Early Stage Disease (T1 - T2, N0)

Two main options:

  • Laser microlaryngectomy
    • Ideally the lesion should be centrally located on the vocal cord
    • Well defined lesion
    • No field change
  • Radical radiotherapy
    • Best for poorly defined lesions that are not centrally located


Radiotherapy planning

Classical field is a parallel opposed field that covers that larynx from cricoid to top of thyroid cartilage, and posteriorly to the anterior vertebral body.
Modern volume based treatment counts the cords as the CTV, witha significant margin to account

Radiotherapy dose

66 Gy in 2 Gy fractions with classical fractionation.
Hypofractionation is used elsewhere in the world (eg. 50 Gy / 20 fractions, 60 Gy / 25 fractions).
Accelerated radiotherapy (6 fractions per week instead of 5) can be used

  • DAHANCA trials support accelerated radiotherapy

Advanced Disease (T3+ and/or N1+)

Choice of management depends on:

  • Patient factors
    • Ability of patient to tolerate extended therapy
  • Tumour factors
    • Very advanced local disease which is causing laryngeal obstruction may best be treated with laryngectomy
    • T4 disease has a higher risk of recurrence and some recommend proceeding to laryngectomy as the first option in this case


In order of curability:

Conventionally fractionated radiotherapy

Easiest treatment but also poorest outcomes. Best option for elderly patients with limited reserves.

Radiation alone, altered fractionation

Harder for patient to tolerate, but easier than combined chemoradiation.

  • DAHANCA - 6 fractions / week
  • Concommitant boost - BD treatments for two weeks
  • Pure hyperfractionation - Used in France, BD fractionation for entire treatment

Radiotherapy & Cetuximab

Only approved in Australia if patients are unable to tolerate cisplatin. Cetuximab is a chimeric monoclonal antibody directed against the ERBB1 (aka. HER1 or EGFR) receptor.

  • Cetuximab given one week prior to starting radiotherapy
    • Pharmacologically, this saturates ERBB1 receptors in the liver and is thought to increase the dose to tumour
  • There is evidence for minimal benefit in the elderly however this is the group who most often receives cetuximab!

Concurrent Chemoradiotherapy (with Cisplatin)

Cisplatin has been shown in meta-analysis to improve local control (unlike all other cytotoxics)
Key trials:

  • Pignion meta-analysis (MAC-NC)
  • 91-11

Cisplatin is given in weeks 1, 4 and 7. There is significantly increased toxicity and often the week 7 dose is omitted.

  • Other options use weekly cisplatin or alternatively two cycles

Induction chemotherapy

This is a controversial treatment option!
Key trials:

  • VA Trial (1970s) showed benefit of induction cisplatin/5FU over no induction chemotherapy.
    • This schedule fell out of use when it was shown to be inferior to concurrent chemoradiotherapy
  • TAC 323/324 suggest a benefit of cisplatin/5FU/docetaxal over cisplatin/5FU
    • However there is no comparison of cisplatin/5FU/docetaxal with chemoradiotherapy and many radiation oncologists are sceptical

Further studies for induction chemotherapy is

Post-laryngectomy treatment

In the modern setting, most patients who have a laryngectomy will have very advanced disease which will still benefit from radiotherapy.

  • Positive margins (or close margins)
  • T4 disease
  • N2 disease
  • Extracapsular extension

Chemoradiotherapy is only indicated for positive margins and/or extracapsular extension. Carboplatin has less toxicity than cisplatin; however many patients with advanced disease are not suitable for addition of chemotherapy due to concurrent health problems.

Palliative Patients (M1)

Short courses of radiotherapy to the larynx are suitable for palliation:

  • 30 Gy / 10 #
  • 20 Gy / 5 #
  • 'Quad shots'