive discussion with patient about advantages and disadvantages of larynx-preservation versus total laryngectomy 1

Metastatic Disease

For metastatic laryngeal cancer, pembrolizumab combined with platinum-based chemotherapy (cisplatin or carboplatin) plus 5-fluorouracil is the first-line treatment, improving overall survival to 13 months versus 10.7 months with older regimens. 2

Systemic Treatment Algorithm

First-line for fit patients: 2

• Pembrolizumab + platinum (cisplatin or carboplatin) + 5-fluorouracil
• Objective response rate: 36.3%, progression-free survival: 5.1 months 2
• Grade 3-5 adverse events occur in 83.3% of patients 2

First-line for patients with PD-L1 CPS ≥1 who cannot tolerate intensive chemotherapy: 2

• Pembrolizumab monotherapy alone 2

For patients unfit for platinum-based therapy: 2

• Single-agent options: docetaxel, paclitaxel, methotrexate, or cetuximab with best supportive care 2

Oligometastatic Disease

For highly selected patients with oligometastatic disease (≤2 distant sites, non-visceral), consider local/regional treatment with curative intent, particularly after response to upfront systemic therapy. 2

Salvage Treatment

Total laryngectomy is reserved exclusively for surgical salvage of local tumor recurrences that cannot be optimally treated with additional partial surgery. 1

Locoregional Recurrence Management

• All patients with locoregional recurrence require referral to a tertiary center for multidisciplinary evaluation to assess salvage surgery or re-irradiation feasibility 2
• Patients with good performance status and early-stage recurrence occurring >2 years after primary treatment can be offered salvage surgery with reasonable oncological outcomes 2

Essential Pretreatment Evaluation

Perform comprehensive pretreatment evaluation including: 1

• Careful cancer staging 1
• Voice and swallowing function assessment (new emphasis in updated guidelines) 1
• Clinical, behavioral, psychologic, socioeconomic, and logistic factors 1
• Patient preferences 1

Common Pitfalls to Avoid

Do not combine surgery with radiation therapy for T1/T2 disease—this compromises functional outcomes without survival benefit. 1

Do not use chemotherapy for limited-stage disease outside clinical trials—insufficient data support this approach, and added toxicities must be balanced against expected benefit. 1

Do not continue tobacco use during or after treatment—ongoing smoking is associated with worse outcomes. 3

Do not proceed without multidisciplinary evaluation—optimal outcomes require input from surgical oncology, medical oncology, radiation oncology, speech pathology, and rehabilitation services. 1, 3