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CARCINOMA OF THE LARYNX
758 years ago.
They were, however, prone to certain physical
disorders. In one area otitis media was a common defect among schoolleavers. Acne was widespread and more attention should be " paid to it. The encouraging comment You’ll grow out of it " was no help to self-conscious boys and girls. Bad diet was a possible cause of many unpleasant skin conditions. The excessive consumption of carbohydrates and the appalling dental problems of adolescence were deplored. Many patients seemed to prefer wholesale extraction to having their teeth filled and regularly examined. Faults of posture and foot defects were also increasingly common, and unremitting efforts should be made to educate girls and parents in the choice of shoes that would not deform the feet. Tuberculosis was no longer a big problem; but at least in some areas there was a tendency for girls to break down with sore throats, tonsillitis, and catarrhal infections when they first started work. One group also thought that throat and upperrespiratory infections were becoming increasingly severe and intractable. Smoking aggravated these conditions.
general feeling seemed to be that the psychological problems of adolescence tended to be exaggerated. Only about 10% of delinquents, one report pointed out, could be said to need psychiatric treatment. More concern was expressed about exposure to materialism. Adolescents were wealthier than ever before and were recognised as significant consumers ". Their wants, fears, and tastes The
"
studied with great care for commercial purposes. If only a small part of the ingenuity, inventiveness, and creativeness now directed to the sale of commercial goods to the teenage market were turned towards encouraging and popularising well-run youth organisations, much might be done to remedy the futility, boredom, and lethargic apathy in which so many people of today spent their leisure. Unfortunately, the pamphlet offers no precise suggestions as to how this might be achieved. It does, however, suggest that the B.M.A. might well undertake training courses for parents and that family doctors should play a much greater part in helping adolescents with their personal problems. were
other cancer, except basal-cell carcinoma of the skin 1: ill 70-95% of such cases the patient remains free of recurrence for at least five years after treatment by surgery or irradiation. This rate falls to around 40% for more extensive lesions. McCabe and Magielski1 declare that attention should be centred less on devising an operation to encompass the large lesion than on establishing the diagnosis while the lesion is still small. With the early, mobile, mid-cord carcinoma an excellent result may follow either surgery or radiotherapy;z but the choice of treatment must be considered carefully in each case, with the available resources and skills in mind. Radiotherapeutic techniques have made great strides. The conventional high-voltage (250 kV) treat. ment, though effective, carried the penalties of severe skin and mucosal reactions and of general reactions. With the modern cobalt or csesium bombs or supervoltage beams the side-effects are less severe, but treatment still has to be fairly lengthy and is associated with some dascomfort. A normal voice nearly always returns with the disappearance of the tumour; and radiotherapy is generally preferable in the otherwise fit, younger patient, who often depends on his voice for a living. Surgical treatment consists in resecting the affected vocal cord together with a margin of healthy tissue all round the This operation of laryngofissure does not tumour. necessitate lengthy convalescence and is not usually accompanied by any general disturbance; and the voice is often surprisingly good. Surgery is indicated where the tumour is not regressing satisfactorily after radiotherapy ; where the facilities for irradiation are inadequate; and sometimes in the elderly, who may be unsuitable for a complete course of radiotherapy and the associated discomfort. There is no place for an attenuated dose of irradiation, however small the lesion. Equally, local excision of the tumour is unlikely to eradicate the disease, In occasional cases it is permissible to observe the appearance of a doubtful lesion for a short time. McCabe and Magielski cite Furstenberg as claiming a 100% cure-rate
CARCINOMA OF THE LARYNX
THE division of laryngeal cancers into intrinsic and extrinsic forms has given rise to much confusion, and has now been largely abandoned. The extrinsic form is, in fact, a tumour of the pharynx, and except for proximity it has very little in common with true laryngeal cancer. Carcinoma of the larynx may present above or below the true vocal cords, but the commonest site is the cords themselves. The glottis is continuously exposed to all the inspired, carcinogen-laden air, which is then distributed over the much larger area of the bronchial tree. Yet, though the incidence of bronchial carcinoma has increased beyond doubt, there has been no parallel increase in the incidence of laryngeal cancer. Clinically, the larynx is one of the less unpleasant sites for carcinoma. For this there are several reasons. The larynx is accessible and readily examined; and the smallest macroscopic lesion causes hoarseness. (This symptom is generally ascribed at first to laryngitis; and absence of response to treatment within two to three weeks constitutes a clear indication for laryngoscopy.) Furthermore, the subepithelial space tends to delay deep invasion of the cord, and the relatively poor lymphatic supply makes for late dissemination of the neoplasm. A small, localised, squamous-cell carcinoma on the edge of the vocal cord is more amenable to cure than any
from
merely stripping the cord-repeatedly, if
necessary-and close observation. Others1 have had similar experience ir, this small group of cases. In keratosis of the larynx, a precancerous state corresponding to leucoplakia which presents with white or grey nodules on one or both vocal cords, careful and frequent examinations are essential in order to detect any change Radiotherapy has two disadvantages in keratosis: once applied, it cannot later be used effectively for frank carcinoma; and keratosis is relatively radioresistant even to full tumour doses. Some workers recommend stripping the cords; but the lesion tends to recur, and, if both vocal cords are involved, stripping may lead to glottic oedema. When carcinoma supervenes, laryngofissure offers the best prospects with unilateral disease. With more extensive disease, radiotherapy is usually applied in the first instance, and surgery for any residual disease. The United Kingdom is fortunate in having efficient radiotherapy centres with highly skilled staffs throughout the country. Early carcinoma of the larynx is therefore generally irradiated, with excellent results. More advanced laryngeal cancers are also treated in the fúS( place by radiotherapy; and total laryngectomy with or without radical dissection of the cervical lymph-glas.iis then undertaken for any residual disease. PreopeHQ’.e radiotherapy makes subsequent recurrence less likely. especially in cases with subglottic extension of the lesion. 1.
McCabe, B. F., Magielski, J. E.
Ann.
Otol., &c.,
St. Louis,
1960. 69,
’
They were, however, prone to certain physical
disorders. In one area otitis media was a common defect among schoolleavers. Acne was widespread and more attention should be " paid to it. The encouraging comment You’ll grow out of it " was no help to self-conscious boys and girls. Bad diet was a possible cause of many unpleasant skin conditions. The excessive consumption of carbohydrates and the appalling dental problems of adolescence were deplored. Many patients seemed to prefer wholesale extraction to having their teeth filled and regularly examined. Faults of posture and foot defects were also increasingly common, and unremitting efforts should be made to educate girls and parents in the choice of shoes that would not deform the feet. Tuberculosis was no longer a big problem; but at least in some areas there was a tendency for girls to break down with sore throats, tonsillitis, and catarrhal infections when they first started work. One group also thought that throat and upperrespiratory infections were becoming increasingly severe and intractable. Smoking aggravated these conditions.
general feeling seemed to be that the psychological problems of adolescence tended to be exaggerated. Only about 10% of delinquents, one report pointed out, could be said to need psychiatric treatment. More concern was expressed about exposure to materialism. Adolescents were wealthier than ever before and were recognised as significant consumers ". Their wants, fears, and tastes The
"
studied with great care for commercial purposes. If only a small part of the ingenuity, inventiveness, and creativeness now directed to the sale of commercial goods to the teenage market were turned towards encouraging and popularising well-run youth organisations, much might be done to remedy the futility, boredom, and lethargic apathy in which so many people of today spent their leisure. Unfortunately, the pamphlet offers no precise suggestions as to how this might be achieved. It does, however, suggest that the B.M.A. might well undertake training courses for parents and that family doctors should play a much greater part in helping adolescents with their personal problems. were
other cancer, except basal-cell carcinoma of the skin 1: ill 70-95% of such cases the patient remains free of recurrence for at least five years after treatment by surgery or irradiation. This rate falls to around 40% for more extensive lesions. McCabe and Magielski1 declare that attention should be centred less on devising an operation to encompass the large lesion than on establishing the diagnosis while the lesion is still small. With the early, mobile, mid-cord carcinoma an excellent result may follow either surgery or radiotherapy;z but the choice of treatment must be considered carefully in each case, with the available resources and skills in mind. Radiotherapeutic techniques have made great strides. The conventional high-voltage (250 kV) treat. ment, though effective, carried the penalties of severe skin and mucosal reactions and of general reactions. With the modern cobalt or csesium bombs or supervoltage beams the side-effects are less severe, but treatment still has to be fairly lengthy and is associated with some dascomfort. A normal voice nearly always returns with the disappearance of the tumour; and radiotherapy is generally preferable in the otherwise fit, younger patient, who often depends on his voice for a living. Surgical treatment consists in resecting the affected vocal cord together with a margin of healthy tissue all round the This operation of laryngofissure does not tumour. necessitate lengthy convalescence and is not usually accompanied by any general disturbance; and the voice is often surprisingly good. Surgery is indicated where the tumour is not regressing satisfactorily after radiotherapy ; where the facilities for irradiation are inadequate; and sometimes in the elderly, who may be unsuitable for a complete course of radiotherapy and the associated discomfort. There is no place for an attenuated dose of irradiation, however small the lesion. Equally, local excision of the tumour is unlikely to eradicate the disease, In occasional cases it is permissible to observe the appearance of a doubtful lesion for a short time. McCabe and Magielski cite Furstenberg as claiming a 100% cure-rate
CARCINOMA OF THE LARYNX
THE division of laryngeal cancers into intrinsic and extrinsic forms has given rise to much confusion, and has now been largely abandoned. The extrinsic form is, in fact, a tumour of the pharynx, and except for proximity it has very little in common with true laryngeal cancer. Carcinoma of the larynx may present above or below the true vocal cords, but the commonest site is the cords themselves. The glottis is continuously exposed to all the inspired, carcinogen-laden air, which is then distributed over the much larger area of the bronchial tree. Yet, though the incidence of bronchial carcinoma has increased beyond doubt, there has been no parallel increase in the incidence of laryngeal cancer. Clinically, the larynx is one of the less unpleasant sites for carcinoma. For this there are several reasons. The larynx is accessible and readily examined; and the smallest macroscopic lesion causes hoarseness. (This symptom is generally ascribed at first to laryngitis; and absence of response to treatment within two to three weeks constitutes a clear indication for laryngoscopy.) Furthermore, the subepithelial space tends to delay deep invasion of the cord, and the relatively poor lymphatic supply makes for late dissemination of the neoplasm. A small, localised, squamous-cell carcinoma on the edge of the vocal cord is more amenable to cure than any
from
merely stripping the cord-repeatedly, if
necessary-and close observation. Others1 have had similar experience ir, this small group of cases. In keratosis of the larynx, a precancerous state corresponding to leucoplakia which presents with white or grey nodules on one or both vocal cords, careful and frequent examinations are essential in order to detect any change Radiotherapy has two disadvantages in keratosis: once applied, it cannot later be used effectively for frank carcinoma; and keratosis is relatively radioresistant even to full tumour doses. Some workers recommend stripping the cords; but the lesion tends to recur, and, if both vocal cords are involved, stripping may lead to glottic oedema. When carcinoma supervenes, laryngofissure offers the best prospects with unilateral disease. With more extensive disease, radiotherapy is usually applied in the first instance, and surgery for any residual disease. The United Kingdom is fortunate in having efficient radiotherapy centres with highly skilled staffs throughout the country. Early carcinoma of the larynx is therefore generally irradiated, with excellent results. More advanced laryngeal cancers are also treated in the fúS( place by radiotherapy; and total laryngectomy with or without radical dissection of the cervical lymph-glas.iis then undertaken for any residual disease. PreopeHQ’.e radiotherapy makes subsequent recurrence less likely. especially in cases with subglottic extension of the lesion. 1.
McCabe, B. F., Magielski, J. E.
Ann.
Otol., &c.,
St. Louis,
1960. 69,
’