Supraglottic Cancer Treatment & Management
- Author: Joshua D Hornig, MD, FRCSC; Chief Editor: Arlen D Meyers, MD, MBA more...
Cancers of the supraglottis commonly manifest in patients who are debilitated from years of smoking and drinking. Because of the high surgical risk in some of these patients, radiation therapy can be a better option than surgery. Treatment options involving radiotherapy are numerous, as protocols differ in dose, extent, and fractionation.
Comparing results of supraglottic laryngectomy with those of radiotherapy is difficult because some series of patients treated with radiotherapy alone include those with lesions that were anatomically unsuitable for conservative laryngeal surgery. In addition, patients treated with radiotherapy tend to be those whose medical conditions contraindicate surgical modalities. Both of these factors seem to bias a comparison against radiation therapy. Remember, however, that patients in whom radiation therapy fails have the option of surgical salvage, which increases overall survival rate for patients treated with definitive radiation therapy.
Primary radiotherapy is accepted as appropriate treatment for early-stage disease. Current recommendations for the use of radiation therapy in advanced disease, however, advocate the addition of platinum agents, particularly cisplatin, to radiation therapy when nonsurgical treatment is chosen.
Adjuvant radiation therapy has become highly recommended in patients whose tumor pathology suggests a high risk for recurrence, such as those with high-grade tumors or extracapsular spread. Postlaryngectomy patients are more commonly undergoing radiotherapy even without these risk factors, because of the propensity of supraglottic cancers for occult metastasis.
Role of chemotherapy
In the early 1990s, a landmark trial conducted by the Department of Veterans Affairs demonstrated that, in some patients, induction chemotherapy followed by radiation therapy allowed for preservation of the larynx while maintaining the same survival rates achieved with surgery followed by adjuvant radiation therapy. The regimen used in this trial, cisplatin plus 5-FU followed by radiation therapy, has been used by many as an alternative to laryngectomy in patients with advanced disease. Single agent cisplatin given concurrently with radiation therapy has since been shown to be more effective and better tolerated and is currently considered the standard when nonsurgical definitive treatment is chosen.[11, 13] Cisplatin has been shown to enhance the effects of radiation on tumor cells, which is a likely explanation for the superiority of concurrent administration versus sequential administration.
Trials that compare larynx preservation regimens consisting of chemoradiation with those with radiation therapy alone have shown that chemotherapy adds the additional benefit of reducing the rate of distant metastasis. Currently ongoing trials are examining the usefulness of adjuvant chemotherapy regimens, as well as the use of some of the newer biologic agents in patients with various stages of this disease.
Various combinations of cytotoxic chemotherapy have been used for palliation of disease. SCC of the larynx often responds to chemotherapy in this setting, although it has not been shown to be effective in cure.
Decisions regarding proper management of primary supraglottic carcinoma remain controversial despite advances in radiotherapy and surgical procedures. Of the common treatment modalities, none have shown an advantage in overall survival.
The goal of treatment for supraglottic cancer is cure of disease, with preservation of speech, when possible. Treatment options include surgery, radiation therapy, chemotherapy, or a combination thereof. The selection of treatment modality relies on many factors: tumor size, clinical stage, the patient's overall medical condition, the philosophy and experience of the physician, and the patient's choice.
Early and moderately advanced lesions are usually managed with supraglottic laryngectomy or radiotherapy. Advanced lesions are usually managed with total laryngectomy, preoperative or postoperative radiotherapy, and, possibly, chemotherapy, since combined-modality therapy produces better results than a single modality alone.
The propensity of supraglottic lesions to spread to the cervical nodes should be kept in mind when treatment options for this disease are considered. A retrospective study by Yilmaz et al indicated that in cases of lateral supraglottic cancer, the rate of occult contralateral lymph node metastasis is high enough to warrant routine bilateral dissection even when midline crossing is minimal or absent. The study, which involved 305 surgically treated patients with T1-3 squamous cell carcinoma (SCC) of the supraglottis, found the rates of occult and overall metastasis to be 16% and 28%, respectively, with the degree of midline crossing having no statistically significant association with the rate of contralateral neck metastasis.
Supraglottic laryngectomy versus total laryngectomy
The traditional treatment for SCC of the larynx is laryngectomy. The classic supraglottic laryngectomy extends through the vallecula superiorly, the aryepiglottic folds posteriorly, the apex of the ventricle inferiorly, and the thyroid cartilage anteriorly. Included in the resection are the hyoid bone, epiglottis, superior half of the thyroid cartilage, aryepiglottic folds, and the false folds to the arytenoids. Occasionally, one or both arytenoid cartilages are removed. If surgery is selected as the primary treatment of supraglottic carcinoma, many believe that transcervical partial laryngectomy is the surgical therapy of choice for T1 and T2 lesions, while lesions that are more extensive (eg, T3, T4) demand total laryngectomy. Transcervical supraglottic laryngectomy, however, can be performed on T3 lesions, provided no true vocal fold involvement exists.
Contraindications for transcervical supraglottic laryngectomy include tumors that extend to the interarytenoid space, postcricoid mucosa, and true vocal folds. Additionally, tumors that cause cord fixation are a contraindication for supraglottic laryngectomy. Because aspiration is an issue in patients after supraglottic laryngectomy, patients with poor pulmonary function would be more appropriately treated with total laryngectomy or transoral supraglottic laryngectomy.
The carbon dioxide laser is useful because of its hemostatic effects and precise tissue ablation. Consequently, the carbon dioxide laser has become an option for addressing T1 and T2 lesions transorally to avoid transcervical supraglottic laryngectomy.[16, 17, 18]
Carbon dioxide laser surgery is performed with a spreadable laryngoscope. The laser is used as a cutting instrument and not used to vaporize tumor. Small tumors of the epiglottis and aryepiglottic folds are excised with a 1-cm margin as an excisional biopsy. In large tumors of the suprahyoid epiglottis, vertical division of the epiglottis facilitates resection. An incision is then made, guided by the valleculae, until the hyoid bone is reached and exposed. The incision continues caudal from the hyoid toward the thyrohyoid membrane until the upper border of the thyroid cartilage is reached. The entire preepiglottic space is then removed along the inner surface of the lamina of the thyroid cartilage toward the anterior commissure of the vocal fold. False cord tumors are excised similarly. Resection includes the preepiglottic space if the infrahyoid epiglottis is invaded and the preepiglottic space and paraglottic space if the false cords are involved.
The transoral use of the carbon dioxide laser has made it possible to avoid some of the complications that have traditionally excluded patients with pulmonary comorbidities from undergoing supraglottic laryngectomy. Studies have shown a rapid return of swallowing function and the virtual elimination of the need for tracheostomy when a supraglottic laryngectomy is performed transorally with a carbon dioxide laser.
A recent Phase II study conducted by the Southwest Oncology Group (SWOG) confirmed the relative safety and efficacy of this procedure when used in conjunction with postoperative radiation therapy in patients with Stage I, II, and III disease. Cabanillas et al performed a study that showed similar benefits when transoral laser supraglottic laryngectomy was compared with a traditional transcervical approach in patients with T1 or T2 supraglottic tumors. Assessment of the oncologic results of numerous series indicates that both the survival and local recurrence rates associated with transoral laser resection are comparable with those seen in patients who undergo traditional transcervical partial laryngectomy.
These results combined with those of other studies demonstrate that supraglottic laryngectomy can be a reasonable option not only in the typical patient but also in patients with pulmonary comorbidities.
Elective neck dissection
Long-term survival for patients with SCC of the supraglottic larynx is most dependent on the successful management of neck disease.[21, 22] This is partially due to occult metastasis found on neck dissection in patients with supraglottic carcinoma is more common than in the other laryngeal subsites. Occult metastases are present approximately 16% of the time in patients with T1/T2 tumors and have been reported to be present as much as 62% of the time in patients with T3/T4 tumors. Because of this, bilateral neck dissections are performed when treating patients with advanced disease. Many institutions perform bilateral neck dissections on patients with any nodal stage; however, recent evidence suggests that a less extensive neck dissection may be adequate in patients with N0 disease.
Complications of treatment for supraglottic carcinoma largely depend on the therapeutic modality selected to treat the disease. For example, complications of radiotherapy include xerostomia, dysphagia, hoarseness, excessively thick mucous secretions, chondronecrosis of the larynx, transverse myelitis, and laryngeal edema with airway obstruction.
Patients who undergo supraglottic laryngectomy have a high incidence of aspiration, approximately 40-70%. Postoperative alteration of swallowing function is caused by disruption of the superior laryngeal nerves. Because of the high incidence of postoperative aspiration, some patients with poor pulmonary function are better served by nonsurgical therapy, total laryngectomy, or transoral supraglottic laryngectomy.
The transoral use of the carbon dioxide laser can reduce the incidence of aspiration because this technique does not involve disruption of the superior laryngeal nerves and, therefore, has a less deleterious effect on swallowing function. This makes supraglottic laryngectomy an option for some patients who have not been considered candidates for surgery in the past. Remember, however, that patients undergoing laser surgery may have an increased risk for bleeding and vestibular stenosis.
An additional complication seen in surgical patients, especially those with prior radiation therapy, is fistulous tract formation. The incidence of pharyngocutaneous fistula is also greatly reduced by using transoral laser surgery instead of transcervical resection.
Outcome and Prognosis
The survival and prognosis of patients with laryngeal cancer has been shown to differ based on subsite. Supraglottic cancers have a worse prognosis than glottic cancers and are also more likely to be high-grade cancers. Supraglottic cancers have few initial symptoms; thus, they are often discovered later than cancers of the glottis and subglottis. Later presentation leads to a greater likelihood that the cancer has spread outside of the capsule or spread to regional lymph nodes. The presence of extracapsular spread and regional lymph node metastases are the 2 most significant negative prognostic indicators in supraglottic cancer.[25, 26] Tumors with extracapsular spread and regional metastases indicate a lower survival rate and a higher recurrence rate. High-grade tumors are also a factor associated with decreased survival.
Five-year overall survival for supraglottic cancers in general is reported to be between 40-50%. When broken down by cancer stage, the 5-year overall survival can vary significantly—from up to 82% in stage I disease to 45% or lower for stage IV disease. Recent analysis of the SEER database, however, has shown that the 5-year overall survival for patients with laryngeal cancer has decreased over the past 20 years. This decrease in survival corresponds with a change in treatment patterns in the 1990s that saw an increase in nonsurgical treatment of laryngeal cancer. Although the reasons for this decline in survival are unknown, a change in treatment patterns likely played some role; the treatment selection for patients with laryngeal cancer must be considered carefully, and, in patients with supraglottic SCC, the more aggressive behavior of the disease in comparison with glottic cancer should be kept in mind.
A retrospective study by Elegbede et al indicated that patients who undergo nonsurgical treatment for stage III or IV SCC of the supraglottis have a higher rate of disease recurrence than do those who undergo surgical treatment but that the two groups have a comparable overall survival rate. The study, which included 97 patients who underwent surgical treatment and 138 who were treated with nonsurgical therapy, found the 5-year freedom-from-recurrence rates for the surgical and nonsurgical patients to be 75% and 55%, respectively, while the 5-year overall survival rate was 52% for both groups. Laryngeal preservation was achieved in 83% of the nonsurgical patients, compared with 42% of the surgical group. In addition, over the course of the study’s 5-year follow-up period, voice function values were better in the nonsurgical patients, while swallowing function scores were similar in the surgical and nonsurgical groups.
Future and Controversies
The diagnosis and treatment of supraglottic cancer has progressed greatly over the past 150 years. Surgical procedures, such as the supraglottic laryngectomy and laser excision, have allowed surgeons to remove tumors with less morbidity. Radiotherapists have developed better protocols and techniques to administer radiation to more precise anatomical fields. Chemotherapy is being used to protect laryngeal function through organ sparing protocols.
In the future, further refinements in diagnostic and therapeutic techniques will allow physicians to better treat patients with laryngeal cancers. Positron emission tomography (PET) scans may help diagnose lesions earlier and more accurately assess recurrence. Working with improved vectors and a better knowledge of the molecular biology of cancer may afford patients better treatment with fewer adverse effects using gene therapy.
Jackson C. Malignant diseases of the epiglottis. Peroral Endoscopy and Laryngeal Surgery. 1915. 438-9.
Alonso J. Conservation surgery of cancer of the larynx. Am Acad Ophthalmol Otolaryngol. 1947 Jul-Aug.
Ogura JH. Supraglottic subtotal laryngectomy and radical neck dissection for carcinoma of the epiglottis. Laryngoscope. 1958 Jun. 68(6):983-1003. [Medline].
Chu EA, Young JK. Laryngeal cancer: diagnosis and pre-operative work-up. Otolaryngol Clin N Am. 2008. 41:673-695.
Parkin DM, Bray F, Ferlay J, et al. Global cancer statistics, 2002. CA Cancer J Clin. 2005 Mar-Apr. 55(2):74-108. [Medline].
Morales-Angulo C, Val-Bernal F, Buelta L, et al. Prognostic factors in supraglottic laryngeal carcinoma. Otolaryngol Head Neck Surg. 1998 Nov. 119(5):548-53. [Medline].
De Stefani E, Boffetta P, Deneo-Pellegrini H, et al. Supraglottic and glottic carcinomas: epidemiologically distinct entities?. Int J Cancer. 2004 Dec 20. 112(6):1065-71. [Medline].
Slaughter D. Multicentric origin of intra-oral carcinoma. Surgery. 1946. 20:133-46.
Lin JY, Li XY, Dong P, Nakashima T. Prognostic value of lymphangiogenesis in supraglottic laryngeal carcinoma. J Laryngol Otol. 2011 Sep. 125(9):945-51. [Medline].
Lopchinsky RA, Amog-Jones GF, Pathi R. Ultrasound-guided fine needle aspiration diagnosis of supraglottic laryngeal cancer. Head Neck. 2011 Aug 8. [Medline].
National Comprehensive Cancer Network. National Comprehensive Cancer Network Practice Guidelines in Oncology, v.2.2008, Section: SUPRA. [Full Text].
The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med. 1991 Jun 13. 324(24):1685-90. [Medline].
Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003 Nov 27. 349(22):2091-8.
Reizenstein JA, Holmberg L, Bergqvist M, Linder A, Ekman S, Lödén B, et al. Time trends in T3-4 laryngeal cancer - a population based long term analysis. Head Neck. 2013 Oct 25. [Medline].
Yılmaz T, Suslu N, Atay G, Gunaydın RO, Bajin MD, Ozer S. The effect of midline crossing of lateral supraglottic cancer on contralateral cervical lymph node metastasis. Acta Otolaryngol. 2015 May. 135 (5):484-8. [Medline].
Grant DG, Salassa JR, Hinni ML, et al. Transoral laser microsurgery for carcinoma of the supraglottic larynx. Otolaryngol Head Neck Surg. 2007 Jun. 136(6):900-6. [Medline].
Csanády M, Czigner J, Vass G, Jóri J. Transoral CO2 laser management for selected supraglottic tumors and neck dissection. Eur Arch Otorhinolaryngol. 2011 Aug. 268(8):1181-6. [Medline].
Suárez C, Rodrigo JP, Silver CE, Hartl DM, Takes RP, Rinaldo A, et al. Laser surgery for early to moderately advanced glottic, supraglottic, and hypopharyngeal cancers. Head Neck. 2011 Apr 15. [Medline].
Agrawal A, Moon J, Davis RK, et al. Transoral carbon dioxide laser supraglottic laryngectomy and irradiation in stage I, II, and III squamous cell carcinoma of the supraglottic larynx: report of Southwest Oncology Group Phase 2 Trial S9709. Arch Otolaryngol Head Neck Surg. 2007 Oct. 133(10):1044-50. [Medline].
Cabanillas R, Rodrigo JP, Llorente JL, et al. Oncologic outcomes of transoral laser surgery of supraglottic carcinoma compared with a transcervical approach. Head Neck. 2008 Jun. 30(6):750-5. [Medline].
Rodrigo JP, Cabanillas R, Franco V, et al. Efficacy of routine bilateral neck dissection in the management of the N0 neck in T1-T2 unilateral supraglottic cancer. Head Neck. 2006 Jun. 28(6):534-9. [Medline].
Sevilla MA, Rodrigo JP, Llorente JL, et al. Supraglottic laryngectomy: analysis of 267 cases. Eur Arch Otorhinolaryngol. 2008 Jan. 265(1):11-6. [Medline].
Dünne AA, Davis RK, Dalchow CV, et al. Early supraglottic cancer: how extensive must surgical resection be, if used alone?. J Laryngol Otol. 2006 Sep. 120(9):764-9. [Medline].
Cagli S, Yuce I, Yigitbasi OG, et al. Is routine bilateral neck dissection absolutely necessary in the management of N0 neck in patients with supraglottic carcinoma?. Eur Arch Otorhinolaryngol. 2007 Dec. 264(12):1453-7. [Medline].
Nicolai P, Redaelli de Zinis LO, Tomenzoli D, et al. Prognostic determinants in supraglottic carcinoma: univariate and Cox regression analysis. Head Neck. 1997 Jul. 19(4):323-34. [Medline].
Petrakos I, Kontzoglou K, Nikolopoulos TP, Papadopoulos O, Kostakis A. Glottic and supraglottic laryngeal cancer: epidemiology, treatment patterns and survival in 164 patients. J BUON. 2012 Oct-Dec. 17(4):700-5. [Medline].
Carvalho AL, Nishimoto IN, Califano JA, Kowalski LP. Trends in incidence and prognosis for head and neck cancer in the United States: a site-specific analysis of the SEER database. Int J Cancer. 2005 May 1. 114(5):806-16. [Medline].
Hoffman HT, Porter K, Karnell LH, et al. Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Laryngoscope. 2006 Sep. 116(9 Pt 2 Suppl 111):1-13. [Medline].
Cosetti M, Yu GP, Schantz SP. Five-year survival rates and time trends of laryngeal cancer in the US population. Arch Otolaryngol Head Neck Surg. 2008 Apr. 134(4):370-9. [Medline].
Elegbede AI, Rybicki LA, Adelstein DJ, et al. Oncologic and Functional Outcomes of Surgical and Nonsurgical Treatment of Advanced Squamous Cell Carcinoma of the Supraglottic Larynx. JAMA Otolaryngol Head Neck Surg. 2015 May 7. [Medline].
Ali S, Tiwari RM, Snow GB. False-positive and false-negative neck nodes. Head Neck Surg. 1985 Nov-Dec. 8(2):78-82. [Medline].
Alpert TE, Morbidini-Gaffney S, Chung CT, et al. Radiotherapy for the clinically negative neck in supraglottic laryngeal cancer. Cancer J. 2004 Nov-Dec. 10(6):335-8. [Medline].
Bocca E, Calearo C, de Vincentiis I, et al. Occult metastases in cancer of the larynx and their relationship to clinical and histological aspects of the primary tumor: a four-year multicentric research. Laryngoscope. 1984 Aug. 94(8):1086-90. [Medline].
Bocca E, Pignataro O, Mosciaro O. Supraglottic surgery of the larynx. Ann Otol Rhinol Laryngol. 1968 Dec. 77(6):1005-26. [Medline].
Boring CC, Squires TS, Tong T. Cancer statistics, 1991. CA Cancer J Clin. 1991 Jan-Feb. 41(1):19-36. [Medline].
Byers RM, Wolf PF, Ballantyne AJ. Rationale for elective modified neck dissection. Head Neck Surg. 1988 Jan-Feb. 10(3):160-7. [Medline].
Cancer Registry Public Information Data. 1999-2002, WONDER Online Database. United States Department of Health and Human Services, National Program of Cancer Registries, Centers for Disease Control and Prevention. November 2005.
Davidson J, Gilbert R, Irish J, et al. The role of panendoscopy in the management of mucosal head and neck malignancy-a prospective evaluation. Head Neck. 2000 Aug. 22(5):449-54; discussion 454-5. [Medline].
De Stefani E, Correa P, Oreggia F, et al. Risk factors for laryngeal cancer. Cancer. 1987 Dec 15. 60(12):3087-91. [Medline].
Esposito ED, Motta S, Cassiano B, et al. Occult lymph node metastases in supraglottic cancers of the larynx. Otolaryngol Head Neck Surg. 2001 Mar. 124(3):253-7. [Medline].
Ferlito A, Olofsson J, Rinaldo A. Barrier between the supraglottis and the glottis: myth or reality?. Ann Otol Rhinol Laryngol. 1997 Aug. 106(8):716-9. [Medline].
Gallus S, Bosetti C, Franceschi S, et al. Laryngeal cancer in women: tobacco, alcohol, nutritional, and hormonal factors. Cancer Epidemiol Biomarkers Prev. 2003 Jun. 12(6):514-7. [Medline].
Gavilán C, Gavilán J. Five-year results of functional neck dissection for cancer of the larynx. Arch Otolaryngol Head Neck Surg. 1989 Oct. 115(10):1193-6. [Medline].
Green H. Morbid growths within the larynx. In: On the Surgical Treatment of Polypi of the Larynx and Oedema of the Glottis. 1852. 56-65.
Holland Frei, Bast Kufe, Pollock, Weichselbaum. Cancer Medicine. 6th ed. BC Decker: 2000. chap 27.
Iro H, Hosemann W. Minimally invasive surgery in otorhinolaryngology. Eur Arch Otorhinolaryngol. 1993. 250(1):1-10. [Medline].
Iro H, Waldfahrer F, Altendorf-Hofmann A, et al. Transoral laser surgery of supraglottic cancer: follow-up of 141 patients. Arch Otolaryngol Head Neck Surg. 1998 Nov. 124(11):1245-50. [Medline].
Kirchner JA, Owen JR. Five hundred cancers of the larynx and pyriform sinus. Results of treatment by radiation and surgery. Laryngoscope. 1977 Aug. 87(8):1288-303. [Medline].
Laccourreye O, Diaz EM, Bassot V, et al. A multimodal strategy for the treatment of patients with T2 invasive squamous cell carcinoma of the glottis. Cancer. 1999 Jan 1. 85(1):40-6. [Medline].
Lalwani AK. Current Diagnosis and Treatment in Otolaryngology - Head and Neck Surgery. New York, NY: McGraw-Hill; 2006. chap 29.
Lee JG, Krause CJ. Radical neck dissection: Elective, therapeutic, and secondary. Arch Otolaryngol. 1975 Nov. 101(11):656-9. [Medline].
Leipzig B, Wetmore SJ, Putzeys R, et al. Cisplatin potentiation of radiotherapy. Long-term follow-up. Arch Otolaryngol. 1985 Feb. 111(2):114-8. [Medline].
Mackenzie M. Resection of epiglottic neoplasms of the thyrohyoid membrane of supraglottic laryngectomy. Diseases of the Pharynx, Larynx, and Trachea. 1980. 241-3.
Mendenhall WM, Parsons JT, Stringer SP, et al. Carcinoma of the supraglottic larynx: a basis for comparing the results of radiotherapy and surgery. Head Neck. 1990 May-Jun. 12(3):204-9. [Medline].
Million R, Cassisi N, Mancusa A. Larynx. Management of Head and Neck Cancer. New York, NY: Springer-Verlag; 1994. 467-87.
Myers EN, Alvi A. Management of carcinoma of the supraglottic larynx: evolution, current concepts, and future trends. Laryngoscope. 1996 May. 106(5 Pt 1):559-67. [Medline].
Ogura JH, Biller HF, Wette R. Elective neck dissection for pharyngeal and laryngeal cancers. An evaluation. Ann Otol Rhinol Laryngol. 1971 Oct. 80(5):646-50. [Medline].
Pillsbury HR, Kirchner JA. Clinical vs histopathologic staging in laryngeal cancer. Arch Otolaryngol. 1979 Mar. 105(3):157-9. [Medline].
Redaelli de Zinis LO, Nicolai P, Tomenzoli D, et al. The distribution of lymph node metastases in supraglottic squamous cell carcinoma: therapeutic implications. Head Neck. 2002 Oct. 24(10):913-20. [Medline].
Rudert HH, Werner JA, Höft S. Transoral carbon dioxide laser resection of supraglottic carcinoma. Ann Otol Rhinol Laryngol. 1999 Sep. 108(9):819-27. [Medline].
Sessions DG, Lenox J, Spector GJ. Supraglottic laryngeal cancer: analysis of treatment results. Laryngoscope. 2005 Aug. 115(8):1402-10. [Medline].
Sinard R, Netterville J, Garrett C. Cancer of the larynx. Cancer of the Head and Neck. Philadelphia, Pa: WB Saunders Co; 1996. 394-6.
Som ML. Conservation surgery for carcinoma of the supraglottis. J Laryngol Otol. 1970 Jul. 84(7):655-78. [Medline].
Spaulding CA, Krochak RJ, Hahn SS, et al. Radiotherapeutic management of cancer of the supraglottis. Cancer. 1986 Apr 1. 57(7):1292-8. [Medline].
Staffiere A, Miani C, Pedace E. Supraglottic laryngectomy today. Laryngeal Cancer. Thieme Medical Publishers; 1994. 471-5.
Stupp R, Weichselbaum RR, Vokes EE. Combined modality therapy of head and neck cancer. Semin Oncol. 1994 Jun. 21(3):349-58. [Medline].
Suarez C, Rodrigo JP, Herranz J, et al. Complications of supraglottic laryngectomy for carcinomas of the supraglottis and the base of the tongue. Clin Otolaryngol. 1996 Feb. 21(1):87-90. [Medline].
Urba S, Wolf G, Eisbruch A, et al. Single-cycle induction chemotherapy selects patients with advanced laryngeal cancer for combined chemoradiation: a new treatment paradigm. J Clin Oncol. 2006 Feb 1. 24(4):593-8. [Medline].
Vermund H, Boysen M, Evensen JF, et al. Survival of patients with squamous cell carcinoma of the supraglottic larynx--thirty-five-year experience with radiotherapy. Acta Oncol. 1999. 38(7):961-8. [Medline].
Wynder EL, Stellman SD. Comparative epidemiology of tobacco-related cancers. Cancer Res. 1977 Dec. 37(12):4608-22. [Medline].
|Stage||Tumor Spread||Node Involvement||Distant Metastases|
|Stage IVB||T4b||Any N||M0|
|Stage IVC||Any T||Any N||M1|