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Larynx Cancer Larynx Cancer Page 1 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients. INITIAL EVALUATION CONSULTATIONS PRE-TREATMENT EVALUATION ● Confirm outside pathology ● If no biopsy/pathology, consider ● History examination under anesthesia (EUA), ○ Chief complaint direct laryngoscopy (DL), biopsy, ○ History of present illness and previous treatment esophagoscopy ● Past medical history including but not limited to: ● Radiation Oncology ○ Social history (including tobacco and alcohol use) ● Thoracic/Head and Neck Medical Glottic See Page 2 ○ Previous radiation therapy – head and neck, Oncology (THNMO) for patients thoracic, breast (for previous primary or benign with stage III or IV diagnosis) ● Dental Oncology for dentulous Supraglottic: ● Physical examination patients except those receiving Patient information Node negative (based ○ Full head and neck examination narrow field radiation See Page 3 presented at on clinical and/or ○ Fiberoptic exam ● Speech Pathology for all patients multidisciplinary radiographic imaging) ○ Videostroboscopy (optional) and videostroboscopy, if indicated planning conference ○ General medical examination ● Consider esophagoscopy or barium ● Stage T and N (AJCC) swallow Supraglottic: ● Imaging studies ● Perioperative Evaluation and Node positive (based 1 See Page 4 ○ CT head and neck with contrast or MRI with Management (POEM) on clinical and/or contrast ● Plastic Surgery for patients who radiographic imaging) ○ Consider PET-CT scan for stage III/IV will require major reconstruction ○ Modified barium swallow/esophagoscopy (pharyngeal reconstruction) ○ Chest imaging (PET-CT preferred, but CT chest ● Nutritional assessment with contrast acceptable) ● Smoking cessation for active 2 ● Lifestyle risk assessment smokers only 1 CT is tailored to oncologic imaging: high-resolution, bone and soft tissue window, 90-100s contrast delay for optimal opacification of mucosa and soft tissues 2 See Physical Activity, Nutrition, and Tobacco Cessation algorithms; ongoing reassessment of lifestyle risks should be a part of routine clinical practice Department of Clinical Effectiveness V8 Approved by the Executive Committee of the Medical Staff on 09/21/2021 Larynx Cancer Page 2 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients. EVALUATION PRIMARY TREATMENT ADJUVANT TREATMENT SURVEILLANCE Severe dysplasia/ ● Endoscopic removal (stripping/laser) or carcinoma in situ ● Radiation therapy as clinically indicated for patients who may have poor functional surgical outcome ● Radiation therapy or Is Yes ● Radiation to primary tumor or ● Neck dissection(s) Primary tumor nodal status ● Endoscopic partial laryngectomy or most T1-2, any N positive? ● Open partial laryngectomy No Observe 1,2 17● Total laryngectomy and neck ● Radiation therapy Yes 4 dissection(s) as indicated, and Presence of ● Consider chemoradiation ipsilateral thyroidectomy pathological risk ● For recurrent or persistent 3 disease, see Page 5 Glottic ● Consider primary tracheoesophageal features ? puncture (TEP) No Observe ● Surveillance (see Page 6) ● Consider THNMO consult Primary tumor for chemoprevention trials most T3, any N Yes Neck dissection(s) Residual nodal ● Consider Yes disease? induction Complete No Observe 3 Pathological risk features include: chemotherapy response at primary ● Primary pathology ● Concurrent 1,2 ○ Any T1 or T2 with perineural invasion chemoradiation site? No Total laryngectomy and neck dissection(s), or lymphovascular invasion as clinically indicated ○ Any T3 or T4 ● Regional pathology ○ Multiple lymph nodes (any N2, N3) 4 ● Total laryngectomy and neck dissection(s) as ● Radiation therapy Pathological risk factors for addition of Primary tumor 4 chemotherapy include: clinically indicated, and ipsilateral thyroidectomy ● Consider chemoradiation T4 disease, any N ● Positive margins (re-excision to clear ● Consider primary TEP ● Supportive Care margins is preferred) 1 ● Extracapsular extension Primary tumors requiring total laryngectomy not amenable to partial surgery 2 Total laryngectomy to be considered for patients with significant pretreatment laryngopharyngeal dysfunction or are medically unable to tolerate organ preservation therapy Department of Clinical Effectiveness V8 Approved by the Executive Committee of the Medical Staff on 09/21/2021 Larynx Cancer Page 3 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients. EVALUATION PRIMARY TREATMENT ADJUVANT TREATMENT SURVEILLANCE 2 Surgery Yes Radiation or chemoradiation ● Endoscopic resection with Presence of Consider neck dissection(s) or pathological risk Yes ● Open partial laryngeal surgery features1 ? radiation therapy No Pathologic Primary tumor with neck dissection(s) N1? most T1-2, N0 No Observe Definitive radiation ● Radiation therapy 4,5 Yes 2 ● Total laryngectomy and neck ● Consider chemoradiation Presence of ● For recurrent or persistent dissection(s) as indicated, and pathological risk disease, see Page 5 ipsilateral thyroidectomy 1 Yes Radiation therapy features ? ● Surveillance (see Page 6) ● Consider primary TEP No Pathologic ● THNMO consult (optional) Supraglottic N1? No Observe node Primary tumor for chemoprevention trials ● T3, N0 negative 3 ● Selected T4 , N0 Residual Yes Neck dissection(s) Yes nodal ● Consider induction Complete disease? No Observe chemotherapy response at primary ● Concurrent chemoradiation site? Laryngectomy and neck dissection(s), No as clinically indicated ● Total laryngectomy and neck dissection(s), ● Radiation therapy Primary tumor 2 as indicated, and ipsilateral thyroidectomy ● Consider chemoradiation T4, N0 ● Consider primary TEP ● Supportive Care 1 Pathological risk features include: 2 4 Pathological risk factors for addition Primary tumors requiring total laryngectomy not amenable to partial surgery ● Primary pathology 5 ○ Any T1 or T2 with perineural invasion or lymphovascular invasion of chemotherapy include: Total laryngectomy to be considered for patients with significant pretreatment ● ○ Any T3 or T4 Positive margins (re-excision to clear margins is preferred) laryngopharyngeal dysfunction or are medically unable to tolerate organ preservation therapy ● Extracapsular extension ● Regional pathology 3 ○ Multiple lymph nodes (any N2, N3) Low-volume base-of-tongue involvement Department of Clinical Effectiveness V8 Approved by the Executive Committee of the Medical Staff on 09/21/2021 Larynx Cancer Page 4 of 8 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients. EVALUATION TREATMENT SURVEILLANCE N1 Yes Observe Complete (initial stage) Primary tumor Yes response of nodal ● T1-2, N+ and Complete disease? Neck Concurrent No N2-3 ● Selected T3 1 response at primary chemoradiation dissection (not requiring total site? laryngectomy) No Salvage surgery as clinically indicated ● Radiation therapy 3 Yes 1 ● Total laryngectomy and neck ● Consider chemoradiation ● For recurrent or persistent Presence of dissection(s) as indicated, and disease, see Page 5 pathological risk ipsilateral thyroidectomy ● Surveillance (see Page 6) Supraglottic features4? node ● Consider primary TEP No Radiation therapy ● THNMO consult (optional) positive for chemoprevention trials Primary tumor 2 ● Most T3, N+ or 2 Yes Observe ● Selected T4 Complete ● Consider induction Yes response of nodal Complete chemotherapy disease? No Neck dissection response at primary ● Concurrent site? chemoradiation ● Salvage surgery as clinically indicated No ● Supportive care ● Total laryngectomy and neck 1 Primary tumor dissection(s)
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