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In Reply

Memorial Sloan-Kettering Cancer Center, New York, NY

Scott A. Laurie

Ottawa Hospital Regional Cancer Centre, Ottawa, Ontario, Canada

Gregory S. Weinstein

University of Pennsylvania School of Medicine, Philadelphia, PA

Kie-Kian Ang

University of Texas M.D. Anderson Cancer Center, Houston, TX

Louis B. Harrison

Beth Israel Health Care System, New York, NY

Gregory T. Wolf

University of Michigan, Ann Arbor, MI

We thank Dr Thankappan for his letter. The optimal management of a T2 glottic lesion with unfavorable prognostic characteristics is indeed controversial. Selecting and prioritizing among available treatment options is a challenge, as there is an absence of randomized trials comparing the treatment efficacies or functional outcomes for different therapeutic approaches in this disease setting. Our panel's recommendations¹ were based on our evaluation of lower quality evidence, which is summarized in the unabridged version of the practice guideline available at www.asco.org, as well as extensive multidisciplinary discussion.

Primary radiotherapy alone has been used with curative intent in this setting, and certainly may be a good option for selected patients. But available data indicate that the local failure rate may be as high as 50% for some of these poorer prognostic, T2 glottic cancers, with concern regarding a potential adverse impact on survival if initial local control is not obtained. Furthermore, if surgical salvage is required, total laryngectomy is most often necessary. Anticipated local control rates after treatment of these tumors with open organ preservation surgery (eg, hemilaryngectomy or supracricoid partial laryngectomy with cricohyoidoepiglottopexy) will generally be superior to those reported with radiation alone, although long-term hoarseness will result. The risk of functional compromise further increases if postoperative radiation is indicated based on pathologic features at resection, although the need for this added treatment should be infrequent if patients are accurately staged and appropriately selected. Considering these factors, the panel recommended open organ preservation surgery in this poorer prognostic setting. However, radiation alone, with consideration of altered fractionation techniques to improve local control, remains an option if organ preservation surgery is not feasible because of anatomic or medical reasons, or the patient prefers a primary radiation approach after a discussion of the risks, benefits, and alternatives. Endoscopic resection may also be a therapeutic option, but only for carefully selected patients. A discussion with the patient of the advantages and disadvantages of these different treatment approaches is important before a final decision regarding therapy. Involvement of a multidisciplinary team with special expertise in the management of laryngeal cancer will greatly facilitate clinical decision making and related care, as well as optimize outcomes.

Treatment with concurrent chemoradiotherapy for early-stage, node-negative, laryngeal cancer is not well-studied, but we anticipate it will likely be the subject of future investigations for poorer prognostic patients with early stage disease. Until such data become available, however, the panel does not recommend its application in the T2N0 setting, as the added morbidity and toxicity with such approaches outweigh proven benefits based on our present knowledge. Similarly, the use of induction chemotherapy as primary treatment with the intent modifying local therapy or eliminating it completely, remains investigational and is not recommended by the panel outside a clinical trial.

Finally, it should be emphasized that T2 glottic cancer, even when unfavorable prognostic characteristics are present, should be treated initially with the intent to preserve the larynx. Primary total laryngectomy in this setting is rarely indicated.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The authors indicated no potential conflicts of interest.

REFERENCES

1. Pfister DG, Laurie SA, Weinstein GS, et al: American Society of Clinical Oncology clinical practice guideline for the use of larynx-preservation strategies in the treatment of laryngeal cancer. J Clin Oncol 24:3693-3704, 2006[Abstract/Free Full Text]

Related Correspondence

• Recommended Organ Preservation Strategy for T2 Unfavorable Glottis Cancer
  Krishnakumar Thankappan
  JCO 2007 25: 735-736 [Full Text]

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