Chapter 13 - Evidence-Based Practice: Management of Glottic Cancer

Abstract

Management of glottic squamous cell carcinoma integrates optimizing local control with preserving the voice and swallowing functions of the larynx. Treatment choices for early stage and midstage lesions (Tis, T1, T2) rely on low-level evidence, with no randomized trials comparing surgery (open or transoral laser resection) with radiation therapy. The bulk of the currently existing data show comparable rates of local control using either modality. Treatment decisions are thus based on the relative advantages and disadvantages of each modality, and patient and physician preferences. For advanced lesions (T3T4), the same can be said for the absence of randomized controlled trials comparing surgery as the initial treatment modality with organ preservation protocols, and patient, physician, and center-related preferences play a role in treatment choice. When a nonsurgical organ sparing protocol is chosen, however, high-level evidence, with randomized controlled trials, is in favor of concurrent chemoradiation with cisplatin to optimize local control and organ preservation. High-level evidence also favors concurrent chemoradiation with cisplatin for improving the overall survival, as compared with induction chemotherapy regimens. When cisplatin cannot be used, high-level evidence is in favor of concomitant radiation therapy with cetuximab, as compared with radiation therapy alone. The addition of taxanes for induction chemotherapy has not been shown to improve survival as compared with the current gold standard of chemoradiation with cisplatin. For very locally advanced tumors with massive cartilage and/or tongue base invasion, lower-level evidence favors an extended total laryngectomy followed by radiation therapy to optimize survival advantage, but randomized trials are lacking.