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Management of advanced glottic carcinomas
Management of Advanced Glottic Carcinomas Mohamed S. Razack,
MD,
Tanaphon Maipang, Donald P. Shedd,
One hundred twenty-eight patients with Ta or T* glottic cancers were treated by initial surgery; 59 had a total laryngectomy and 69 had total laryngectomy with regional node dissection. Fifty-eight percent of the total laryngectomy group and fortynine percent of the total laryngectomy with neck dissection group remained fret of disease for 5 or more years. Forty-seven percent (60 of 128 patients) treated surgically developed regional recurrences rcquir@ further treatment. Nine patients had evidence of widespread metastases, leaving 51 suitable for salvage radiotherapy. Twenty-three percent ( 12 of 51 patients) were salvaged with radiotherapy given for postoperative recurrences. Twenty-five patients received an initial 6,600 rads to larynx and neck with curative intent, 28 percent of whom remained free of disease for 5 or more years. Seventeen percent of patients were salvaged with one laryngectomy for persistent or recurring tumors. Initial total laryngectomy gave better survival figures for advanced glottic carcinoma.
dvances in radiotherapy have it possible to cure a high percentage of the early glottic tumors (Ti or A T2) without sacrificing the voice [l-5]. Controversy ex-
MD,
Kumao Sako,
MD,
Buffalo,NOW York
MD,
Vahram Bakamjian,
MD,
some larynges with cure rates comparable with patients initially treated by laryngectomy [8]. In a clinical study in 1968, we reported that we could achieve better survival rates for fmed cord glottic cancers with initial laryngectomy than with radiotherapy [9]. The purpose of this nonrandomized study is to present our experience in patients treated for advanced glottic cancer in the past two decades and to document the influence of the initial mode of treatment on diseasefree 5-year survival, local and nodal recurrences, and 5-year salvage rate with second treatment. MATERIAL AND METHODS From January 1963 to December 1983,365 patients with glottic cancer were treated at Roswell Park Memorial Institute. One hundred and seven patients with Ti and 36 with T2 lesions were excluded. Forty-eight others who died from causes unrelated to laryngeal cancer and 21 patients who died from a second cancer within 2 years of initial treatment were also excluded, leaving 153 patients for the present review. The primary tumor and its local extensions with cord fmation were fully defined by an indirect and direct laryngoscopy in all patients. The American Joint Committee TNM staging system for laryngeal cancer ( 1980) was followed, resectional margins were checked and nodal clearances were performed by the pathologist on all surgically removed specimens. All patients who were alive and free of disease at last followup had a minimum of 5 years follow-up.
made
ists, however, regarding the initial treatment of the more advanced stages. Although total laryngectomy with or without neck dissection offers a higher cure rate in the advanced glottic carcinomas than radiotherapy, it is argued that patients pay a heavy price for this increment in cure rate in terms of loss of the voice and a permanent tracheostomy [G’J . Proponents of laryngectomy feel that a curative intent with radiotherapy makes little sense in advanced disease with cord fixation, since the probability for requiring subsequent surgery is so high that only a few patients are likely to benefit by preservation of the larynx [fl. Radiotherapists, on the other hand, strongly favor radiotherapy, with salvage surgery only for persisting or recurring disease. By so doing, they believe they can save From the Department of Head and Neck Surgery and Oncology, Roswell Park Memorial Institute., Buffalo, New York. Requests for reprints should be addressed to Mohamed S. Razack, MD, Department of Head and Neck Surgery and Oncology, Roswell Park Memorial Institute, 666 Elm Street, Buffalo, New York 14263. Presented at the 35th Annual Meeting of the Society of Head and Neck Surgeons, San Francisco, California, May 21-24,1989.
318
THE AMERICAN JOURNAL OF SURGERY
RESULTS The age of the patients ranged from 30 to 85 years. Twenty-one patients were in their 4th decade, 52 were in the 5th, 50 were in the 6th, and 30 were in the 7th and 8th decades. The majority of patients were in their 5th and 7th decades. There were 135 men and 18 women with a ratio of 7.5:1. One hundred thirty-eight patients had Tj and 15 had T4 lesions. One hundred thirty-three patients had No, 19 had Ni, and 1 had Nz neck nodal status. Thus, 138 patients were in stage III and 15 in stage IV disease. One hundred twenty-eight patients were treated by surgery initially. Fifty-nine patients (57 stage III and 2 stage IV) had total laryngectomy, and sixty-eight (58 stage III and 10 stage IV) had total laryngectomy with unilateral moditied neck dissection. One patient had a bilateral modified neck dissection with the laryngectomy. Twelve of the 59 patients in the total laryngectomy group (20 percent) subsequently had therapeutic neck dissection for developing nodal metastases and 23 of the 69 patients in the laryngectomy with neck dissection group (3 3 percent) had proven nodal metastases on microscopic review.
VOLUME 158 OCTOBER 1989
Thirty-four of 59 patients in the total laryngectomy group (58 percent; 33 in stage III and 1 in stage IV) and 34 of the 69 patients (49 percent) in the neck dissection with total laryngectomy group remained free of disease for 5 years or more. Thus, an overall 53 percent survival rate (68 of 128 patients) was achieved by initial surgery. Eighteen patients ( 17 in stage III) had total larynges tomy for persisting or recurring cancer after initial radiotherapy, 3 of whom (17 percent) survived for 5 years. Twenty-five patients (23 in stage III) received an initial 6,600 rads to larynx and neck with curative intent, delivered in 3 fractions during a 6’%week period. Seven patients (28 percent; 6 in stage III) remained free of disease for at least 5 years, but with fmed cords and a severely compromised voice. Sixty of 128 patients (47 percent) treated surgically developed nodal recurrences, requiring further treatment. Two patients in stage III and four in stage IV had stoma1 recurrences in addition to the neck disease and 9 patients had evidence of distant and widespread metastases, leaving 5 1 suitable for salvage radiotherapy. Salvage radiotherapy was successful for 5 years in 12 of the 5 1 patients (23 percent, 11 in stage III) whereas all others died with disease in 12 months. COMMENTS Fixation of the vocal cord has serious prognostic implications in advanced glottic cancer, signifying infiltration deep into the laryngeal muscles and cricoarytenoid joints in most instances [IO]. Olofsson and coworkers’ [I Z] serial section study of 26 larynges with fured cords indicated that nearly half of the lesions were underestimated clinically. Controversy persists among oncologists over management of stage III and IV glottic carcinoma. Radiation oncologists advocate primary radiotherapy for the sake of saving the larynx, reserving surgery for persistent or recurrent disease. Most other investigators in this field today will employ an initial total laryngectomy with or without neck diiection and with or without postoperative irradiation in order to achieve higher cure rates [ 22141. Kirchner and Sam [I51 and Harris et al [26J have reported achieving 60 percent cures by partial laryngeu tomy in a selected group of patients (tumor limited to one cord) and treating the recurrences by total laryngectomy. In the present study, it was difficult to find advanced glottic carcinoma restricted to one true cord. Harwood and associates [8], advocating radiotherapy, have reported a local recurrence rate of about 50 percent, of whom two-thirds (66 percent) are said to have been salvaged by total laryngectomy. In our present re view of 25 initially irradiated advanced glottic cancers, we achieved seven 5-year diseasefree survivals (28 percent), which is very similar to the 25 to 30 percent rates published by other investigators [15-Z 91. However, of the 18 postradiotherapy failures (72 percent), we were able to save only 3 (16.7 percent) for 5 years by salvage surgery, a much lower percentage than the 50 to 60 percent rates reported by other investigators [8,20,21]. Patients with advanced glottic cancers when radiated
have a 50 to 70 percent probability of recurrence and will need retreatment [22,23]. Hence, this modality should not be used for curative purpose in these patients. The argument of voice and voice quality preservation in such situations deserves serious consideration. There is no dispute that the quality of voice in a successfully radiated early cancer is good, and the price to be paid is usually restricted to a dry throat, but in advanced cases (T3 or T4 cancers), irradiated patients have neither a satisfactory voice nor a good chance for salvage by second treatment with total laryngectomy. Earlier clinical studies had shown better survival figures with initial surgery [6,9]. Because of these persistently higher cure rates during the past four decades at our institution, we believe we are justified in contimiing our management for advanced stages of laryngeal cancer. In the present study with 128 initial total laryngecto mies performed, plus or minus modified radical neck dissections, 68 patients (53 percent) remained free of diise for 5 or more years. An additional 12 of 5 1 patients from the surgically failed group were saved by salvage radiotherapy, bringing the overall survival figure to 62.5 percent in contrast to the 40 percent rate we achieved by initial radiotherapy and salvage surgery. In 54 percent of patients with advanced glottic cancers, nodal metastases were present either at the initial time of neck dissection or developed subsequently, adversely affecting the prognosis. We therefore strongly advise a neck diiion in addition to total larygectomy for these patients.
1. Leonard MR, Holt GP, Maran AG. Treatment of vocal cord carcinoma by vertical hemilaryngectomy. Ann Otol Rhino1 Laryngo1 1972; 81: 469-78. 2. Marks RD Jr, Fitx-Hugh GS, Cox-Stable WC. Fourteen years experience with cobalt-68 radiation therapy in treatment of early cancer of true vocal cords. Cancer 1971; 28: 571-6. 3. Ogura JH, Bier HF. Surgical management. JAMA 1972; 221: 77-9. 4. Putny FJ, Chapman CE. Carcinoma of larynx: analysis of 3 11 cases treated surgically. Ami Otol Rhino1 Laryngol1972; 81: 4% 64. 5. Wang CC. Radiotherapeutic approach. JAMA 1972; 221: 7980. 6. Pradhan SA, Pawar AS, Rajpal RM, Rae DN. Radical radiotherapy and salvage surgery for T3 NO MO glottic cancer: is it feasible in the Indian population? Indian J Cancer 1985; 22: 29-32. 7. DeSanto LW, Llllie JC, Devine RD. Surgical salvage after radiation for laryngeal cancer. Laryngoscope 1976; 86: 649-57. 8. Harwcod AR, Bryce DP, Rider WD. Management of T3 glottic cancer. Arch Otolaryngol 1980; 106: 697. 9. Marchetta FC, Sako K, Mattick WL. Squamous cell carcinoma of the larynx. Am J Surg 1968; 116: 491.10. Thawlev SE. Panie WR. eds. Comnrehensive manaaement of head and n&k tumi. Vol. i. Philadel&iaz WB Saund&i, 1987. 11. Olofsson J, Lord IJ, Van Nostrand AWP. Vocal cord fixation in laryngeal carcinoma. Acta Otolaryngol (Stockh) 1973; 75: 496. 12. Kirchner JA, Owen JR. Five hundred cancers of the larynx and pyriform sinus: results of treatment of radiation and surgery. Laryngoscope 1977; 87: 1288. 13. Martensson B, Fluur E, Jacobsson F. Aspects on treatment of
THE AMERICAN JOURNAL OF SURGERY
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319
cancer of the larynx. Ann Otol Rhino1 Laryngol 1967; 76: 313. 14. Vermund H. Role of radiotherapy in cancer of the larynx as related to the TNM system of staging: a review. Cancer 1970; 25: 485. 15. Kirchner JA, Som ML. The anterior commissure technique of partial laryngectomy: clinical and laboratory observations. Laryngoscope 1975; 85: 1308. 16. Harris HS Jr, Watson PR, Spratt JS Jr. Carcinoma of the larynx: a retrospective study of 144 cases. Am J Surg 1969; 118: 676-84. 17. Enuuyer A, Bat&i P. Laryngeal carcinomas. Laryngoscope 1975; 85: 1467. 18. Miller D. Management of glottic carcinoma. Laryngoscope
320
THE AMERICAN JOURNAL OF SURGERY
1975; 85: 1435. 19. Wang CC. Treatment of squamous cell carciuoma of the laryux by radiation. Radio1 Clin North Am 1978; 16: 209. 20. Perez CA, Mii WB, Ogura JH, Powers WE. Irradiation of early carcinoma of the larynx: signiiicance of tumor extent. Arch Otolaryngol 1971; 93: 465-72. 21. Shaw HJ. Glottic cancer of the larynx, 1947-1956. Laryngoscope 1965; 79: 1. 22. Hawkins NV. The treatment of glottic carcinoma: an analysis of 800 cases. Laryugoscope 1975; 85: 1485. 23. Stewart JG, Brown JR, Palmer MK, Cooper A. The manage ment of glottic carcinoma by primary irradiation with surgery in reserve. Laryngoscope 1975; 85: 1477.
VOLUME 158
OCTOBER 1989
MD,
Tanaphon Maipang, Donald P. Shedd,
One hundred twenty-eight patients with Ta or T* glottic cancers were treated by initial surgery; 59 had a total laryngectomy and 69 had total laryngectomy with regional node dissection. Fifty-eight percent of the total laryngectomy group and fortynine percent of the total laryngectomy with neck dissection group remained fret of disease for 5 or more years. Forty-seven percent (60 of 128 patients) treated surgically developed regional recurrences rcquir@ further treatment. Nine patients had evidence of widespread metastases, leaving 51 suitable for salvage radiotherapy. Twenty-three percent ( 12 of 51 patients) were salvaged with radiotherapy given for postoperative recurrences. Twenty-five patients received an initial 6,600 rads to larynx and neck with curative intent, 28 percent of whom remained free of disease for 5 or more years. Seventeen percent of patients were salvaged with one laryngectomy for persistent or recurring tumors. Initial total laryngectomy gave better survival figures for advanced glottic carcinoma.
dvances in radiotherapy have it possible to cure a high percentage of the early glottic tumors (Ti or A T2) without sacrificing the voice [l-5]. Controversy ex-
MD,
Kumao Sako,
MD,
Buffalo,NOW York
MD,
Vahram Bakamjian,
MD,
some larynges with cure rates comparable with patients initially treated by laryngectomy [8]. In a clinical study in 1968, we reported that we could achieve better survival rates for fmed cord glottic cancers with initial laryngectomy than with radiotherapy [9]. The purpose of this nonrandomized study is to present our experience in patients treated for advanced glottic cancer in the past two decades and to document the influence of the initial mode of treatment on diseasefree 5-year survival, local and nodal recurrences, and 5-year salvage rate with second treatment. MATERIAL AND METHODS From January 1963 to December 1983,365 patients with glottic cancer were treated at Roswell Park Memorial Institute. One hundred and seven patients with Ti and 36 with T2 lesions were excluded. Forty-eight others who died from causes unrelated to laryngeal cancer and 21 patients who died from a second cancer within 2 years of initial treatment were also excluded, leaving 153 patients for the present review. The primary tumor and its local extensions with cord fmation were fully defined by an indirect and direct laryngoscopy in all patients. The American Joint Committee TNM staging system for laryngeal cancer ( 1980) was followed, resectional margins were checked and nodal clearances were performed by the pathologist on all surgically removed specimens. All patients who were alive and free of disease at last followup had a minimum of 5 years follow-up.
made
ists, however, regarding the initial treatment of the more advanced stages. Although total laryngectomy with or without neck dissection offers a higher cure rate in the advanced glottic carcinomas than radiotherapy, it is argued that patients pay a heavy price for this increment in cure rate in terms of loss of the voice and a permanent tracheostomy [G’J . Proponents of laryngectomy feel that a curative intent with radiotherapy makes little sense in advanced disease with cord fixation, since the probability for requiring subsequent surgery is so high that only a few patients are likely to benefit by preservation of the larynx [fl. Radiotherapists, on the other hand, strongly favor radiotherapy, with salvage surgery only for persisting or recurring disease. By so doing, they believe they can save From the Department of Head and Neck Surgery and Oncology, Roswell Park Memorial Institute., Buffalo, New York. Requests for reprints should be addressed to Mohamed S. Razack, MD, Department of Head and Neck Surgery and Oncology, Roswell Park Memorial Institute, 666 Elm Street, Buffalo, New York 14263. Presented at the 35th Annual Meeting of the Society of Head and Neck Surgeons, San Francisco, California, May 21-24,1989.
318
THE AMERICAN JOURNAL OF SURGERY
RESULTS The age of the patients ranged from 30 to 85 years. Twenty-one patients were in their 4th decade, 52 were in the 5th, 50 were in the 6th, and 30 were in the 7th and 8th decades. The majority of patients were in their 5th and 7th decades. There were 135 men and 18 women with a ratio of 7.5:1. One hundred thirty-eight patients had Tj and 15 had T4 lesions. One hundred thirty-three patients had No, 19 had Ni, and 1 had Nz neck nodal status. Thus, 138 patients were in stage III and 15 in stage IV disease. One hundred twenty-eight patients were treated by surgery initially. Fifty-nine patients (57 stage III and 2 stage IV) had total laryngectomy, and sixty-eight (58 stage III and 10 stage IV) had total laryngectomy with unilateral moditied neck dissection. One patient had a bilateral modified neck dissection with the laryngectomy. Twelve of the 59 patients in the total laryngectomy group (20 percent) subsequently had therapeutic neck dissection for developing nodal metastases and 23 of the 69 patients in the laryngectomy with neck dissection group (3 3 percent) had proven nodal metastases on microscopic review.
VOLUME 158 OCTOBER 1989
Thirty-four of 59 patients in the total laryngectomy group (58 percent; 33 in stage III and 1 in stage IV) and 34 of the 69 patients (49 percent) in the neck dissection with total laryngectomy group remained free of disease for 5 years or more. Thus, an overall 53 percent survival rate (68 of 128 patients) was achieved by initial surgery. Eighteen patients ( 17 in stage III) had total larynges tomy for persisting or recurring cancer after initial radiotherapy, 3 of whom (17 percent) survived for 5 years. Twenty-five patients (23 in stage III) received an initial 6,600 rads to larynx and neck with curative intent, delivered in 3 fractions during a 6’%week period. Seven patients (28 percent; 6 in stage III) remained free of disease for at least 5 years, but with fmed cords and a severely compromised voice. Sixty of 128 patients (47 percent) treated surgically developed nodal recurrences, requiring further treatment. Two patients in stage III and four in stage IV had stoma1 recurrences in addition to the neck disease and 9 patients had evidence of distant and widespread metastases, leaving 5 1 suitable for salvage radiotherapy. Salvage radiotherapy was successful for 5 years in 12 of the 5 1 patients (23 percent, 11 in stage III) whereas all others died with disease in 12 months. COMMENTS Fixation of the vocal cord has serious prognostic implications in advanced glottic cancer, signifying infiltration deep into the laryngeal muscles and cricoarytenoid joints in most instances [IO]. Olofsson and coworkers’ [I Z] serial section study of 26 larynges with fured cords indicated that nearly half of the lesions were underestimated clinically. Controversy persists among oncologists over management of stage III and IV glottic carcinoma. Radiation oncologists advocate primary radiotherapy for the sake of saving the larynx, reserving surgery for persistent or recurrent disease. Most other investigators in this field today will employ an initial total laryngectomy with or without neck diiection and with or without postoperative irradiation in order to achieve higher cure rates [ 22141. Kirchner and Sam [I51 and Harris et al [26J have reported achieving 60 percent cures by partial laryngeu tomy in a selected group of patients (tumor limited to one cord) and treating the recurrences by total laryngectomy. In the present study, it was difficult to find advanced glottic carcinoma restricted to one true cord. Harwood and associates [8], advocating radiotherapy, have reported a local recurrence rate of about 50 percent, of whom two-thirds (66 percent) are said to have been salvaged by total laryngectomy. In our present re view of 25 initially irradiated advanced glottic cancers, we achieved seven 5-year diseasefree survivals (28 percent), which is very similar to the 25 to 30 percent rates published by other investigators [15-Z 91. However, of the 18 postradiotherapy failures (72 percent), we were able to save only 3 (16.7 percent) for 5 years by salvage surgery, a much lower percentage than the 50 to 60 percent rates reported by other investigators [8,20,21]. Patients with advanced glottic cancers when radiated
have a 50 to 70 percent probability of recurrence and will need retreatment [22,23]. Hence, this modality should not be used for curative purpose in these patients. The argument of voice and voice quality preservation in such situations deserves serious consideration. There is no dispute that the quality of voice in a successfully radiated early cancer is good, and the price to be paid is usually restricted to a dry throat, but in advanced cases (T3 or T4 cancers), irradiated patients have neither a satisfactory voice nor a good chance for salvage by second treatment with total laryngectomy. Earlier clinical studies had shown better survival figures with initial surgery [6,9]. Because of these persistently higher cure rates during the past four decades at our institution, we believe we are justified in contimiing our management for advanced stages of laryngeal cancer. In the present study with 128 initial total laryngecto mies performed, plus or minus modified radical neck dissections, 68 patients (53 percent) remained free of diise for 5 or more years. An additional 12 of 5 1 patients from the surgically failed group were saved by salvage radiotherapy, bringing the overall survival figure to 62.5 percent in contrast to the 40 percent rate we achieved by initial radiotherapy and salvage surgery. In 54 percent of patients with advanced glottic cancers, nodal metastases were present either at the initial time of neck dissection or developed subsequently, adversely affecting the prognosis. We therefore strongly advise a neck diiion in addition to total larygectomy for these patients.
1. Leonard MR, Holt GP, Maran AG. Treatment of vocal cord carcinoma by vertical hemilaryngectomy. Ann Otol Rhino1 Laryngo1 1972; 81: 469-78. 2. Marks RD Jr, Fitx-Hugh GS, Cox-Stable WC. Fourteen years experience with cobalt-68 radiation therapy in treatment of early cancer of true vocal cords. Cancer 1971; 28: 571-6. 3. Ogura JH, Bier HF. Surgical management. JAMA 1972; 221: 77-9. 4. Putny FJ, Chapman CE. Carcinoma of larynx: analysis of 3 11 cases treated surgically. Ami Otol Rhino1 Laryngol1972; 81: 4% 64. 5. Wang CC. Radiotherapeutic approach. JAMA 1972; 221: 7980. 6. Pradhan SA, Pawar AS, Rajpal RM, Rae DN. Radical radiotherapy and salvage surgery for T3 NO MO glottic cancer: is it feasible in the Indian population? Indian J Cancer 1985; 22: 29-32. 7. DeSanto LW, Llllie JC, Devine RD. Surgical salvage after radiation for laryngeal cancer. Laryngoscope 1976; 86: 649-57. 8. Harwcod AR, Bryce DP, Rider WD. Management of T3 glottic cancer. Arch Otolaryngol 1980; 106: 697. 9. Marchetta FC, Sako K, Mattick WL. Squamous cell carcinoma of the larynx. Am J Surg 1968; 116: 491.10. Thawlev SE. Panie WR. eds. Comnrehensive manaaement of head and n&k tumi. Vol. i. Philadel&iaz WB Saund&i, 1987. 11. Olofsson J, Lord IJ, Van Nostrand AWP. Vocal cord fixation in laryngeal carcinoma. Acta Otolaryngol (Stockh) 1973; 75: 496. 12. Kirchner JA, Owen JR. Five hundred cancers of the larynx and pyriform sinus: results of treatment of radiation and surgery. Laryngoscope 1977; 87: 1288. 13. Martensson B, Fluur E, Jacobsson F. Aspects on treatment of
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cancer of the larynx. Ann Otol Rhino1 Laryngol 1967; 76: 313. 14. Vermund H. Role of radiotherapy in cancer of the larynx as related to the TNM system of staging: a review. Cancer 1970; 25: 485. 15. Kirchner JA, Som ML. The anterior commissure technique of partial laryngectomy: clinical and laboratory observations. Laryngoscope 1975; 85: 1308. 16. Harris HS Jr, Watson PR, Spratt JS Jr. Carcinoma of the larynx: a retrospective study of 144 cases. Am J Surg 1969; 118: 676-84. 17. Enuuyer A, Bat&i P. Laryngeal carcinomas. Laryngoscope 1975; 85: 1467. 18. Miller D. Management of glottic carcinoma. Laryngoscope
320
THE AMERICAN JOURNAL OF SURGERY
1975; 85: 1435. 19. Wang CC. Treatment of squamous cell carciuoma of the laryux by radiation. Radio1 Clin North Am 1978; 16: 209. 20. Perez CA, Mii WB, Ogura JH, Powers WE. Irradiation of early carcinoma of the larynx: signiiicance of tumor extent. Arch Otolaryngol 1971; 93: 465-72. 21. Shaw HJ. Glottic cancer of the larynx, 1947-1956. Laryngoscope 1965; 79: 1. 22. Hawkins NV. The treatment of glottic carcinoma: an analysis of 800 cases. Laryugoscope 1975; 85: 1485. 23. Stewart JG, Brown JR, Palmer MK, Cooper A. The manage ment of glottic carcinoma by primary irradiation with surgery in reserve. Laryngoscope 1975; 85: 1477.
VOLUME 158
OCTOBER 1989