What are the absolute and relative contraindications for performing a laryngectomy?

Laryngectomy Contraindications

Absolute Contraindications

Total laryngectomy is absolutely contraindicated in patients with distant metastatic disease, as the goal shifts from cure to palliation, making this morbid procedure inappropriate. 1

• Distant metastases (M1 disease) represent an absolute contraindication, as total laryngectomy is a curative procedure reserved for locoregional disease without distant spread 1
• Medically unfit patients with prohibitive surgical risk due to severe cardiopulmonary comorbidities or performance status precluding major surgery should not undergo laryngectomy 1

Relative Contraindications (Larynx-Preservation Preferred)

Early-Stage Disease (T1-T2)

All patients with T1 or T2 laryngeal cancer should be treated with larynx-preservation approaches as the standard of care, making total laryngectomy inappropriate except in rare circumstances. 1

• Single-modality treatment (radiation therapy or transoral laser surgery) achieves equivalent survival to laryngectomy with superior functional outcomes 1
• Total laryngectomy for early-stage disease is only justified after failed larynx-preservation attempts or in the rare patient with severe pre-existing laryngeal dysfunction 1

Selected Advanced Disease (T3 and Limited T4a)

For most patients with T3 or limited T4a disease meeting RTOG 91-11 eligibility criteria (excluding tumors with >1 cm base of tongue extension or extensive cartilage penetration), concurrent chemoradiation is the preferred standard approach, achieving 77% 5-year larynx preservation with equivalent survival to primary laryngectomy. 1, 2

The key relative contraindications to primary laryngectomy in this population include:

• Good pre-treatment laryngeal function (phonation, swallowing, breathing) favors larynx-preservation over primary surgery 1, 2
• T3 disease with mobile or partially mobile vocal cords responds well to concurrent chemoradiation and should not undergo primary laryngectomy 1, 2
• Limited T4a tumors without extensive cartilage destruction can achieve successful larynx preservation in 70-80% of cases, making primary laryngectomy premature 1, 2

Clinical Scenarios Favoring Primary Laryngectomy (When Larynx-Preservation is Contraindicated)

Anatomic Factors

Patients with nonfunctional larynx or tumor penetration through cartilage into surrounding soft tissues are poor candidates for larynx-preservation and should undergo primary total laryngectomy. 1

• Extensive T4a disease with cartilage penetration into soft tissues has poor larynx-preservation outcomes and warrants primary surgery 1
• Pre-existing severe laryngeal dysfunction (chronic aspiration, airway obstruction requiring tracheostomy) makes functional preservation futile 1
• Tumor extending >1 cm into base of tongue was excluded from successful larynx-preservation trials 1

Patient Factors Predicting Larynx-Preservation Failure

The TALK score identifies patients unlikely to succeed with organ preservation (only 6% success when score ≥3): 1

• T4 stage (1 point)
• Albumin <4 g/dL (1 point)

• 6 alcoholic drinks/day (1 point)

• Karnofsky performance status <80% (1 point)

Additional poor prognostic factors include: 1

• Active smoking during treatment (mandatory cessation required for larynx-preservation attempts) 2
• Significant medical comorbidities affecting tolerance of chemoradiation
• Prior tracheostomy for airway obstruction
• Anemia at presentation

Post-Treatment Scenarios

Recurrent disease after definitive radiation therapy or chemoradiation requires salvage total laryngectomy in the majority of cases, particularly for initial T2 or higher tumors. 1

• Salvage laryngectomy is the standard approach for local recurrence after failed larynx-preservation 1
• Only highly selected small recurrences may be amenable to salvage partial laryngectomy 1

Critical Pitfalls to Avoid

The most dangerous error is attempting larynx-preservation in poorly selected patients, which results in treatment failure, decreased survival, and ultimate need for salvage laryngectomy under worse conditions. 1, 2

• Never attempt larynx-preservation in patients with extensive cartilage invasion through to soft tissues - these patients have uniformly poor outcomes and should undergo primary laryngectomy 1
• Do not use twice-daily radiation fractionation in larynx-preservation protocols, as this significantly increases severe late dysphagia (26.5% at 5 years) without improving outcomes 2
• Avoid combining surgery with radiation therapy for early-stage disease, as functional outcomes are compromised by combined-modality therapy when single-modality treatment is curative 1
• Surgery anticipating positive margins requiring postoperative radiation is not acceptable for larynx-preservation attempts - this defeats the purpose of organ preservation 1