In the majority of patients with advanced primary tumors of the larynx, the surgical treatment consists of a total laryngectomy. It should be remembered, however, that partial laryngectomy and conserva-tional surgical procedures which preserve the function of the larynx may be options in selected patients. As discussed in the section on early larynx cancer, vertical partial, supraglottic partial and supracricoid partial laryngectomies can be performed in carefully selected patients. In patients with advanced lesions, however, the more extensive partial laryngectomies are utilized more frequently and even more selectively. These procedures, although categorized in broad terms such as near-total laryngectomy or supracricoid partial laryngec-tomy with cricohyoidopexy, are usually individually designed to adequately encompass each patient's tissues
T4: Tumor invades through the thyroid cartilage, and/or extends into the soft tissues of the neck, thyroid and/or esophagus
Subglottis particular tumor while sparing as much functional tissue as oncologically feasible (Figure 8-6).28-31
Appropriate management of the neck is critical to maximizing survival in patients with advanced cancer of the larynx. The treatment of the neck depends in part on the treatment of the primary. If the primary is to be treated by surgical means, then an elective dissection of the lymph nodes at risk should be planned in the clinically negative neck. For a glottic lesion, the ipsilateral levels II to IV should be cleared, while for a supraglottic lesion, bilateral levels II to IV are at risk and should be dissected. If there is clinically apparent lymph node metastasis in the neck and the primary is to be treated by surgery, then a comprehensive neck dissection (levels I to V) should be performed.
Figure 8-6. Schematic diagram of two well-described voice-preserving, extended laryngeal procedures: A, supracricoid laryngectomy with cricohyoidoepiglottopexy and B, supracricoid laryngectomy with cricohyoidopexy (dotted lines represent line of surgical excision).
Alternatively, if a patient with a clinically negative neck is to be treated by chemotherapy and radiation therapy to the primary lesion, the neck at risk should also be treated electively by radiation therapy. A somewhat more controversial situation exists if there is a clinically positive neck and the primary is to be treated by chemotherapy and radiation therapy. The options that exist include performing a comprehensive neck dissection prior to chemotherapy/radiation therapy, performing a planned comprehensive or selective neck dissection after chemotherapy/ radiation therapy or assessing response following chemotherapy/radiation therapy and performing appropriate neck dissection based on response. At this time, data is lacking to substantiate an advantage in any of these approaches and all are acceptable.
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