Larynx preservation: the discussion is not closed

Advanced but resectable larynx and hypopharynx squamous cell carcinomas are, in the vast majority of cases, treated by radical surgery and postoperative irradiation, resulting in the total ablation of the voice box. Some institutions prefer to use irradiation and reserve radical surgery for salvage. There is no randomized comparison of results obtained with these two strategies. Induction chemotherapy with the use of platinum and 5-fluorouracil provides notable response rates and allows the prediction of radiosensitivity in those patients who show a response to chemotherapy. This has been the basis of the most frequent larynx preservation approach: induction chemotherapy followed by irradiation in good responders or by radical surgery in poor responders. This strategy did not jeopardize survival and allowed larynx preservation in 50% to 66% of survivors. These results are of importance but it should nonetheless be remembered that irradiation is an efficient treatment of these tumors and may have an improved activity (with modified fractionation or concurrent administration of chemotherapy and irradiation) and that selected cases are amenable to subtotal laryngectomy. On the other hand, new prospects for treatment are emerging (biologic tools, place of imaging), as well as new parameters for the success of treatment (quality of life, quality of preserved function, cost effectiveness). In summary, larynx preservation is undoubtedly feasible but remains investigational.