A 62-year-old male smoker has hoarseness for 5 months now with progressive exertional stridor. Laryngoscopy shows a left glottic mass with a fixed left vocal cord, and contrast CT demonstrates erosion of the thyroid cartilage ala with a 1.5 cm ipsilateral level III node. Biopsy confirms moderately differentiated squamous cell carcinoma. The most appropriate definitive management is:

• A CO2 laser cordectomy followed by observation
• B Definitive radiotherapy alone to 66 Gy
• C Vertical partial laryngectomy with postoperative chemotherapy
• D Total laryngectomy with ipsilateral neck dissection followed by adjuvant radiotherapy ✓

Explanation

Thyroid cartilage invasion makes this a T4a glottic carcinoma, and with a fixed cord plus nodal disease the standard of care is total laryngectomy with neck dissection, followed by adjuvant radiotherapy for cartilage erosion and nodal involvement. Organ preservation protocols are compromised by gross cartilage destruction, which predicts poor function and complications after radiation. Cordectomy treats only T1 disease, vertical partial laryngectomy requires mobile cords and cannot clear T4a disease, and radiotherapy alone undertreats bulky cartilage-invasive tumours.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.