Management of advanced glottic carcinomas

One hundred twenty-eight patients with T3 or T4 glottic cancers were treated by initial surgery; 59 had a total laryngectomy and 69 had total laryngectomy with regional node dissection. Fifty-eight percent of the total laryngectomy group and forty-nine percent of the total laryngectomy with neck dissection group remained free of disease for 5 or more years. Forty-seven percent (60 of 128 patients) treated surgically developed regional recurrences requiring further treatment. Nine patients had evidence of widespread metastases, leaving 51 suitable for salvage radiotherapy. Twenty-three percent (12 of 51 patients) were salvaged with radiotherapy given for postoperative recurrences. Twenty-five patients received an initial 6,600 rads to larynx and neck with curative intent, 28 percent of whom remained free of disease for 5 or more years. Seventeen percent of patients were salvaged with one laryngectomy for persistent or recurring tumors. Initial total laryngectomy gave better survival figures for advanced glottic carcinoma.     

Management of stage T3 and T4 glottic carcinomas

Between 1959 and 1979, 242 patients with T3 and T4 lesions of the vocal cords were treated at our institution. Treatment consisted of total laryngectomy in all patients. Different modalities of regional node dissections were performed on 187 patients. In addition, 50 patients received irradiation with cobalt-60 postoperatively for specific features of the disease. In the group of 192 patients whose treatment consisted of surgery alone, 28 (14 percent) had recurrence in the neck and 10 (5 percent) had stomal recurrence. Of the patients treated with combined therapy, three (6 percent) had ipsilateral neck recurrences and one (2 percent) had stomal recurrence. For lesions staged N0, failure rates above the clavicles were 16 percent and 31 percent for patients with T3 and T4 lesions, respectively, in the group treated by surgery alone, 9 percent and 6 percent for patients with T3 and T4 lesions, respectively, in the combined therapy group. The rate of failure above the clavicles for lesions staged N+ was 32 percent in the group treated with surgery alone and 8 percent in the combined therapy group. In this study, a correlation was made between the failure rates above the clavicles and different clinical and histologic characteristics of the tumor, surgical findings, and the different modalities of cervical node dissection used. From analysis of the data, recommendations have been made for the selective treatment of patients with advanced glottic carcinomas.     

Outcome after partial frontolateral laryngectomy

The purpose of this study was to determine the recurrence rate and the long-term survival of patients treated with frontolateral laryngectomy for early glottic cancer. The study is a retrospective analysis of a cohort of patients who underwent frontolateral laryngectomy from 1995 to 2002 with a median follow-up of 48 months. This was a consecutive series of 30 patients with T1bN0 and T2N0 vocal fold carcinoma. Previously treated patients were excluded. Surgical treatment consisted of frontolateral partial vertical laryngectomy and reconstruction with bipedicle sternohyoid muscle flap. Twenty-five patients have been alive with no evidence of the disease. The median follow-up was 48 months (range, 6-85 months). Five patients experienced local recurrence. One of them underwent salvage partial hemilaryngectomy, and 4 underwent wide-field total laryngectomy with adjuvant postoperative radiation therapy. Four of five patients with retreatment were ultimately salvaged, with a median follow-up of 30 months. We had one death caused by the disease. Frontolateral laryngectomy is an efficient treatment for selected cases of early glottic carcinoma.     

The incidence of hypopharyngeal stenosis after surgery for laryngeal cancer

Hypopharyngeal stenosis is a frequent complication of laryngectomy and radiotherapy in patients treated for carcinoma. In a retrospective study of patients treated in the University of Washington Affiliated Hospitals, hypopharyngeal stenosis was more frequent after laryngectomy with partial pharyngectomy than after laryngectomy alone and occurred more commonly in lesions of the pyriform fossa than in glottic tumors. Neck disease and inclusion of radical neck dissection were both significant factors in the development of hypopharyngeal stenosis. Recurrent tumor was significantly more prevalent in these patients.     

CO2-laser treatment of recurrent glottic carcinoma.

BACKGROUND: Evaluation of the results of CO2 laser treatment of recurrent glottic carcinoma after radiotherapy. METHODS: Records of all patients treated in the University Hospital Rotterdam and the Dr. Daniel den Hoed Cancer Center between 1980 and 1996 by CO2 laser for recurrent glottic carcinoma were studied. RESULTS: Forty patients were treated by laser surgery. Average follow-up was 77 months. Twenty-three patients (58%) had another recurrence develop after laser surgery. Three were cured by a second laser procedure. Therefore, 20 patients (50%) were successfully treated with laser surgery. In 23 patients the recurrence did not extend into the anterior commissure; in 57% a total laryngectomy could be avoided. In 17 patients the recurrence did extend into the anterior commissure; in 41% a total laryngectomy was avoided. CONCLUSION: Most patients with recurrent carcinoma of the larynx after radiotherapy can be cured by laser surgery if the tumor does not extend into the anterior commissure.     

Efficacy of routine bilateral neck dissection in the management of the N0 neck in T1-T2 unilateral supraglottic cancer

BACKGROUND: The treatment of the clinically negative (N0) neck in supraglottic laryngeal cancer continues to be an area of controversy. The aim of this study was to analyze the long-term efficacy of routine bilateral neck dissection compared with ipsilateral neck dissection in T1-T2 N0 lateral supraglottic carcinomas. METHODS: A retrospective review of 108 patients who underwent surgery for T1-T2 supraglottic squamous cell carcinoma was performed. Forty-eight had undergone ipsilateral functional neck dissection, and 60 had undergone bilateral functional neck dissections. None of these patients received adjuvant radiotherapy. RESULTS: No significant differences (p = .78) in regional recurrence were observed between the patients treated with bilateral neck dissection (13%) and those treated with ipsilateral neck dissection (17%). The 5-year survival rates were 73% and 80% for the patients who received a bilateral and ipsilateral neck dissection, respectively (p = .51). CONCLUSIONS: This study suggests that routine bilateral neck dissection may not be necessary in the surgical treatment of all supraglottic cancers.     

Carcinoma of the supraglottic larynx: a basis for comparing the results of radiotherapy and surgery

An analysis of 129 patients with 131 squamous cell carcinomas of the supraglottic larynx treated between October 1964 and April 1987 with radiotherapy alone or radiotherapy followed by neck dissection is presented. All patients had a minimum 2-year follow-up. Patients were excluded from analysis of disease control at the primary site and/or neck if they died within 2 years of treatment with the site(s) continuously disease-free. Local control rates with radiotherapy and ultimate local control rates, including patients successfully salvaged after a local recurrence, were as follows: T1, 13 of 13 and 13 of 13; T2, 34 of 42 (81%) and 37 of 42 (88%); T3, 25 of 41 (61%) and 34 of 41 (83%); and T4, 3 of 9 and 6 of 9. There was no significant difference in local control rates when comparing patients who were anatomically suitable for a supraglottic laryngectomy with those who would have required a total laryngectomy. Local control rates were slightly diminished in patients with T2-T3 lesions who had impaired or absent vocal cord mobility. The overall rates of ultimate local control with voice preservation for the entire series of 129 patients were as follows: T1, 100%; T2, 87%; T3, 69%; and T4, 57%. Cause-specific survival rates at 5 years by stage were I, 2 of 2; II, 10 of 12 (83%); III, 9 of 13 (69%); IVA, 4 of 6; and IVB, 7 of 22 (32%). The incidence of severe complications was 4 of 115 (3%) for T1-T3 lesions and 4 of 14 (29%) for T4 lesions.     

Treatment of the N0 neck during salvage surgery after radiotherapy of head and neck squamous cell carcinoma

BACKGROUND: The morbidity and mortality rates of salvage surgery in patients with local recurrence of head and neck squamous cell carcinoma (HNSCC) after radiotherapy are high. The aim of this study was to determine the rate of occult neck node metastasis and the surgical morbidity of patients after salvage surgery for local relapse after definitive radiotherapy. METHODS: Thirty patients who underwent salvage surgery with a simultaneous neck node dissection for a local relapse after definitive radiotherapy for HNSCC between 1992 and 2000 were included in this study. The primary tumor sites were oral cavity in six patients, oropharynx in 17, supraglottic larynx in three, and hypopharynx in four. Initially, seven patients had T2 disease, eight had T3, and 15 had T4. RESULTS: Twelve patients (40%) experienced postoperative complications, including two deaths. There was no cervical lymph node metastasis (pN0) in 29 of the 30 patients. Fifteen patients (50%) had a recurrence after salvage surgery, including 11 new local recurrences and four patients with distant metastasis. CONCLUSIONS: The risk of neck node metastasis during salvage surgery for local recurrence in patients treated initially with radiation for N0 HNSCC is low. Neck dissection should be performed in only limited area, depending on the surgical procedure used for tumor resection.     

Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned neck dissection

PURPOSE: To present the results of radiotherapy with or without neck dissection for squamous cell carcinoma of the supraglottic larynx treated at the University of Florida and to compare these data with those obtained after conservation surgery. METHODS AND MATERIALS: Continuous-course radiotherapy alone or combined with a planned neck dissection was used to treat 274 patients with squamous cell carcinoma of the supraglottic larynx between 1964 and 1998. All patients had follow-up for a minimum of 2 years, and 250 (91%) had follow-up for 5 years or more. RESULTS: At 5 years, the actuarial probability of local control after radiotherapy according to T stage was as follows: T1, 100%; T2, 86%; T3, 62%; and T4, 62%. The probability of cause-specific survival at 5 years by AJCC stage was as follows: stage I, 100%; II, 93%; III, 81% IVA, 50%; and IVB, 13%. The risk of severe late complications was 4%. Of 57 patients undergoing planned postradiotherapy neck dissection, 7% experienced a severe complication. CONCLUSIONS: On the basis of our data and the literature, early or moderately advanced supraglottic carcinomas may be treated successfully with either supraglottic laryngectomy or radiotherapy. Supraglottic laryngectomy probably produces a higher initial local control rate but, based on anatomic and coexisting medical constraints, is suitable for a smaller subset of patients and has a higher risk of complications compared with radiotherapy.     

Subtotal laryngectomy with crico-hyoido-epiglotto-pexy for the treatment of extended glottic carcinomas

We first described subtotal laryngectomy with crico-hyoido-epiglotto-pexy in 1974. This procedure is a modification of Majer's operation and results in the complete resection of the intact thyroid cartilage. The epiglottic petiole, the false cords, the true cords, and one arytenoid are also excised, along with the paraglottic space. The pharynx is closed by suturing the cricoid to the epiglottis and the hyoid bone. The neoglottis is occluded during deglutition by the epiglottis and the base of tongue, which come into contact with the remaining arytenoid. Postoperative hospitalization lasts approximately 3 weeks, and patients have a strong but deep voice. Between 1972 and 1985, we treated 104 patients with stage T2 and T3 lesions of the glottis using this method. A retrospective analysis showed that the overall survival rate of patients was 86% at 3 years and 75% at 5 years. Five patients experienced local recurrence. Seven patients had recurrences in the neck, and eight developed second primaries. Thirteen patients were lost to follow-up or developed intercurrent disease. Patients with T3NO lesions were treated with unilateral prophylactic neck dissection, and positive nodes were found in 23% of cases. We believe that the high proportion of positive nodes justifies routine prophylactic neck dissection in these patients. Because our operation is associated with good local control (5% recurrence rate), we propose that, for the treatment of extended glottic cancers, it replace transcartilaginous procedures that are associated with much higher recurrence rates.     

Management of stage II (T2N0M0) glottic carcinoma by radiotherapy and conservation surgery

BACKGROUND: The best therapeutic approach for the treatment of stage II (T2N0M0) glottic carcinoma is controversial. METHODS: A retrospective tumor registry data retrieval of patients with stage II glottic carcinoma treated with curative intent at Washington University Medical Center-Barnes Hospital between January 1971 and December 1989 (surgery) and December 1995 (radiotherapy) was performed. RESULTS: Among 134 patients with stage II glottic carcinomas treated with curative intent and function preservation, there were 47 patients treated with low dose radiotherapy (median dose, 58.5 Gy at 1.5-1.8 Gy daily fractions), 16 patients with high dose radiotherapy (67.5-70 Gy) at higher daily fractionation doses (2-2.25 Gy), and 71 patients underwent conservation surgery. The overall local control rate was 85%. The overall salvage rate was 68%. The 5-year actuarial and disease specific survivals were 81.5% and 92%, respectively. Unaided phonation was achieved in 84.4% of the patients. An incidence of 10.4% regional metastases, 2.2% distant metastases, and 6% second primary tumors was documented. There were no statistical differences in local control, voice preservation, and 5-year actuarial and disease specific cure rates between conservation surgery and high dose radiation (p = .89). Low dose radiation had statistically lower local controls, 5-year survival, and voice preservation (p = .014). In advanced T2B disease, treating the ipsilateral neck nodes reduced regional metastases (p = .02). CONCLUSIONS: High dose and daily fractionation (70 Gy at 2 Gy daily fraction doses) radiation achieved results equivalent to those of conservation surgery in 5-year local control, survival, and voice preservation. In advanced T2B disease, treatment of the ipsilateral neck nodes by radiotherapy or functional neck dissection reduced regional metastases.     

Planned neck dissection as an adjunct to the management of patients with advanced neck disease treated with definitive radiotherapy: for some or for all?

BACKGROUND: Management of patients with head and neck carcinoma and advanced nodal disease is controversial. The purpose of this analysis was to evaluate the efficacy and toxicity of definitive radiotherapy followed by planned neck dissection in patients with bulky neck disease. MATERIALS AND METHODS: The records of 52 patients who were treated between 1989 and 1995 at the Peter MacCallum Cancer Institute with a planned neck dissection after radical radiotherapy were reviewed. All had advanced neck disease with one or more nodes >/=3 cm in maximum diameter, 94% being staged N2-3. The most common primary site was the oropharynx (56%). Sixty percent of patients had either T2 or T3 primaries and all were AJCC stage IV. Treatment consisted of high-dose radiotherapy to the primary and involved neck sites using various fractionation protocols followed by radical or modified radical neck dissection after confirmation of a complete response at the primary site. The median follow-up for living patients was 58 months (range 32-97). RESULTS: There were nine regional failures, of which three were outside the dissected neck, yielding a 5-year actuarial overall neck control rate of 83% and an in-field control rate of 88%. In-field control rates by neck stage were N1 3/3; N2 31/35; N3 11/13 and NX 1/1. There was only one in-field failure among 28 patients who had pathologically negative neck specimens compared with five in 24 patients with morphologic evidence of residual disease. Of the 24 patients with pathologically positive necks, 5 were long-term survivors and were probably cured by their surgery. Another 4 died of intercurrent disease without documented recurrence of their head and neck cancer. Ten patients recurred at their primary sites (5-year actuarial control 79%) and 8 developed distant metastases (5-year actuarial rate 20%). A total of 21 patients failed at one or more sites and none was salvaged. Five-year actuarial disease-free survival was 57% and overall survival 38%. Nine patients (17%) sustained significant complications following neck dissection. CONCLUSIONS: In patients with advanced neck disease who are treated primarily with radical radiotherapy, planned neck dissection provides excellent regional control and appears to cure a subset of patients. However, routine neck dissection adds significant morbidity to treatment and should ideally be avoided in those patients in whom surgery is either unnecessary (no residual tumor) or futile (unsalvageable disease recurrence outside the dissected neck). Based on our analysis and other recently reported series, we now recommend observing patients who have a complete response to high-dose radiotherapy (+/- chemotherapy). The ability of PET imaging to detect residual viable tumor in the head and neck or at distant sites is under investigation.     

Salvage vertical partial laryngectomy for radiation failure in early glottic carcinoma

Background: Partial laryngectomy after failure of radiotherapy for early glottic cancer is an accepted surgical salvage procedure. However,there have been only a few studies on recurrent disease or long‐term survival. Methods: Twenty‐one patients who were treated with salvage partial vertical laryngectomy (PVL) following failure of primary radiotherapy were prospectively studied. Median follow up was 69 months(range 24?204 months). Patients were seen at two‐ monthly intervals for the first 24 months and then 3?4 monthly for 5 years after their partial surgery or until death. Results: Local control was 71.4% (15/21).Among the six patients who recurred within the larynx, two patients developed a second primary; one on the ipsilateral false cord at 24 months and the other on the contra‐lateral vocal cordat 10 years. The no evidence of disease rate following salvage PVL was 95%, 85% and 73% at 12,24 and 36 months, respectively, with a mean disease free interval of 34.9 months (range 7?120). Survival was 90%, 85% and 80% at 12, 24 and 36 months, respectively, with a median survival of 152 months forthe group. Three patients died of their disease and four from other causes. Four local recurrences occurred within 32 months.Two developed neck metastases and died of their disease. Four patients were treated successfully with completion laryngectomy. Only one of these died, but this was due to a second primary squamous cell carcinoma in the lung. Three of the four patients with local recurrences had an extended procedure. Conclusion: Partial vertical laryngectomy is an excellent alternative to total laryngectomy for salvage following failure of ­radiation.Although local recurrence occurred more frequently in those patient shaving an extended partial procedure, this was not statistically different.     

Carbon dioxide laser salvage surgery after radiotherapy failure in T1 and T2 glottic carcinoma.

OBJECTIVES: Recurrent glottic carcinoma after radiotherapy (RT) may be managed by open neck or endoscopic surgery. The impact of endoscopic treatment with CO(2) laser for recurrent glottic carcinoma after RT is reported. METHODS: We present the oncologic and vocal outcomes of a retrospective study based on a series of 16 patients with rT1 and rT2 glottic carcinoma who were endoscopically managed between February 1995 and December 1999 after RT failure. All patients were males with a mean age of 68.7 years (range, 50 to 87 years). Before RT, the lesions had been staged as T1 N0 in 11 patients and T2 N0 in 5, and after RT as rT1 N0 in 12 and rT2 N0 in 4. According to the European Laryngological Society classification, a total of 9 transmuscular, 3 total, and 4 extended cordectomies were performed. Mean follow-up was 45 months (range, 9 to 79 months). RESULTS: Endoscopic salvage surgery was successful in 14 patients. One of them developed a second recurrence and was definitively cured with an additional endoscopic procedure. Two of the 16 patients had recurrent disease after salvage laser surgery and died due to progression of disease. Ultimate local control with laser alone at 3 years was 87.1%, according to the Kaplan-Meier method. Laryngeal preservation was obtained in all survivors after endoscopic rescue surgery. Voice analysis showed a clear correlation between the amount of vocal cord tissue resected and decrease of the vocal outcome. CONCLUSIONS: The present series indicates that selected recurrences after primary RT for T1 and T2 glottic carcinoma are eligible for endoscopic salvage surgery with oncologic results comparable to those with open neck procedures but with a lower complication rate and a favorable functional outcome.     

Clinical outcome following total laryngectomy for cancer

Background: Patients with advanced cancers of the larynx and hypopharynx have been treated with total laryngectomy at the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney in the past. Increasingly, these patients are being managed with organ‐sparing protocols using chemo­therapy and radiotherapy. The aim of the present study was to review complication, recurrence and survival rates following total laryngectomy. Methods: Patients who had total laryngectomy for squamous carcinomas of the larynx or hypopharynx between 1987 and 1998 and whose clinicopathological data had been prospectively accessioned onto the computerized database of the Department of Head and Neck Surgery, Royal Prince Alfred Hospital, were reviewed. Patients whose laryngectomy was a salvage procedure for failed previous treatment were included. Results: A total of 147 patients met the inclusion criteria for the study, including 128 men and 19 women with a median age of 63 years. Primary cancers involved the larynx in 90 patients and hypopharynx in 57. There were 30 patients who had recurrent (n = 24) or persistent disease (n = 6) after previous treatment with radiotherapy (26 larynx cases and four hypopharynx cases). Pharyngo‐cutaneous fistulas occurred in 26 cases (17.7%) and, using multivariate analysis, the incidence did not correlate with T stage, previous treatment or concomitant neck dissection. Local control rates were 86% for the larynx and 77% for the hypo­pharynx groups and neck control was 84% and 75%, respectively. Five‐year survival for the larynx cancer group was 67% and this was significantly influenced by T stage and clinical and pathological N stage. Survival in the hypopharynx group was 37% at 5 years and this did not significantly correlate with T or N stage. There was a non‐significant trend to improved survival among previously treated patients whose laryngectomy was a salvage procedure. Conclusion: Patients with cancer of the larynx had a significantly better survival following total laryngectomy than patients with hypopharyngeal cancer. Those whose laryngectomy was carried out as a salvage procedure following failed previous treatment did not have a worse outcome than previously untreated patients.     

Results of hemilaryngectomy in primary surgical treatment of laryngeal carcinoma

Hemilaryngectomy is the resection of a true anatomic half of the larynx with preservation of the cricoid cartilage. We present a retrospective study of 438 patients with glottic carcinoma, treated with hemilaryngectomy, at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia between 1988 and 1997. The patients with positive margins (19.4% of all) were postoperatively irradiated. Local recurrences of carcinoma were found in 17.3% of subjects, and regional recurrences in 16.4% of subjects. Those patients were treated with total laryngectomy or radical neck dissection, and with radiotherapy. 5-years survival rate in our patients was 79%. Hemilaryngectomy provided acceptable percent of local and regional recurrences, and good functional results: respiration, swallowing and voice quality. Therefore it could be the first choice surgery technique in treatment of T2 laryngeal carcinoma.     

Radiation therapy of glottic carcinoma: Peter MacCallum Cancer Institute experience.

The medical records of patients with T1N0, T2N0 and T3N0 squamous cell carcinomas of the glottis treated at the Peter MacCallum Cancer Institute between January 1983 and October 1988 were retrospectively reviewed. One hundred and twenty-seven patients were identified. There were 93 T1, 26 T2 and eight T3 tumours. These patients were treated with curative radiotherapy (60-70 Gy). The survival from glottic cancer of patients with T1, T2 and T3 tumours at 5 years was estimated to be 97, 62 and 100% respectively. The local disease free survival for T1 and T2 disease at 5 years was estimated to be 82 and 65% respectively. The local disease free survival for T3 tumours at 2 years was estimated to be 63% with 5 year survival not yet reached. The surgical salvage rates for 24 radiotherapy failures were 77, 25 and 66% for T1, T2 and T3 tumours respectively. Radiotherapy remains the treatment of choice for T1 tumours and a viable alternative to primary laryngectomy in more advanced glottic tumours, with salvage surgery in reserve.     

Partial laryngectomy after irradiation failure.

INTRODUCTION: Radiation therapy is often the first method of treating patients with early cancer of the glottis. There is a substantial failure rate among these patients. Total laryngectomy has usually been the means of treating patients with failure after radiation. In recent decades, partial laryngectomy has been used for salvage in such patients. This article will discuss the use of partial laryngectomy for radiation failure both from the oncologic result as well as the morbidity. PATIENTS AND METHODS: Between 1984 and 1995, 27 patients with early-stage laryngeal carcinoma underwent salvage partial laryngectomy after irradiation failure. Vertical laryngectomy was performed in 18 patients (13 with T1 N0 and 5 with T2 N0) and horizontal-supraglottic laryngectomy in 9 patients (3 with T1 N0, 1 with T2 N0, and 5 with T2 N1). The mean follow-up was 4.1 years. RESULTS: Local control was obtained in 77.7% of patients with glottic lesions (T1: 84.6%; T2: 60%, P = NS) and in 55.5% of patients with supraglottic lesions (T1: 66.6%; T2: 50%; P = NS). There was no regional recurrence in the vertical laryngectomy group, whereas the regional control rate in the horizontal-supraglottic laryngectomy group was 77.7%. Distant control was achieved in 94.4% of patients with glottic disease and in 77.7% of patients with supraglottic disease. The overall survival rate for glottic lesions was 88.8% (T1: 92.3%; T2: 80%; P = NS) versus 66.6% for supraglottic lesions (T1: 100%; T2: 50%; P = NS). CONCLUSION AND SIGNIFICANCE: Vertical laryngectomy was not associated with an increased complication rate. Morbidity in the horizontal-supraglottic laryngectomy group was higher, but a satisfactory functional outcome was obtained in all cases. Therefore, in early laryngeal cancer (glottic T1-T2, supraglottic T1) partial laryngectomy can be performed with good expectation of cure and satisfactory laryngeal function. In T2 supraglottic lesions, the oncologic results are less satisfactory; further research is required for developing more efficient complimentary or alternative treatments modalities.     

Laryngectomy alone for T3 glottic cancer

Background. The long-term survival of 81 patients with T3 squamous cell carcinoma of the glottic larynx treated with laryngectomy alone is presented and pathologic predictors for cancer recurrence above the clavicles and cancer death are identified. Methods. Clinical records, operative notes, and pathologic slides were reviewed. The major end points were failure above the clavicles, cause-specific survival, and overall survival. All patients were followed until death or a minimum of 10.8 years. Results. The main pattern of treatment failure was within an undissected ipsilateral or contralateral neck. Subglottic extension and nodal metastases predicted failure above the clavicles and delayed metastasis within an undissected neck. The 5-year rate of control of disease above the clavicles, cause-specific survival, and overall survival were 74.1%, 73.7%, and 54.3%, respectively. Conclusions. Patients treated with laryngectomy for T3 glottic cancer who have pathologic evidence of subglottic extension or nodal metastasis are at higher risk for recurrence above the clavicles, particularly within an undissected neck. © 1994 John Wiley & Sons, Inc.