Laryngeal squamous cell cancer (SCC)

• Consider obtaining a photographic record of laryngeal lesion with a detailed description on report (to aid future oncological or surgical treatment planning) at the time of flexible endoscopic evaluation along with documentation of vocal cord mobility. This may be supplemented with videostroboscopy.

• Offer flexible nasoendoscopy/EUA and biopsy. At the time of EUA, with angled endoscope evaluation and biopsy, map lesional tissue and note made of any access limitations. Obtain these small fragment biopsies without thermal injury.

• The aim of treatment is to use a single treatment modality to effect cure. Offer transoral excisions as a treatment option if a macroscopic clearance of tumour is possible. Carefully orientate specimens for the reporting histopathologist. The interpretation of the surgical margin needs a close collaborative decision based on the surgeon's findings and the pathologist's interpretations of the specimen. 

• Consider second look surgery for patients with involved surgical margins. Consider close follow-up where margins are <1mm but without tumour at the resection “cut-through” margin. Where uncertainty exists, consider second look surgery.
  
  

Glottis

• Consider transoral laser microsurgery resection for suitable patients with T1a glottic SCC. Difficult access and extension to arytenoid may preclude this.
  
  
• Consider laser resection for glottic T1b disease and select T2 cases noting that voice and swallow outcomes are variable for both primary surgery and radiotherapy.
  
  
• Offer consultation with an appropriate surgeon and clinical oncologist to all suitable patients undergoing curative treatment for T1b and T2 glottic SCC, to discuss the relative merits of each treatment.
  
  
• Pathological neck staging is not indicated in early-stage T1 SCC confined to the glottis.

Supraglottis

• Consider radiotherapy as optimal management for the majority of patients with early stage (T1/T2) supraglottic SCC. Taking into account patient and tumour characteristics and discussing treatment options with the patient, in certain cases, consider primary surgery via minimally invasive transoral laser microsurgery or robotic surgery for the primary tumour.
  
  
• Where access is problematic consider open partial laryngectomy if patient has sufficient pulmonary reserve and good swallow function. Reserve this for highly motivated individuals where primary radiotherapy may not be desirable/feasible and emphasising a long rehabilitation process.
  
  
• For T1/T2N0 low volume tumours that are well lateralised, not involving the epiglottis and pre-epiglottic space, ipsilateral levels II-IV neck lymphadenectomy may be considered. For all others offer bilateral lymphadenectomy.

• When multi-modality treatment (surgery then adjuvant (chemo) radiotherapy) is indicated, consider prior to initiating any management:

1. 1. Balance long term control/cure with acute and late morbidity from treatment
   2. Patient suitability and likelihood of completing whole package of treatment
   3. Alternative non-curative options

• Counsel patients carefully on all these factors prior to commencing radical treatment pathway.

• Consider laryngectomy rather than organ-preservation, for T3 disease if airway concern likely or concern regarding laryngeal function (airway compromise).

• For tumours with early cartilage invasion and T4a disease offer primary surgery with laryngectomy and neck dissection.

• Consider open partial laryngectomy for carefully selected patients with T3 disease confined to the anterior larynx.

• Partial laryngectomy is not advisable in the N+ve neck.

• Anticipate partial pharyngectomy and/or tongue base resection based upon imaging and examination findings. Consider pharyngeal reconstruction with a pedicled or free flap if less than half of the contralateral pharyngeal mucosa remains. Primary reconstruction with a free flap preserves the pedicled options for use in the case of a pharyngeal leak in the early post-operative period.

• Offer pathological neck staging for locally advanced disease:

  • Offer bilateral II-IV neck dissections in the presence of N0 disease.

  • For patients with subglottic extension total or partial thyroidectomy may be necessary due to local extension.

  • Consider central compartment lymphadenectomy.

  • Consider lymphadenectomy in patients with N+ve disease extended to at least levels II-IV bilaterally.

  • Consider primary tracheoesophageal puncture.

Consider prior to initiating any management for salvage:

1. Balance of chance of long term control/cure versus.
2. Likely acute and late morbidity from additional treatment.
3. Likelihood of requiring adjuvant treatment to achieve disease control/cure and patient suitability and likelihood to be offered this depending on patient factors and previous treatment.
4. Alternative non-curative options.

Counsel patients carefully on all these factors prior to commencing salvage treatment pathway.

Salvage surgery is usually undertaken in the context of persistent/recurrent disease after organ preservation treatment.

• Consider salvage neck dissection to the affected nodal basin to patients with N+ve disease who have undergone (chemo)radiotherapy and who have FDG PET-CT residual avidity in neck nodes at 3 months post-treatment, with the primary controlled.
  
  
• Patients with recurrent/persistent resectable disease at the primary site may be considered for salvage surgery in the absence of distant disease. Consider salvage surgery in the event of recurrence taking into account patient factors including age, co-morbidities, and preferences. Anticipate a high complication rate including fistula formation and major haemorrhage. The value of elective neck dissection in the salvage setting is uncertain. Patients with T3/T4 recurrence and those with supraglottic tumours are most at risk of occult metastasis. Elective neck dissection does appear to be associated with an increased risk of postoperative complications. These factors should be considered when deciding on whether to perform elective neck dissection in salvage laryngectomy. Reconstructive flap surgery is usually required.
  
  
• Patients with relapse at the primary site as well as regional recurrence have a poor prognosis.
  
  
• Patients with a short disease-free interval have a poor prognosis.

For patients not suitable for radical treatment consider debulking and/or discuss tracheostomy in event of airway crisis to elicit patient wishes and assist with advance care planning.