What is the primary treatment for a patient with vocal cord squamous cell carcinoma?

Primary Treatment for Vocal Cord Squamous Cell Carcinoma

For early-stage (T1-T2) vocal cord squamous cell carcinoma, single-modality treatment with either radiotherapy or conservative surgery (transoral laser microsurgery or transoral robotic surgery) provides excellent locoregional control with similar outcomes, and the choice should be based on expected functional outcomes and treatment-related side effects. 1

Treatment Algorithm by Stage

Early Disease (T1-T2)

• Single-modality treatment is the standard approach for early vocal cord cancer, avoiding unnecessary treatment toxicity 1

• Radiotherapy option: Definitive radiation therapy (using IMRT or VMAT) achieves 97% ultimate local control for T1 lesions and 91% for T2 lesions when surgical salvage is included 1, 2

  • Voice quality remains satisfactory in 95% of controlled patients 2
  • IMRT significantly reduces carotid artery radiation dose compared to conventional techniques 3

• Conservative surgery option: Transoral laser microsurgery or transoral robotic surgery provides comparable control rates 4

  • Laser excision achieves 81% normal voice preservation in T1 lesions 5
  • Anterior commissure involvement is not a contraindication to laser excision 5

• Both modalities provide similar locoregional control, so the decision hinges on patient-specific factors including vocal demands, comorbidities, and patient preference 1

Locally Advanced Disease (T3-T4)

• Primary surgical treatment followed by radiotherapy or chemoradiotherapy is the preferred approach for T3/T4 laryngeal cancers 1, 4

• For T3 lesions where larynx preservation is desired: Induction chemotherapy with TPF (docetaxel, cisplatin, 5-FU) for three courses followed by radiotherapy alone is a validated option 1

  • This approach achieves 63% 5-year local control with radiotherapy alone, and 86% ultimate local control with surgical salvage 6

• For T4 lesions: Total laryngectomy with postoperative radiotherapy or chemoradiotherapy is standard 1

  • Extension to pharyngeal wall, positive cervical lymph nodes, and previous emergency tracheostomy are adverse prognostic factors requiring postoperative radiation 7

Adjuvant Therapy Indications

Postoperative radiotherapy is mandatory for:

• pT3-4 tumors 1, 4
• Resection margins with macroscopic (R2) or microscopic (R1) residual disease 1, 4
• Perineural infiltration 1, 4
• Lymphatic infiltration 1, 4
• More than one invaded lymph node 1, 4
• Presence of extracapsular infiltration 1, 4

Postoperative chemoradiotherapy is mandatory for:

• R1 resection margins 1, 4
• Extracapsular extension 1, 4

Timing: Postoperative radiotherapy or chemoradiotherapy must start within 6-7 weeks of surgery 1

Radiation Therapy Technical Requirements

• All patients must be treated with IMRT or VMAT to minimize toxicity 1, 4

• Standard dose: 70 Gy for definitive treatment 1

• Concurrent chemotherapy regimen: Cisplatin 100 mg/m² on days 1,22, and 43 of radiotherapy 1, 4

• Alternatives for cisplatin-unfit patients: Carboplatin combined with 5-FU, cetuximab with radiotherapy, or hyperfractionated/accelerated radiotherapy without chemotherapy 1, 4

Recurrent/Metastatic Disease

For PD-L1 expressing tumors (CPS ≥1):

• Pembrolizumab in combination with platinum/5-FU or pembrolizumab monotherapy 1, 4
• Use combination therapy when rapid tumor shrinkage is needed 1

For non-PD-L1 expressing tumors:

• Platinum/5-FU/cetuximab remains standard therapy 1, 4

For progression within 6 months of platinum therapy:

• Nivolumab is FDA- and EMA-approved 1, 4

Critical Management Considerations

• Treatment at high-volume facilities improves outcomes 1

• DPD testing is required before initiating 5-FU to prevent severe toxicity 1, 4

• Neck dissection is not recommended if FDG-PET is negative and lymph nodes are normal size at 12 weeks post-chemoradiotherapy 1, 4

• Multidisciplinary team involvement including dieticians, speech/swallowing specialists, and psychological support is essential 1

Common Pitfalls to Avoid

• Do not perform emergency tracheostomy unless absolutely necessary, as it significantly worsens prognosis in advanced disease 6, 7

• Do not delay adjuvant therapy beyond 6-7 weeks post-surgery, as this compromises outcomes 1

• Do not use conventional radiotherapy techniques when IMRT/VMAT is available, as carotid dose reduction is clinically significant 1, 3

• Do not assume vocal cord mobility recovery during radiotherapy predicts better outcomes—tumor volume is a more reliable prognostic factor 6