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  Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 57  |  Issue : 5  |  Page : 19-21
 

Indian clinical practice consensus guidelines for the management of laryngeal cancer


1 Department of Medical Oncology, Indraprastha Apollo Hospital, New Delhi, India
2 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
4 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
5 Department of Surgical Oncology, Cochin Cancer Research Centre, Cochin, Kerala, India
6 Department of Oral Medicine and Radiology, KLE Society's Institute of Dental Sciences (KLESIDS), Bangalore, Karnataka, India
7 Department of Radiation Oncology, Max Super Speciality Hospital, Saket, New Delhi, India
8 Department of Medical Oncology, HCG Cancer Centre, Ahmedabad, Gujarat, India
9 Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
10 Department of Radiation Oncology, Civil Hospital, Shillong, Meghalaya, India
11 Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
12 Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Centre, Bangalore, Karnataka, India
13 Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
14 Department of Radiotherapy, Christian Medical College, Vellore, Tamil Nadu, India
15 Department of Surgical Oncology, Max Super Speciality Hospital, Saket, New Delhi, India
16 Department of Surgical Oncology, HCG Cancer Centre, Bangalore, Karnataka, India
17 Department of Radiation Oncology, Shri Mata Vaishno Devi Narayana Superspeciality Hospital, Jammu, Jammu and Kashmir, India
18 Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, Delhi, India

Date of Submission25-Jul-2019
Date of Decision13-Nov-2019
Date of Acceptance29-Dec-2019
Date of Web Publication25-Feb-2020

Correspondence Address:
Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.278973

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How to cite this article:
Singhal M, Prabhash K, Babu G, Chaturvedi P, Kuriakose M, Birur P, Anand AK, Kaushal A, Mahajan A, Syiemlieh J, Gairola M, Ramachandra P, Goyal S, John S, Nayyar R, Patil VM, Rao V, Roshan V, Rath G K. Indian clinical practice consensus guidelines for the management of laryngeal cancer. Indian J Cancer 2020;57, Suppl S1:19-21

How to cite this URL:
Singhal M, Prabhash K, Babu G, Chaturvedi P, Kuriakose M, Birur P, Anand AK, Kaushal A, Mahajan A, Syiemlieh J, Gairola M, Ramachandra P, Goyal S, John S, Nayyar R, Patil VM, Rao V, Roshan V, Rath G K. Indian clinical practice consensus guidelines for the management of laryngeal cancer. Indian J Cancer [serial online] 2020 [cited 2022 Jul 6];57, Suppl S1:19-21. Available from: https://www.indianjcancer.com/text.asp?2020/57/5/19/278973





  Diagnosis Workflow for Evaluation of Clinical Stages Top


Routine examination includes history and physical examination (with a complete head and neck exam, mirror and fiberoptic examination), a biopsy of primary site or fine-needle aspiration of the neck. Computed tomography with contrast and thin-angled cuts through larynx and/or magnetic resonance imaging with contrast of primary and neck is recommended. In selected patients, pre-anesthesia studies, examination under anesthesia with endoscopy, and fluorodeoxyglucose-positron emission tomography/computed tomography for stage III–IV diseased should be performed. Consider videostrobe for selected patients and pulmonary function evaluation for conservation surgery candidates. Dental evaluation and nutrition, speech and swallowing evaluation/therapy only for selected at-risk patients (if indicated) should be performed[1] (evidence level [EL] 2; Grade A).


  Treatment of Laryngeal Carcinoma Top


The goal of the treatment is to achieve maximum cure and preserve function of larynx with good quality of voice. A multidisciplinary approach is essential.

Early laryngeal cancer (in situ; T1–2, N0)

Surgery

In patients with carcinoma in situ, endoscopic resection (transoral laser microsurgery) is the preferred choice.[2] However, choice of treatment should depend on the patient and tumor factors. Patients treated with transoral laser microsurgery may have poor voice quality than patients who received radiotherapy (RT)[3]; however, 5-year disease-specific survival, disease-free survival, and total laryngectomy-free survival were comparable between both the treatment modalities.[4]

In patients with T1–2, N0 laryngeal cancer, partial laryngectomy/endoscopic or open resection, and neck dissection (as indicated) should be performed. Postsurgery in case of adverse features, adjuvant treatment is recommended. In case of extranodal extension, chemotherapy and radiotherapy (CT/RT); in case of positive margins, re-resection (if feasible) or RT; and in case of other features, RT is recommended.

RT/Definitive RT

Another option for treatment of carcinoma in situ is RT which includes 60.75 Gy (2.25 Gy/fraction) to 66 Gy (2.0 Gy/fraction) radiation dose.[5],[6]

Patients with T1/T2 disease (selected patients, who are medically inoperable or refuse surgery) can be treated with definitive RT:

  • T1, N0: 63 Gy (2.25 Gy/fraction) to 66 Gy (2.0 Gy/fraction)
  • T2, N0: 65.25 Gy (2.25 Gy/fraction) to 70 Gy (2.0 Gy/fraction).


Locally advanced laryngeal carcinoma (T3, N0–3; T4a, N0–3)

Management of resectable, advanced-stage laryngeal cancer should be done with a combined modality approach.

Concurrent chemoradiotherapy

Patients should be carefully chosen for organ preservation. Patients with arytenoid fixation, invasion of the posterior commissure, subglottic extension of more than 5 mm posteriorly and 5–10 mm anteriorly or to the upper border of the cricoid cartilage, cricoid cartilage invasion and major thyroid cartilage invasion (T4), massive pre-epiglottic space involvement, positive margins in a frozen section and extralaryngeal spread are not the candidates for organ preservation. For organ preservation, concurrent chemoradiotherapy (CTRT) is an option.[7],[8] Concurrent CTRT with high-dose cisplatin (three-weekly 100 mg/m2) should be used.[9],[10]

Chemotherapy (CT) regimens include (a) cisplatin 100 mg/m2 three weekly, (b) nimotuzumab + weekly 30 or 40 mg/m2 cisplatin,[11],[12],[13],[14] (c) weekly cisplatin 30 or 40 mg/m2, (d) cisplatin plus paclitaxel, and (e) cisplatin plus infusional 5-fluorouracil (FU).[15],[16]

CT regimens for cisplatin unsuitable patients include (a) weekly cetuximab, (b) weekly nimotuzumab, (c) carboplatin plus infusional 5-FU, (d) 5-FU plus hydroxyurea, or (e) carboplatin plus paclitaxel.

Induction CT

Induction therapy with TPF (docetaxel, cisplatin, and FU) followed by definitive RT or definitive CTRT can be one of the organ preservation approaches for the patients undergoing total laryngectomy.[7],[17] General approach of the treatment for organ preservation in patients with T3, N0–3 can be induction CT, followed by definitive RT in patients with complete response, and definitive RT or CTRT in patients with partial response. Surgery can be considered in patients with no response (complete/partial response).

Cisplatin-based induction CT regimens are as follows:

  • Docetaxel 75 mg/m2 on day 1 + cisplatin 75 mg/m2 on day 1 + 5-FU 750 mg/m2/day for 5 days every 3 weeks for three cycles.
  • Paclitaxel 175 mg/m2 on day 1 + cisplatin 100 mg/m2 on day 2 + 5-FU 500–750 mg/m2/day from day 2 to day 6 every 3 weeks for three cycles.
  • Cisplatin 100 mg/m2 on day 1 + 5-FU 1000 mg/m2/day for 4 days every 3 weeks for three cycles.


Surgery

For patients with locally advanced disease (T3, N0–3), surgery (laryngectomy with thyroidectomy, ipsilateral or bilateral neck dissection, and pretracheal and ipsilateral paratracheal lymph node dissection) with RT or CTRT should be considered in patients who are not fit for laryngeal preservation. Among patients with extranodal extension and/or positive margins, CTRT is recommended, and among patients with other risk factors, RT or CTRT is recommended.

For patients with glottic and supraglottic T4a, N0–3 larynx cancers, total laryngectomy with thyroidectomy ± unilateral/bilateral/contralateral neck dissection and paratracheal lymph node dissection, as indicated (depending on the node involvement) followed by adjuvant treatment (RT, or systemic therapy/RT may be considered), is recommended.[5]Algorithm for management of laryngeal cancer is given in [Figure 1]. Appendix 1 gives the summary of clinical evidences in laryngeal cancer.
Figure 1: Algorithm for management of laryngeal cancer

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Acknowledgement

We acknowledge the significant contribution of J Balawardana, C Vithanage, S Resnayaka from Sri Lanka during the meeting and S Ghosh Laskar, S Ranjan, P Chavan, R Halkud and C Ramachandra for their involvement and insights. We also acknowledge the medical writing support provided by an independent medical writing agency, IQVIA. We are fully responsible for the content of this manuscript and the recommendations described in the review reflect the views and opinions of the authors only.

Financial Support and Sponsorship

Oral Cancer Task Force (OCTF) with a multidisciplinary expert panel, has a long standing commitment to work for early detection and management of oral cancer in underserved populations. The task force members have taken this educational initiative of developing India specific consensus guidelines for management of head and neck cancer under its ambit. The meeting and supplement were supported by an unrestricted grant by Biocon Foundation.

Conflicts of interest

Oral Cancer Task Force (OCTF) members and authors do not have any conflicts of interest.

 
  References Top

1.
National Comprehensive Cancer Network (NCCN). Guideline Version 2.2019. Head and neck cancers. Available from: https://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf. [Last accessed on 2019 Dec 01].  Back to cited text no. 1
    
2.
Mo HL, Li J, Yang X, Zhang F, Xiong JW, Yang ZL, et al. Transoral laser microsurgery versus radiotherapy for T1 glottic carcinoma: A systematic review and metanalysis. Lasers Med Sci 2017;32:461-7.  Back to cited text no. 2
    
3.
Kerr P, Mark Taylor S, Rigby M, Myers C, Osborn H, Lambert P, et al. Oncologic and voice outcomes after treatment of early glottic cancer: Transoral laser microsurgery versus radiotherapy. J Otolaryngol Head Neck Surg 2012;41:381-8.  Back to cited text no. 3
    
4.
De Santis RJ, Poon I, Lee J, Karam I, Enepekides DJ, Higgins KM. Comparison of survival between radiation therapy and trans-oral laser microsurgery for early glottic cancer patients; a retrospective cohort study. J Otolaryngol Head Neck Surg 2016;45:42.  Back to cited text no. 4
    
5.
Yoo J, Lacchetti C, Hammond JA, Gilbert RW. Role of endolaryngeal surgery (with or without laser) versus radiotherapy in the management of early (T1) glottic cancer: A systematic review. Head Neck 2014;36:1807-19.  Back to cited text no. 5
    
6.
Silver CE, Beitler JJ, Shaha AR, Rinaldo A, Ferlito A. Current trends in initial management of laryngeal cancer: The declining use of open surgery. Eur Arch Otorhinolaryngol 2009;266:1333-52.  Back to cited text no. 6
    
7.
Forastiere AA, Zhang Q, Weber RS, Maor MH, Goepfert H, Pajak TF, et al. Long-term results of RTOG 91-11: A comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol 2013;31:845-52.  Back to cited text no. 7
    
8.
Samstein R, Leeman JE, Li JG, Venigalla P, Ganly I, Wong RJ, et al. Outcomes for locally advanced laryngeal cancer treated with definitive chemoradiation with intensity modulated radiation therapy. Int J Radiant Oncol 2016;96:2965 [poster abstract].  Back to cited text no. 8
    
9.
Strojan P, Vermorken J, Beitler J, Saba NF, Haigentz M Jr, Bossi P, et al. Cumulative cisplatin dose in concurrent chemoradiotherapy for head and neck cancer: A systematic review. Head Neck 2016;38:E2151-8.  Back to cited text no. 9
    
10.
Bauml JM, Vinnakota R, Anna Park YH, Bates SE, Fojo T, Aggarwal C, et al. Cisplatin every 3 weeks versus weekly with definitive concurrent radiotherapy for squamous cell carcinoma of the head and neck. J Natl Cancer Inst 2019;111:490-49.  Back to cited text no. 10
    
11.
Patil VM, Noronha V, Joshi A, Agarwal J, Ghosh-Laskar S, Budrukkar A, et al. A randomized phase 3 trial comparing nimotuzumab plus cisplatin chemoradiotherapy versus cisplatin chemoradiotherapy alone in locally advanced head and neck cancer. Cancer 2019;125:3184-97.  Back to cited text no. 11
    
12.
Kumar A, Chakravarty N, Bhatnagar S, Chowdhary GS. Efficacy and safety of concurrent chemoradiotherapy with or without Nimotuzumab in unresectable locally advanced squamous cell carcinoma of head and neck: Prospective comparative study-ESCORT-N study. South Asian J Cancer 2019;8:108-11.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Li Z, Li Y, Yan S, Fu J, Zhou Q, Huang X, et al. Nimotuzumab combined with concurrent chemoradiotherapy benefits patients with advanced nasopharyngeal carcinoma. Onco Targets Ther 2017;10:5445-58.  Back to cited text no. 13
    
14.
Prabhash K, Patil VM, Noronha V, Joshi AP, Bhattacharjee A, Mathrudev V, et al. Nimotuzumab-cisplatin-radiation versus cisplatin radiation in HPV-negative oropharyngeal cancer. Ann Oncol 2019;30:1121 [Abstract].  Back to cited text no. 14
    
15.
Lee YJ, Lee CG, Cho BC, Kim GE, Choi HJ, Choi EC, et al. Weekly 5-fluorouracil plus cisplatin for concurrent chemoradiotherapy in patients with locally advanced head and neck cancer. Head Neck 2010;32:235-43.  Back to cited text no. 15
    
16.
Karatzanis AD, Psychogios G, Waldfahrer F, Kapsreiter M, Zenk J, Velegrakis GA, et al. Management of locally advanced laryngeal cancer. J Otolaryngol Head Neck Surg 2014;43:4.  Back to cited text no. 16
    
17.
Ghi MG, Paccagnella A, Ferrari D, Foa P, Alterio D, Codecà C, et al. Induction TPF followed by concomitant treatment versus concomitant treatment alone in locally advanced head and neck cancer. A phase II–III trial. Ann Oncol 2017;28:2206-12.  Back to cited text no. 17
    


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