A 62-year-old man with a 2-year history of smoking presents with progressive dysphagia, odynophagia, and stridor. Laryngoscopy reveals a large, fixed left vocal cord with extension to the anterior commissure and left arytenoid. Biopsy confirms squamous cell carcinoma. CT shows a 4 cm mass with left level II and III lymph node involvement (T3N2bM0). What is the most appropriate next step in management?

Explanation

## Clinical Staging and Assessment This patient has **locally advanced laryngeal carcinoma**: - **T3** disease: fixed vocal cord with anterior commissure and arytenoid involvement - **N2b** disease: ipsilateral multiple lymph nodes (level II and III) - **M0**: no distant metastases - **Stage III** (AJCC) laryngeal cancer ## Management Strategy for Locally Advanced Laryngeal Cancer ```mermaid flowchart TD A[Locally advanced laryngeal SCC<br/>T3-T4, N0-N3, M0]:::outcome --> B{Organ preservation<br/>candidate?}:::decision B -->|Yes<br/>Good PS, no<br/>distant mets| C[Concurrent chemoRT<br/>cisplatin + 70 Gy]:::action B -->|No<br/>Poor PS or<br/>recurrent| D[Total laryngectomy<br/>+ neck dissection<br/>+ adjuvant RT]:::action C --> E{Response?}:::decision E -->|Complete| F[Surveillance]:::outcome E -->|Incomplete| G[Salvage laryngectomy]:::urgent D --> H[Adjuvant RT ±<br/>chemotherapy]:::action ``` ## Why Concurrent Chemoradiotherapy is the Next Step **Key Point:** For **T3–T4 laryngeal cancers with nodal involvement (N1–N3)**, concurrent chemoradiotherapy (cisplatin + external beam radiotherapy) is the **organ-preservation standard** and is preferred over laryngectomy in fit patients [cite:Harrison 21e Ch 80]. ### Evidence Base | Feature | Concurrent ChemoRT | Laryngectomy + Adj RT | |---------|-------------------|----------------------| | **Laryngeal preservation** | ~60–70% at 5 years | 0% (larynx removed) | | **Overall survival** | 55–60% at 5 years | 50–55% at 5 years | | **Voice quality** | Preserved (if successful) | Lost (tracheal speech) | | **Acute toxicity** | Mucositis, dysphagia (reversible) | Surgical complications, pain | | **Late toxicity** | Xerostomia, stenosis | Pharyngeal stenosis, fistula | **High-Yield:** The **RTOG 91-11 trial** established concurrent chemoRT as superior to RT alone for laryngeal preservation in locally advanced disease, with equivalent or better survival than laryngectomy [cite:Robbins 10e Ch 16]. **Clinical Pearl:** This patient is a **good candidate for organ preservation** because: 1. He has no distant metastases (M0) 2. He is fit enough to tolerate concurrent chemotherapy 3. His tumor is fixed but not involving the cricoid or extending outside the larynx 4. Concurrent chemoRT offers a 60–70% chance of laryngeal preservation with voice function intact **Mnemonic:** **CHEMORT** for locally advanced laryngeal cancer — **C**isplatin + **H**igh-dose **E**xternal beam **M**odality **O**rgan **R**eserving **T**herapy. ## Why Other Options Are Incorrect See distractor analysis below.