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Stage IV Laryngeal Cancer

    Supraglottis

    Standard treatment options:

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    1. Total laryngectomy with postoperative radiation therapy, as evidenced in RTOG-7303, for example.[1,2,3,4,5,6,7,8]
    2. Definitive radiation therapy with surgery for salvage of radiation failures.[9]
    3. Chemotherapy administered concomitantly with radiation therapy can be considered for patients who would require total laryngectomy for control of disease. Laryngectomy would be reserved for patients with less than a 50% response to chemotherapy or who have persistent disease following radiation.[10,11,12,13,14,15]

    Treatment options under clinical evaluation:

    1. Hyperfractionated radiation therapy to improve tumor control rates and diminish late toxicity to normal tissue.[3,16]
    2. Clinical trials exploring chemotherapy, radiosensitizers, or particle-beam radiation therapy.[17,18,19,20,21]

      A meta-analysis of three trials of patients with locally advanced laryngeal carcinomas compared patients who received standard radical surgery plus radiation therapy with patients who received neoadjuvant cisplatin and fluorouracil, followed by radiation therapy alone in responders or radical surgery plus radiation therapy in nonresponders.[22] The meta-analysis demonstrated a nonsignificant trend in favor of the control group, who received standard radical surgery plus radiation therapy with an absolute negative effect in the chemotherapy arm that reduced survival at 5 years by 6%. The possibility of a slightly decreased survival must be balanced by the retention of the larynx in those patients whose disease was controlled.

    3. Isotretinoin (i.e., 13-cis-retinoic acid) daily for 1 year to prevent development of second upper aerodigestive tract primary tumors.[23]

    Glottis

    Standard treatment options:

    1. Total laryngectomy with postoperative radiation therapy.[1,2,3,4,5,24]
    2. Definitive radiation therapy with surgery for salvage of radiation failures.[9]
    3. Chemotherapy administered concomitantly with radiation therapy can be considered for patients who would require total laryngectomy for control of disease. Laryngectomy would be reserved for patients with less than a 50% response to chemotherapy or who have persistent disease following radiation.[10,11,12,13,14,15]

    Treatment options under clinical evaluation:

    1. Hyperfractionated radiation therapy to improve tumor control rates and diminish late toxicity to normal tissue.[3,16]
    2. Clinical trials exploring chemotherapy, radiosensitizers, or particle-beam radiation therapy.[17,18,20,21]

      A meta-analysis of three trials of patients with locally advanced laryngeal carcinomas compared patients who received standard radical surgery plus radiation therapy with patients who received neoadjuvant cisplatin and fluorouracil, followed by radiation therapy alone in responders or radical surgery plus radiation therapy in nonresponders.[22] The meta-analysis demonstrated a nonsignificant trend in favor of the control group who received standard radical surgery plus radiation therapy with an absolute negative effect in the chemotherapy arm that reduced survival at 5 years by 6%. The possibility of a slightly decreased survival must be balanced by the retention of the larynx in those patients whose disease was controlled.

    3. Isotretinoin daily for 1 year to prevent development of second upper aerodigestive tract primary tumors.[23]
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