Preservation of form and function during management of cancer of the larynx and hypopharynx.

The treatment of laryngeal and hypopharyngeal cancer has seen notable changes during the twentieth century. Intensive surgical research has allowed laryngologists to deal with almost any local extension and to propose an appropriate surgical procedure for each case. This surgery is able to control the disease in most patients locally but is limited in its indications (resectable diseases and operable patients). On the other hand, radiotherapy has been impressively improved (dosimetry, definition of target volume) and has become an indisputable alternative to surgery. The two approaches are comparable in terms of local control and functional results when dealing with early disease. For advanced disease, however, the debate is open between surgery, which is more efficient but mutilating, and radiotherapy, which can preserve the larynx in many instances even though it requires sometimes mutilating surgery for salvage. The appearance of platinum-based chemotherapy has updated this discussion. To date, most of the randomized comparisons of mutilating/nonmutilating approaches have been with induction chemotherapy followed by irradiation if there has been a good clinical response to the chemotherapy. There are other options as well that deserve evaluation (e.g., radiotherapy with altered fractionation or with concurrent chemotherapy), although surgery still seems to be indicated in certain cases. Finally, efforts should be made to select patients properly (based on tumor characteristics, clinical aspects, imaging, and biology) for the various strategies with the primary goal of curing the patient and secondarily to preserve laryngeal form and function when possible.