A 68-year-old woman with a 20 pack-year smoking history presents with hoarseness for 2 months. Laryngoscopy reveals a left vocal cord in the paramedian position with a bulky left supraglottic mass. CT chest shows a 4 cm left laryngeal mass with left RLN involvement and no distant metastases. After staging, she is deemed suitable for curative intent treatment. What is the most appropriate next step?

Explanation

## Clinical Context This is a **laryngeal cancer with vocal cord paralysis** secondary to RLN invasion. The patient is fit for curative treatment, and the goal is organ preservation while achieving oncologic control. ## Laryngeal Cancer Management Framework ```mermaid flowchart TD A[Laryngeal cancer diagnosed]:::outcome --> B{Stage & Fitness?}:::decision B -->|Early stage T1-T2, no RLN involvement| C[Radiation OR transoral laser/endoscopic resection]:::action B -->|Advanced T3-T4 OR RLN involvement, fit for chemo| D[Concurrent chemoradiation CCRT]:::action B -->|Advanced, unfit for chemo OR failed CCRT| E[Total laryngectomy ± neck dissection]:::action B -->|Metastatic/palliative| F[Palliative chemotherapy ± RT]:::action D --> G[Assess response at 6-8 weeks]:::decision G -->|Complete response| H[Surveillance]:::outcome G -->|Partial/no response| I[Salvage laryngectomy]:::action ``` ## Why CCRT for This Patient? **Key Point:** The presence of **RLN invasion (T4b equivalent)** in a fit patient makes this an **advanced laryngeal cancer**. CCRT is the standard organ-preservation approach for: - T3–T4 laryngeal cancer - RLN involvement - Patients fit enough to tolerate chemotherapy **High-Yield:** CCRT achieves 5-year overall survival of 60–70% in advanced laryngeal cancer while preserving laryngeal function in ~70% of responders. ## CCRT vs. Laryngectomy Decision | Factor | CCRT (Organ Preservation) | Total Laryngectomy | |---|---|---| | **Indication** | Advanced, fit for chemo, RLN involved | Unfit for chemo, failed CCRT, T4a with thyroid invasion | | **Voice outcome** | Preserved (if response) | Permanent tracheostomy, alaryngeal speech | | **Morbidity** | Acute: mucositis, dysphagia; Late: xerostomia, stenosis | Permanent: aspiration risk, loss of normal speech | | **Salvage option** | Laryngectomy if no response | None | | **5-yr OS** | 60–70% | 40–50% | **Clinical Pearl:** RLN paralysis from tumor invasion does NOT preclude CCRT. In fact, CCRT is preferred to preserve laryngeal function if the patient responds. ## Why Other Options Are Suboptimal **Warning:** - **Voice therapy alone** is inadequate for cancer treatment and risks disease progression. - **Tracheostomy without definitive treatment** is a temporizing measure, not curative. - **Laryngectomy** is reserved for patients unfit for chemo, or as salvage after failed CCRT, not as first-line in a fit patient. [cite:NCCN Head and Neck Cancer Guidelines 2023; Harrison 21e Ch 432]