Recommendations of the ENT Society of Cyprus and OEK for the Diagnosis and Treatment of Laryngeal Cancer – February 2024

Recommendations of the Cyprus Otolaryngology Society and the Cyprus Oncology Society (OEK)

for the Diagnosis and Treatment of Laryngeal Cancer.

This text is a product of collaboration between the Cyprus Otolaryngology Society and the Cyprus Oncology Society (OEK) and is based on the Clinical Guidelines of the American National Comprehensive Cancer Network (NCCN).

Edition: February 2024

DIAGNOSIS – STAGEING

Diagnosis and staging in patients with suspected laryngeal cancer should include the following procedures:

• Clinical Examination of the oropharynx, Laryngoscopy/Pharyngoscopy with white light or NBI, cervical palpation
• Microlaryngoscopy – panendoscopy under general anesthesia always as part of histological confirmation and staging.
• Illustration :

1. Computed Tomography (CT) of the neck and chest
2. Magnetic Resonance Imaging (MRI) of the Cervical Spine
3. Cervical Ultrasound (US)
4. PET/CT (in selected patients)

• FNA (cervical lymph nodes where indicated)

All cases with confirmed head and neck carcinoma should be presented to the Head and Neck Oncology Board where imaging is reviewed and available treatment options are discussed.

Use of the TNM (Tumor, Nodes, Metastasis) system for staging local disease.

Supraglottic Cancer	Glottic Cancer	Subglottic Cancer
T 1 Limited to a subregion of the supraglottic region, normal mobility	T1a Limited to one vocal cord	T1 Limited to the subglottic region
	T1 b extension to both vocal cords, invasion of anterior or posterior notch
T2 Extension to mucosa in more than one subregion or outside the supraglottic region (e.g. glottis, glossopiglottic fossae, medial wall of uvular fossa)	T2 Extension to supraglottic or subglottic region or limited mobility.	T2 Extension of the vocal cords
T3 Hemilaryngeal fixation or invasion of the retrocricoid region or preepiglottic space or paraglottic space or internal perichondrium of the thyroid cartilage.	T3 Hemilaryngeal fixation or invasion of the retrocricoid region or preepiglottic space or paraglottic space or internal perichondrium of the thyroid cartilage.	T3 Hemilaryngeal fixation or invasion of the retrocricoid region or preepiglottic space or paraglottic space or internal perichondrium of the thyroid cartilage.
T4a Extralaryngeal extension (e.g. disruption of thyroid cartilage, invasion of tongue muscles or hypopharynx or soft tissues of the neck or cricoid cartilages/trachea or esophagus)	T4a Extralaryngeal extension (e.g. disruption of thyroid cartilage, invasion of tongue muscles or hypopharynx or soft tissues of the neck or cricoid cartilages/trachea or esophagus)	T4a Extralaryngeal extension (e.g. disruption of thyroid cartilage, invasion of tongue muscles or hypopharynx or soft tissues of the neck or cricoid cartilages/trachea or esophagus)
T4b Invasion of common or internal carotid artery or prevertebral space or mediastinum	T4b Invasion of common or internal carotid artery or prevertebral space or mediastinum	T4b Invasion of common or internal carotid artery or prevertebral space or mediastinum

Subregions of the supraglottic portion of the larynx : 1) Epiglottis above the hyoid,

2) Epiglottis below hyoid, 3) Arytenoid epiglottis folds, 4) Arytenoids,

5) False vocal cords.

TREATMENT

Treatment is determined based on staging after discussion in the oncology board and is also discussed with the patient, who is extensively informed of all available options where applicable depending on the stage (surgery, radiotherapy, chemotherapy or a combination of these).

The HPV factor (p16+) does not affect treatment based on current data for laryngeal cancer.

Stage	T1- T 2, N0	T 3, N0	T 4 a , N0	T 4 b , N0
Primary and cervical treatment	Endoscopic LASER,or open surgery or radical radiotherapy.In non-invasive Ka (in situ Tis), endoscopic LASER (preferred) or radiotherapy is recommended.In stage T2 supraglottic cancer, ND is recommended	Total laryngectomyor partial laryngectomy (very selected patients) + ND bilaterally Alternatives: radical Chemoradiotherapy	Total Laryngectomy + ND bilaterally + complementary Chemoradiotherapy (adverse features) Alternative: radical Chemoradiotherapy	Radical Chemoradiotherapy
Stage	T1-T2, N+	T3, N+	T4a, N+	T4b, N+
Primary and cervical treatment	Endoscopic LASER,or open surgery in combination with ND arrays +/-adjuvant radiotherapy. Alternatively: radical (Chemo)radiotherapy	Total laryngectomyor partial laryngectomy (very selected patients) with ND Bilateral +/- adjunctive Chemo-Octine therapyAlternative: radical radiotherapy	Total Laryngectomy with bilateral ND + complementary Chemoradiotherapy (adverse features) Alternative: radical Chemoradiotherapy	Radical Chemoradiotherapy

• Surgical treatment is recommended only when it is possible to remove the tumor within healthy margins, R0
• Monotherapy is recommended for primary tumors and cervix (surgery or radiotherapy) when feasible.
• Postoperative administration of adjunctive (Chemo)radiotherapy is recommended for negative prognostic factors in the final biopsy: perineural, perivascular or perilymphatic infiltration, positive margins of the preparation, pT3, pT4 tumor, pN2, pN3, extracapsular lymph node infiltration.
• It is recommended to perform cervical lymph node dissection and in cases of salvage surgery depending on the stage.
• Induction Chemotherapy may be administered in locally advanced stages. Depending on the response, Radiation Therapy +/- Chemotherapy or Surgery will follow.
• PET/CT is useful for evaluating the cervix approximately 10-12 weeks after radiation therapy.

POST-TREATMENT FOLLOW-UP

Simultaneous ENT and Oncology monitoring is recommended.

Clinical examination and laryngoscopy are recommended at regular intervals:

• Every 2-3 months in the first year and the second year,
• Every 6 months from the 3rd to the 5th year.

In selected patients, otolaryngological follow-up is recommended for up to 10 years.

Oncological monitoring is recommended for a period of 5 years.

Microlaryngoscopy and Imaging: Neck/Chest CT / Neck MRI

• Strong recommendation for microlaryngoscopy as part of restaging especially when office laryngoscopy cannot rule out recurrence, approximately 3 months after radiotherapy, if suspected earlier, up to 1 month post-treatment after previous surgical treatment.
• repeat in 6 months
• subsequently annually

Cervical Ultrasound:  Cervical Ultrasound is a useful screening method for possible metastatic lymph nodes and can be used as a complement to the clinical examination during each visit of the oncology patient to the ENT Clinic.

PET – CT : Performing PET/CT approximately 3 months after Chemoradiotherapy or a combination of surgery/chemoradiotherapy can help monitor the response to treatment based on suspicion on CT or MRI scans.

Bibliography:

• NCCN Guidelines Head and Neck Cancer Version 1.2024
• S3-Guideline for the diagnosis, therapy and follow-up of laryngeal cancer Long version 1.0– January 2019 (Clinical guideline of the German ENT Society for the treatment and post-treatment follow-up of patients with laryngeal cancer)