Cancers of Larynx

Early cancers of glottis cancers (affecting the vocal cords) present early in the course of the illness owing disruption of voice which can easily affect day to day activities of an individual making them seek early medical attention . A visit to an ENT surgeon should lead to a visualization of the tumor by relatively simple fibreoptic laryngoscopy which is an office procedure ; most of the afflicted individuals have history of tobacco use and an endoscopic examination under general anaesthesia and submission of the piece for histologic examination will help clinch the diagnosis of cancer which in its commonest form may be described as the Squamous cell cancer ( SCC ) and initiate the treatment which may comprise of either external beam radiotherapy (EBRT ) or transoral laser microsurgery ( TLM ). If the lesion is small and affects part of the larynx which will not cause overt detioration in voice the TLM is preferred procedure that is usually undertaken as a day procedure and has added advantage of predicting the prognosis by detailed HPE examination of the whole tumor . However if the patient is a professional voice user and has a lesion that affects critical part of the larynx such as the anterior commissure or paraglottic space , functional as well oncologic outcome with regard to voice may be sub-optimal despite presenting with a mobile vocal cord ( Shenoy 2012).

EBRT : Prior to 1990’s EBRT over a 6 week treatment schedule was considered the standard of care as it controlled T1 and T2 cancers of glottis in 95% and 72% over a 5 year period . However the prolonged treatment period and the costs of treatment especially in the time spent to visit the radiation suite 5days a week for 6 weeks especially for patients from far flung places , made this option a less attractive one . Further the follow up for prolonged periods especially in the T2 lesions involving the anterior commissure and subglottis where oncologic results were in realms of 52 % especially in the Indian subcontinent ( Dinshaw KT 1990 , Shenoy AM 1996 ) with total laryngectomy being the only salvage option. Today with technologic advances there has been quantum leap in the evaluation of larynx cancers with regard to its biology , staging , organ preservation strategies in moderately advanced lesions and speech and swallowing rehabilitation and improved oncologic control in those advanced tumors that undergo ablative surgery . The clock seems to have turned a full circle with H&N oncologists( post VALSEC and post RTOG 91-11- both randomized clinical trials providing level 1 data) realizing that not all advanced laryngeal cancers ( Viz .T3 & 4- N+ ) may be amenable to successful organ preservation with chemoradiotherapy especially when this approach is adopted at community level hospitals. While T3-4a staged supraglottic tumors show good response to non -surgical chemoradiotherapy , the issues of acute toxicities ( Gr3-4 in 55 % Of the RTOG91-11 cohort and death in5 % ) as well chronic sequelae of pharyngo-esophageal dysfunction in 15% that undergo hyperfractionated RT with Concomitant CT ( MSKCC data ) have alerted that this option is not without life threatening side –effects as well as sequelae which seriously undermine long-term survival . In fact several publications ,after 10 year ASCO update by the RTOG 91-11 study , have attributed the decline in survival in advanced laryngeal cancers to over use of Chemoradiotherapy.

So a more balanced view today would be to offer EBRT for T1 &2 supraglottic lesions with TLM for those early glottis lesions that are superficial and restricted to membranous vocal cord with very minimal infiltrative component to the subglottis with little or nil restriction in cord mobility . This diminution in cord mobility has been associated with poor control with RT alone and therefore Mendenhall and group from Gainesville ,Florida have recommended weekly cisplatinum with EBRT for this group with improved disease free survival.

Primary partial functional laryngeal resection Viz . Supracricoid laryngectomy is fast emerging as an important surgical option with excellent oncologic and functional outcome ( Pellini , Shenoy , Lacourreye ) .

For more extensive T3 lesions with subcricoid extension with no extralaryngeal spread ,they can be still be amenable to concurrent chemoradiotherapy but with poorer local control which may result in salvage total laryngectomy in high number of cases and can be recommended in extremely robust candidates only; those with minimal co morbid condition but otherwise amenable to total laryngectomy under general anaesthetic , should be offered this option with primary trachea-esophageal prostheses.