Radiotherapy. The mainstay in the treatment of early glottic carcinoma

Early squamous cell carcinoma of the glottis may be effectively treated with surgery or radiation therapy. Controversy exists as to whether radiation therapy effects survival at the expense of vocal function by ultimately requiring more total laryngectomies for salvage of local tumor recurrence. This study reviewed the medical records of 185 patients with T1 or T2, NO invasive squamous cell carcinoma of the glottis treated with primary radiation therapy between 1969 and 1984. All patients were followed up for a minimum of 5 years after completion of therapy. One hundred sixty-one patients met the criteria for local control analysis. Radiation therapy controlled disease in 93% (105 of 113) of patients with T1 lesions and 73% (38 of 48) of those with T2 tumors. Ultimate control of disease for T1 and T2 lesions, including surgical salvage, was 111 (98%) of 113 and 44 (92%) of 48 patients, respectively. The rate of successful surgical salvage was 75% (T1) and 70% (T2). The T2 lesions with impaired vocal cord mobility or anterior commissure disease were identified as being at increased risk for recurrence after primary radiation therapy. Overall voice preservation was 90%. Our data demonstrate that radiation therapy effects disease-free survival rates that are comparable to those produced by surgery, without sacrificing voice. Although a small percentage of patients with selected early glottic lesions may be more effectively treated with primary conservation surgery, these data do not support a change in philosophy concerning primary treatment of early glottic cancer with radiation therapy.     

Early vocal cord carcinoma in obese patients: A surgical lesion

Early epidermoid carcinoma of the vocal cord is treated successfully by radiation therapy with high 5-year survival rates, low morbidity, and preservation of excellent voice quality in most cases. Typically, surgery is reserved for salvage of radiation failure and provides overall 5-year survival rates of 98% and 90% for T1 and T2 lesions, respectively. The extremely obese patient, often with a short neck and excessive amounts of subcutaneous fat, is difficult for both radiotherapist and surgeon to diagnose and treat. The recent observation of an unusually high rate of radiotherapy failure in a cluster of obese patients with early vocal cord cancer called attention to this problem. Because the larynx is near the thoracic inlet in obese patients, they are not suitable for administration of radiotherapy by accurate opposed lateral portals. The patients reported herein were treated entirely with anterior oblique portals. Of the five obese patients who underwent primary radiation therapy for early vocal cord cancer, three developed recurrent disease (60%) and a fourth developed a severe perichondritis requiring tracheostomy. Two patients with recurrent disease were successfully salvaged with total laryngectomy, while the third patient refused surgery and died 2 years later. The sixth patient was treated by partial laryngectomy with imbrication reconstruction and is alive and without evidence of disease 2 years following surgery. Recurrence rates and complication rates following primary radiation therapy for early vocal cord cancer appear to be unacceptably high in obese patients treated with anterior oblique portals. Therefore, we recommend primary conservation laryngeal surgery for obese patients with early vocal cancer who cannot undergo “standard” radiotherapeutic techniques.     

Current trends in initial management of laryngeal cancer: the declining use of open surgery

The role of open surgery for management of laryngeal cancer has been greatly diminished during the past decade. The development of transoral endoscopic laser microsurgery (TLS), improvements in delivery of radiation therapy (RT) and the advent of multimodality protocols, particularly concomitant chemoradiotherapy (CCRT) have supplanted the previously standard techniques of open partial laryngectomy for early cancer and total laryngectomy followed by adjuvant RT for advanced cancer. A review of the recent literature revealed virtually no new reports of conventional conservation surgery as initial treatment for early stage glottic and supraglottic cancer. TLS and RT, with or without laser surgery or CCRT, have become the standard initial treatments for T1, T2 and selected T3 laryngeal cancer. Photodynamic therapy (PDT) may have an emerging role in the treatment of early laryngeal cancer. Anterior commissure involvement presents particular difficulties in application of TLS, although no definitive conclusions have been reached with regard to optimal treatment of these lesions. Results of TLS are equivalent to those obtained by conventional conservation surgery, with considerably less morbidity, less hospital time and better postoperative function. Oncologic results of TLS and RT are equivalent for glottic cancer, but with better voice results for RT in patients who require more extensive cordectomy. The preferred treatment for early supraglottic cancer, particularly for bulkier or T3 lesions is TLS, with or without postoperative RT. The Veterans Administration Study published in 1991 established the fact that the response to neoadjuvant CT predicts the response of a tumor to RT. Patients with advanced tumors that responded either partially or completely to CT were treated with RT, and total laryngectomy was reserved for non-responders. This resulted in the ability to preserve the larynx in a significant number of patients with locally advanced laryngeal cancer, while achieving local control and overall survival results equivalent to those achieved with initial total laryngectomy. Following this report, similar “organ preservation” protocols were employed in many centers. By 2003, results of the RTOG 93-11 trial, utilizing CCRT as initial treatment, were published, demonstrating a higher rate of laryngeal preservation with this protocol. Surgery was reserved for treatment failures. This concept changed the paradigm for management of advanced laryngeal cancer, greatly reducing the number of laryngectomies performed. While supracricoid laryngectomy has been employed for selected patients, total laryngectomy is the usual procedure for salvage of failure after non-surgical treatment.     

Paranasal sinus malignancy: a comprehensive update

A retrospective analysis of 60 cases of paranasal sinus cancer in patients admitted between 1970 and 1985 was undertaken. Forty-six tumors originated in the maxillary sinus, and 14 originated in the ethmoid sinuses. Computed tomography, magnetic resonance imaging, and endoscopic sinus examination aided in early diagnosis of sinus cancer. Computed tomography aided in staging tumors; Caldwell-Luc alone was inadequate for staging tumors invading deeper sites such as the orbits or pterygoid muscle. There were 15 early (T1 or T2) and 31 advanced (T3 or T4) maxillary sinus cancers. Multimodality therapy incorporated radiation, surgery, and chemotherapy. The 5-year survival rate was 49%. We prefer preoperative radiotherapy for advanced lesions and postoperative radiotherapy for early lesions. The use of preoperative radiation therapy has increased our globe salvage rate. All but one of the patients who developed recurrent disease showed recurrence at the primary site prior to developing regional or distant metastasis. Radiation therapy, combined with aggressive surgical management to remove all tumor, provided the best survival rates in advanced lesions.     

Management decisions in laryngeal carcinoma in situ

Twenty-one patients with laryngeal carcinoma in situ (n = 12) or carcinoma in situ with microinvasion (n = 9) were treated with laser mucosal dissection of the vocal cords and/or superficial laser cordectomy. The normal architecture of the vocal cords was preserved because the depth of vaporization was usually superficial in these early cases. Five patients had recurrence, new tumor, or persistence of abnormal tissue that required additional laser surgical treatments. With a follow-up range of 6 months to 4 years, all patients currently are free of laryngeal abnormality, and no patient has needed open laryngeal surgery or radiation therapy. Transoral endoscopic laser resection of laryngeal carcinoma in situ with or without microinvasion should be the treatment of choice for these early lesions.     

Prognostic significance of G1 cell-cycle inhibitors in early laryngeal cancer

BACKGROUND: Radiation therapy yields a 2-year local control rate of 80% to 90% in early laryngeal squamous cell carcinoma. However, a subset of early laryngeal cancers has a significantly higher rate of local recurrence and lower rate of overall survival. OBJECTIVE: The objective of this study was determine the prognostic significance of p53, p27, and p21 expression in patients with early laryngeal cancer. METHODS: Expression of p53, p27, and p21 proteins in pretreatment biopsies from sixty-eight patients was analyzed by using immunohistochemistry. Low (10% cells) levels of expression were measured. All patients were newly diagnosed and treated with external beam radiation. Other contributing factors were also studied, such as age, sex, race, tumor site, and stage. RESULTS: Forty (58.8%) and 28 (41.2%) lesions were staged as T1 and T2, respectively, whereas 16 (23.5%) and 52 (76.5%) were located in the supraglottis and glottis, respectively. Overexpression of p27, p53, and p21 was found in 36.7%, 60.6%, and 60% of cases, respectively. Overexpression of p27 was found to be a significant predictor of recurrence by multivariate analysis (RR 3.3, P = .017). Overexpression of p21 and/or p53 was not predictive of recurrence. No factor predicted disease specific or nonspecific overall survival. CONCLUSION: Our results indicate the significance of p27 overexpression as an indicator of recurrence in patients with early laryngeal squamous cell carcinoma.     

Hemilaryngectomy rescue surgery for radiation failure in early glottic carcinoma

Radiotherapy for early glottic carcinoma has produced excellent results and low complication rates. Therefore, hemilaryngectomy and other forms of vertical partial laryngectomy have been used mainly for rescue therapy following radiation failure. Over a 9-year period selective application of this approach was used in eight patients out of 122 laryngeal cancer surgeries performed. Five patients were T1N0 and three were T2N0 at the time of initial diagnosis and at the time of recurrence. Three patients had healing problems postoperatively. Tracheal decannulation time was increased compared to patients who had hemilaryngectomy without previous radiotherapy. To date there has been no recurrence of carcinoma at any site with a mean follow-up of 58 months in surviving patients. This experience confirms reports which indicate that with careful selection, radiation failures for early glottic carcinoma can be rescued by hemilaryngectomy achieving excellent tumor control and moderately good preservation of laryngeal function.     

Laser surgery for vocal cord carcinoma involving the anterior commissure

Endoscopic laser surgery is an established means of treatment for benign laryngeal lesions. Laser surgery for early (stages I and II) squamous cell carcinoma is still being tested. Treatment of glottic tumors extending to the anterior commissure is in itself controversial. Approximately 20% of all glottic tumors involve the anterior commissure, with only 1% of these lesions being purely anterior commissure tumors. The anatomy of the anterior commissure is such that an apparent T1 lesion may actually be a T4 lesion if it involves the thyroid cartilage. The distance between the anterior commissure ligament and the thyroid cartilage is only 2 to 3 mm. A preoperative computed tomographic scan can aid us in evaluating this space. Therefore, tumors of the anterior commissure present as a therapeutic challenge. Radiation therapy has proven to be inadequate, with a high rate of recurrence and increased risk for radiochondronecrosis. The literature with regard to radiotherapy varies widely as to survival rates. Conservation surgery has consistently demonstrated an 80% survival in T1 lesions. Recently, it has been suggested that laser surgery in the region of the anterior commissure might offer satisfactory results. We have found the opposite. We will report on five patients who underwent endoscopic laser surgery on T1 vocal cord lesions involving the anterior commissure. All of these patients had tumor recurrence and subsequently have undergone salvage surgery and/or radiation therapy. The difficulties associated with endoscopic laser surgery of the anterior commissure will be discussed with a supporting animal study.     

喉功能保留的梨状窝癌外科治疗

目的　评价喉功能保留梨状窝癌的手术治疗效果。方法　回顾性分析了 1974～ 1994年 6月我院初治的 44例经保留喉功能手术治疗的梨状窝癌病例。其中T110例 ,T2 14例 ,T3 18例 ,T42例。 2例术后放射治疗 ,42例术前放射治疗。原发灶术式包括 :36例梨状窝切除术 ;8例喉及下咽部分切除术。结果　 44例 5年生存率为 5 0 % ,I期为 80 % ,II期为 71 43% ,III期为 5 2 9% ,IV期为2 6 7%。总的局部控制率为 81 8%。T3 加T4 的 5年生存率为 45 %。T3 加T4 的 5年局部控制率为75 % (15 /2 0 )。结论　综合治疗过程中选择适宜患者 ,行保留喉功能的梨状窝癌手术 ,可取得满意的治疗效果。术前放射治疗有助于梨状窝癌尤其是T3 梨状窝癌患者喉功能的保留。     

喉癌治疗后复发的临床因素分析及治疗

目的 探讨喉癌治疗后复发的临床因素以及诊断与治疗。方法 应用χ2检验以及logistic多因素回归分析方法分析114例喉癌的临床复发因素并分析其中23例复发喉癌的临床资料。结果 χ2检验统计结果显示,喉癌术后复发与原发肿瘤部位、分化程度以及T分期有关,与首次手术方式无关;Logestic多因素回归分析显示,切缘阳性是喉癌复发的高危因素。23例复发性喉癌中,喉癌局部复发13例,颈淋巴结转移7例,局部复发并颈淋巴结转移3例。治疗采取放疗、部分喉切除、（扩大）全喉切除及(或)颈廓清术。局部复发组随访5年13例中8例生存,3例死亡,2例失访;颈淋巴结转移组7例中4例生存,2例死亡,1例失访;局部复发并颈淋巴结转移3例,1例存活,1例死亡,1例失访。结论 喉癌手术后复发与原发肿瘤部位、分化程度、T分期以及阳性切缘有关;喉癌术后定期随访有助于早期明确有无复发;对复发性喉癌的治疗仍以手术为主。     

喉功能保留的梨状窝癌外科治疗

目的 评价喉功能保留梨状窝癌的手术治疗效果。方法 回顾性分析了１９７４～１９９４年６月我院初治的４４例经保留喉功能手术治疗的梨状窝癌病例,其中Ｔ１１０例Ｔ２１８例,Ｔ４２例。２例术后放射治疗,４２例术前放射治疗,原发灶术式包括：３６例梨状窝切除术;８例喉及下咽部分切除术。结果 ４４例５年生存率为５０％,Ｉ期为８０％,Ⅱ期为７１．４３％,Ⅲ期为５２．９％,Ⅳ期为２６．７％,总的局部控制率为８１．８％     

Transoral CO<Subscript>2</Subscript> laser management for selected supraglottic tumors and neck dissection

This study aimed to evaluate transoral laser resection as a method of choice for conservation surgery for supraglottic laryngeal carcinoma in carefully selected patients. Between 1987 and 2006, 55 patients with early supraglottic carcinoma were selected for transoral laser surgery. The outcome of the endoscopic CO₂ laser resection and larynx-sparing functional results without tracheotomy was evaluated. Fifty-five patients with T1, T2 supraglottic carcinomas underwent transoral CO₂ laser resection and seven patients with manifest neck metastasis required a neck dissection at one session with additional postoperative radiation therapy. There was no need for tracheotomy; deglutition was moderately disturbed. Forty of the 55 (73%) patients had no signs of recurrence to date. Fifteen patients with local recurrences underwent salvage therapies: six repeated laser excisions, three radiotherapies, four supraglottic laryngectomies and two total laryngectomies. Laser-specific survival is 84% and larynx preservation is 96%. The overall 5-year-survival after salvage treatment is 98%. Development of late metastasis required five radical neck dissections (RND) and radiation therapy. The results indicated that transoral laser resection can control early supraglottic cancer in selected patients and can be combined with simultaneous neck dissection with less morbidity than “open surgery”.     

Primary radiation therapy for T1 glottic cancer. Factors influencing local control

One hundred and seventy-four patients with early glottic cancer received radiation therapy on the kV250 and cobalt 60 machines. Crude survival rates at 5, 10 and 15 years were 83%, 73% and 60%, respectively. Salvage surgery for locoregional recurrences was successful in 85% of the patients. A significantly higher failure rate was noted in patients with a pre-existing chronic laryngitis, with lesions confined to the left vocal cord and in those treated with KV250 irradiation. The rate of second primaries in this case material was 11%, 70% of which were noted in the respiratory tract. Megavoltage radiotherapy offers excellent chances for cure in T₁ laryngeal carcinoma with preservation of good voice in most patients. Patients with chronic laryngitis carry a high risk of local recurrence and therefore should be considered for primary conservation surgery.     

Squamous cell carcinoma of the paranasal sinuses: the Cleveland Clinic experience 1977-1986

Fifty-four of 103 malignancies of the paranasal sinuses treated at the Cleveland Clinic Foundation between 1977 and 1986 were squamous cell carcinomas. Six arose from the ethmoid sinus and 48 from the maxillary sinus. Of the maxillary sinus patients, 11 presented with T1 or T2 lesions, 20 with T3, 16 with T4, and 7 of these had nodal disease. Treatment was surgery and/or radiation therapy. There was local recurrence in 25 of 48 maxillary sinus patients and in 1 of 6 ethmoid patients. Overall 5-year survival was 38.2% in the maxillary sinus group: T1, 100.0%; T2, 85.7%; T3, 31.8%; and T4, 6.7%. Three of six patients with ethmoid tumors were cured. There was a statistical trend for better prognosis in those patients presenting with ethmoid primaries, with early lesions, treated with both radiation and surgery, and with history of inverting papilloma. There were complications of treatment in 10 patients, four of which resulted in death. Local control was the major problem for these patients; therefore, early detection and aggressive local treatment are desirable.     

Salvage resection after previous laryngeal surgery: total laryngectomy with en bloc resection of the overlying cervical skin.

OBJECTIVE: To evaluate the effectiveness of extended total laryngectomy for the treatment of recurrences of laryngeal cancer. DESIGN: We conducted a retrospective clinical study of patients who had undergone extended total laryngectomy and were seen over a 15-year period. The follow-up period ranged from 3 to 15 years. SETTING: Academic tertiary referral medical center. PATIENTS: We observed 15 patients who were affected by a recurrence of laryngeal cancer that extended to the overlying soft tissue. All patients were male. The mean age was 61.5 years. Thirteen patients had previously undergone partial laryngeal surgery, and 2 patients had undergone radiation therapy, without success. INTERVENTION: All patients underwent total laryngectomy extending to the soft tissue, including the overlying skin. RESULTS: Five of the 15 patients died of local recurrence, and 1 patient died of massive postoperative hemorrhaging. An actuarial survival rate of 60% was observed at 5 years. CONCLUSION: Total laryngectomy extending to the soft tissues seems to be an effective procedure for treating local recurrences of laryngeal cancer after partial laryngectomy or failure of radiation therapy.     

Return of vocal cord movement: an independent predictor of response to nonsurgical management of laryngeal cancers

OBJECTIVE: To determine whether return of vocal cord function after treatment of T2b/T3 laryngeal carcinoma is an independent prognostic factor for locoregional recurrence. STUDY DESIGN: A retrospective review of patients treated with radiation +/- chemotherapy between 2000 and 2005 for T2 with vocal cord paresis and T3 laryngeal carcinoma was conducted. METHODS: Only those patients obtained from the tumor registry with pre-and posttreatment video stroboscopies were included. Patients' charts were reviewed for local and regional recurrence after treatment. Fisher's exact test was used to determine significant association between recurrence and possible risk factors. RESULTS: Fourteen patients met the inclusion criterion. Six patients had T2 lesions with vocal cord paresis, and eight patients had T3 lesions. Fifty percent of patients with T2 and 75% of patients with T3 lesions had return of vocal cord function after treatment. Five of 14 patients did not have return of vocal cord function, and of these, 100% had locoregional recurrence. Of the nine patients who had return of vocal cord movement, none of the patients had recurrence. The proportion of recurrence was significantly higher for those whose vocal function did not return compared with the patients whose vocal function returned (100% vs. 0%, P < .01). CONCLUSION: The immobile vocal cord is associated with a worse prognosis and is therefore factored into the American Joint Commission on Cancer staging for laryngeal tumors. We show that vocal cord immobility is an independent prognostic factor of recurrence even after treatment and can predict treatment failure in T2 and T3 lesions of the larynx.     

Observations on immunologic parameters in laryngeal cancer patients

Patients with laryngeal cancer were examined immunologically before treatment and for 1-10 years after treatment. In the pretreatment group, the percentage of T cells, lymphocyte blastoid reaction (PHA, concanavalin A), and skin reactions (PHA) were generally in the normal range, but absolute numbers of T cells and lymphocytes were reduced in most patients. In the group with no recurrence after surgery, the absolute number of T cells and lymphocytes, IgG X FcR+T cells (T gamma), and skin reactions was normal in many cases. The group with recurrence showed reduced percentage of T cells and an absolute number of T cells and lymphocytes. The absolute number of T cells and lymphocytes and the PPD skin reaction increased after surgery in some cases, but reductions in some of the parameters were noted in a few cases long after surgery. Radiation therapy for patients with tumors at early stages did not significantly change the percentage of T cells or the skin reactions.     

CO2激光显微手术在喉癌前病变和早期声门型喉癌中的应用

目的 探讨CO₂激光显微手术在喉癌前病变和早期声门型喉癌治疗中的应用价值。 方法 选取南京医科大学附属南京医院耳鼻咽喉科自2014年1月~2018年8月期间收治的27例行CO₂激光显微手术治疗的喉癌前病变(9例)和早期声门型喉癌(18例)作为研究对象,观察术后并发症、对比手术前后的生活质量及术后1~2年局部的复发率,探讨其应用价值。 结果 根据CO₂激光显微手术切除的范围和深度进行手术:9例癌前病变中8例行I型手术、1例行Ⅱ型手术;18例早期声门型喉癌中3例行Ⅱ型手术、11例行Ⅲ型手术、3例行Ⅳ型手术、1例行Ⅴ型手术。1例因切缘阳性改行开放式手术,其余患者均未行气管切开,亦无气道烧伤等严重并发症。患者术后6 h软食,均无呛咳、呼吸困难等不良反应,术后抗感染抗炎治疗2~3 d。术后随访1~2年,嗓音恢复可。 结论 CO₂激光显微手术治疗喉癌前病变和早期声门型喉癌临床效果显著、安全性较高、创伤小、术后嗓音恢复快、住院时间缩短、并能较为理想的保留喉功能、提高患者术后的生活质量。     

Glottic cancer. Surgical salvage for radiation failure

Radiation therapy is a well-established treatment for early squamous cell carcinoma of the glottic larynx. However, the management of patients suspected to have persistent or recurrent disease may present both diagnostic and therapeutic dilemmas, particularly when laryngeal edema persists months after conclusion of radiation therapy. We reviewed the outcome of 212 patients with T1s, T1, and T2NOMO carcinoma of the glottic larynx who had been treated for cure with radiation therapy, with surgical salvage reserved for radiation failures. Twenty-four patients (11%) had recurrences after radiation therapy, 13 (59%) of whom had successful salvage by surgery. The five-year, recurrence-free survival in this series was 92% for T1s and T1 and 69% for T2. We conclude that T1s, T1, T2NOMO carcinoma of the glottic larynx is effectively managed by radiation therapy and surgical salvage for radiation failure. Total laryngectomy usually was necessary for surgical salvage.     

Results of treatment of 584 laryngeal cancers at the Ear-Nose-Throat Clinic of Marburg University

The results in the management of 460 vocal cord carcinomas and 124 supraglottic carcinomas are reported. Of the vocal cord carcinomas, 63.3% were diagnosed in the early Tis and T1 stage. Seventy-six tumors were resected endoscopically, 128 by laryngofissure and chordectomy. Not one of these patients has lost his life, larynx or voice. In bilateral tumors of the T1b category, 2 patients developed local recurrences and lost their larynx. Sixty-two carcinomas of the Tis, T1a and T1b categories were irradiated primarily. Two of these patients died and 14 underwent laryngectomy for local recurrence. In T2 carcinomas a 5-year cure rate of 87.5% was achieved by vertical partial resection. The 5-year cure rate after laryngectomy or laryngectomy with neck dissection for T2N0 and T2N+ carcinoma was 86.2% and 75.0% respectively. Most treatment failures were due to late metastases which could not be controlled. In T3 carcinomas with a 5-year cure rate of 71.4% (N0) and 70.0% (N+) respectively, treatment failures were also mainly seen in patients with N0 necks where we did not carry out a prophylactic neck dissection. Five-year survival rates for primary surgery in supraglottic T1-T4 carcinomas were 100%, 82.4%, 84% and 58.3%. The widely hel opinion that laryngeal carcinoma should only be subjected to surgery for irradiation failure can no longer be sustained. More patients lose their larynx or their life after irradiation of small carcinomas than after primary surgery. Furthermore, too many patients have to undergo two major cancer treatments (irradiation and salvage surgery). In larger carcinomas radiotherapy produces a lower survival rate and too many patients require two stressful cancer therapies. The number of retained larynges is not substantially higher than with primary surgery. Primary irradiation for selected cases should be part of every therapy concept that aims at an adequate and individual treatment of every patient.