N0-2cM0期即无局部或远处淋巴结转移(N0M0)或转移淋巴结大小≤6cm但无远处转移(N1M0、N2aM0、N2bM0、N2cM0)。
T3 期肿瘤治疗包括同步放化疗或手术治疗。可行部分或喉全切除。对于精心挑选的患者,部分喉切除术可以保留发声和吞咽功能。对于原发性 T3 期肿瘤患者,选择手术还是同步放化疗仍有争议。[50]Chen AY, Halpern M. Factors predictive of survival in advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg. 2007 Dec;133(12):1270-6.https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/484903http://www.ncbi.nlm.nih.gov/pubmed/18086971?tool=bestpractice.com[51]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.http://www.ncbi.nlm.nih.gov/pubmed/2034244?tool=bestpractice.com 若需行喉全切除术,那么放化疗能够更好地保留言语和吞咽功能。然而,一项针对 7,000 多名来自美国国家癌症数据库的患者进行的回顾性观察队列研究发现,在 T3 期喉癌患者中,接受放化疗的患者的死亡风险明显高于行喉全切除术治疗(风险比=1.18;P=0.03)。[50]Chen AY, Halpern M. Factors predictive of survival in advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg. 2007 Dec;133(12):1270-6.https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/484903http://www.ncbi.nlm.nih.gov/pubmed/18086971?tool=bestpractice.com T3和T4期肿瘤单独放疗效果要比上文提到的治疗方案的效果差。[50]Chen AY, Halpern M. Factors predictive of survival in advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg. 2007 Dec;133(12):1270-6.https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/484903http://www.ncbi.nlm.nih.gov/pubmed/18086971?tool=bestpractice.com[3]Adams GL, Maisel RH. Malignant tumors of the larynx and hypopharynx. In: Cummings otolaryngology: head and neck surgery. Cummings CW, Flint PW, Harker LA, et al, eds. 4th ed. Philadelphia, PA: Elsevier Mosby; 2005:2222-2283.[53]Ghadjar PS, Zimmermann FB. Concomitant cisplatin and hyperfractionated radiotherapy in locally advanced head and neck cancer: 10-year follow-up of a randomized phase III trial (SAKK 10/94). Int J Radiat Oncol Biol Phys. 2012 Feb 1;82(2):524-31.http://www.ncbi.nlm.nih.gov/pubmed/21300466?tool=bestpractice.com[52]Bourhis JS, Martin LA, ly-Schveitzer NS, et al. Concomitant chemoradiotherapy versus acceleration of radiotherapy with or without concomitant chemotherapy in locally advanced head and neck carcinoma (GORTEC 99-02): an open-label phase 3 randomised trial. Lancet Oncology. 2012 Feb;13(2):145-53.http://www.ncbi.nlm.nih.gov/pubmed/22261362?tool=bestpractice.com
顺铂可单独或结合 5-氟尿嘧啶使用。毒性反应较重的患者可换用卡铂或西妥昔单抗治疗。但是,与仅放射 + 顺铂治疗相比,西妥昔单抗另加顺铂结合放射治疗未使结局改善。[54]Ang KK, Zhang Q, Rosenthal DI, et al. Randomized phase III trial of concurrent accelerated radiation plus cisplatin with or without cetuximab for stage III to IV head and neck carcinoma: RTOG 0522. J Clin Oncol. 2014 Sep 20;32(27):2940-50.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4162493/http://www.ncbi.nlm.nih.gov/pubmed/25154822?tool=bestpractice.com 同样,与标准顺铂放化疗相比,改变的分次放射治疗 + 顺铂无任何优势。[55]Nguyen-Tan PF, Zhang Q, Ang KK, et al. Randomized phase III trial to test accelerated versus standard fractionation in combination with concurrent cisplatin for head and neck carcinomas in the Radiation Therapy Oncology Group 0129 trial: long-term report of efficacy and toxicity. J Clin Oncol. 2014 Dec 1;32(34):3858-66.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239304/http://www.ncbi.nlm.nih.gov/pubmed/25366680?tool=bestpractice.com
放化疗后颈部肿物长期存在或喉切除术伴有颈部阳性发现时需行颈淋巴清扫术。[49]Tandon S, Munir N, Roland NJ, et al. A systematic review and number needed to treat analysis to guide the management of the neck in patients with squamous cell carcinoma of the head and neck. Auris Nasus Larynx. 2011 Dec;38(6):702-9.http://www.ncbi.nlm.nih.gov/pubmed/21315526?tool=bestpractice.com 然而,放化疗后是否行颈部淋巴结清扫术仍有争议。[56]Wee JT, Anderson BO, Corry J, et al. Management of the neck after chemoradiotherapy for head and neck cancers in Asia: consensus statement from the Asian Oncology Summit 2009. Lancet Oncol. 2009 Nov;10(11):1086-92.http://www.ncbi.nlm.nih.gov/pubmed/19880062?tool=bestpractice.com
术后可利用辅助化疗管理某些不良的肿瘤特征(如切缘阳性、>4 个淋巴结、囊外扩散)。[57]Lefebvre JL, Ang KK; Larynx Preservation Consensus Panel. Larynx preservation clinical trial design: key issues and recommendations: a consensus panel summary. Head Neck. 2009 Apr;31(4):429-41.http://www.ncbi.nlm.nih.gov/pubmed/19283793?tool=bestpractice.com 参考当地专科医生治疗方案作为剂量指导。
同步放化疗比序贯放化疗或单独放疗可更好地保留喉功能和局部区域肿瘤控制。[58]Forastiere AA, Zhang Q, Weber RS, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol. 2013 Mar 1;31(7):845-52.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3577950/http://www.ncbi.nlm.nih.gov/pubmed/23182993?tool=bestpractice.com