The Laryngologist in Organ Preservation for Laryngeal Cancer

With increased use of organ preservation strategies for laryngeal cancer,1,2 we would like to encourage fellow otolaryngologists and head and neck surgeons in their role as organ specialists in the diagnosis, work-up, and treatment of laryngeal cancers in a multidisciplinary approach.3 The term “organ preservation” has become a synonym for nonsurgical treatment of laryngeal cancer based on associations with chemotherapy and radiation therapy. Despite excellent voice and swallowing results and high local control rates for selected cancers, surgical organ preservation is considered a marginal treatment at some institutions. As Weinstein et al.4 and Lefebvre3 have remarked, reports concerning nonsurgical treatment for laryngeal cancer do not take into account the fact that many laryngeal tumors can be treated surgically with voice preservation.3,4 We need to defend the role of the organ specialist in allowing 1) the integration of conservation laryngeal surgery into the global organ preservation strategy to optimize the treatment of laryngeal cancer and 2) the selection of homogeneous groups of patients according to tumor characteristics for prospective clinical trials. Conservation laryngeal surgery has been shown, for decades, to be a reliable alternative to total laryngectomy for selected tumors. Reported 5-year actuarial local control rates for T1 to T3 tumors treated with conservation surgery range from 73% to 100%. For T3 tumors, a 98% to 100% overall local control and a 90% laryngeal preservation rate have been reported using the supracricoid partial laryngectomy procedures.5–7 The larynx plays a major role in breathing, airway protection during swallowing, coughing, upper limb efforts, communication, social organization, and self-identity. The basic laryngeal structure that performs the sphincteric function is the cricoarytenoid unit, comprised of the cricoid cartilage, the arytenoid cartilage, the cricoarytenoid musculature, the recurrent laryngeal nerve, and the superior laryngeal nerve. This “unit” has a reflexive action at the level of the medulla: the stimulation of the mucosa sets off a specific pattern of muscular contraction, resulting in laryngeal closure. Conservation laryngeal surgery can include simple cordectomy all the way to supracricoid partial laryngectomy with resection of one arytenoid. Supraglottic laryngectomy, which preserves the vocal folds, is the conservation procedure “par excellence,” but all of the other procedures also preserve voice, swallowing, and natural breathing. Minimally invasive techniques involving transoral laser resection follow the same principles and, when feasible for selected tumors, decrease postoperative morbidity without compromising local control or survival. The selection for tumors amenable to conservation laryngeal surgery is based on meticulous tumor mapping and patient evaluation. This requires experience in clinical examination, especially in the evaluation of vocal fold and arytenoid mobilities and knowledge of laryngeal physiology and micro-anatomy. This meticulous tumor selection provides the basis for the excellent local control obtained with these techniques. For T1a glottic cancer, conservation surgery and radiation therapy provide comparable local control and organ preservation (90%–100%). For other laryngeal tumors, conservation laryngeal surgery provides better local control than radiation therapy alone. For selected T3 and T4 tumors, a locoregional control rate of 90% to 96% can be obtained with conservation surgery,5–7 as compared with 78% to 88% using induction chemotherapy8 or chemoradiation.1 However, no prospective, randomized study has ever been conducted to compare the surgical organ preservation strategy with the nonsurgical approach in a comparable group of patients with comparable tumors. The TNM classification does not allow distinction between tumors amenable to conservation surgery and those that are not. Patient stratification according to more precise tumor characteristics could provide insight into reasons for local failure in nonsurgical organ preservation protocols and allow more precise evaluation of tumor response to newer regimens including molecular-targeted therapies, for which Response Evaluation Criteria in Solid Tumors (RECIST) alone may not suffice. Only careful examination of the larynx by an organ specialist and discussion in a multidisciplinary setting can provide this type of patient stratification. The functional advantages of conservation laryngeal surgery or nonsurgical approaches as compared with total laryngectomy are obvious. The permanent tracheostomy has a major negative impact on quality of life, even with voice rehabilitation.6 Nonsurgical larynx preserving treatments may also carry side effects that are detrimental to quality of life, such as dysphagia, xerostomia, and pain.9 The other long-term effects of chemoradiation regimens, such as dysphagia, aspiration, and laryngeal immobility caused by fibrosis, are just beginning to be studied10 and need to be more adequately assessed. Conservation surgery has the advantage of providing local and regional control without radiation therapy, making radiation therapy available for treatment of second primary cancers. The one true disadvantage of organ preservation surgery is the time and investment needed to train