Laryngeal cancer most commonly presents as squamous cell carcinoma of the larynx. For early stage disease, options include laser surgery or radiation therapy, which have similar effectiveness. For advanced stages, concurrent chemotherapy and radiation allows better larynx preservation compared to induction chemotherapy and radiation or radiation alone, though overall survival is similar. Organ preservation is prioritized when selecting treatment options for advanced laryngeal cancer.

1. Laryngeal Cancer Anh Q. Truong MS-4 University of Washington, SOM

2. Anatomy

3. Vaezi, MF . Nature Clinical Practice Gastroenterology & Hepatology (2005) 2 , 595-603 Anatomy – cont’

4. Anatomy – subdivision Source: AJCC Cancer Staging Manual, 6 th Ed (2002)

15. Stage Grouping Early stage Advanced stage Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T3 N0 M0 T1-3 N1 M0 Stage IVA T4a N0-1 M0 T1-4a N2 M0 Stage IVB T4b any N M0 any T N3 M0 Stage IVC any T any N M1

21. Treatment – Advanced Stage (III/IV) – VA Study cont’ Department of Veterans Affairs Laryngeal Cancer Study Group, N Engl J Med 1991;324:1685-90. Overall Survival Surg + XRT Chemo + XRT 2 yr OS = 68% in both groups, P = 0.9846 Surg + XRT Chemo + XRT Chem + XRT shorter disease free interval, but dif not significant Disease Free Survival

22. Treatment – Advanced Stage (III/IV) – VA Study cont’ Department of Veterans Affairs Laryngeal Cancer Study Group, N Engl J Med 1991;324:1685-90. Site of recurrence Surgery (N = 166) Chemotherapy (N=166) Primary 4 (2%) 20 (12%) Regional 9 (5%) 14 (8%) Distant 29 (17%) 18 (11%) All 42 (25%) 52 (31%) No difference in rate of recurrence, significant difference in site of recurrence, significant difference in development of a 2nd primary CA (surg 6%, chemo 2%)

23. Treatment – Advanced Stage (III/IV) – VA Study cont’ Of the 166 pts in the chemo arms - 107 (64%) patients had preserved larynx - 30 patients (18%)  laryngectomy before definitive XRT - 29 patients (18%)  laryngectomy after definitive XRT Department of Veterans Affairs Laryngeal Cancer Study Group, N Engl J Med 1991;324:1685-90.

26. Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study 2 yr 3.8 yr 5 yr update A - induction chemo  XRT: 75% 72% 70.5% - concurrent chemoXRT : 88%* 84%* 83.6% - XRT alone : 70% 67% 65.7% Laryngeal Preservation Forastiere AA et al, N Engl J Med 2003;349:2091-8. A Forastiere AA et al, Journal of Clinical Oncology , Vol 24, No. 18S(June 20 Supplement),2006:5517.

27. Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study Locoregional Control Forastiere AA et al, N Engl J Med 2003;349:2091-8. A Forastiere AA et al, Journal of Clinical Oncology , Vol 24, No. 18S(June 20 Supplement),2006:5517. 2 yrs 5 yr update A - induction chemo  XRT: 64% 54.9% - concurrent chemoXRT : 80% 68.8% - XRT alone : 58% 51%

28. Treatment – Advanced Stage (III/IV) – RTOG 91-11 Study A Chemo therapy  significant decreased in dz free survival compared to XRT alone (P =0.02 compared w/induction, P = 0.06 compared w/conccurent Tx) B No significant difference C Difference only significant comparing concurrent chemoXRT vs XRT alone. Forastiere AA et al, N Engl J Med 2003;349:2091-8. Concurrent chemoXRT Induction chemo  XRT XRT alone 2 yrs 5 yrs 2 yrs 5 yrs 2 yrs 5 yrs Dz Free Survival A 61% 36% 52% 38% 44% 27% Overall Survival B 74% 54% 76% 55% 75% 56% Distant mets C 8% 12% 9% 15% 16% 22%

29. Treatment – Advanced Stage (III/IV) – cont’ Forastiere AA et al, N Engl J Med 2003;349:2091-8.

32. An Actual Picture of a Laryngeal Cancer (L) Source: http://www.medscape.com/content/2002/00/44/25/442595/442595_fig.html (R) Source: http://www.som.tulane.edu/classware/pathology/medical_pathology/New_for_98/Lung_Review/Lung-62.html

33. Questions?