The purpose of this guideline is to identify quality improvement opportunities in the assessment, diagnosis, and management of laryngeal cancer and to create explicit and actionable recommendations to implement these opportunities in clinical practice.

1. Definition and incidence: The larynx is divided into 3 regions: supraglottis, glottis, and subglottis. The distribution of cancers is as follows: 30% to 35% in the supraglottic region, 60% to 65% in the glottic region, and 5% in the subglottic region. The incidence and pattern of metastatic spread to regional nodes vary with the primary region. (Strong Recommendation)
2. Multidisciplinary consultation is critical for laryngeal cancer management because of the potential for loss of speech and, in some instances, for swallowing dysfunction. (Referral to tertiary care center with radiotherapy and partial laryngectomy facilities and multidisciplinary medical teams available is recommended) (Strong Recommendation)
3. For patients with carcinoma in situ of the larynx, recommended treatment options include: 1) endoscopic removal (ie, stripping, laser), which is preferred; or 2) RT. (Meticulous follow-up is then mandatory). (Strong Recommendation)
4. A. For early stage glottic or supraglottic cancer, surgery or RT have similar effectiveness, the choice of treatment modality depends on anticipated functional outcome, the patient’s wishes, reliability of follow-up, and general medical condition (Open partial laryngectomy as VPL and supraglottic laryngectomy, are valid options in selected cases). (Strong Recommendation)

B. Adjuvant treatment depends on the presence (or absence) of adverse features. Adjuvant treatment for selected patients with T1-2, and N0 supraglottic cancer may include re-resection if there are positive margins. For selected patients with T1-3, N+ supraglottic disease, re-resection may be attempted if negative margins are feasible and can be achieved without total laryngectomy, and if re-resection has the potential to change the indication for adjuvant systemic therapy/RT. (Strong Recommendation)

5. A. Resectable, advanced stage glottic and supraglottic primaries are usually managed with a combined modality approach. If treated with primary surgery, total laryngectomy is usually indicated, although selected cases can be managed with conservation surgical techniques that preserve vocal function as supracricoid laryngectomy. Pulmonary function tests should be considered. (Strong Recommendation)

     B. If total laryngectomy is indicated but laryngeal preservation is desired, concurrent systemic therapy/RT is recommended. When using systemic therapy/RT, high-dose cisplatin is preferred (at 100 mg/m2 on days 1, 22, and 43). Induction chemotherapy with management based on response is an option for all but T1-2, and N0 glottic cancer. (Strong Recommendation)

     C. Definitive RT (without systemic therapy) is an option for patients with T3, and N0-1 disease who are medically unfit or refuse systemic therapy. Surgery is reserved for managing the neck as indicated, for those patients whose disease persists after systemic therapy/RT or RT, or for those patients who develop a subsequent locoregional recurrence. (Strong Recommendation)

 D.Management of locally advanced, resectable glottic and supraglottic cancers (in which total laryngectomy is indicated but laryngeal preservation is desired) with concurrent cisplatin and radiation. Concurrent RT and systemic therapy (eg, cisplatin 100 mg/m2 preferred) is the recommended option for achieving laryngeal preservation with Long-term follow-up (10 years). (Strong Recommendation)

E. In cases with T3 laryngeal cancer if IMRT and modern radiotherapy are available and affordable, concomitant radiotherapy with systemic therapy in the form of cisplastin can be tried as an organ preservation treatment. (Strong Recommendation)

F.  For patients with glottic and supraglottic T4a tumors, the recommended treatment approach is total laryngectomy with thyroidectomy and neck dissection as indicated (depending on node involvement) followed by adjuvant treatment (RT, or systemic therapy/RT may be considered).

G. For patients with glottic T4a laryngeal cancer, postoperative observation is an option for highly selected patients with good-risk features (eg, indolent histopathology). For selected patients with T4a tumors who decline surgery, the NCCN Panel recommends: 1) considering concurrent chemoradiation; 2) clinical trials; or 3) induction chemotherapy with additional management based on response. (Strong Recommendation)

6. Follow-up examinations in patients treated from laryngeal caner may need to be supplemented with serial endoscopy or high-resolution, advanced radiologic imaging techniques because of the scarring. (Strong Recommendation)