Arlene A. Forastiere, MD

Gregory T. Wolf, MD

AS REPORTED in the Journal of Clinical Oncology by Arlene A. Forastiere, MD, of The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, and colleagues, ASCO has issued a clinical practice guideline update on the use of larynx-preservation strategies in the treatment of laryngeal cancer.¹ The prior guideline was issued in 2006. The guideline update was informed by an expert panel systematic review of the literature from January 2005 to May 2017. The expert panel was co-chaired by Dr. Forastiere and Gregory T. Wolf, MD, of the University of Michigan. 

Reproduced/summarized here are the guideline clinical questions addressed and new recommendations and recommendations that have been altered from the 2006 guideline. 

Clinical Question 1 

What are the larynx-preservation treatment options for limited-stage (T1, T2) primary site disease that do not compromise survival? What are the considerations in selecting among them? 

• Recommendation 1.3—New: The success of the larynx-preservation approach may be higher with initial larynx-preserving surgery compared with radiotherapy based on retrospective studies; however, this may be subjected to patient-selection factors. In experienced hands, endoscopic resections are preferred because of equal or better outcomes compared with open partial laryngectomy, unless there are issues with tumor exposure or safety of the endoscopic approach. 
• Recommendation 1.4—Updated: Surgical excision of the primary tumor with intent to preserve the larynx should be undertaken with the aim of achieving tumor-free margins. Surgery that anticipates the need for postoperative radiotherapy to treat close or involved tumor margins or widespread dysplasia is not an acceptable treatment approach. 
• Recommendation 1.7—Updated: Limited-stage laryngeal cancer constitutes a wide spectrum of disease. The clinician must exercise judgment when recommending treatment in this category. For a given patient, factors that may influence the selection of treatment modality include the extent and volume of the tumor; vocal cord mobility; involvement of the anterior commissure; lymph node metastasis; the patient’s age, occupation, pretreatment voice, and swallowing function; patient preference and compliance; and the availability of expertise in radiotherapy or surgery. Optimal outcomes require specialized skills, judgment, and expertise. Poorly performed open or endoscopic surgery or radiotherapy will raise the risk for recurrence or the need for additional modalities of therapy to achieve disease control. 

“Pretreatment voice and swallowing assessments should establish the functional impact of tumor volume and the extent and stage of disease on voice and swallowing outcomes.”

— Arlene A. Forastiere, MD, and colleagues

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Clinical Question 2 

What are the larynx-preservation treatment options for advanced-stage (T3, T4) primary site disease that do not compromise survival? What are the considerations in selecting among them? 

• Recommendation 2.1—Reworded: Organ-preservation surgery, combined chemotherapy and radiotherapy, and radiotherapy alone, all with further surgery reserved for salvage, offer the potential for larynx preservation without compromising overall survival. Anticipated success rates for larynx preservation, associated toxicities, and suitability for a given patient will vary among these approaches. Selection of a treatment option will depend on patient factors, including age, comorbidities, preferences, socioeconomic factors, local expertise, and the availability of appropriate support and rehabilitation services. 
• Recommendation 2.2—New: For selected patients with extensive T3 or large T4a lesions and/or poor pretreatment laryngeal function, better survival rates and quality of life may be achieved with total laryngectomy than with organ-preservation approaches and may be the preferred approach. 
• Recommendation 2.4—Updated: A minority of patients with T3, T4 primary site disease will be suitable for specialized organ-preservation surgical procedures, such as a supracricoid partial laryngectomy. The addition of postoperative radiotherapy will compromise functional outcomes. Induction chemotherapy before organ-preservation surgery is not recommended outside a clinical trial. 
• Recommendation 2.5—Updated: Concurrent chemoradiotherapy offers a significantly higher chance of larynx preservation than radiotherapy alone or induction chemotherapy followed by radiotherapy, albeit at the cost of higher acute in-field toxicities and without improvement in overall survival. The best available evidence supports the use of cisplatin as the drug of choice in this setting. 
• Recommendation 2.6—Updated: There is insufficient evidence to indicate that survival or larynx-preservation outcomes are improved by the addition of induction chemotherapy before concurrent treatment or the use of concurrent treatment with altered fractionation radiotherapy in this setting. 

Clinical Question 3 

What is the appropriate treatment of the regional cervical nodes for patients with laryngeal cancer who are treated with an organ-preservation approach? 

• Recommendation 3.3—Updated: Patients with clinically involved regional cervical nodes (N+) who are treated with definitive radiotherapy or chemotherapy and radiotherapy and who have complete clinical, radiologic, and metabolic imaging (positron-emission tomography/computed tomography at 12 weeks or later after therapy) do not require elective neck dissection. 
• Recommendation 3.4—Updated: Patients with equivocal [18F] fluorodeoxyglucose uptake should undergo neck dissection. The risks and cost of expectant observation vs surgery should be discussed with the patient. 

Clinical Question 4 

Are there methods for prospectively selecting patients with laryngeal cancer to increase the likelihood of success of larynx preservation? 

• Recommendation 4.1—Updated: There are no validated markers that consistently predict outcomes of larynx-preservation therapy. However, patients with a nonfunctional larynx (eg, extensive T3 or T4a) or tumor penetration through cartilage into surrounding soft tissues are considered poor candidates for a larynx-preservation approach. Primary surgery, usually total laryngectomy, is commonly recommended in this setting.
• Recommendation 4.2—Updated: Selection of therapy for an individual patient requires assessment by the multidisciplinary team as well as consideration of voice and swallowing function; patient comorbidity, psychosocial situation, and preferences; and local therapeutic expertise. The multidisciplinary team should include surgical oncology, medical oncology, radiation oncology, speech pathology, radiology, pathology, nursing, dietetics, psychology, and a variety of rehabilitative services (including dental/prosthodontics, smoking cessation, and other ancillary services as required for pain management and psychosocial support). 

Clinical Question 5 

New: What are the best measures to evaluate airway, voice, and swallowing function? What are the considerations to determine the best function-preservation treatment or to recommend laryngectomy? What are the best measures for the pre- and post-treatment assessment of function? 

• Recommendation 5.1—New: As part of a comprehensive pretreatment evaluation, all patients should undergo a baseline assessment of voice and swallowing function; voice (use and requirements); and counseling with regard to the potential effect of treatment options on voice, swallowing, and quality of life. 
• Recommendation 5.2—New: Pretreatment voice and swallowing assessments should establish the functional impact of tumor volume and the extent and stage of disease on voice and swallowing outcomes. 
• Recommendation 5.3—New: Instrumental, performance status, and quality-of-life measures of voice and swallowing should be used to evaluate pre- and post-treatment function. Multiple assessment tools are available for voice and swallowing. Routine methods of assessment include self-recorded and/or expert-rated voice-quality measures, voice-related quality-of-life tools, videostroboscopy, radiographic (videofluoroscopic) or fiberoptic laryngoscopic evaluation of swallowing, and dietary assessment. 

DISCLOSURE: For full disclosures of the study authors, visit www.jco.ascopubs.org. 

REFERENCE 

1. Forastiere AA, Ismaila N, Lewin JS, et al: Use of larynx-preservation strategies in the treatment of laryngeal cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. November 27, 2017 (early release online).