1. DIAGNOSTIC EVALUATION
2. EXAMINATION UNDER ANESTHESIA AND BIOPSY
3. TREATMENT
4. POSTOPERATIVE IRRADIATION
5. FOLLOW UP
6. BIBLIOGRAPHY

I.DIAGNOSTIC EVALUATION:

Clinical Evaluation:

Management of a patient with suspected cancer of the supraglottic larynx should be directed by a physician capable of surgically treating laryngeal cancer as well as managing the associated problems of airway obstruction, dysphagia with aspiration, and compromised vocal capacity. The clinical examination should include:

• Complete history and physical examination
  
  Recording the presence and duration of symptoms such as pain, soreness of throat, otalgia, odynophagia, dysphagia, trismus and hoarseness. It should include history of risk factors such as the use of tobacco and alcohol, the occurrence and extent of weight loss and of all other medical conditions.

• Complete examination of the head and neck.
  
  Includes examination of all the areas of the oral cavity, pharynx, and indirect laryngoscopy. If indirect laryngoscopy is not adequate, fiberoptic examination of the larynx and pharynx is necessary. Palpation of the floor of the mouth, tongue, base of the tongue and or tonsil to evaluate the "base" or depth of the tumor and its proximity to the mandible. The examination includes an assessment of the status of the mandible and the dentition, as well as an evaluation of the status of the airway. Palpation of the neck bilaterally, recording the location (Group or Level I - VI), size, mobility, and relationship of the node(s) to adjacent structures. The staging of the primary and of the cervical lymph nodes must be documented.

• Biopsy of primary
   
  Usually requires direct laryngoscopy under general anesthesia. In selected cases it may be done in the outpatient setting employing indirect mirror exposure of the larynx or through a flexible fiberoptic laryngoscope.
  
• Fine needle aspiration biopsy of suspected metastatic disease may be performed in selected cases. (Open surgical biopsy of suspected metastatic disease is not indicated)

Imaging Studies:

• Panoramic view (Panorex) of the mandible and/or dental X-rays. 
  
  When necessary to adequately assess the status of the patient's dentition.
  
  
• Chest radiographs, PA and lateral 
  
  To rule out (1) A synchronous pulmonary tumor, (2) Acute or chronic pulmonary disease (3) Metastatic tumor. Abnormal findings on chest x-ray with suspicions lesions may need further imaging including a chest CT.
  
  
• CT or MRI of the larynx and neck
  
  Valuable in most cases to assess: extent of primary tumor, extra-laryngeal extension (i.e. into tongue base), extension within the larynx (i.e. pre-epiglottic and paraglottic space), and cartilage invasion.
  
  In the absence of palpable adenopathy, they may be useful to assess the status of the cervical lymph nodes in patients who are obese or have a thick, muscular neck.
  
  When a large node is palpable in the neck, may be useful to clarify its relationship to the carotid artery, the paraspinal muscles or the cervical spine.

Laboratory Tests:

• Laboratory tests as directed by findings upon history and physical as well as per institutional guidelines.

• Pulmonary function tests, when considering partial laryngectomy.
  
• Baseline liver function tests (optional)

Consultations:

• Radiation therapy
  
  Regarding counseling about alternative treatment approaches, and in anticipation of postoperative radiotherapy.
  
• Dental
  
  To assess the status of the teeth and make recommendations considering that radiation therapy may be indicated.
  
• Speech Pathology
  
  For pre-treatment counseling regarding possible postoperative speech and swallowing rehabilitation.
  
• Internal Medicine, Cardiology, Pulmonology or Anesthesiology
  
  When significant comorbid conditions are identified that may preclude or increase the risk of general anesthesia or influence therapeutic decisions.

• General
  
  Assessment of margins with frozen section as needed to ensure adequate resection
  
  Orientation and mapping of the primary and neck dissection specimen for the pathologist by the surgeon
  
• Endoscopic Laser Supraglottic Laryngectomy
  
  May be performed as an outpatient procedure only for the smallest tumors
  
  Generally monitor in hospital until airway is deemed adequate both from perspective of edema and potential bleeding before discharge
  
• Supraglottic Laryngectomy
  
  Insertion of feeding tube
  
  Temporary tracheotomy
  
  Insertion of drains (suction or passive)
  
  Cricopharyngeal myotomy (optional)
  
  Laryngeal suspension (optional)
  
  Preservation of hyoid bone in selected cases is controversial
  
  Postoperative Care:
  
  -Hospitalization: 7 - 14 days, monitor for wound breakdown, development of salivary fistula, chyle leak, adequate recovery from surgery and anesthetic.
  
  -Removal of suction drains when output < 30-50 ml/24 hours
  
  -Suture removal from neck in 5-10 days
  
  - Remove tracheotomy tube when airway patent; may confirm with successful overnight "capping" monitored with pulse oximeter
  
  -Begin trial feeding when postoperative edema is sufficiently resolved, ideally after tracheotomy tube has been removed. Consider study with modified barium swallow ("oropharyngeal motility study") prior to feeding
  
  -Tube feedings until oral intake is adequate
  
  - May require discharge with tracheotomy tube and feeding tube in place. Adequate training of patient and support personnel is needed before discharge can safely be effected. Ensure that a portable suction machine is available to the patient and consult a home-visiting nursing service (optional)
  
  
• Total Laryngectomy
  
  Insertion of feeding tube
  
  Insertion of drains (suction or passive)
  
  Consider augmenting closure with pedicled regional or free flap if hypopharyngeal stenosis otherwise likely to result (i.e. pectoralis major, latissimus, or trapezius myocutaneous flap/free flap including radial forearm free flap)
  
  Postoperative Care
  
  - Hospitalization: 7 - 14 days, monitor for wound breakdown, development of salivary fistula, chyle leak, adequate recovery from surgery and anesthetic.
  
  - Removal of suction drains when output < 35-50 ml/24 hours
  
  - Suture removal from neck in 5-10 days
  
  - Begin feeding postoperative day #5 - 7 unless irradiated in which case delay feeding to postoperative day #10-14.
  
  - Tube feedings until oral intake is adequate.

Top

It includes:

• Direct laryngoscopy to obtain:
  
  A biopsy of the primary tumor.
  
  Accurate assessment of extent of the primary tumor which may require additional mapping biopsies.
  
  Assessment for other primary tumors of the upper respiratory tract.

This complete assessment may be performed under local anesthesia with sedation. In patients with large tumors it may require tracheostomy under local anesthesia.

• Esophagoscopy (optional unless symptoms present). 
• Bronchoscopy if indicated by clinical or radiographic findings.

Top

III.TREATMENT:

General Principles:

Single modality therapy employing either radiotherapy or surgery by partial laryngectomy is the usual treatment for stage I or II supraglottic cancers (T1N0 and T2N0). Although controversy exists regarding the relative merits of either of these treatment modalities, patients should be made aware that cure is possible with either of them. Selection of a treatment modality should be made with full knowledge of their advantages and disadvantages. Single modality treatment engenders less morbidity and cost; thus, it is encouraged in most cases of localized supraglottic cancer (stage I and II).

Multimodality therapy employing surgery and irradiation is generally offered in one of several ways:

• Surgical treatment addressing both the primary site and draining lymphatics on both sides of the neck. Postoperative radiotherapy is added when there is one or more of the following situations:
  
• Related to the primary site: extensive intralymphatic or perineural invasion, or microscopically positive margins.
  
• Related to the regional lymphatics: (1) multiple positive nodes at one level (2) positive nodes at multiple levels (3) extracapsular spread of tumor.
  
• Radiotherapy for cure to the primary site and neck with planned post-irradiation neck dissection. This approach limits treatment of the primary site to a single modality (radiotherapy) in an effort to preserve laryngeal function. This approach can be considered for T1-3 disease associated with N2, N3 disease. The role for radiotherapy in curing N1 disease is controversial and dependent on the characteristics of the neck involvement. The capacity for radiotherapy alone to offer adequate chance for cure of T3 supraglottic disease is similarly controversial.
  
• Radiotherapy may be administered for intended cure with surgical treatment offered, not as part of the original treatment plan, but as salvage in case of unsatisfactory response or recurrence of tumor. In most cases, surgical salvage following failed irradiation for a supraglottic cancer will require a total or near-total laryngectomy rather than partial laryngeal surgery.
  
• Chemotherapy
  
  Chemotherapy may be used in the treatment of supraglottic cancers in the following situations:
  
  - Clinical trials approved as investigational by institution review boards.
  
  Chemotherapy plus radiotherapy have been shown in a controlled randomized trial to provide survival equal to surgery plus radiotherapy in stage III and IV laryngeal cancer. Furthermore, tumor regression with chemotherapy has been found to be useful in identifying a subset of patients with advanced supraglottic cancer who have a higher chance of cure employing radiotherapy without surgery than those who do not respond to the chemotherapy. The optimal method of combining chemotherapy and radiation remains controversial and questions exist regarding the effectiveness of chemotherapy in comparison to radiotherapy alone. As a result, induction chemotherapy in the treatment of supraglottic cancer should be limited to use by investigators addressing research issues including patient selection, cost, quality of life and survival in a carefully controlled fashion.
  
  - Palliation of unresectable or recurrent cancer following treatment
  
  - Palliation of disseminated cancer

Surgical Indications:

Indications for Laryngectomy

• Endoscopic (laser) supraglottic laryngectomy
  
  Indicated primarily as a method of improving the airway of a patient with invasive squamous cell carcinoma prior to definitive treatment with radiotherapy
  
  Indicated in the treatment of T0 supraglottic tumors (carcinoma in situ)
  
  Adequate treatment only for selected superficial T1 lesions
  
• Supraglottic Laryngectomy
  
  T1, T2 supraglottic cancers
  
  T3 supraglottic cancers without extension to the vocal cord. Candidates for supraglottic laryngectomy include those with pre-epiglottic space involvement or extension into the pyriform sinus above the level of the vocal cords. Involvement of the arytenoid mandates extension of the excision to remove the arytenoid cartilage increasing the risk of aspiration and vocal impairment.
  
  Adequate general health and pulmonary reserve in particular is required for the patient to be a candidate for this procedure, otherwise total laryngectomy would be required.
  
  Prior to supraglottic laryngectomy, consent from the patient needs to be obtained for extension of the resection to include a total laryngectomy, if tumor extent as determined at the time of planned supraglottic laryngectomy is greater than anticipated preoperatively. If the patient is unwilling to consent to a total laryngectomy an alternative treatment plan should be considered.
  
• Total Laryngectomy
  
  All T3 supraglottic cancers not amenable to supraglottic laryngectomy according to the criteria above
  
  All T4 supraglottic cancers (Thyroid or cricoid cartilage invasion, extension to soft tissues of the neck, apex of pyriform sinus, or beyond posterior 1/3 of the base of tongue)
  
  Tumors involving the posterior commissure.
  
  Patients with poor pulmonary reserve who do not want or can not undergo radiation therapy.
  
• Near Total Laryngectomy is an appropriate alternative to total laryngectomy when the tumor does not involve one vocal cord.
  
• Supracricoid Partial Laryngectomy may be used for transglottic tumors with one mobile arytenoid, even if vocal cord motion is decreased.

Indications for Neck Dissection

N₀: The incidence of occult metastases from supraglottic cancer is sufficiently high for all patients with invasive carcinomas that the neck nodes at risk should be addressed with either radiotherapy or surgery, even in the absence of palpable or radiographically defined adenopathy. Due to the propensity for bilateral spread of disease, bilateral neck dissections should be performed if radiotherapy is not part of the treatment plan.

Removal of uninvolved structures such as the sternocleidomastoid muscle (SCM), internal jugular vein (IJV), spinal accessory nerve (XI) is not indicated and therefore radical neck dissection is not indicated. Controversy exists regarding the need for a comprehensive neck dissection (including levels I - V) or selective neck dissection employing lateral neck dissection which addresses the nodes at highest risk for involvement (levels II - IV) (12).

N₁: Small N1 disease may be addressed by selective (lateral) or comprehensive neck dissection sparing the SCM, IJ, and XI if not involved. More aggressive cervical lymphadenectomy including radical neck dissection may be indicated depending on the size and location of he N1 disease.

N_{2 - 3}: Generally requires radical neck dissection or a comprehensive modified radical neck dissection sparing XI and less commonly sparing the SCM and/or IJ.

Top

IV.POSTOPERATIVE IRRADIATION:

Indications: 

• T₄N₀ and N₊
  
• T_{1 - 3}N₀ and N₊:
  
  - Microscopically positive margins
  
  - Presence of extensive intravascular or perineural invasion
  
  - T₃ cancers treated with supraglottic laryngectomy 
  
  - Multiple positive nodes in the first echelon of drainage, nodes at multiple levels or presence of extracapsular spread of tumor.
  
  - When both sides of the neck have not been addressed surgically 

Top

Follow-up appointments are scheduled on an individual basis determined by the risk of recurrence, to survey for the development of second primary tumors, to deal with morbidity from treatment (i.e. speech and swallowing problems as well as wound care), to provide social and psychological support, and to deal with comorbidity not directly related to the cancer itself.

• Periodic examinations by the head and neck surgeon may be necessary during radiation therapy in patients experiencing difficulty with nutritional intake, airway or pain control.
  
  
• Periodic examinations by the radiation oncologist and a dentist in patients that received radiation therapy
  
  
• After all treatment is completed a general formula which is modified according to the individual patient's characteristics is:
  
  1st year post treatment: 1-3 months
  
  2nd year post treatment: 2-4 months
  
  3rd year post treatment: 3- 6 months
  
  4th and 5th years: 4- 6 months
  
  After 5 years: Every 12 months
  
• Chest radiographs, yearly.
  
• Liver enzymes, yearly.
  
• Thyroid function tests should be monitored within the first year following completion of treatment if a thyroid lobectomy is performed (along with laryngectomy) or if the patient received radiation to the lower neck. These studies should be repeated according to clinical findings on follow-up examinations.

Top

Korver K., Graham S., Funk G., McCulloch T., Hoffman H.: "Liver Function Studies in the Assessment of Head and Neck Cancer Patients:" Head & Neck (in press).

Parket JT and Hill JH: Panendoscopy in Screening for Synchronous Primary Malignancies. Laryngoscope 98: February 1988 pp 147-149.

McGuirt WF: Panendoscopy as a Screening Examination for Simultaneous Primary Tumors in Head and Neck Cancer: A Prospective Sequential Study and Review of the Literature Laryngoscope 92: May 1982 pp 569-576.

Hoffman HT and Karnell LH: National Cancer Database's 1995 Annual Review: Laryngeal Cancer (in press -- manuscript enclosed)

Hoffman HT, Krause CJ and Eschwege: Combined Surgery and Radiotherapy Ch. 5 pp 76-94 in Multimodality Therapy for Head and Neck Cancer Ed Gordon B. Snow, MD, PhD Georg Thieme Verlag New York 1992.

Kramer S, Gelber RD, Snow JB, et al. Combined radiation therapy and surgery in the management of advanced head and neck cancer: Final report of study 73-03 of the radiation therapy oncology group. Head and Neck Surg 1987, 10: 19-27.

Wolf GT and Hong WK: Induction Chemotherapy for Organ Preservation in Advanced Laryngeal Cancer: Is There a Role?

Department of Veterans Affairs Laryngeal Cancer Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991; 324: 1685-1690.

Zeitels

Hoffman, H: "Review of Endoscopic Treatment of Supraglottic and Hypopharyngeal Cancer" in The Otolaryngology Journal Club Journal Vol. 1 (4): 200-202, August 1994.

Robbins KT, Davidson W, Peters LJ and Goepfert H: Conservation Surgery for T2 and T3 Carcinomas of the Supraglottic Larynx Arch Otolaryngol Head Neck Surg -- Vol 114, April 1988 pp 421-426.

Robbins KT, Medina JE, Wolfe GT, Levine PA, Session RB and Pruet CW: Standardizing Neck Dissection Terminology Arch otolaryngol Head and Neck Surgery -- Vol 117, June 1991 pp 601-605.

Boysen M, Lovdal O, Tausjo J and Winther F: The Value of Follow-up in Patients Treated for Squamous Cell Carcinoma of the Head and Neck. Eur J Cancer, Vol 28, No. 2/3, pp 426-430, 1992.

Snow GB: Follow-up in Patients Treated for Head and Neck Cancer: How Frequent, How Thorough and for How Long? Eur J Cancer, Vol. 28, No. 2/3, pp 315-316, 1992