What is the recommended treatment for an older adult with a history of smoking and a transglottic mass?

Treatment of Transglottic Mass in an Older Adult with Smoking History

For a transglottic mass in an older adult smoker, total laryngectomy with neck dissection is the recommended treatment, followed by adjuvant radiation therapy if risk features are present, as transglottic tumors behave more aggressively than pure glottic cancers and require comprehensive surgical management. 1, 2

Critical First Step: Establish Histologic Diagnosis

Before proceeding with definitive treatment, biopsy confirmation is mandatory to distinguish between squamous cell carcinoma (the most common pathology in smokers) and laryngeal lymphoma, as these require fundamentally different treatment approaches 3:

• Squamous cell carcinoma requires surgery, radiation, or chemoradiation with curative intent 4, 1
• Laryngeal lymphoma requires systemic chemotherapy with rituximab-based regimens (R-CHOP for 6-8 cycles), not surgical resection 3
• Deep biopsies including lesion edges with comprehensive immunophenotyping are essential if lymphoma is suspected 3

Staging and Multidisciplinary Evaluation

Once squamous cell carcinoma is confirmed, complete staging determines treatment intensity 4:

• T3 transglottic tumors (most common presentation) cross the ventricle and involve both supraglottic and glottic subsites 5, 6
• Transglottic tumors have 27% cervical metastasis rate at presentation versus 17% for pure glottic cancers 2
• Occult nodal disease occurs in 12% of transglottic cases 2
• Multidisciplinary consultation with head and neck surgery, radiation oncology, medical oncology, speech pathology, and nutrition is required before treatment 4, 1

Surgical Treatment Algorithm

For T3 Transglottic Carcinoma (Most Common Scenario)

Total laryngectomy with bilateral neck dissection is the standard surgical approach 2:

• Every patient with T3 transglottic carcinoma should undergo total laryngectomy with neck dissection due to the 27% rate of cervical metastasis and 43% rate of extracapsular spread when nodes are positive 2
• Voice conservation surgery has a 23% primary failure rate versus 12% for total laryngectomy, though ultimate failure after salvage is similar (12-13%) 5
• Transglottic tumors treated surgically achieve 5-year cause-specific survival of 66.8% and relapse-free survival of 63.7% 6

For T4a Transglottic Carcinoma (Moderately Advanced)

Two evidence-based options exist 1:

1. Primary total laryngectomy followed by adjuvant therapy (preferred when laryngeal preservation not feasible)
2. Concurrent chemoradiation with high-dose cisplatin for laryngeal preservation (Category 1 recommendation) 1

Critical caveat: Planning surgery with anticipated positive margins requiring postoperative radiation is unacceptable, as this compromises both oncologic and functional outcomes 1

Adjuvant Therapy Decision-Making

Post-surgical pathology determines adjuvant treatment 1:

Adjuvant Radiation Alone

• Indicated for T2-3N0 disease with risk features (perineural invasion, lymphovascular invasion, close margins) but negative margins 1
• RTOG 95-01 showed no benefit from adding chemotherapy in this scenario 1

Adjuvant Concurrent Chemoradiation

• Mandatory for extracapsular spread and/or positive margins based on unplanned subgroup analysis showing improved locoregional control and disease-free survival 1
• Must begin within 6 weeks of surgery—delays beyond this compromise outcomes 1

Alternative Approach: Laryngeal Preservation

For patients refusing laryngectomy or medically unfit for surgery, concurrent chemoradiation achieves 70-80% local control for favorable T3 disease 1:

• High-dose cisplatin with radiation is the Category 1 recommendation 1
• Induction chemotherapy followed by response-based management is Category 2A for T3N2-3 disease 1
• Critical understanding: No larynx-preservation approach offers survival advantage over total laryngectomy with appropriate adjuvant treatment 1
• Radiation alone has 33% primary failure rate versus 12% for total laryngectomy 5
• 67% of patients treated with radiation alone preserve voice function 5

Prognostic Factors Requiring Aggressive Treatment

Unfavorable features that worsen outcomes include 5, 6, 2:

• Older age (worse prognosis) 6
• Dyspnea at presentation (worse prognosis) 6
• Pretreatment tracheostomy (worse prognosis) 5, 6
• Positive pathologic lymph nodes (worse prognosis) 6
• Extracapsular spread (43% incidence in transglottic tumors with positive nodes, dramatically increases distant metastasis risk) 2

Essential Supportive Care Measures

Concurrent with oncologic treatment 4:

• Smoking cessation is mandatory—continued smoking worsens outcomes after therapy and patients must be enrolled in cessation programs (1-800-QUIT-NOW) 4, 1
• Nutritional support with dietician involvement prevents severe weight loss during treatment 4
• Depression screening is advised given high risk from disease and treatment sequelae 4
• Pre-treatment voice and swallowing function assessment guides treatment selection 1

Common Pitfalls to Avoid

• Do not treat transglottic T3 tumors with voice conservation surgery alone—the 27% nodal metastasis rate and 43% extracapsular spread rate when nodes are positive mandate neck dissection 2
• Do not delay adjuvant radiation beyond 6 weeks post-surgery—this compromises outcomes 1
• Do not assume transglottic tumors behave like pure glottic cancers—they have higher rates of nodal disease and extracapsular spread requiring more aggressive neck management 2
• Do not proceed with definitive treatment without tissue diagnosis—laryngeal lymphoma masquerading as a transglottic mass requires completely different chemotherapy-based treatment 3