TREATMENT OF SQUAMOUS CELL CARCINOMA, chapter 106 of cummings otolaryngology

1. TREATMENT OF SQUAMOUS
CELL CARCINOMA

2. • Goals :
1) Cure the patient
2) Preserve the larynx or, more correctly, preserve the function of the larynx
3) Minimize the morbidity of the treatment.
• Functional larynx:
Patient can communicate with an intelligible voice, swallow adequate nutrition without aspiration,
and to breathe through the nose or mouth without the need for a stoma or a tracheostomy tube.

3. • Most important information required for therapeutic decision making:
1) The histologic diagnosis of the tumor
2) The site of origin of the tumor
3) The stage of disease (T, N, and M stages)
• The importance of accurate staging cannot be underestimated; therefore a thorough
evaluation of the patient is crucial.

4. • A number treatment options for patients with laryngeal cancer:
1) Surgery and RT  two most important treatment modalities
New surgical techniques for conservation laryngeal surgery (partial laryngectomy) and
chemotherapy + RT (chemoradiotherapy [CRT]),  may be used in a neoadjuvant, concurrent, or
adjuvant role.
In general:
 Early stage (stage I / II)  single-modality therapy  Surgery or RT
 Advanced stage (stage III / IV)  combined modality therapy (primary surgery followed by RT /
CRT / primary CRT or RT with surgery for salvage

5. TREATMENT OF GLOTTIC
SQUAMOUS CELL CARCINOMA

6. TREATMENT OF THE EARLY PRIMARY TUMOR
IN GLOTTIC SQUAMOUS CELL CARCINOMA
• Early  stage I or II disease (i.e., T1N0 or T2N0)  may be treated with either RT or surgery
without elective treatment of the neck
1) Primary RT (T1 glottic SCC)  provides 5-year local control rates of 81% to 90% & laryngeal
preservation 90-98% of patients.
2) T2 tumors (normal vocal cord mobility) RT achieves local control 64-87% with laryngeal
preservation rates of 75-87%.
Surgical treatment of early glottic SCC  also aims to preserve the larynx and referred as
conservation laryngeal surgery / partial laryngectomy
Traditionally, limited laryngeal resections performed via two classic open external approach 
cordectomy & vertical hemilaryngectomy (VHL)

7. • Endoscopic approaches analogous to the open procedures have been developed to accomplish
the same resection without disruption of the supporting structures of the larynx
• The oncologic results for transoral laser microsurgery (TLM) reviewed by Ambrosch  Tis - T2
tumors, local control rates are 80-94% with greater than 94% laryngeal preservation rate
• Compare with open surgical techniques, TLM avoids a tracheostomy, the hospital stay is shorter,
the cost is reduced, and the incidence of postoperative dysphagia is lower
• Lesions of the middle third of the true vocal cord  best local control rates, may be treated by
TLM, open cordectomy, or RT; local control approaches 100% after surgical excision, whereas RT
achieves 95% local control rate.

8. • T2 glottic lesions + impaired vocal cord mobility  special consideration.
Although classified as T2  worse prognosis than tumors classified as T2 on the basis of
supraglottic or infraglottic invasion.
• Impaired vocal cord mobility usually secondary to either tumor bulk or deep invasion.
• RT less effective in controlling these lesions, and this is probably often due to tumor
volume
• Fein and Dickens  4% tumors smaller than 15 mm recurred after RT, whereas 26% of
larger lesions of similar stage recurred, even when only one true vocal cord involved. T2
tumors managed by primary RT showed a 30% local failure rate, which improved to 94%
after surgical salvage
• Harwood and DeBoer  impaired vocal cord mobility resulted in lower control rates in
T2 lesions, and suggested classification divided into T2a & T2b basis of mobility. In this
analysis, 70% local control rate noted for T2a category versus 51% in T2b group

9. • Voice quality  surgery or RT is influenced by the extent of tumor
and depth of invasion.
• Small superficial tumors  allow excellent voice quality with either
surgery or RT, comparable voice results.
• Deeper tumors with muscular invasion  inferior voice outcomes
with either treatment modality  the tumor control rate with RT will
be lower.
• Surgical treatment  better assessment of tumor extent, some cases
may result in upstaging of the tumor
• Small superficial tumors  voice quality with surgery or RT is

10. EARLY GLOTTIC SQUAMOUS CELL CARCINOMA
AND THE ANTERIOR COMMISSURE
• Anterior commissure involvement  associated with decreased local
control rates with surgery and RT
• One hypothesis  decreased effectiveness of RT has been underdosage
with supervoltage RT at the tumor-air interface. Increased dose fractions
(to >2 Gy) believed solved this problem.
• Anterior commissure  difficult region to assess, and deep invasion may
not be recognized  results in understaging and undertreatment.
• Lack of perichondrium at the insertion of the anterior commissure tendon
 increase the risk of cartilage invasion
• Kirchner and Carter  discovered that the anterior commissure tendon is a
strong barrier to cancer spread. Deep invasion only seen in cases where the
tumor had invaded the supraglottis superiorly or the subglottis inferiorly.

11. • Frontolateral VHL  local control rates of 80-90% for T1 carcinomas that
involve the anterior commissure.
• Supracricoid partial laryngectomy (SCPL) is a more extensive procedure
that removes the anterior commissure and the anterior two thirds of the
vocal folds.
• Laccourreye et al  reported a 5-year local control rate of 98% for T1 and
T2 glottic tumors with anterior commissure involvement.
• Bron et al  reported local control of 94.5% for 45 previously untreated
laryngeal SCCs involving the anterior commissure that treated with SCPL.
• Although oncologically effective, voice quality is significantly impaired
following this technique.

12. • Early reports of TLM for glottic carcinoma considered anterior commissure
involvement to be a contraindication.
• Krespi and Meltzer  noted a high rate of failure at the anterior commissure
difficult to visualize at the time of surgical resection. Improved understanding of
anatomy, instrumentation, and technique  achieved excellent control rates
• Pearson and Salassa  reported initial experience of 39 patients with anterior
commissure involvement; they had no local failures among 17 pT1 and pT2a
tumors. The majority (19/22) of advanced tumors with anterior commissure
involvement (pT2b, pT3 to pT4) tumors were controlled with endoscopic surgery.
• Steiner and colleagues reported results on 263 patients with early glottic
tumors treated over a 10-year period and observed a modest decrease in local
control and laryngeal preservation rates, with equivalent 5-year survival. For T1a
tumors, local control was 90% anterior commissure was not involved & 84% with
anterior commissure involvement. The corresponding laryngeal preservation
rates were 99% versus 93%. Similar findings were seen with T1b and T2a tumors.

13. TREATMENT OF THE ADVANCED PRIMARY TUMOR
IN GLOTTIC SQUAMOUS CELL CARCINOMA
• Advanced glottic SCC (stage III/ IV )  associated with vocal cord fixation,
cartilage invasion, transglottic spread of tumor, subglottic extension, laryngeal
framework invasion, extralaryngeal spread, lymph node metastases, and distant
metastases—features that portend worse prognosis.
• Treatment of choice for T3 and T4 glottic tumors  controversial because of the
heterogeneity of the tumors & lack of reliable studies to compare surgery and RT
for T3 and T4 carcinoma of the larynx.
• T3 glottic carcinomas are unusual low risk of nodal metastasis. Variable
spectrum of disease and ranges from low-volume tumors that invade the vocalis
muscle and cause fixation to very large transglottic tumors. Tumor volume and
transglottic spread of T3 tumors predict increased aggressiveness, increased rate
of lymph node metastasis, and poorer response to treatment.
• Tumors >1.5 cm, subglottic extension, & lymph node metastasis laterally or to
paratracheal or anterior pretracheal nodes  predict failure above the clavicle

14. • Traditionally, T3 tumors  total laryngectomy as single-modality therapy. Open
VHL and more extensive partial laryngectomies
• Kirchner and Somreported a 2-year survival rate of 60% following open partial
laryngectomy and noted that failures occurred when tumor extended inferiorly
into the larynx.
• Biller and Lawson reported a 73% absolute 2-year tumor-free control rate
following partial laryngectomy (with resection extended to include a portion of
the cricoid cartilage when subglottic extension was >5 mm).
• Pearson and coworkers  extensive experience of near-total laryngectomy (NTL)
patients with tumors unsuitable for other conservation procedures  preserves
one arytenoid and a portion of the cricoid cartilage to create a diversionary voice
shunt from the trachea. Patients remain tracheotomy dependent for breathing
and use the shunt to produce speech.

15. • RT  local control rate approximately 50% for T3 tumors  lower than
surgery. The return of vocal cord mobility following RT predicts a good
response
• Tumor volume may predict the response to irradiation, with poor results in
larger tumors.
• Small T3 tumors  amenable to partial laryngectomy, primary RT could be
considered to those not wishing to pursue a surgical option, although
surgical resection generally has higher local control.
• Intensified RT regimens (twice-daily treatments and the use of intensity-
modulated radiotherapy) may improve local control.
• Total laryngectomy or CRT recommended for bulky T3 tumors or tumors
not suitable for conservation laryngeal surgery

16. • In general, T4 glottic carcinoma  not considered amenable to
conservative laryngeal resection.
• Options for T4 glottic carcinoma: Total laryngectomy, usually with
postoperative RT or CRT; NTL; or primary CRT in selected low-volume
disease, with limited cartilage destruction to preserve the larynx.
• NTL may be considered in cases with limited subglottic extension &
no interarytenoid involvement
• Recent encouraging results for TLM for T3 to T4 laryngeal cancer
support its use for organ preservation in carefully selected cases
performed by experienced surgeons

17. • Primary RT for T4 glottic carcinoma has poor local control rates
• Patients unable or unwilling to undergo concurrent CRT and unwilling to have a
total laryngectomy  primary RT may provide a chance of local control
• Some patients, the addition of newer agents, such as cetuximab, may increase
the effectiveness of RT with an acceptable risk of increased toxicity
• RT may result significant local tissue destruction, scarring, and persistent edema.
Larynx may be preserved, but the patient may be left with a severely
compromised organ with a restricted airway, a poor voice, dysphagia, and/or
aspiration.
• If RT selected as primary management  close follow-up is required, the success
of this approach relies on the early detection of residual / recurrent disease,
which may be challenging in a larynx scarred from irradiation
• Total laryngectomy usually required for salvage if recurrent disease is diagnosed.
close follow-up with endoscopy and imaging is vital.

18. • Selected T4a tumors  may be considered for nonsurgical organ-
preservation trials
• The success of organ-preservation protocols for bulky T4a tumors is lower
than T3 tumors, because cartilage destruction predicts poor response to
organ-preservation protocols.
• When total laryngectomy is undertaken for T4 disease, hemithyroidectomy
or subtotal thyroidectomy is recommended for cases of palpable
abnormality, subglottic tumors, or glottic tumors with greater than 1 cm of
subglottic extension.
• Thyroid gland invasion may be predicted if a positive Delphian node or
cartilage destruction is present. Cancer is found in 3% to 8% of thyroid
specimens

19. TREATMENT OF THE NECK IN GLOTTIC
SQUAMOUS CELL CARCINOMA
• incidence lower than supraglottic or subglottic SCC
• When metastasis does occur, the nodes at risk are the prelaryngeal,
pretracheal, and paratracheal nodes in addition to the upper, mid, and
lower deep cervical chain nodes (levels II, III, and IV).
• Occult metastases from T1 to T2 glottic SCCs are uncommon, and elective
treatment of the N0 neck is not required
• T3 glottic SCC is more controversial. Occult nodal metastases are
uncommon from T3 glottic carcinomas, except in the presence of
transglottic spread of the tumor, which has a higher rate of occult
metastasis.
• national survey of otolaryngologists (2003)  87% respondents treated the
neck in patients with T3N0 glottic SCC, and 90% treated the neck in those
with T4N0 glottic SCC

20. • T4 glottic carcinomas  higher risk of occult metastases
(approximately 20%)  treatment of the neck is recommended
• If the primary tumor is being treated surgically  ipsilateral selective
neck dissection is also recommended.
• Glottic carcinoma  Paratracheal nodes and levels II through IV are
dissected
• Adjuvant treatment with RT or CRT is used, depending on pathologic
findings in the neck dissection specimen
• If used RT to treat the primary tumor, the central compartment and
ipsilateral lateral neck are included in the field.

21. • All T stages, clinically evident nodal disease warrants aggressive treatment, the
choice of which depends on the management of the primary tumor
• Postoperative RT is recommended when multiple nodes, extracapsular spread,
extralaryngeal invasion, and perineural or lymphovascular invasion are present
• Cooper et al  10% increase in the 2-year locoregional control rate (82% vs.
72%), although an associated 43% increase in acute grade III or higher toxicity
(34% vs. 77%) was also reported
• Bernier et al  11% increase in 5-year progression-free survival, which was also
associated with a higher rate of acute toxicity
• A comparative analysis of the combined results of these two studies 
extracapsular spread and microscopically positive surgical margins were the only
risk factors for which adjuvant chemotherapy enhanced the efficacy of RT in both
studies.

22. • Improved locoregional control with primary concurrent CRT  led to
the addition of chemotherapy to RT as an adjuvant treatment for
patients with adverse pathologic findings in the surgical specimen.
• Decision to use chemotherapy requires careful consideration of the
ability patient to tolerate the treatment, & the success of this therapy
dependent on completion of the treatment regimen without
significant breaks
• Recent analysis of the tolerability of concurrent CRT in patients age
>70 years demonstrated high compliance with a regimen of
concurrent carboplatin and RT, an encouraging finding

23. TREATMENT OF SUPRAGLOTTIC
SQUAMOUS CELL CARCINOMA

24. • SCC of the supraglottis metastasizes to the cervical lymph nodes more
frequently than glottic SCC
• Management of the cervical lymphatics plays a prominent role in
treatment planning of supraglottic SCC
• Regional nodal status (N stage) of a patient with supraglottic SCC is
the most important predictor of survival  similar to other Head and
Neck SCC
• Early (stage I/II)  generally treated with single-modality therapy
• Advanced (stage III/IV) generally treated with combined-modality
therapy.

25. • Sessions et al  results of 653 patients with supraglottic SCC treated
with a number of modalities except chemotherapy. Overall 5-year
disease-specific survival for all stages was 66%, with rates of 77%,
74%, 64%, and 50% for stages I, II, III, and IV, respectively. No
treatment modality found to result in superior survival. Larynx
preserved in 86% patients treated with open partial laryngectomy &
in 73% of RT patients.
• In another large series of patients (n = 903) treated with conservation
surgery, the 5-year uncorrected actuarial survival for stage I, II, III, and
IV disease was 84%, 81%, 76%, and 55%, respectively

26. • Important point survival from laryngeal SCC has diminished over
the past 20 to 30 years in the United States
• A review of the National Cancer Database (Hoffman et al)  5-year
relative survival from supraglottic SCC decreased from 52.2% (1985-
1987) to 47.3% (1994-1996) over the span of a decade. The greatest
decline in those with T1N0 and T2N0 tumors, with a lesser but still
significant decline in survival for T3N0 tumors.

27. TREATMENT OF THE EARLY PRIMARY TUMOR IN
SUPRAGLOTTIC SQUAMOUS CELL CARCINOMA
• Two most frequently used treatment options: Supraglottic partial
laryngectomy (SGPL) or RT
• SGPL for early supraglottic SCC, as well as for T3 tumors, is achieved by an
open supraglottic laryngectomy (OSGL) or TLM
• The traditional OSGL first described by Alonso (1947), subsequently refined
by Ogura and Som.
• The oncologic validity of OSGL as a treatment for supraglottic SCC comes
from the principle that the supraglottis is embryologically separate from
the glottis and subglottis, and for this reason, supraglottic SCC remains
localized to the supraglottis in most cases, despite the lack of an anatomic
structure to prevent invasion of the glottis

28. • OSGL removes all laryngeal structures
superior to the floor of the ventricle,
preserving both true vocal cords, both
arytenoids, the base of tongue, and the
hyoid bone (Fig. 106-10).

29. • Indications for OSGL are T1, T2, or selected T3 supraglottic tumors
• T3 tumors with PES & no transglottic spread and/or vocal cord impairment are
amenable to OSGL
• Contraindications: poor general physical condition/comorbidity, glottic
involvement, impaired mobility / fixation of the vocal cord, thyroid / cricoid
cartilage invasion, involvement of the base of tongue to within 1 cm of the
circumvallate papilla, or involvement of the deep muscles of the tongue
• The functional morbidity of OSGL is significant, & almost all patients will
experience some aspiration postoperatively  careful patient selection is
crucial to the overall success of this procedure: candidates must have good
pulmonary function to tolerate the expected aspiration.
• An OSGL is referred to as an extended OSGL when a more extensive resection is
carried out for the treatment of SCC that involves the lingual surface of the
epiglottis, the base of the tongue, or one of the arytenoids

30. • OSGL disrupts the pharyngeal muscles, strap muscles, and sensory
innervation of the pharynx and larynx, swallowing is markedly impaired,
especially in the early postoperative period.
• A tracheostomy is required in all patients to provide a safe airway and to
protect the lower airway from aspiration
• Suarez et al  reported that 10% of patients in their series required a
completion total laryngectomy for chronic aspiration. Advanced age (>65
years) was the major risk factor for intractable aspiration. An additional
24% of subjects required permanent tracheostomy
• Bron et al approximately one quarter of their patients aspirated in the
early postoperative period. The median duration until normal oral feeding
was established was 16 days, and the median duration until decannulation
was 17 days.

31. • OSGL yields excellent local control in the treatment of early supraglottic
cancer in the range of 80% to 100%
• Adjuvant RT was given in 30% for positive surgical margins or adverse
pathologic findings in the lymph nodes
• Local control and survival were poor when cartilage invasion was present
or when extralaryngeal extension of disease was present (i.e., pT4)
• Transoral laser microsurgery (TLM) for supraglottic carcinoma, first
described by Vaughan (1978), has become an accepted alternative to OSGL
for supraglottic SCC.
• The indications for TLM are similar to those for OSGL (i.e., T1 to T2 and
selected T3 tumors), although some institutions will use TLM for more
advanced lesions, such as T4 tumors.

32. • Few contraindications to TLM but these include incomplete exposure of the
tumor, tumor that involves the great vessels of the neck, and tumor location
and/or bulk that requires an extensive resection that would place the patient at
high risk of aspiration (e.g., extensive tongue base involvement)
• Indications for neck dissection are not changed with TLM, both sides of the neck
may be dissected at the same time the primary is resected, or, more commonly,
this is performed in a staged fashion several weeks after the initial TLM
• The local control rates of TLM are similar to those of OSGL; however, the
functional morbidity is much less following TLM, because the extrinsic muscles of
the larynx, pharyngeal muscles, cartilaginous framework of the larynx, and
superior laryngeal nerves are left intact
• Functional advantages of TLM  possible avoidance of a temporary or
permanent tracheostomy; less impairment of swallowing postoperatively,
which includes less aspiration; lower incidence of pharyngocutaneous fistulae

33. • Transoral resections are also possible using robotic techonology. Transoral robotic surgery (TORS)
of the supraglottic larynx reported by several authors with similar oncologic and functional
outcomes to TLM
• The surgeon’s ability to expose the tumor and insert instruments for TORS of the larynx is limited
by narrow exposure through the mouth and the relatively bulky instrumentation currently
available. Expanded utility of TORS for laryngeal procedures will require further miniaturization
and/or design modifications to improve surgical exposure and access.
• The role of adjuvant RT in TLM has been unclear, and up to 94% of subjects receive adjuvant RT
after TLM in some series
• Zeitels et al  concluded that small T1 to T2 supraglottic lesions in subsites amenable to
endoscopic resection (suprahyoid epiglottis, aryepiglottic fold, vestibular fold) could be treated
successfully with TLM without RT but recommended that RT should be given after endoscopic
resections of larger lesions (T2 to T3) in less favorable sites, such as the infrahyoid epiglottis.

34. • RT important role in the treatment of patients whose tumors are not amenable to
partial laryngectomy, who are medically unfit for surgery, or who prefer to avoid surgery
• In general, surgical excision  higher local control rate for early supraglottic tumors than
RT
• RT alone is also less effective than surgery (with adjuvant RT) or CRT in patients with
advanced laryngeal carcinoma; however, RT as a single modality may be used to treat
patients who are not eligible for CRT protocols but who wish to attempt to preserve the
larynx
• RT is not without complications, and these include dysphagia, aspiration, laryngeal
edema, and chondronecrosis, which may require tracheostomy or total laryngectomy
• Mendenhall et al  treated 209 supraglottic carcinomas with primary RT and obtained
initial local control rates of 100%, 85%, 64%, and 36% for T1, T2, T3, and T4 lesions,
respectively. Patients with recurrent disease were salvaged with either a total
laryngectomy or, if possible, an OSGL to give an ultimate local control rate of 100%, 88%,
81%, and 57%.

35. TREATMENT OF THE ADVANCED PRIMARY TUMOR
IN SUPRAGLOTTIC SQUAMOUS CELL CARCINOMA
• Advanced primary supraglottic tumors (i.e., T3 or T4)  traditionally been
treated with total laryngectomy, bilateral neck dissections, and
postoperative RT  laryngeal preservation become an important aim in
the treatment of laryngeal cancer in an attempt to improve the quality of
life of patients.
• Followed by adjuvant RT or concurrent CRT; primary RT with surgical
salvage, usually total laryngectomy; or concurrent CRT with surgical salvage
• The Department of Veterans Affairs (VA) Laryngeal Cancer Study(1991) was
a landmark trial in the development of nonsurgical organ preservation and
chemotherapy for the treatment of advanced laryngeal cancer

36. • A second important trial to investigate the nonsurgical treatment of advanced
laryngeal SCC, the Head and Neck Intergroup Study (RTOG 91-11), was reported
in 2003. Over two thirds of the subjects (356 of 518) had supraglottic tumors.
• The concurrent CRT group had statistically significant higher rates of locoregional
control (78%) and laryngeal preservation (88%) compared with the induction
chemotherapy– alone and RT-alone arms.
• The findings of this study have led to concurrent CRT becoming the standard
nonsurgical organ preservation protocol for advanced laryngeal cancers with T2,
T3, and low-volume T4 tumors without gross cartilage destruction
• The surgical excision of advanced primary tumors been achieved by total
laryngectomy, although this remains the most commonly used procedure,
conservative laryngeal resections such as OSGL, extended OSGL, supracricoid
partial laryngectomy (SCPL), or TLM may be used

37. • Majer and Rieder(1959)  first described SCPL, is an organ-preserving
surgical technique in which the aim is to preserve function without the
need for a stoma of any kind. It may be used as a primary treatment or as a
salvage procedure after RT
• This procedure resects both true vocal cords, both false vocal cords, both
paraglottic spaces, the entire thyroid cartilage, and the epiglottis. The
hyoid bone and the cricoid cartilage are preserved. One of the arytenoids
may also be included in the resection, but at least one intact cricoarytenoid
unit must be preserved for postoperative function
• Following the resection of a supraglottic cancer, the surgical defect is
closed by tightly apposing the hyoid bone and base of the tongue to the
cricoid cartilage, termed cricohyoidopexy (CHP).

38. • An SCPL with CHP is used for selected T2, T3, and T4 supraglottic and transglottic tumors: T2
tumors not amenable to OSGL because of involvement of the true vocal cords or anterior
commissure, extension to the floor of the ventricle, and/ or impaired motion of the true vocal
cord; T3 transglottic and supraglottic tumors with true vocal cord fixation and/or preepiglottic
space invasion; and T4 transglottic and supraglottic tumors with limited invasion of the thyroid
cartilage without extension to the outer thyroid perichondrium or extralaryngeal spread
• Contraindications  poor general health, poor pulmonary function, invasion of the
cricoarytenoid joint, invasion of the cricoid cartilage, involvement of the posterior commissure,
extension to the subglottis, invasion of the hyoid bone, extension of tumor to the outer
perichondrium of the thyroid cartilage, or extralaryngeal spread
• The oncologic results of SCPL with CHP are excellent, with 5-year survival rates of 67% to 95% and
local control rates of 88% to 95%

39. • Total laryngectomy is the recommended salvage procedure for
recurrent disease
• In general, laryngeal function is good after SCPL. A tracheostomy and
feeding tube are required for all patients initially but are temporary in
most.
• A completion total laryngectomy may be required on occasion for
intractable aspiration.
• The major disadvantage of SCPL is poor voice quality

40. • In summary, for T3 or T4a supraglottic tumors without extensive tongue
base involvement or cartilage destruction, either nonsurgical organ
preservation (using concurrent CRT) or, in selected cases, conservative
laryngeal surgery (with adjuvant RT) may be used primarily in an effort to
preserve a functional larynx
• Adjuvant RT or concurrent CRT may be required after primary surgical
treatment, and total laryngectomy may be required as a salvage procedure
after either nonsurgical or surgical organ-preservation treatment.
• For extensive T4 tumors with gross cartilage destruction and/or
extralaryngeal spread, total laryngectomy is the preferred initial treatment.

41. TREATMENT OF THE NECK IN SUPRAGLOTTIC
SQUAMOUS CELL CARCINOMA
• Supraglottic SCC has a high incidence of clinically apparent and occult
regional metastases and usually metastasizes to levels II, III, and IV;
bilateral metastases occur frequently
• Elective treatment of the clinically node-negative neck is indicated in all
supraglottic SCCs except T1 lesions
• The choice of either surgery or RT for the neck will vary according to how
the primary tumor is to be treated
• For early stage tumors (T1 to T2), either surgery or RT may be used as a
single modality to treat both the primary site and the neck
• Indications for neck dissection do not change when the primary tumor is
treated with a partial laryngeal resection. For advanced primary lesions (T3
to T4), combined-modality therapy is usually indicated.

42. • Often, nonsurgical organ-preservation treatment, such as CRT or RT, is
used initially, with surgery to the primary and/or neck for salvage
• Alpert et al  investigated the use of RT for the treatment of clinically
nodenegative necks in SCC: for patients staged N0, both sides of the
neck were treated with RT; and for patients with ipsilateral nodal
metastases, the ipsilateral neck was treated with surgery, and the
contralateral neck was treated with RT, which was effective in this
role; failure was observed in only 3% of nodenegative necks
• The standard surgical treatment of the neck in N0 supraglottic SCC is
bilateral selective neck dissection of levels II to IV.

43. • Several studies observed that levels I and V are rarely involved by
metastases when clinically apparent metastases are present in levels II
through IV, and they are never involved when occult metastases are
present in the lateral neck
• A selective neck dissection (levels II to IV) is as effective as a
comprehensive neck dissection (levels I to V) for N0 and N1 disease
• Further studies of N0 supraglottic and glottic SCC have observed that
metastases are not common in sublevel IIb and level IV
• Ferlito et al  suggested that a more targeted selective neck dissection of
sublevel IIa and level III may be adequate for the elective surgical
treatment of the neck in these cases  important note that an exception
to these findings was a study that found occult metastases were present in
level I in 82% of supraglottic SCC staged cN0

44. • Treatment of the node-negative neck is less controversial. If surgery is the
primary treatment modality, a selective neck dissection (levels II through
IV) is as effective as a comprehensive neck dissection for N1 disease, but
for more extensive nodal disease (N2 to N3), a comprehensive neck
dissection should be undertaken
• Bilateral neck dissection has been found to decrease the regional failure
rate of the surgical treatment of supraglottic SCC from 20% of cases (in
which the contralateral undissected neck was the most common site for
recurrence) to 8%
• Adjuvant RT is indicated for neck dissections that show unfavorable
pathologic findings, including multiple involved nodes, extracapsular
spread, or soft tissue extension of tumor

45. • In summary, for supraglottic SCC, surgical treatment of the N0 and N1
neck is usually with a bilateral selective neck dissection (levels II
through IV). For N2 or N3 disease, a comprehensive neck dissection
(levels I through V) is indicated for the node-positive neck, with a
contralateral selective neck dissection (levels II through IV) if the
contralateral neck is node negative. Primary nonsurgical treatment
should include RT to both sides of the neck