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Carcinoma of the larynx
Carcinoma of the Larynx A Retrospective Study of 144 Cases HUGH S. HARRIS, Jr., M.D., Columbia, Missouri FRANCIS R. WATSON, Ph.D., Columbia, Missouri JOHN S. SPRATT, Jr., Columbia, Missouri
The medical records of all patients having carcinoma of the larynx diagnosed at the Ellis Fischel State Cancer Hospital from 1940 through 1967 have been reviewed to evaluate the methods of treatment. All lesions were categorized according to the staging system proposed by the American Joint Committee for Cancer Staging and End Results Reporting by utilizing descriptions of the disease prior to any treatment, as recorded in the patients’ charts. The staging system has been well described but some definition of it is needed at this time to interpret this study. To standardize anatomic terminology and clinical classification of carcinoma of the larynx in the United States, the Subcommittee on the Larynx of the American Joint Committee for Cancer Staging and End Results Reporting devised a TNM system in 1959 [I]. A cooperative study of the end results in 600 cases of carcinoma of the larynx was reported by this committee in 1961 [Z] and another cooperative study is currently underway. Using this classification, the larynx is divided anatomically into supraglottic, glottic, and subglottic regions. The lingual surface of the epiglottis as well as the valleculae, the pyriform sinuses, and the postcricoid areas are not considered portions of the larynx. The anatomic regions are further divided into “sites” such as an aryepiglottic fold or a true cord. Table I summarizes “T,” “N,” and “M” definitions according to this clinical staging From the Departments of Surgery and Biomathematics, Ellis Fischel State Cancer Hospital and Cancer Research Center, Columbia, Missouri. This study was supported in part by U.S. Public Health Service Grant No. CA-08023. Presented at the Fifteenth Annual Meeting of The Society of Head and Neck Surgeons, Mexico City, Mexico, March 16-19. 1969.
676
system. The four clinical stages of the disease based on the TNM description of the disease are defined in Table II. Clinical Material From 1940 through 1967, 144 patients with histologically proved epidermoid carcinoma of the larynx received primary treatment at the Ellis Fischel State Cancer Hospital. The records of these patients were reviewed and data representing approximately 150 different social, clinical, therapeutic, and pathologic variables were abstracted and transposed onto IBM punch cards to make them readily available for computer recall and analysis. No patient was lost to follow-up study in this series. Methods and Results One hundred and twenty-four of the 144 patients were males. One hundred and thirtynine of the 144 patients were Caucasian. The patients’ ages ranged from thirty-seven to eighty-eight years with a median age of sixtyfour. The age distribution of the 144 patients and their age-specific five year survival is shown in Table III. Since ‘72 per cent of the lesions were advanced locally (T3 or T, lesions), separation into supraglottic, glottic, and subglottic areas of primary origin tends to be artificial. However, all except four lesions were categorized as to probable anatomic site of origin, as indicated in Table IV. The four unclassified lesions could not be categorized due to insufficient information. The majority of the patients had advanced disease when first seen. (Fig. 1.) Only 9 or 6 per cent were stage I lesions. Sixty-two patients or 43 per cent had clinically positive cervical lymph nodes when first seen and one patient had distant metastases. The
American
Journal
of
Surgery
Carcinoma
TABLE
I
American
Joint Committee’s
TNM Clinical Classification
Local Extent I
T
,I
of Primary
Supraglottis 1
2
3
__~
Carcinoma
(“T”)
Glottis
Tumor confined to laryngeal epiglottis, or aryepiglottic fold, or arytenoid, or false cord, or ventricle Tumor confined to supraglottic region involving more than a single site listed above Tumor of supraglottis extending onto the true cords Tumor of supraglottis extending beyond the confines of the anatomic larynx
4
Tumor
of Laryngeal
of the Larynx
Subglottis
Tumor confined to one true cord with normal mobility
Tumor confined to one side of subglottic region
Tumor confined to glottis causing limitation in mobility or involving both cords Tumor of glottis extending to supraglottic or subglottic region Tumor of glottis extending beyond the confines of the true larynx
Tumor confined but extending
to subglottis to both sides
Tumor of subglottis extending onto the true cords Tumor of subglottis extending beyond the confines of the true larynx
~~~ ___ Extent
of Cervical
Lymph
Node Metastases
(“N”)
No No clinical evidence of cervical lymph node metastasis N1 Clinically involved cervical lymph nodes that are not fixed NS Fixed cervical lymph nodes Presence of Distant ___M. No clinical evidence of metastases beyond cervical MI Clinical evidence of metastases other than cervical
Due to varying philosophies of the Chiefs of Surgery and Radiotherapy at the Ellis Fischel Hospital over these twenty-seven years, the indications for radiotherapy and for total laryngectomy have varied and examination of the resulting survivals is of interest. Primary forms of treatment used over this twenty-seven year period are shown in Table V.
TABLE
II
Clinical Stages of Carcinoma of the Larynx According to System Developed by the American Joint Committee Stage I
TlNoMo
Stage II
TsNoMa TaNoMo T,NoMo
Metastases lymph lymph
(“M”)
nodes nodes
Actuarial (life table) survivals of these patients were calculated with and without age correction. Age correction takes into account the over-all survival of a population of specific ages which are identical to the ages in any given life table and is determined according to a special computer program. It is based on Missouri Life Tables and, in this instance, is determined from normal survivals of Missouri
TABLE
III
Age-Specific Patients with of the Larynx
Age by Decade No. of Patients Stage III
Stage IV
T,NlM, -Nz---MI
Vol. 118, November 1969
30-39 40-49 50-59 60-69 70-79 80-89
3 13 38 51 30 9
Survival Among 144 Epidermoid Carcinoma
Observed Five Year Actuarial Survival (Per cent)
Normal Five Year Survival (Per cent)
33 66 43 33 35 10
98 95 90 82 68 52
677
Harris, Watson, and Spratt
males. Age correction is used to compare survivals excluding deaths from causes other than the disease in question, in this case carcinoma of the larynx. Figure 2 shows the over-all survival of the 144 patients in this series, indicating a 37 per cent five year observed actuarial survival or 45 per cent age-corrected survival. It is apparent from this curve, as well as from the
other survival curves in this study, that very few deaths from laryngeal cancer occurred after the fifth year and, hence, five year survival curves for laryngeal cancer probably approximate “cure” of this disease. In Figure 3, age-corrected survivals according to various modes of therapy, disregarding stages of the disease, are illustrated. Of the eighty-four patients treated originally with
TABLE
Anatomic Carcinoma
IV
Location
Location of 144 Cases of the Larynx No. of Patients
Per cent ___
78 58 4 4 144
54 40 3 3 100
Supraglottis Glottis Subglottis Unclassified Total
of 144 patients with carcinoma Fig. 1. Distribution of the larynx according to clinical stage (American Joint Committee for Cancer Staging and End Results Reporting).
Treatment Methods Used in Treating 144 Patients with Carcinoma of the Larynx
TABLE V
No. of Patients
Form of Treatment
Fie. 2. Actuarial survival of 144 oatients having e$dermoid carcinoma of the larynx: all stages an; all methods of treatment are included.
TABLE VI
No. of Patients
I II (T2) (Tz) (T4) III IV +I”c,“dri
po,,e,>t,
lotrs
(T,N,M,)
i,rrr,ng laryngrc,cnly
Fig. 3. Age-corrected actuarial survivals among 144 patients with carcinoma of the larynx according to various modes of therapy.
*
According
Joint
Committee
25 50 1 9 144
Five Year Actuarial Survival by Clinical among 144 Patients with Stage* Carcinoma of the Larynx
Clinical Stage
678
59
Radiotherapy alone Radiotherapy followed by attempted surgical salvage Total laryngectomy with or without neck dissection Laryngofissure No treatment or palliative chemotherapy only Total
L
of
Observed Survival (Per cent)
9 69
56 48
71 61
(19) (32) (18) 26 36
(55) (48) (43) 21 28
(73) (61) (50) 25 35
(31)
(32) to
staging for
Age-Corrected Survival (Per cent)
system
Cancer
adopted
Staging
and
(39) by End
American Results
Re-
porting.
The
American
Journal
of
Surgery
Carcinoma
2
4
6
e
of the Larynx
io
Yeor*
Fig. 4. Age-corrected of the larynx.
Fig. 5. larynx.
Age-corrected
4 actuarial survival
survival after laryngzctomy after
laryngectomy
radiotherapy, it was indicated in their medical records that thirty were treated for “palliation,” despite the fact that some of these patients had prolonged survivals. The survival curve for the remaining fifty-four patients treated originally with radiotherapy for “cure” is shown to compare it with the fifty patients treated originally with total laryngectomy. Twenty-five of the patients in the group receiving primary radiotherapy later underwent laryngectomy for postirradiation persistence as indicated by the appropriate survival curve. A separate category of fifty-nine patients who were treated originally with radiotherapy and who did not undergo any subsequent surgery had a low survival curve. Of nine untreated
Age-corrected Fig. 6. cinoma of the larynx. Fig. 7. clinical
actuarial
survival
after
and after
and
after radiotherapy
radiotherapy
for stage II carcinoma
for stage
Ill carcinoma
patients, all except one died within one year after diagnosis. Table VI indicates the five year actuarial survival for each of the four clinical stages. Not included are four patients whose lesions could not be staged because of inadequate available information. Of the nine patients with stage I lesions in this series, eight were treated originally with radiotherapy and one, a patient with verrucous carcinoma of the true cord, was treated originally by laryngofissure. Sixty-five patients underwent primary treatment for stage II lesions, either by total laryngectomy or radiotherapy, and the resulting observed survival rates are shown in Figure 4. Survival rates of twenty-five patients
faryngectomy
and
after
radiotherapy
for
stage
Age-corrected actuarial SUNiVaf curves of patients with carcinoma of the larynx according assessment of the cervical lymph nodes. All modes of therapy are included.
Vol. 118. November 1969
of the
IV
car-
to the
679
Harris, Watson, and Spratt
100*
Fig. 8. Comparison of age-corrected survival curves of patien’ts having clinically positive cervical lymph nodes when treated by laryngectomy and by radiotherapy. Patients in whom surgical salvage was attempted after radiotherapy failure are excluded.
with stage III lesions having total laryngectomy or radiotherapy are shown in Figure 5. Thirty-two patients underwent treatment of stage IV lesions and their survival rates after the two modes of therapy are shown in Figure 6. It is evident that patients with quite far advanced clinical stage IV diseases (chiefly T,N,M,, lesions having large primary tumors with clinically positive lymph nodes) are POtentially curable by total laryngectomy. The improved survival in patients with stage IV laryngeal cancers over those with stage III lesions probably is indicative of difficulty in accurately determining the extent of primary lesions in a retrospective study. Also, an unusual number of false-positive cervical lymph nodes may have occurred in those with stage IV tumors. Of interest is that the age-corrected five year survival rates for T,NIM, and T,N,Mo lesions were similar, being 31.5 and 39 per cent, respectively. The influence of clinically involved cervical lymph nodes is illustrated by the survival curves shown in Figure 7, without separation of the therapeutic modalities involved. The presence of clinically positive lymph nodes bilaterally in the neck was a particularly grave prognostic sign, worse than the over-all T,N,M,, category. Figure 8 compares the age-corrected survival curves of patients having clinically positive nodes when treated either by total laryngectomy or by primary radiotherapy. A policy of treating advanced cancer of the larynx with radiotherapy followed by observation and attempted surgical salvage if persis-
tent disease is discovered had been severely criticized [3]. Nevertheless, this method of treating laryngeal cancer is practiced [4] and has been used on several occasions in this institution. During the twenty-seven year period covered by this series, twenty-five total laryngectomies were performed for presumed irradiation failures, although in three of the resection specimens, no residual tumor was found. The operative mortality was high (24 per cent) in this group. Of the twelve patients treated more than four years ago who survived the surgical procedure, six lived for four years or more without evidence of recurrent disease. The actuarial survival curve for these twenty-five patients is shown in Figure 3. Complications The complications which occurred among the seventy-five patients who underwent total laryngectomy (with or without neck dissections) are shown in Table VII. A comparison of the incidence of these complications is made between the twenty-five patients having received previous radiotherapy and those fifty who had had no previous radiotherapy. No statistically significant difference in the relative incidence of these complications exists. The most apparent difference was the 12 per cent incidence of rupture of the carotid artery occurring among the twenty-five patients who had undergone previous radiotherapy versus the 2 per cent incidence among patients with no previous radiotherapy. However, this difference is not significant statistically (P = 1.0). Of interest is the fact that five pharyngocutaneous fistulas occurred among the twentyfive patients who had undergone previous radiotherapy and of these, two required surgical correction. Ten pharyngocutaneous fistulas (the same incidence) occurred among the fifty patients who had not received prior radiotherapy, but of these, all but one healed without requiring surgical intervention, This suggests impaired healing of the irradiated tissue. There was no difference in the length of hospital stay after laryngectomy between the group of patients having had previous radiotherapy and those who had not. The mean length of hospitalization after laryngectomy in patients without previous radiotherapy was 24.5 days. It was 22.4 days for those who had had previous radiotherapy. The median stay The American
Journal
of Surgery
Carcinoma
TABLE
VII
Complications Dissection
among
Seventy-five
Patients
Complication Occurring Hemorrhage into wound requiring reoperation Hematoma requiring aspiration Seroma requiring aspiration Seroma requiring drainage Minor skin slough Skin slough requiring grafting Pharyngeal fistula not requiring surgery Pharyngeal fistula requiring surgical procedures Carotid artery rupture Wound infection Tracheal retraction postoperatively Late tracheal stenosis requiring revision Pneumonia Cardiovascular complications Cerebrovascular accidents Thrombophlebitis Pulmonary embolus Lymph fistula Acute parotitis Upper gastrointestinal hemorrhage
was twenty days for both groups. Patients dying in the postoperative period were excluded in determining the mean and median of these groups. More striking is the difference in operative mortality among those with and without previous irradiation. The over-all operative mortality from total laryngectomy was 13 per cent, representing ten deaths among the seventy-five undergoing patients total laryngectomy. However, six of these deaths occurred among the twenty-five patients who had previously received radiotherapy, giving an operative mortality of 24 per cent in this particular group. Four deaths occurred among the fifty patients without previous radiotherapy, an operative mortality of 8 per cent. Again, however, this difference is only of borderline statistical significance with a P value of .075. Table VIII indicates the operative procedures which were carried out in these two groups along with the apparent cause of each postlaryngectomy death. Of the four deaths occurring among the fifty patients who did not receive previous radiotherapy, none were directly related to local complications, whereas among the patients with irradiation, two died as a result of rupture of the carotid artery. One patient in this group underwent Vol. 118, November 1969
Undergoing
Total No.
12 3 4 9 1 9 5 2 1 1 1 1
Laryngectomy
with
No. among Twenty-five Patients with Previous Radiotherapy
and
of the
without
3(6%,)
3(120/o) 1(4%‘0) 0
&%b) 0
2@%) 302%) 1(4%,) 1(4%‘0) 1(4%‘0) 1(4%,) 1(4%) 0 0
Neck
No. among Fifty Patients with No Previous Radiotherapy
1(4%,) 0
2@%0) 302%) 2(8%) 302%) 405%) 0
Larynx
2~4%) 5(10%) 9(1g%,) 1(2%) 1(2%> 5(10%) 1(2%) 704%) 2(4%1 1(2%,) 0 0 0 0 1(2%,) 1(2%,)
laryngectomy at another hospital and the cause of death is not known.
Comments Terminology which has been used to describe the location of laryngeal lesions has varied widely among various authors, as has the method of clinical staging of the disease. If one compares anatomic definitions as given by two sources in the literature [5,6], one finds that the term “endolaryngeal” refers to a lesion confined to the true and false cords and the ventricle according to one authority, whereas according to the other author, it also refers to lesions involving the supraglottis and subglottis. “Intrinsic” refers to tumors involving the true cords or anterior commissure according to one author, but has been used to describe any lesion located within the lumen of the laryngeal organ according to the other authors. The term “vestibule” seems to be synonymous with the supraglottis, although it has been limited on some occasions to the area formed by the base of the epiglottis and the false cords. “Extrinsic” lesion8 have been those lesions considered involving the epiglottis, aryepiglottic fold, pyriform sinus, and arytenoid eminence, while a recent study in the literature uses the terms “extrinsic 681
Harris,
Watson,
TABLE VIII
No.
and Spratt
Postlaryngectomy
AgeW.1 and Sex
Stage
Deaths Occurring
Months after Radiation Therapy
With Previous Radiotheraov 45-08115 53, M Unknown 47-09619 73, F TSNIMO
2 4
58-24943
74, M
T,N,Mo
4112
60-27910
44, F
ToNoM,,
6
58-25056
53, M
TsNoMo
I’/2
64-32356
77, F
TpNoMo
Without Any Previous Radiotherapy 57-24172 60, M TzNlM,, 62-30401
57, M
T,NIMo
65-33578
59, M
TdNIMo
67-36853
71, M
TBN,Mo
28
Operation Laryngectomy Laryngectomy Laryngectomy dissection Laryngectomy dissection Laryngectomy dissection Laryngectomy
Laryngectomy dissection
Year
Cause
and neck
Unknown (fourth day) Pneumonia Cerebrovascular accident
1945 1947 1960
and neck
Carotid
1960
and neck
Pharyngocutaneous fistula carotid artery rupture Unknown (elsewhere)
1964
Perforated
1957
Laryngectomy and neck dissection Laryngectomy and bilateral neck dissection Laryngectomy and bilateral neck dissection
exolaryngeal” endolaryngeal” and “extrinsic [7]. The term “infraglottic” has been used to describe tumors involving the glottis and subglottis whereas “transglottic” tumors are those which cross the ventricle of Morgagni [S]. This plethora of ambiguous terms indicates the need for standardizing terminology used in studies describing therapeutic end results. A preferable method of describing the location and extent of the primary tumor is to indicate the exact anatomic sites in the larynx and adjacent structures which appear to be involved by the tumor. This avoids the use of vague nonanatomic terms and makes use of anatomic sites which are well defined in standard textbooks of anatomy. This method has been used by the American Joint Committee in devising their clinical staging system. Although the American Joint Committee System tends to be complicated, it encourages precision in examination and description. It has been found to be a usable system and its stages reflect differing survival rates [S,g]. However, because of the difficulty of emsloying the American Joint Committee’s booklet for the Staging of Cancer of the Larynx, we attempted to devise a simple tabular method which follows the same staging procedure outlined in the booklet. Table IX is the result of this effort. To employ this table, one 682
within Thirty Days after Surgery
and neck
artery
rupture
duodenal
ulcer
1966
Death on operating room table (10 hour operation) Tracheal mucous plug
1965
Pneumonia,
1967
parotitis
merely notes the various characteristics of the lesion, drawing a line through the numbers to the right of each characteristic which is positive for the given tumor. Once this procedure is completed for the entire list, one may find the appropriate stage, T value, N value, and M value by starting from the bottom of the corresponding column and going up until the first number through which a line has been drawn is encountered. It should be noted that regarding tumor extension there are two sets of identical items depending on whether there are clinically positive nodes or no lymph nodes. Only the appropriate set is to be considered. For example, in staging a lesion of the aryepiglottic fold extending into the pyriform sinus and with palpable cervical lymph nodes, one would first draw a line through “aryepiglottic fold and arytenoid,” extending the line through the numbers to its right. Next, a line would be drawn through “lymph nodes not fixed” and this line again continued through the numbers to the right of this item. Finally, a line would be drawn through “extension to the pyriform sinus” and the numbers to its right in the section “lymnh nodes.” Then, one would find upon beginning at the bottom of the table, that the lesion would be staged as 4 because of the lowermost line The Amerlcsn
Journal
of Surgery
Carcinoma of being through the number 4 under Stage. Similarly, it would be a T4N,M, classification. Other problems are encountered in using the American Joint Committee system. In evaluating an advanced local lesion, an error in judgement in determining the presence or absence of cervical lymph node metastases will change the clinical staging of the disease from a stage IV to a stage II, since a T,N,MO lesion is stage II whereas a TIN,M, lesion is stage IV. Another defect in the system is the inability to indicate bilateral cervical lymph node metastases. Any unusual number of bilateral cervical lymph node metastases adversely affects the survival in patients with stage III lesions, as indicated in Figure 7. A similar staging system used at the M. D. Anderson Hospital takes into account the presence of bilateral cervical lymph node metastases and these particular lesions are included with the stage IV lesions regardless of the size of the primary lesion [ZO]. The clinical stage II lesions cover a rather wide spectrum of local disease in the larynx and, hence, this stage is usually further subdivided into T2, T,, and T4 categories in reporting end results. It includes diseases varying in extent from a relatively small cord lesion with invasion of the laryngeal ventricle to a large supraglottic lesion involving the entire interior of the larynx with extension to the pyriform sinus, subcutaneous tissues, and skin. It is illogical that these tumors should be placed in the same clinical stage and, indeed, survivals differ rather widely between these two extremes. (Table VI.) In this series, surgery resulted in the salvage of a large percentage of those in whom radiation failed without inordinate postoperative complications. Similarly, Baker Cl11 has reported the salvage by laryngectomy of nineteen of thirty-four patients in whom radiation failed. Larger numbers of cases are necessary to confirm or disprove the opinion of Cantril [3] who stated that a trial of radiotherapy is justifiable prior to surgery. Our data indicate a consistent superiority in survival rates in patients with carcinoma of the larynx when treated by primary total laryngectomy (usually with neck dissection) as opposed to radiotherapy. However, in this group of patients, chiefly indigent Missouri farmers, only twenty-seven of seventy-five having total laryngectomy ever definitely deVol. 118, November 1969
TABLE
IX
the Larynx
Staging of Cancer of the Larynx Tumor Characteristics
Stage T N M
Laryngeal surface of epiglottis Aryepiglottic fold or arytenoid Ventricular cavity or band One cord-normal mobility One side subglottic-not undersurface Epiglottis t3 ventricular bands or cavities Both cords-normal mobility Tumor fixed to cord(s) Both sidessubglottic-not undersurface Epiglottis to cord(s) Ventricular cavity or band to cord(s) Cord(s) to ventricular bands or cavities Subglottic region to cords
1100 1100 1100 1100 1100 2 2 0 0 2 200 2 200 2 2 0 0 2 300 2 300 2 3 0 0 2 300
z 2 z E 3 0
2 2 2 2 2 2
Z
Extension Extension Extension Extension Extension Extension
Lymph m 5 Z z E 3
to to to to to to
pyriform sinus postcricoid region vallecula tongue base trachea skin
nodes-not
Extension Extension Extension Extension Extension Extension
to to to to to to
fixed pyriforms sinus postcricoid region vallecula tongue base trachea skin
Fixed lymph nodes Distant metastasis
3 4 4 4 4 4 4 4 4
400 400 400 400 400 400 1
0
410 410 410 410 410 410 2
0 1
veloped effective means of speech (either by esophageal voice or by mechanical means). It is conceivable that a few other patients did develop effective means of speech but this information is not available in the medical records to verify this. A greater percentage of these patients have been rehabilitated in more recent years than during the 1940’s. A recent policy instituted at this hospital is for patients to be introduced to the technic of esophageal speech prior to laryngectomy and also actually learn to use a mechanical speech device* prior to surgery in order that they *We have used the “Western Electric Electronic Artificial Larynx,” obtained through the Bell Telephone Laboratories and the “Cooper-Rand Electronic Speech Aid,” obtained from the Rand Development Corporation, P.O. Box .3&X, Cleveland, Ohio. 683
Harris, Watson, and Spratt may enjoy some means of verbal communication in the immediate postoperative period. It would appear that total laryngectomy with neck dissection is the preferred method of treating advanced laryngeal cancer from the standpoint of improved survival. Planned combined preoperative irradiation may further improve survival [12,13], although loss of laryngeal speech must be remedied by adequate rehabilitation as an integral part of the treatment plan.
rate or postoperative mortality between those with and without irradiation. Speech rehabilitation was poor in this particular group of indigent patients with only 36 per cent of those undergoing laryngectomy developing effective means of speech. The value of the American Joint Committee’s Staging System for Cancer of the Larynx as well as some of its shortcomings are pointed out. A new method for more efficiently utilizing the Staging System is presented.
Summary
References
The medical records of 144 patients seeking primary care for epidermoid carcinoma of the larynx at the Ellis Fischel State Cancer Haspita1 from 1940 through 1967 were reviewed and data abstracted for computer analysis, studying approximately 150 different social, clinical, therapeutic, and pathologic variables, some of which are presented in this paper. The clinical staging system of the American Joint Committee for Cancer Staging and End Results Reporting was used to compare the results of various therapeutic modalities utilizing the life table or actuarial method with and without age correction. There was a preponderance of patients with advanced cases, 43 per cent having clinically positive nodes. The five year age-corrected actuarial survival was 71 per cent with stage I, 61 per cent with stage II, 25 per cent with stage III, and thirty-five with stage IV lesions. The consistent superiority in cure rate by surgery over radiotherapy for the various clinical stages was evident in this series. Of the twenty-five patients in whom laryngectomy was performed after radiation failure, approximately half were salvaged. No patient with recurrence after laryngectomy was salvaged by subsequent radiotherapy. The operative mortality for the patients having undergone previous radiotherapy was 24 per cent compared with 8 per cent for patients without previous radiotherapy. An analysis of specific complications suggests a greater incidence of more serious complications after surgery in the patients with previous irradiation, although no statistically significant difference could be found either in complication
1.
Clinical Staging System for Cancer of the Larynx: American Joint Committee Booklet, 1959. American Joint Committee for Cancer Staging and End Results Reporting.
2.
SMITH, R. R., CAULK, R. M., RUSSELL,W. O., and JACKSON, C. L. End results in 600 laryngeal cancers using the American Joint Committee’s proposed method of stage classification and end results reporting. Surg. Ggneo. & Obst., 113: 435,196l. CANTRIL, S. T. Radiation therapy in cancer of the larynx. Am. J. Roentaenol.. I-~83: 17, 1960. KLOPP, C. T. and KIRSON, S. M. Treatment of cancer of the larynx. Am. J. Roentgenol., 83: 10, 1960. OGURA, j. H. Surgical pathology of cancer of the larynx. Laylngoscope, 65: 867, 1955. ACKERMAN, L. V. and DEL REGATO, J. A. Cancer, 3rd ed., p. 431. St. Louis, 1962. C. V. Mosby Co. MARCHETTA,F. C., SAXO, K., and MATTICK, W. L. Squamous cell carcinoma of the larynx. Am. J. Surg.. 116: 491. 1968. MCGAVRAN, M. H.,- BAUER, I$. C., and OGURA, J. H. The incidence of cervical lymph node metastases from epidermoid carcinoma of the larynx and their relationship to certain characteristics of the primary tumor. Cancer, 14: 55, 1961. ALEXANDER,F. W. and CASSADY,C. L. 306 Laryngeal carcinomas: staging and end results. Arch. OtoZaryngoZ., 83: 112, 1966. MACCOMB. W. S.. FLETCHER. G. H. GALLAGER,h. S., H~ALEY, J. E.; JR. and LEHMANN, &. H. Cancer of the Head and Neck : Larynx, p. 274. Baltimore, 1967. The Williams & Wilkins Co. BAKER, H. W. Surgical management of recurrent laryngeal cancer after irradiation. Cancer, 16: 774, 1963. REED, G. F. Preoperative irradiation in laryngeal carcinoma. Arch. Otolaryngol., 86: 94. 1967. OGURA,j. H. Personal communication.
3. 4. 5. 6. 7. 8.
9. 10.
11. 12. 13.
The American
Journal
of Surgery
The medical records of all patients having carcinoma of the larynx diagnosed at the Ellis Fischel State Cancer Hospital from 1940 through 1967 have been reviewed to evaluate the methods of treatment. All lesions were categorized according to the staging system proposed by the American Joint Committee for Cancer Staging and End Results Reporting by utilizing descriptions of the disease prior to any treatment, as recorded in the patients’ charts. The staging system has been well described but some definition of it is needed at this time to interpret this study. To standardize anatomic terminology and clinical classification of carcinoma of the larynx in the United States, the Subcommittee on the Larynx of the American Joint Committee for Cancer Staging and End Results Reporting devised a TNM system in 1959 [I]. A cooperative study of the end results in 600 cases of carcinoma of the larynx was reported by this committee in 1961 [Z] and another cooperative study is currently underway. Using this classification, the larynx is divided anatomically into supraglottic, glottic, and subglottic regions. The lingual surface of the epiglottis as well as the valleculae, the pyriform sinuses, and the postcricoid areas are not considered portions of the larynx. The anatomic regions are further divided into “sites” such as an aryepiglottic fold or a true cord. Table I summarizes “T,” “N,” and “M” definitions according to this clinical staging From the Departments of Surgery and Biomathematics, Ellis Fischel State Cancer Hospital and Cancer Research Center, Columbia, Missouri. This study was supported in part by U.S. Public Health Service Grant No. CA-08023. Presented at the Fifteenth Annual Meeting of The Society of Head and Neck Surgeons, Mexico City, Mexico, March 16-19. 1969.
676
system. The four clinical stages of the disease based on the TNM description of the disease are defined in Table II. Clinical Material From 1940 through 1967, 144 patients with histologically proved epidermoid carcinoma of the larynx received primary treatment at the Ellis Fischel State Cancer Hospital. The records of these patients were reviewed and data representing approximately 150 different social, clinical, therapeutic, and pathologic variables were abstracted and transposed onto IBM punch cards to make them readily available for computer recall and analysis. No patient was lost to follow-up study in this series. Methods and Results One hundred and twenty-four of the 144 patients were males. One hundred and thirtynine of the 144 patients were Caucasian. The patients’ ages ranged from thirty-seven to eighty-eight years with a median age of sixtyfour. The age distribution of the 144 patients and their age-specific five year survival is shown in Table III. Since ‘72 per cent of the lesions were advanced locally (T3 or T, lesions), separation into supraglottic, glottic, and subglottic areas of primary origin tends to be artificial. However, all except four lesions were categorized as to probable anatomic site of origin, as indicated in Table IV. The four unclassified lesions could not be categorized due to insufficient information. The majority of the patients had advanced disease when first seen. (Fig. 1.) Only 9 or 6 per cent were stage I lesions. Sixty-two patients or 43 per cent had clinically positive cervical lymph nodes when first seen and one patient had distant metastases. The
American
Journal
of
Surgery
Carcinoma
TABLE
I
American
Joint Committee’s
TNM Clinical Classification
Local Extent I
T
,I
of Primary
Supraglottis 1
2
3
__~
Carcinoma
(“T”)
Glottis
Tumor confined to laryngeal epiglottis, or aryepiglottic fold, or arytenoid, or false cord, or ventricle Tumor confined to supraglottic region involving more than a single site listed above Tumor of supraglottis extending onto the true cords Tumor of supraglottis extending beyond the confines of the anatomic larynx
4
Tumor
of Laryngeal
of the Larynx
Subglottis
Tumor confined to one true cord with normal mobility
Tumor confined to one side of subglottic region
Tumor confined to glottis causing limitation in mobility or involving both cords Tumor of glottis extending to supraglottic or subglottic region Tumor of glottis extending beyond the confines of the true larynx
Tumor confined but extending
to subglottis to both sides
Tumor of subglottis extending onto the true cords Tumor of subglottis extending beyond the confines of the true larynx
~~~ ___ Extent
of Cervical
Lymph
Node Metastases
(“N”)
No No clinical evidence of cervical lymph node metastasis N1 Clinically involved cervical lymph nodes that are not fixed NS Fixed cervical lymph nodes Presence of Distant ___M. No clinical evidence of metastases beyond cervical MI Clinical evidence of metastases other than cervical
Due to varying philosophies of the Chiefs of Surgery and Radiotherapy at the Ellis Fischel Hospital over these twenty-seven years, the indications for radiotherapy and for total laryngectomy have varied and examination of the resulting survivals is of interest. Primary forms of treatment used over this twenty-seven year period are shown in Table V.
TABLE
II
Clinical Stages of Carcinoma of the Larynx According to System Developed by the American Joint Committee Stage I
TlNoMo
Stage II
TsNoMa TaNoMo T,NoMo
Metastases lymph lymph
(“M”)
nodes nodes
Actuarial (life table) survivals of these patients were calculated with and without age correction. Age correction takes into account the over-all survival of a population of specific ages which are identical to the ages in any given life table and is determined according to a special computer program. It is based on Missouri Life Tables and, in this instance, is determined from normal survivals of Missouri
TABLE
III
Age-Specific Patients with of the Larynx
Age by Decade No. of Patients Stage III
Stage IV
T,NlM, -Nz---MI
Vol. 118, November 1969
30-39 40-49 50-59 60-69 70-79 80-89
3 13 38 51 30 9
Survival Among 144 Epidermoid Carcinoma
Observed Five Year Actuarial Survival (Per cent)
Normal Five Year Survival (Per cent)
33 66 43 33 35 10
98 95 90 82 68 52
677
Harris, Watson, and Spratt
males. Age correction is used to compare survivals excluding deaths from causes other than the disease in question, in this case carcinoma of the larynx. Figure 2 shows the over-all survival of the 144 patients in this series, indicating a 37 per cent five year observed actuarial survival or 45 per cent age-corrected survival. It is apparent from this curve, as well as from the
other survival curves in this study, that very few deaths from laryngeal cancer occurred after the fifth year and, hence, five year survival curves for laryngeal cancer probably approximate “cure” of this disease. In Figure 3, age-corrected survivals according to various modes of therapy, disregarding stages of the disease, are illustrated. Of the eighty-four patients treated originally with
TABLE
Anatomic Carcinoma
IV
Location
Location of 144 Cases of the Larynx No. of Patients
Per cent ___
78 58 4 4 144
54 40 3 3 100
Supraglottis Glottis Subglottis Unclassified Total
of 144 patients with carcinoma Fig. 1. Distribution of the larynx according to clinical stage (American Joint Committee for Cancer Staging and End Results Reporting).
Treatment Methods Used in Treating 144 Patients with Carcinoma of the Larynx
TABLE V
No. of Patients
Form of Treatment
Fie. 2. Actuarial survival of 144 oatients having e$dermoid carcinoma of the larynx: all stages an; all methods of treatment are included.
TABLE VI
No. of Patients
I II (T2) (Tz) (T4) III IV +I”c,“dri
po,,e,>t,
lotrs
(T,N,M,)
i,rrr,ng laryngrc,cnly
Fig. 3. Age-corrected actuarial survivals among 144 patients with carcinoma of the larynx according to various modes of therapy.
*
According
Joint
Committee
25 50 1 9 144
Five Year Actuarial Survival by Clinical among 144 Patients with Stage* Carcinoma of the Larynx
Clinical Stage
678
59
Radiotherapy alone Radiotherapy followed by attempted surgical salvage Total laryngectomy with or without neck dissection Laryngofissure No treatment or palliative chemotherapy only Total
L
of
Observed Survival (Per cent)
9 69
56 48
71 61
(19) (32) (18) 26 36
(55) (48) (43) 21 28
(73) (61) (50) 25 35
(31)
(32) to
staging for
Age-Corrected Survival (Per cent)
system
Cancer
adopted
Staging
and
(39) by End
American Results
Re-
porting.
The
American
Journal
of
Surgery
Carcinoma
2
4
6
e
of the Larynx
io
Yeor*
Fig. 4. Age-corrected of the larynx.
Fig. 5. larynx.
Age-corrected
4 actuarial survival
survival after laryngzctomy after
laryngectomy
radiotherapy, it was indicated in their medical records that thirty were treated for “palliation,” despite the fact that some of these patients had prolonged survivals. The survival curve for the remaining fifty-four patients treated originally with radiotherapy for “cure” is shown to compare it with the fifty patients treated originally with total laryngectomy. Twenty-five of the patients in the group receiving primary radiotherapy later underwent laryngectomy for postirradiation persistence as indicated by the appropriate survival curve. A separate category of fifty-nine patients who were treated originally with radiotherapy and who did not undergo any subsequent surgery had a low survival curve. Of nine untreated
Age-corrected Fig. 6. cinoma of the larynx. Fig. 7. clinical
actuarial
survival
after
and after
and
after radiotherapy
radiotherapy
for stage II carcinoma
for stage
Ill carcinoma
patients, all except one died within one year after diagnosis. Table VI indicates the five year actuarial survival for each of the four clinical stages. Not included are four patients whose lesions could not be staged because of inadequate available information. Of the nine patients with stage I lesions in this series, eight were treated originally with radiotherapy and one, a patient with verrucous carcinoma of the true cord, was treated originally by laryngofissure. Sixty-five patients underwent primary treatment for stage II lesions, either by total laryngectomy or radiotherapy, and the resulting observed survival rates are shown in Figure 4. Survival rates of twenty-five patients
faryngectomy
and
after
radiotherapy
for
stage
Age-corrected actuarial SUNiVaf curves of patients with carcinoma of the larynx according assessment of the cervical lymph nodes. All modes of therapy are included.
Vol. 118. November 1969
of the
IV
car-
to the
679
Harris, Watson, and Spratt
100*
Fig. 8. Comparison of age-corrected survival curves of patien’ts having clinically positive cervical lymph nodes when treated by laryngectomy and by radiotherapy. Patients in whom surgical salvage was attempted after radiotherapy failure are excluded.
with stage III lesions having total laryngectomy or radiotherapy are shown in Figure 5. Thirty-two patients underwent treatment of stage IV lesions and their survival rates after the two modes of therapy are shown in Figure 6. It is evident that patients with quite far advanced clinical stage IV diseases (chiefly T,N,M,, lesions having large primary tumors with clinically positive lymph nodes) are POtentially curable by total laryngectomy. The improved survival in patients with stage IV laryngeal cancers over those with stage III lesions probably is indicative of difficulty in accurately determining the extent of primary lesions in a retrospective study. Also, an unusual number of false-positive cervical lymph nodes may have occurred in those with stage IV tumors. Of interest is that the age-corrected five year survival rates for T,NIM, and T,N,Mo lesions were similar, being 31.5 and 39 per cent, respectively. The influence of clinically involved cervical lymph nodes is illustrated by the survival curves shown in Figure 7, without separation of the therapeutic modalities involved. The presence of clinically positive lymph nodes bilaterally in the neck was a particularly grave prognostic sign, worse than the over-all T,N,M,, category. Figure 8 compares the age-corrected survival curves of patients having clinically positive nodes when treated either by total laryngectomy or by primary radiotherapy. A policy of treating advanced cancer of the larynx with radiotherapy followed by observation and attempted surgical salvage if persis-
tent disease is discovered had been severely criticized [3]. Nevertheless, this method of treating laryngeal cancer is practiced [4] and has been used on several occasions in this institution. During the twenty-seven year period covered by this series, twenty-five total laryngectomies were performed for presumed irradiation failures, although in three of the resection specimens, no residual tumor was found. The operative mortality was high (24 per cent) in this group. Of the twelve patients treated more than four years ago who survived the surgical procedure, six lived for four years or more without evidence of recurrent disease. The actuarial survival curve for these twenty-five patients is shown in Figure 3. Complications The complications which occurred among the seventy-five patients who underwent total laryngectomy (with or without neck dissections) are shown in Table VII. A comparison of the incidence of these complications is made between the twenty-five patients having received previous radiotherapy and those fifty who had had no previous radiotherapy. No statistically significant difference in the relative incidence of these complications exists. The most apparent difference was the 12 per cent incidence of rupture of the carotid artery occurring among the twenty-five patients who had undergone previous radiotherapy versus the 2 per cent incidence among patients with no previous radiotherapy. However, this difference is not significant statistically (P = 1.0). Of interest is the fact that five pharyngocutaneous fistulas occurred among the twentyfive patients who had undergone previous radiotherapy and of these, two required surgical correction. Ten pharyngocutaneous fistulas (the same incidence) occurred among the fifty patients who had not received prior radiotherapy, but of these, all but one healed without requiring surgical intervention, This suggests impaired healing of the irradiated tissue. There was no difference in the length of hospital stay after laryngectomy between the group of patients having had previous radiotherapy and those who had not. The mean length of hospitalization after laryngectomy in patients without previous radiotherapy was 24.5 days. It was 22.4 days for those who had had previous radiotherapy. The median stay The American
Journal
of Surgery
Carcinoma
TABLE
VII
Complications Dissection
among
Seventy-five
Patients
Complication Occurring Hemorrhage into wound requiring reoperation Hematoma requiring aspiration Seroma requiring aspiration Seroma requiring drainage Minor skin slough Skin slough requiring grafting Pharyngeal fistula not requiring surgery Pharyngeal fistula requiring surgical procedures Carotid artery rupture Wound infection Tracheal retraction postoperatively Late tracheal stenosis requiring revision Pneumonia Cardiovascular complications Cerebrovascular accidents Thrombophlebitis Pulmonary embolus Lymph fistula Acute parotitis Upper gastrointestinal hemorrhage
was twenty days for both groups. Patients dying in the postoperative period were excluded in determining the mean and median of these groups. More striking is the difference in operative mortality among those with and without previous irradiation. The over-all operative mortality from total laryngectomy was 13 per cent, representing ten deaths among the seventy-five undergoing patients total laryngectomy. However, six of these deaths occurred among the twenty-five patients who had previously received radiotherapy, giving an operative mortality of 24 per cent in this particular group. Four deaths occurred among the fifty patients without previous radiotherapy, an operative mortality of 8 per cent. Again, however, this difference is only of borderline statistical significance with a P value of .075. Table VIII indicates the operative procedures which were carried out in these two groups along with the apparent cause of each postlaryngectomy death. Of the four deaths occurring among the fifty patients who did not receive previous radiotherapy, none were directly related to local complications, whereas among the patients with irradiation, two died as a result of rupture of the carotid artery. One patient in this group underwent Vol. 118, November 1969
Undergoing
Total No.
12 3 4 9 1 9 5 2 1 1 1 1
Laryngectomy
with
No. among Twenty-five Patients with Previous Radiotherapy
and
of the
without
3(6%,)
3(120/o) 1(4%‘0) 0
&%b) 0
2@%) 302%) 1(4%,) 1(4%‘0) 1(4%‘0) 1(4%,) 1(4%) 0 0
Neck
No. among Fifty Patients with No Previous Radiotherapy
1(4%,) 0
2@%0) 302%) 2(8%) 302%) 405%) 0
Larynx
2~4%) 5(10%) 9(1g%,) 1(2%) 1(2%> 5(10%) 1(2%) 704%) 2(4%1 1(2%,) 0 0 0 0 1(2%,) 1(2%,)
laryngectomy at another hospital and the cause of death is not known.
Comments Terminology which has been used to describe the location of laryngeal lesions has varied widely among various authors, as has the method of clinical staging of the disease. If one compares anatomic definitions as given by two sources in the literature [5,6], one finds that the term “endolaryngeal” refers to a lesion confined to the true and false cords and the ventricle according to one authority, whereas according to the other author, it also refers to lesions involving the supraglottis and subglottis. “Intrinsic” refers to tumors involving the true cords or anterior commissure according to one author, but has been used to describe any lesion located within the lumen of the laryngeal organ according to the other authors. The term “vestibule” seems to be synonymous with the supraglottis, although it has been limited on some occasions to the area formed by the base of the epiglottis and the false cords. “Extrinsic” lesion8 have been those lesions considered involving the epiglottis, aryepiglottic fold, pyriform sinus, and arytenoid eminence, while a recent study in the literature uses the terms “extrinsic 681
Harris,
Watson,
TABLE VIII
No.
and Spratt
Postlaryngectomy
AgeW.1 and Sex
Stage
Deaths Occurring
Months after Radiation Therapy
With Previous Radiotheraov 45-08115 53, M Unknown 47-09619 73, F TSNIMO
2 4
58-24943
74, M
T,N,Mo
4112
60-27910
44, F
ToNoM,,
6
58-25056
53, M
TsNoMo
I’/2
64-32356
77, F
TpNoMo
Without Any Previous Radiotherapy 57-24172 60, M TzNlM,, 62-30401
57, M
T,NIMo
65-33578
59, M
TdNIMo
67-36853
71, M
TBN,Mo
28
Operation Laryngectomy Laryngectomy Laryngectomy dissection Laryngectomy dissection Laryngectomy dissection Laryngectomy
Laryngectomy dissection
Year
Cause
and neck
Unknown (fourth day) Pneumonia Cerebrovascular accident
1945 1947 1960
and neck
Carotid
1960
and neck
Pharyngocutaneous fistula carotid artery rupture Unknown (elsewhere)
1964
Perforated
1957
Laryngectomy and neck dissection Laryngectomy and bilateral neck dissection Laryngectomy and bilateral neck dissection
exolaryngeal” endolaryngeal” and “extrinsic [7]. The term “infraglottic” has been used to describe tumors involving the glottis and subglottis whereas “transglottic” tumors are those which cross the ventricle of Morgagni [S]. This plethora of ambiguous terms indicates the need for standardizing terminology used in studies describing therapeutic end results. A preferable method of describing the location and extent of the primary tumor is to indicate the exact anatomic sites in the larynx and adjacent structures which appear to be involved by the tumor. This avoids the use of vague nonanatomic terms and makes use of anatomic sites which are well defined in standard textbooks of anatomy. This method has been used by the American Joint Committee in devising their clinical staging system. Although the American Joint Committee System tends to be complicated, it encourages precision in examination and description. It has been found to be a usable system and its stages reflect differing survival rates [S,g]. However, because of the difficulty of emsloying the American Joint Committee’s booklet for the Staging of Cancer of the Larynx, we attempted to devise a simple tabular method which follows the same staging procedure outlined in the booklet. Table IX is the result of this effort. To employ this table, one 682
within Thirty Days after Surgery
and neck
artery
rupture
duodenal
ulcer
1966
Death on operating room table (10 hour operation) Tracheal mucous plug
1965
Pneumonia,
1967
parotitis
merely notes the various characteristics of the lesion, drawing a line through the numbers to the right of each characteristic which is positive for the given tumor. Once this procedure is completed for the entire list, one may find the appropriate stage, T value, N value, and M value by starting from the bottom of the corresponding column and going up until the first number through which a line has been drawn is encountered. It should be noted that regarding tumor extension there are two sets of identical items depending on whether there are clinically positive nodes or no lymph nodes. Only the appropriate set is to be considered. For example, in staging a lesion of the aryepiglottic fold extending into the pyriform sinus and with palpable cervical lymph nodes, one would first draw a line through “aryepiglottic fold and arytenoid,” extending the line through the numbers to its right. Next, a line would be drawn through “lymph nodes not fixed” and this line again continued through the numbers to the right of this item. Finally, a line would be drawn through “extension to the pyriform sinus” and the numbers to its right in the section “lymnh nodes.” Then, one would find upon beginning at the bottom of the table, that the lesion would be staged as 4 because of the lowermost line The Amerlcsn
Journal
of Surgery
Carcinoma of being through the number 4 under Stage. Similarly, it would be a T4N,M, classification. Other problems are encountered in using the American Joint Committee system. In evaluating an advanced local lesion, an error in judgement in determining the presence or absence of cervical lymph node metastases will change the clinical staging of the disease from a stage IV to a stage II, since a T,N,MO lesion is stage II whereas a TIN,M, lesion is stage IV. Another defect in the system is the inability to indicate bilateral cervical lymph node metastases. Any unusual number of bilateral cervical lymph node metastases adversely affects the survival in patients with stage III lesions, as indicated in Figure 7. A similar staging system used at the M. D. Anderson Hospital takes into account the presence of bilateral cervical lymph node metastases and these particular lesions are included with the stage IV lesions regardless of the size of the primary lesion [ZO]. The clinical stage II lesions cover a rather wide spectrum of local disease in the larynx and, hence, this stage is usually further subdivided into T2, T,, and T4 categories in reporting end results. It includes diseases varying in extent from a relatively small cord lesion with invasion of the laryngeal ventricle to a large supraglottic lesion involving the entire interior of the larynx with extension to the pyriform sinus, subcutaneous tissues, and skin. It is illogical that these tumors should be placed in the same clinical stage and, indeed, survivals differ rather widely between these two extremes. (Table VI.) In this series, surgery resulted in the salvage of a large percentage of those in whom radiation failed without inordinate postoperative complications. Similarly, Baker Cl11 has reported the salvage by laryngectomy of nineteen of thirty-four patients in whom radiation failed. Larger numbers of cases are necessary to confirm or disprove the opinion of Cantril [3] who stated that a trial of radiotherapy is justifiable prior to surgery. Our data indicate a consistent superiority in survival rates in patients with carcinoma of the larynx when treated by primary total laryngectomy (usually with neck dissection) as opposed to radiotherapy. However, in this group of patients, chiefly indigent Missouri farmers, only twenty-seven of seventy-five having total laryngectomy ever definitely deVol. 118, November 1969
TABLE
IX
the Larynx
Staging of Cancer of the Larynx Tumor Characteristics
Stage T N M
Laryngeal surface of epiglottis Aryepiglottic fold or arytenoid Ventricular cavity or band One cord-normal mobility One side subglottic-not undersurface Epiglottis t3 ventricular bands or cavities Both cords-normal mobility Tumor fixed to cord(s) Both sidessubglottic-not undersurface Epiglottis to cord(s) Ventricular cavity or band to cord(s) Cord(s) to ventricular bands or cavities Subglottic region to cords
1100 1100 1100 1100 1100 2 2 0 0 2 200 2 200 2 2 0 0 2 300 2 300 2 3 0 0 2 300
z 2 z E 3 0
2 2 2 2 2 2
Z
Extension Extension Extension Extension Extension Extension
Lymph m 5 Z z E 3
to to to to to to
pyriform sinus postcricoid region vallecula tongue base trachea skin
nodes-not
Extension Extension Extension Extension Extension Extension
to to to to to to
fixed pyriforms sinus postcricoid region vallecula tongue base trachea skin
Fixed lymph nodes Distant metastasis
3 4 4 4 4 4 4 4 4
400 400 400 400 400 400 1
0
410 410 410 410 410 410 2
0 1
veloped effective means of speech (either by esophageal voice or by mechanical means). It is conceivable that a few other patients did develop effective means of speech but this information is not available in the medical records to verify this. A greater percentage of these patients have been rehabilitated in more recent years than during the 1940’s. A recent policy instituted at this hospital is for patients to be introduced to the technic of esophageal speech prior to laryngectomy and also actually learn to use a mechanical speech device* prior to surgery in order that they *We have used the “Western Electric Electronic Artificial Larynx,” obtained through the Bell Telephone Laboratories and the “Cooper-Rand Electronic Speech Aid,” obtained from the Rand Development Corporation, P.O. Box .3&X, Cleveland, Ohio. 683
Harris, Watson, and Spratt may enjoy some means of verbal communication in the immediate postoperative period. It would appear that total laryngectomy with neck dissection is the preferred method of treating advanced laryngeal cancer from the standpoint of improved survival. Planned combined preoperative irradiation may further improve survival [12,13], although loss of laryngeal speech must be remedied by adequate rehabilitation as an integral part of the treatment plan.
rate or postoperative mortality between those with and without irradiation. Speech rehabilitation was poor in this particular group of indigent patients with only 36 per cent of those undergoing laryngectomy developing effective means of speech. The value of the American Joint Committee’s Staging System for Cancer of the Larynx as well as some of its shortcomings are pointed out. A new method for more efficiently utilizing the Staging System is presented.
Summary
References
The medical records of 144 patients seeking primary care for epidermoid carcinoma of the larynx at the Ellis Fischel State Cancer Haspita1 from 1940 through 1967 were reviewed and data abstracted for computer analysis, studying approximately 150 different social, clinical, therapeutic, and pathologic variables, some of which are presented in this paper. The clinical staging system of the American Joint Committee for Cancer Staging and End Results Reporting was used to compare the results of various therapeutic modalities utilizing the life table or actuarial method with and without age correction. There was a preponderance of patients with advanced cases, 43 per cent having clinically positive nodes. The five year age-corrected actuarial survival was 71 per cent with stage I, 61 per cent with stage II, 25 per cent with stage III, and thirty-five with stage IV lesions. The consistent superiority in cure rate by surgery over radiotherapy for the various clinical stages was evident in this series. Of the twenty-five patients in whom laryngectomy was performed after radiation failure, approximately half were salvaged. No patient with recurrence after laryngectomy was salvaged by subsequent radiotherapy. The operative mortality for the patients having undergone previous radiotherapy was 24 per cent compared with 8 per cent for patients without previous radiotherapy. An analysis of specific complications suggests a greater incidence of more serious complications after surgery in the patients with previous irradiation, although no statistically significant difference could be found either in complication
1.
Clinical Staging System for Cancer of the Larynx: American Joint Committee Booklet, 1959. American Joint Committee for Cancer Staging and End Results Reporting.
2.
SMITH, R. R., CAULK, R. M., RUSSELL,W. O., and JACKSON, C. L. End results in 600 laryngeal cancers using the American Joint Committee’s proposed method of stage classification and end results reporting. Surg. Ggneo. & Obst., 113: 435,196l. CANTRIL, S. T. Radiation therapy in cancer of the larynx. Am. J. Roentaenol.. I-~83: 17, 1960. KLOPP, C. T. and KIRSON, S. M. Treatment of cancer of the larynx. Am. J. Roentgenol., 83: 10, 1960. OGURA, j. H. Surgical pathology of cancer of the larynx. Laylngoscope, 65: 867, 1955. ACKERMAN, L. V. and DEL REGATO, J. A. Cancer, 3rd ed., p. 431. St. Louis, 1962. C. V. Mosby Co. MARCHETTA,F. C., SAXO, K., and MATTICK, W. L. Squamous cell carcinoma of the larynx. Am. J. Surg.. 116: 491. 1968. MCGAVRAN, M. H.,- BAUER, I$. C., and OGURA, J. H. The incidence of cervical lymph node metastases from epidermoid carcinoma of the larynx and their relationship to certain characteristics of the primary tumor. Cancer, 14: 55, 1961. ALEXANDER,F. W. and CASSADY,C. L. 306 Laryngeal carcinomas: staging and end results. Arch. OtoZaryngoZ., 83: 112, 1966. MACCOMB. W. S.. FLETCHER. G. H. GALLAGER,h. S., H~ALEY, J. E.; JR. and LEHMANN, &. H. Cancer of the Head and Neck : Larynx, p. 274. Baltimore, 1967. The Williams & Wilkins Co. BAKER, H. W. Surgical management of recurrent laryngeal cancer after irradiation. Cancer, 16: 774, 1963. REED, G. F. Preoperative irradiation in laryngeal carcinoma. Arch. Otolaryngol., 86: 94. 1967. OGURA,j. H. Personal communication.
3. 4. 5. 6. 7. 8.
9. 10.
11. 12. 13.
The American
Journal
of Surgery