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CONSIDERING QUALITY OF VOICE IN EARLY VOCAL CORD CARCINOMA
Radiotherapy and Oncology 56 (2000) 271±272
www.elsevier.com/locate/radonline
Letter to the Editor CONSIDERING QUALITY OF VOICE IN EARLY VOCAL CORD CARCINOMA
To the Editor, We would like to refer to the article by Gregoire et al. [6], which reports the cost of different treatment options in T1N0 vocal cord carcinoma. We would like to emphasize the importance of this paper on this subject because it brings up one of the problems that we presently have in vocal cord carcinoma treatment. We would like to add some considerations and data to this topic and make some comments on voice quality. Surgery and radiotherapy should offer the same results in the treatment of T1N0 vocal cord carcinoma. The election of one of these treatments has usually depended on treatment policy at each hospital. Several years ago, hospitals chose conservative surgery in front of radiotherapy without taking into account the cost of treatments. Nowadays, when rationalization of costs is needed, laser treatment seems the best option. Laser surgery offers a quick treatment, short hospitalization time and thus it has been reported as less expensive. Regarding the article of Gregoire al. [6], there is a slight reduction of the costs for radiotherapy. A low impact in reduction of the costs for laser has also been reported by Foote et al. [5]. In the Gregoire et al. series [6], when those patients without complications and local relapse were considered, the cost of treatments was 4109 Euro for laser and 4051 Euro for radiotherapy. The incidence of relapses in both treatments should be similar and severe complications in radiotherapy should not be higher than 1±2% [12]. In the Gregoire et al. study [6] when those patients with complications and treatment relapses in need of total laryngectomy are considered, the cost increases sharply for laser treatments in front of radiotherapy. The cost for previously irradiated patients is 39 723 Euro and the cost for laser treatment is 54 820 Euro, but if radiotherapy is added then the cost becomes 82 394 Euro. Thus, at this point, perhaps the cost of treatment might be a minor element in choice of treatment, and before choosing between laser surgery and radiotherapy we should take into account two other main considerations. Early vocal cord carcinomas can have a wide spectrum of presentation; from those small tumours located in the anterior commissure, but with in®ltrant component to those which super®cially affect both vocal cords in T1N0 cases, or those which affect ventricles or subglottic space in T2N0
cases. A 2±3 mm of margin is recommended for removal of the tumour by laser. In laser treatment of early vocal cord carcinoma it is some times dif®cult to obtain these margins, which is proven by the number of positive margins reported in different series, which range between 9 and 30%. These patients are usually in need of a new laser treatment or irradiation; the dif®culty in having wide enough margin might be bigger if the tumour affects the anterior commissure (20% of vocal cord carcinomas). In fact, 3±55% of local relapses with laser surgery for early vocal cord carcinoma have been reported in T1N0 vocal cord carcinoma; these patients are in need of other treatments, and some of them might even lose their larynx [2,6,8,9,14,19,20,22]. Quality of voice has not been a topic of interest in the literature in early vocal cord cancer treatment, which is re¯ected by the small number of works done in this ®eld [17]. Voice allows people to express meanings and feelings, thus modulation of the voice is needed for daily use; voice enables communication of these profound connotations that go farther than the meaning of words by themselves. Voice after treatments for early vocal cord carcinoma is the result of non-physiological mechanical effects that cause alteration in the motility of vocal cords. The origin of this alteration in radiotherapy is different to laser treatments [11,12,17,18]. Due to the wide spectrum of T1N0 vocal cord carcinoma in their presentation, the extension of laser resection can vary from one patient to another. If a simple biopsy of a tumoral vocal cord might affect the quality of voice, more alteration could be observed by laser surgery and it will depend on the amount of vocal cord resection. Different authors report a worse quality of voice after laser treatments in comparison to radiotherapy [1,3,4,7,8,14,19]. McGuirt et al. [11] performed a study comparing laser treatment and radiotherapy in highly selected patients by videostroboscopy and acoustic analysis. All of them had only one vocal cord affected by the tumour without extension to the anterior commisure and the selection criteria was that the laser resection needed should involve less than 50% of the tumoral vocal cord. After treatment, vocal cord vibration was abnormal in 75% of laser treatment patients and in 50% of the irradiated group. There was a greater increase in fundamental frequency and air-¯ow resistance with a decrease in the duration of phonation for the laser group, and there was a complete glottic closure in 80% for laser treatment in front of the 100% for the radiotherapy group. They concluded that laser treatment and irradiation might offer similar results in quality of voice when the tumour is small. These ®ndings are in agreement with others reported in the literature; voice after laser surgery depends on the amount of
272
A. Rovirosa, A. Biete / Radiotherapy and Oncology 56 (2000) 271±272
vocal cord resection. Quality of voice after laser treatment will be worse in comparison with irradiation, when the vocal cord tumour is bigger than 5 mm, affects the anterior commissure and there is the need to resect half of the vocal cord muscle or the ventricles [6,8,10,11,13,15,18,21,22]. Obviously, the voice is worse when radiotherapy or other laser treatment is added. This suggests that patients for laser treatments should be carefully selected to obtain a voice quality similar to irradiation. We performed a study of acoustic voice parameters in 18 irradiated T1N0 vocal cord carcinoma in different acoustic situations where fundamental frequency and jitter showed signi®cant increased values to the control group [17]. Seventy-eight percent of the patients referred to having a percentage equal or higher than 90%, and 39% of the cases referred to having the 100% of their previous voice [16,17]. Although radiotherapy affects voice quality, it maintains the anatomy of the larynx and thus permits more voice preservation. Nevertheless, in small vocal cord tumours laser surgery could also offer a good quality of voice. The aim of this letter is to argue that as laser surgery and irradiation have similar costs at present, the choice of one or another treatment in T1N0 should be based on the quality of voice and patient preferences. Prospective studies comparing both treatments on local control, number of total laryngectomies performed by relapses and quality of voice are really necessary to establish which is the best option for each patient in different stages of larynx tumours. References [1] Blakeslee D, Vaughan CW, Shapshay S, Simpson GT, Strong MS. Excisional biopsy in the selective management of T1 glottic cancer: a three year follow-up study. Laryngoscope 1984;94:488±494. [2] Davis K. Selective management of early glottic cancer. Laryngoscope 1990;100:1306±1309. [3] Elner A, Fex S. Carbon dioxide laser as primary treatment of glottic Tis and T1a tumours. Acta Oto-Laryngol. (Stockholm) 1988;449 (Suppl.):135±139. [4] Fex S, Fex BI. Voice quality after radiotherapy or laser evaporation for vocal fold cancer. In: Hirano M, editor. International conference on voice, Kurume, Japan: Kurume University, 1986. pp. 144±146. [5] Foote RL, Buskirk SJ, Grado GL, Bonner JA. Has radiotherapy become too expensive to be considered a treatment option for early glottic cancer? Head Neck 1997;19:692±700. [6] Gregoire V, Hamoir M, Rosier JF, et al. Cost-minimization analysis of treatment options for T1N0 glottic squamous cell carcinoma: comparison between external radiotherapy, laser microsurgery and partial laryngectomy. Radiother. Oncol. 1999;53:1±13. [7] Hirano M, Hirade Y, Kawasaki H. Vocal function following carbon dioxide laser surgery for glottic carcinoma. Ann. Otol. Rhinol. Laryngol. 1985;94:232±235. [8] Koufman JA. The endoscopic management of early squamous carcinoma of the vocal cord with the carbon dioxide laser: clinical experi-
[9] [10] [11] [12] [13] [14] [15]
[16]
[17]
[18] [19] [20] [21] [22]
ence and a proposed subclassi®cation. Otolaryngol. Head Neck Surg. 1986;95:531. Krespi YP, Meltzer CJ. Laser surgery for vocal cord carcinoma involving the anterior commissure. Ann. Otol. Rhinol. Laryngol. 1989;89: 105±109. McGuirt WF, Blalok D, Kouffman JA, Feehs RS. Voice analysis of patients with endoscopically treated early laryngeal carcinoma. Ann. Otol. Rhinol. Laryngol. 1992;101:142±146. McGuirt WF, Blalok D, Kouffman JA, et al. Comparative voice results after laser resection or irradiation of T1 vocal cord carcinoma. Arch. Otolaryngol. Head Neck Surg. 1994;120:951±955. Million RR. Relative in¯uence of tumour dose versus dose per fraction on the local control and late normal-tissue morbidity after larynx radiotherapy. Int. J. Radiat. Oncol. Biol. Phys. 1992;25:149±150. Ossof RH, Sisson GA, Shapshay SM. Endoscopic management of selected early vocal cord carcinoma. Ann. Otol. Rhinol. Laryngol. 1985;94:560±564. Peretti G, Cappiello J, Nicolai P, Smussi C, Antonelli AR. Endoscopic laser excisional biopsy for selected glottic carcinomas. Laryngoscope 1994;104:1276±1279. Reker U. Phonatory ability after surgery for vocal cord carcinoma of limited extension. A comparison between transoral laser microsurgery and frontolateral partial laryngeal resection, Adv. Oto. Rhinol. Laryngol. 1995;49:214±218. Rovirosa A, Martinez-CeldraÂn E, Ortega A. Acoustic voice analysis and subjective patient impression after radiotherapy in T1 vocal cord carcinoma. In: Alvarez Vicent JJ, editor. 1 st World congress on head and neck oncology, Bologna, Italy: Moduzzi Editore, 1998. p. 99. Rovirosa A, Martinez-CeldraÂn E, Ortega A, et al. Acoustic analysis after radiotherapy in T1 vocal cord carcinoma. A new approach to the analysis of voice quality, Int. J. Radiat. Oncol. Biol. Phys. 2000;7(1):73±79. Rudert HW. Technique and results of transoral laser surgery for early glottic carcinoma: a clinical and experimental study. Adv. Oto. Rhino. Laryngol. 1995;49:222±226. Shapsay SM, Hybels RL, Bohigian RK. Laser excision of early vocal cord carcinoma: indications, limitations and precautions. Ann. Otol. Rhinol. Laryngol. 1990;99:46±65. Thomas JJ, Olsen KD, Neel HB, De Santo LW, Suman JJ. Recurrences after endoscopic management of early glottic carcinoma. Laryngoscope 1994;104:1009±1104. Wetmore SJ, Key M, Suen JY. Laser therapy for T1 vocal cord carcinoma of the larynx. Arch. Otolaryngol. Head Neck Surg. 1986;112: 853±855. Wolfensberger MD, Dort DJ. Endoscopic laser surgery for early glottic carcinoma: a clinical and experimental study. Laryngoscope 1990;100:1100±1105.
Sincerely, Angeles Rovirosa*, Albert Biete (Received 28 January 2000; accepted 13 April 2000) Radiation Oncology Department, Hospital CliÂnic i Universitari, C/Villarroel No. 170, 08036 Barcelona, Spain 0167-8140/00/$ - see front matter q 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0 167-8140(00 )00 201-2 * C orrespon ding author.
www.elsevier.com/locate/radonline
Letter to the Editor CONSIDERING QUALITY OF VOICE IN EARLY VOCAL CORD CARCINOMA
To the Editor, We would like to refer to the article by Gregoire et al. [6], which reports the cost of different treatment options in T1N0 vocal cord carcinoma. We would like to emphasize the importance of this paper on this subject because it brings up one of the problems that we presently have in vocal cord carcinoma treatment. We would like to add some considerations and data to this topic and make some comments on voice quality. Surgery and radiotherapy should offer the same results in the treatment of T1N0 vocal cord carcinoma. The election of one of these treatments has usually depended on treatment policy at each hospital. Several years ago, hospitals chose conservative surgery in front of radiotherapy without taking into account the cost of treatments. Nowadays, when rationalization of costs is needed, laser treatment seems the best option. Laser surgery offers a quick treatment, short hospitalization time and thus it has been reported as less expensive. Regarding the article of Gregoire al. [6], there is a slight reduction of the costs for radiotherapy. A low impact in reduction of the costs for laser has also been reported by Foote et al. [5]. In the Gregoire et al. series [6], when those patients without complications and local relapse were considered, the cost of treatments was 4109 Euro for laser and 4051 Euro for radiotherapy. The incidence of relapses in both treatments should be similar and severe complications in radiotherapy should not be higher than 1±2% [12]. In the Gregoire et al. study [6] when those patients with complications and treatment relapses in need of total laryngectomy are considered, the cost increases sharply for laser treatments in front of radiotherapy. The cost for previously irradiated patients is 39 723 Euro and the cost for laser treatment is 54 820 Euro, but if radiotherapy is added then the cost becomes 82 394 Euro. Thus, at this point, perhaps the cost of treatment might be a minor element in choice of treatment, and before choosing between laser surgery and radiotherapy we should take into account two other main considerations. Early vocal cord carcinomas can have a wide spectrum of presentation; from those small tumours located in the anterior commissure, but with in®ltrant component to those which super®cially affect both vocal cords in T1N0 cases, or those which affect ventricles or subglottic space in T2N0
cases. A 2±3 mm of margin is recommended for removal of the tumour by laser. In laser treatment of early vocal cord carcinoma it is some times dif®cult to obtain these margins, which is proven by the number of positive margins reported in different series, which range between 9 and 30%. These patients are usually in need of a new laser treatment or irradiation; the dif®culty in having wide enough margin might be bigger if the tumour affects the anterior commissure (20% of vocal cord carcinomas). In fact, 3±55% of local relapses with laser surgery for early vocal cord carcinoma have been reported in T1N0 vocal cord carcinoma; these patients are in need of other treatments, and some of them might even lose their larynx [2,6,8,9,14,19,20,22]. Quality of voice has not been a topic of interest in the literature in early vocal cord cancer treatment, which is re¯ected by the small number of works done in this ®eld [17]. Voice allows people to express meanings and feelings, thus modulation of the voice is needed for daily use; voice enables communication of these profound connotations that go farther than the meaning of words by themselves. Voice after treatments for early vocal cord carcinoma is the result of non-physiological mechanical effects that cause alteration in the motility of vocal cords. The origin of this alteration in radiotherapy is different to laser treatments [11,12,17,18]. Due to the wide spectrum of T1N0 vocal cord carcinoma in their presentation, the extension of laser resection can vary from one patient to another. If a simple biopsy of a tumoral vocal cord might affect the quality of voice, more alteration could be observed by laser surgery and it will depend on the amount of vocal cord resection. Different authors report a worse quality of voice after laser treatments in comparison to radiotherapy [1,3,4,7,8,14,19]. McGuirt et al. [11] performed a study comparing laser treatment and radiotherapy in highly selected patients by videostroboscopy and acoustic analysis. All of them had only one vocal cord affected by the tumour without extension to the anterior commisure and the selection criteria was that the laser resection needed should involve less than 50% of the tumoral vocal cord. After treatment, vocal cord vibration was abnormal in 75% of laser treatment patients and in 50% of the irradiated group. There was a greater increase in fundamental frequency and air-¯ow resistance with a decrease in the duration of phonation for the laser group, and there was a complete glottic closure in 80% for laser treatment in front of the 100% for the radiotherapy group. They concluded that laser treatment and irradiation might offer similar results in quality of voice when the tumour is small. These ®ndings are in agreement with others reported in the literature; voice after laser surgery depends on the amount of
272
A. Rovirosa, A. Biete / Radiotherapy and Oncology 56 (2000) 271±272
vocal cord resection. Quality of voice after laser treatment will be worse in comparison with irradiation, when the vocal cord tumour is bigger than 5 mm, affects the anterior commissure and there is the need to resect half of the vocal cord muscle or the ventricles [6,8,10,11,13,15,18,21,22]. Obviously, the voice is worse when radiotherapy or other laser treatment is added. This suggests that patients for laser treatments should be carefully selected to obtain a voice quality similar to irradiation. We performed a study of acoustic voice parameters in 18 irradiated T1N0 vocal cord carcinoma in different acoustic situations where fundamental frequency and jitter showed signi®cant increased values to the control group [17]. Seventy-eight percent of the patients referred to having a percentage equal or higher than 90%, and 39% of the cases referred to having the 100% of their previous voice [16,17]. Although radiotherapy affects voice quality, it maintains the anatomy of the larynx and thus permits more voice preservation. Nevertheless, in small vocal cord tumours laser surgery could also offer a good quality of voice. The aim of this letter is to argue that as laser surgery and irradiation have similar costs at present, the choice of one or another treatment in T1N0 should be based on the quality of voice and patient preferences. Prospective studies comparing both treatments on local control, number of total laryngectomies performed by relapses and quality of voice are really necessary to establish which is the best option for each patient in different stages of larynx tumours. References [1] Blakeslee D, Vaughan CW, Shapshay S, Simpson GT, Strong MS. Excisional biopsy in the selective management of T1 glottic cancer: a three year follow-up study. Laryngoscope 1984;94:488±494. [2] Davis K. Selective management of early glottic cancer. Laryngoscope 1990;100:1306±1309. [3] Elner A, Fex S. Carbon dioxide laser as primary treatment of glottic Tis and T1a tumours. Acta Oto-Laryngol. (Stockholm) 1988;449 (Suppl.):135±139. [4] Fex S, Fex BI. Voice quality after radiotherapy or laser evaporation for vocal fold cancer. In: Hirano M, editor. International conference on voice, Kurume, Japan: Kurume University, 1986. pp. 144±146. [5] Foote RL, Buskirk SJ, Grado GL, Bonner JA. Has radiotherapy become too expensive to be considered a treatment option for early glottic cancer? Head Neck 1997;19:692±700. [6] Gregoire V, Hamoir M, Rosier JF, et al. Cost-minimization analysis of treatment options for T1N0 glottic squamous cell carcinoma: comparison between external radiotherapy, laser microsurgery and partial laryngectomy. Radiother. Oncol. 1999;53:1±13. [7] Hirano M, Hirade Y, Kawasaki H. Vocal function following carbon dioxide laser surgery for glottic carcinoma. Ann. Otol. Rhinol. Laryngol. 1985;94:232±235. [8] Koufman JA. The endoscopic management of early squamous carcinoma of the vocal cord with the carbon dioxide laser: clinical experi-
[9] [10] [11] [12] [13] [14] [15]
[16]
[17]
[18] [19] [20] [21] [22]
ence and a proposed subclassi®cation. Otolaryngol. Head Neck Surg. 1986;95:531. Krespi YP, Meltzer CJ. Laser surgery for vocal cord carcinoma involving the anterior commissure. Ann. Otol. Rhinol. Laryngol. 1989;89: 105±109. McGuirt WF, Blalok D, Kouffman JA, Feehs RS. Voice analysis of patients with endoscopically treated early laryngeal carcinoma. Ann. Otol. Rhinol. Laryngol. 1992;101:142±146. McGuirt WF, Blalok D, Kouffman JA, et al. Comparative voice results after laser resection or irradiation of T1 vocal cord carcinoma. Arch. Otolaryngol. Head Neck Surg. 1994;120:951±955. Million RR. Relative in¯uence of tumour dose versus dose per fraction on the local control and late normal-tissue morbidity after larynx radiotherapy. Int. J. Radiat. Oncol. Biol. Phys. 1992;25:149±150. Ossof RH, Sisson GA, Shapshay SM. Endoscopic management of selected early vocal cord carcinoma. Ann. Otol. Rhinol. Laryngol. 1985;94:560±564. Peretti G, Cappiello J, Nicolai P, Smussi C, Antonelli AR. Endoscopic laser excisional biopsy for selected glottic carcinomas. Laryngoscope 1994;104:1276±1279. Reker U. Phonatory ability after surgery for vocal cord carcinoma of limited extension. A comparison between transoral laser microsurgery and frontolateral partial laryngeal resection, Adv. Oto. Rhinol. Laryngol. 1995;49:214±218. Rovirosa A, Martinez-CeldraÂn E, Ortega A. Acoustic voice analysis and subjective patient impression after radiotherapy in T1 vocal cord carcinoma. In: Alvarez Vicent JJ, editor. 1 st World congress on head and neck oncology, Bologna, Italy: Moduzzi Editore, 1998. p. 99. Rovirosa A, Martinez-CeldraÂn E, Ortega A, et al. Acoustic analysis after radiotherapy in T1 vocal cord carcinoma. A new approach to the analysis of voice quality, Int. J. Radiat. Oncol. Biol. Phys. 2000;7(1):73±79. Rudert HW. Technique and results of transoral laser surgery for early glottic carcinoma: a clinical and experimental study. Adv. Oto. Rhino. Laryngol. 1995;49:222±226. Shapsay SM, Hybels RL, Bohigian RK. Laser excision of early vocal cord carcinoma: indications, limitations and precautions. Ann. Otol. Rhinol. Laryngol. 1990;99:46±65. Thomas JJ, Olsen KD, Neel HB, De Santo LW, Suman JJ. Recurrences after endoscopic management of early glottic carcinoma. Laryngoscope 1994;104:1009±1104. Wetmore SJ, Key M, Suen JY. Laser therapy for T1 vocal cord carcinoma of the larynx. Arch. Otolaryngol. Head Neck Surg. 1986;112: 853±855. Wolfensberger MD, Dort DJ. Endoscopic laser surgery for early glottic carcinoma: a clinical and experimental study. Laryngoscope 1990;100:1100±1105.
Sincerely, Angeles Rovirosa*, Albert Biete (Received 28 January 2000; accepted 13 April 2000) Radiation Oncology Department, Hospital CliÂnic i Universitari, C/Villarroel No. 170, 08036 Barcelona, Spain 0167-8140/00/$ - see front matter q 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0 167-8140(00 )00 201-2 * C orrespon ding author.