In a 78‑year‑old man with recurrent T3 laryngeal squamous cell carcinoma and no clinically evident cervical lymphadenopathy, what are the curative treatment options and expected prognosis?

Treatment Approach for Recurrent T3 Laryngeal SCC in a 78-Year-Old Man

Salvage total laryngectomy is the definitive curative treatment for this patient with recurrent T3 laryngeal squamous cell carcinoma, offering 78-89% local-regional control and 62-63% five-year cancer-specific survival, and should be strongly recommended if the patient has good performance status and the recurrence occurred more than 2 years after primary treatment. 1, 2, 3

Curative Treatment Options

Salvage Surgery (Primary Recommendation)

• Total laryngectomy with postoperative radiotherapy achieves local-regional control in 78-89% of T3 laryngeal cancer cases when used as primary or salvage treatment 2, 3
• Patients with good performance status and early-stage laryngeal recurrence occurring more than 2 years after primary treatment can be offered salvage surgery with reasonable oncological outcomes 1
• The five-year cancer-specific survival for T3 laryngeal cancer treated surgically ranges from 62.5-79% depending on the extent of resection 3
• Postoperative radiotherapy is mandatory for pT3 tumors, and should be initiated within 6-7 weeks of surgery 1, 4
• Postoperative chemoradiotherapy (cisplatin 100 mg/m² on days 1,22, and 43 with 70 Gy radiation) is required if surgical margins are positive (R1 resection) or if extracapsular extension is present 1, 4

Re-irradiation (Very Limited Role)

• Re-irradiation can be considered only in very selected cases after multidisciplinary team discussion at a tertiary referral center 1
• This option is generally reserved for patients who are not surgical candidates due to medical comorbidities or poor performance status 1

Expected Prognosis

With Salvage Laryngectomy

• Five-year cancer-specific survival: 62-74% for T3 laryngeal cancer treated with surgery ± adjuvant therapy 5, 3
• Local-regional control: 78-89% when surgery is combined with appropriate adjuvant treatment 2, 3
• Ultimate local control including salvage procedures reaches 81-83% 5, 2

Without Curative Treatment (Palliative Approach)

• If the patient refuses salvage laryngectomy or is not a surgical candidate, systemic therapy becomes the treatment approach 1, 6
• For recurrent disease not amenable to curative surgery/RT, the patient should be evaluated for PD-L1 expression status using FDA-approved immunohistochemistry testing 1
• If PD-L1 positive (CPS ≥1): Pembrolizumab monotherapy (median OS 12.3-14.9 months) or pembrolizumab plus platinum/5-FU (median OS 13 months) are standard options 1
• If PD-L1 negative: Platinum/5-FU/cetuximab (median OS 10.7 months) remains standard therapy 1
• Recent data suggests that immunotherapy alone has poor response rates in recurrent laryngeal cancer, with only 12.5% achieving long-lasting positive response; adding chemotherapy to immunotherapy improves outcomes 6

Critical Decision-Making Algorithm

Step 1: Assess Surgical Candidacy

• Performance status evaluation: Good PS favors surgery; poor PS favors palliative treatment 1
• Time from primary treatment: Recurrence >2 years after initial treatment has better surgical outcomes 1
• Tumor resectability: Discuss in multidisciplinary team at tertiary center 1

Step 2: If Surgical Candidate

• Proceed with total laryngectomy 2, 3
• Plan for postoperative RT (mandatory for pT3) or CRT (if R1 margins or extracapsular extension) 1, 4
• Ensure treatment starts within 6-7 weeks post-surgery 1

Step 3: If Not Surgical Candidate

• Obtain PD-L1 testing (CPS score) 1
• If no platinum-based chemotherapy in last 6 months AND PD-L1 positive: Consider pembrolizumab monotherapy 1
• If rapid tumor shrinkage needed OR PD-L1 positive: Pembrolizumab plus platinum/5-FU 1
• If PD-L1 negative: Platinum/5-FU/cetuximab 1
• Require DPD testing before initiating 5-FU to prevent severe toxicity 1, 4

Important Caveats

Age Considerations

• At 78 years old, careful assessment of comorbidities, functional status, and patient preferences is essential, though age alone should not preclude curative surgery if performance status is good 1
• Surgical complications occur in approximately 15% of cases regardless of treatment approach 5

Airway Management

• 75% of patients with recurrent laryngeal cancer on systemic therapy require tracheostomy for airway management 6
• This should be anticipated and discussed with the patient upfront

Neck Management

• With no clinically evident cervical lymphadenopathy, neck dissection decisions should be based on post-treatment imaging 1
• FDG-PET/CT at 12 weeks post-treatment: if negative with normal-sized lymph nodes, neck dissection is not recommended 1, 4

Realistic Expectations for Non-Surgical Approach

• Patients refusing salvage laryngectomy should understand that systemic therapy is palliative, not curative 1
• Median survival with best systemic therapy is 12-14 months 1
• Immunotherapy monotherapy has particularly poor response rates (only 12.5% long-term responders) in this population 6