Update zum Larynxorganerhalt bei fortgeschrittenen Larynx-/Hypopharynxkarzinomen

Die Therapie von fortgeschrittenen Larynx- und Hypopharynxkarzinomen ist nicht nur aufgrund hoher Rezidivraten unverändert eine große Herausforderung für die behandelnden Ärzte. Sollte eine komplette Kehlkopfentfernung (Laryngektomie) indiziert sein, stehen zwei nicht-chirurgische Konzepte mit dem Ziel des Larynxorganerhalts zur Auswahl: simultane Radiochemotherapie oder Induktionschemotherapie gefolgt von Bestrahlung.

Abstract

The management of locally advanced laryngeal and hypopharyngeal squamous cell carcinomas remains challenging for ENT specialists due to the larynx’s complex multidimensional function and the high rates of local and locoregional recurrence or distant metastatis. Surgical (including total laryngectomy, LE, followed by adjuvant radio(chemo)therapy) and nonsurgical approaches aiming on larynx organ preservation (including definitive concomitant chemoradiation or sequential induction chemotherapy (IC) followed by radiotherapy) are available. These treatment modalities will be critically discussed in this review.

In line with the national German S3 guidelines for laryngeal and oro-/hypopharyngeal cancer, patients must receive comprehensive counseling on both surgical and non surgical concepts. To date, early response to IC constitutes the most robust surrogate marker for organ preservation candidacy, guiding the early redirection of non responders to upfront LE. Late salvage LE after definitive radiochemotherapy is associated with high perioperative morbidity, often rendered unfeasible due to radiation-induced fibrosis and impaired vascularity; thus, it should not be considered as a standard treatment option.

IC and response evaluation after just one cycle of IC, as applied in the DeLOS-II study, allow for early identification of non-responders, for whom LE (associated with significantly lower complication rates than salvage surgery) should be recommended prior to radiotherapy. The neoadjuvant use of immunotherapy in combination with IC likely represents the next frontier in the context of laryngeal organ preservation. The ongoing ELOS study is currently investigating the efficacy of an IC regimen comprising docetaxel and cisplatin in combination with pembrolizumab.

Kernaussagen

• Die deutschen S3-Leitlinien empfehlen bei fortgeschrittenem Larynx-/Hypopharynxkarzinom 3 Therapiekonzepte: 1. Tumorresektion gefolgt von adjuvanter Radio(chemo)therapie, 2. primäre Radiochemotherapie oder 3. Induktionschemotherapie gefolgt von Bestrahlung.

• Entsprechend retrospektiven Datenanalysen ist ein primär chirurgisches Vorgehen gefolgt von postoperativer Radio(chemo)therapie hinsichtlich der lokoregionären Kontrolle und des Gesamtüberlebens von Patienten mit T4a-Karzinomen des Larynx und Hypopharynx einem primär nicht-chirurgischen Vorgehen überlegen.

• Eine gute und frühzeitige Patientenselektion sollte eine Salvage-Chirurgie nach Möglichkeit im Vorfeld vermeiden, da sie insbesondere mehr als 3 Monate nach voller Bestrahlungsdosis aufgrund der Gewebsveränderungen chirurgisch herausfordernd und mit hohen Komplikationsraten (Fisteln, Wundheilungsstörungen) verbunden ist.

• Außer zum Zweck der Selektion zwischen Laryngektomie und Larynxorganerhalt vor geplanter definitiver Radio- oder Radiochemotherapie wird bei fortgeschrittenen Larynx-/Hypopharynxkarzinomen derzeit eine neoadjuvante Chemotherapie nicht empfohlen.

• Eine möglichst frühe Response-Evaluation im Rahmen einer Induktionschemotherapie ermöglicht die Selektion von Patienten, die mit größerer Wahrscheinlichkeit einen dauerhaften Larynxorganerhalt erreichen können. Patienten mit unzureichendem Ansprechen können frühestmöglich einer Laryngektomie ohne radiogen bedingte Komplikationen zugeführt werden.

• Die Anwendung von Immuncheckpoint-Inhibitoren ab dem neoadjuvanten Setting erscheint vielversprechend.

Schlüsselwörter

Larynx-Organerhalt - Induktionschemotherapie - Checkpoint-Inhibitoren - Laryngektomie - Salvage-Chirurgie - ELOS - Larynxkarzinom - Hypopharynxkarzinom - Therapieentscheidung

Keywords

larynx and hypopharynx cancer - induction chemotherapy - larynx organ preservation - laryngectomy - checkpoint inhibition - salvage surgery

Publikationsverlauf

Artikel online veröffentlicht:
02. Oktober 2025

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