Current Role of Total Laryngectomy in the Era of Organ Preservation

Abstract

In this article, we aimed to discuss the role of total laryngectomy (TL) in the management of patients with larynx cancer (LC) in the era of organ preservation. Before the 1990s, TL followed by radiotherapy (RT) was the standard treatment for patients with locally advanced LC. Over the last 30 years, various types of larynx preservation (LP) programs associating induction or concurrent chemotherapy (CT) with RT have been developed, with the aim of treating locally advanced LC patients while preserving the larynx and its functions. Overall, more than two-thirds of patients included in a LP program will not require total laryngectomy (TL) and will preserve a functional larynx. However, despite these advances, the larynx is the only tumor site in the upper aero-digestive tract for which prognosis has not improved during recent decades. Indeed, none of these LP protocols have shown any survival advantage compared to primary radical surgery, and it appears that certain LC patients do not benefit from an LP program. This is the case for patients with T4a LC (extra-laryngeal tumor extension through the thyroid cartilage) or with poor pretreatment laryngeal function and for whom primary TL is still the preferred therapeutic option. Moreover, TL is the standard salvage therapy for patients with recurrent tumor after an LP protocol.

Keywords: head and neck cancer; larynx; organ preservation; total laryngectomy.

Figure 1

Total laryngectomy and larynx preservation strategies in patients with locally advanced laryngeal (T3–4) cancer. TL: total laryngectomy; LP: larynx preservation; RT: radiotherapy; CT: chemotherapy; CRT: concurrent chemoradiotherapy.

Figure 2

CT scan of a 36-year-old patient with T3 laryngeal cancer (red arrows) involving the right glottic and supraglottic levels with laryngeal immobility, and a left metastatic lymph node in level III (red asterix). Indication of inclusion in a larynx preservation program. Pretreatment CT scan (a,b) and CT-scan after three cycles of induction chemotherapy showing a poor response to therapy (c). Indication of total laryngectomy for induction chemotherapy failure.

Figure 3

CT scan of a 72-year-old patient with T4a laryngeal cancer (red arrows) showing a large extralaryngeal extension through the left side of the thyroid cartilage. Indication of primary total laryngectomy.