Supraglottic surgery in vestibular cancer

This paper deals with the experience acquired in the E.N.T. Clinic of the University of Ferrara regarding horizontal supraglottic laryngectomy in vestibular cancer. The anatomical background of this functional surgery and the most important principles of the technique are specified. The results regard 121 cases (13 T1 cases, 93 T2 cases and 15 T4 cases) divided into three groups: 1. patients who had only surgery (68 cases); 2. patients who for various reasons also had complementary postoperative radiotherapy (39 cases); 3. patients with extralaryngeal expansion who had preoperative radiotherapy (14 cases). The high overall survival rate for the 121 cases is particularly significant, as is the shortening of the high-risk period to less than the usual 5 years. The 4-year cure rate is 78% and remains unchanged right through the 7-year follow-up. The authors feel that these data demonstrate further the validity of supraglottic laryngectomy when its precise indications are rigorously observed.     

CO2激光手术治疗声门上型喉癌

目的 总结CO2激光手术治疗声门上型喉癌的临床治疗效果.方法 回顾性分析1995年2月至2005年6月CO2激光手术治疗的32例声门上型喉癌患者临床资料.32例患者中T1N0M0 20例,T1N1M0 2例,T2N0M0 8例,T2N1M0 2例,全部病例术后随诊3年以上.喉部肿瘤均经口行激光手术,同期行择区性(Ⅱ-Ⅳ区)颈清扫术12例,改良全颈清扫术4例.结果 KaplanMeier法统计5年生存率为90.6%,其中T1病变5年生存率为95.6%,T2病变为78.2%.喉的局部控制率为96.8%;喉局部和颈部区域5年控制率为90.3%,其中T1病变5年局部区域控制率为90.9%,T2病变为89.0%.喉部局部复发2例,1例再治疗行喉水平垂直部分切除术,1例行喉全切除术.颈部区域复发2例,其中1例喉部复发伴颈淋巴转移,再治疗后存活;1例颈部复发,治疗后再次颈部复发并伴肺转移死亡.4例患者出现较轻并发症,保守治疗后好转.除1例患者因局部复发行喉全切除外,其余存活患者喉功能良好.结论 激光治疗早期声门上型喉癌创伤小、疗效可靠,是一种理想的治疗方式.     

Conservation surgery for T2 and T3 carcinomas of the supraglottic larynx

The treatment of choice for supraglottic carcinomas of intermediate size (stages T2 and T3) remains controversial. Between 1974 and 1983 in our institution, 139 patients with supraglottic carcinoma of intermediate size were judged retrospectively to have been technically amenable to conservation surgery. Primary disease control at three years was achieved in 100% of the patients treated by supraglottic laryngectomy, 91% (34 patients) of those treated by total laryngectomy, and 69% (81 patients) of those treated by radiotherapy. Of the latter group, 62% were salvaged by total laryngectomy yielding a net three-year local control of 85%. Determinate five-year survival rates were 89% for supraglottic laryngectomy, 78% for total laryngectomy, and 70% for radiotherapy. Significant problems with aspiration occurred in four patients (16%) who were treated by conservation surgery, and two patients (8%) required a permanent tracheostomy. The results of this study show that supraglottic laryngectomy with postoperative radiotherapy as indicated is a highly effective method for the local control of supraglottic carcinoma of intermediate size that is amenable to conservation surgery.     

Supracricoid partial laryngectomy in the treatment of laryngeal cancer: univariate and multivariate analysis of prognostic factors

OBJECTIVES: To evaluate the oncological results of supracricoid partial laryngectomy as a treatment for selected glottic and supraglottic cancer in a large series of patients who had undergone uniform treatment over a 16-year period and to determine the different prognostic factors that may influence local control and survival. DESIGN: Retrospective clinical study. SETTING: Academic tertiary referral medical center. PATIENTS: The study population comprised 253 consecutive patients (234 men and 19 women) with glottic and supraglottic squamous cell carcinoma. The mean age was 58 years for men and 59.2 years for women. INTERVENTION: Supracricoid partial laryngectomy: 180 patients had undergone cricohyoidopexy and 73 had undergone cricohyoidoepiglottopexy. MAIN OUTCOME MEASURES: Local control and overall survival. Potential prognostic factors for local control and survival were evaluated with univariate and multivariate models. RESULTS: The 3-, 5-, 10-, and 16-year overall survival rates in this group of 253 patients were 85.8%, 79.1%, 57.6%, and 57.6%, respectively. With regard to local control, univariate and multivariate analyses showed that a positive resection margin was the only important predictor of local control and that a dysplastic lesion at the margin of resection is just as aggressive as the presence of invasive carcinoma. When considering the prognostic factors influencing survival, univariate analysis showed that the tumor category, lymph node category, tumor stage, and recurrence all had a significant influence on the survival rate. Multivariate analysis showed that the most important predictor of survival was recurrence. CONCLUSIONS: Supracricoid partial laryngectomy is a valid choice in the treatment of selected glottic and supraglottic cancer while maintaining laryngeal functions and achieving a high rate of local control. T category, N category, tumor stage, positive resection margins, and recurrence are the most important predictors of oncological outcome.     

Endoscopic CO2 laser therapy of selected cases of supraglottic marginal tumors

Endoscopic CO₂ laser intervention can be used as conservation surgery for supraglottic laryngeal carcinomas in carefully selected patients. We analyzed retrospectively our experience in managing patients with early supraglottic carcinomas operated on at the Clinic of Otorhinolaryngology, Szeged, Hungary, during the 10-year period between 1987 and 1997. Conservation surgery was the treatment of choice in 187 patients, but only 23 (12%) were selected for endoscopic CO₂ laser surgery. Laser surgery was indicated predominantly for T1 cancer of the epiglottis (n = 15), but was also performed for T2 cancers (n = 8). Of the 23 supraglottic tumors treated, 16 had no signs of recurrence to date (1.5 to 9 years after surgery) a local control rate of 70%. Six patients with recurrences underwent salvage therapies that included repeated laser excisions (n = 3), radiotherapy (to 60 Gy), horizontal supraglottic laryngectomy and total laryngectomy. One patient was not resectable because of multiple metastases. Our experience with endolaryngeal CO₂ laser excision indicates that it is a reasonable method in selected cases of supraglottic tumors, but one-third of the patients required salvage treatment. Recieved: 28 September 1998 / Accepted: 15 March 1999     

Outcome after supracricoid laryngectomies in the material of ENT Department,Poznan University of Medical Sciences

All patients with T1 and T2 laryngeal cancer should be treated with the intent to preserve the larynx. In T3 glottic low-volume tumors, larynx preservation is an appropriate standard treatment option. Supracricoid partial laryngectomy remains a reasonable alternative to radiotherapy for patients with T2–T3 glottic cancer. Prospective clinical study aims to evaluate the oncological results of supracricoid partial laryngectomy as a treatment for selected glottic and supraglottic carcinoma, and to determine the different prognostic factors that may influence local control and survival. In the period of 2000–2007, 145 patients were treated at the academic tertiary referral medical center: ENT Department, University of Medical Sciences, Poznán, Poland. The ages of the analyzed group of patients ranged from 23 to 79, with mean 56.5 age for men and 25 for women. All of the patients had biopsy proven squamous cell carcinoma. Of the 145 patients 82 had glottic cancer and 63 had supraglottic cancer. The patients were staged according to the 2003 edition of the TNM classification established by the AJCC. The pathological TNM classification was additionally taken into consideration. All patients were treated by means of supracricoid and transglottic partial laryngectomy. The type of supracricoid partial laryngectomy was based on tumor localization and extension. Four patients underwent cricohyoidopexy, 57 cricohyoidoepiglottopexy, 65 reconstruction modo Calearo, and 19 modo Sedlacek-Tucker. We performed 21 unilateral selective neck dissections and none bilateral. A nasogastric feeding tube was inserted in all patients, and removed in patients that regained proper swallowing. As a result, we took into consideration the oncological and functional results. Histopathological examination of the operating specimen revealed the presence of dysplasia or invasive carcinoma at the margins, or a close margin of less than 5 mm from the edge of the resection (16 cases). The metastases were found on the neck in three cases, predominantly in the level II (2 cases) and III (1 case). Metastasis was found in one patient that had undergone CHP, Sedlacek-Tucker, and Calearo, respectively. Five patients received postoperative radiotherapy. The decision to use adjuvant radiotherapy was based on the presence of invasive carcinoma at the resection margin and on the presence of multiple positive neck nodes or extracapsular spread of the disease. The Kaplan–Meier estimated 3- and 5-year overall survival rates in the group of 122 because 23 patients did not report for medical check-ups.     

喉声门上型低分化鳞状细胞癌57例临床观察

目的 探讨喉声门上型低分化鳞状细胞癌(简称鳞癌)的临床特点、治疗及预后。方法 回顾分析1980～1998年我院57例喉声门上型低分化鳞癌病例(1997年UICC分期：Ⅰ期4例，Ⅱ期5例，Ⅲ期18例，Ⅳ期30例)。单纯手术25例，单纯放射治疗9例，术前放射治疗加手术14例，手术加术后放射治疗7例，术前化学治疗加手术2例。喉全切除23例，喉部分切除25例；同期颈清扫31例(单侧17例，双侧14例)，上颈清扫12例。结果5年生存率47．4％(27／57)，颈部转移率63．2％(36／57)，双颈转移率24．6％(14／57)，远处转移率21．1％(12／57)，局部复发率10．5％(6／57)，颈部复发率28．1％(16／57)，喉部分切除的局部复发率12．0％(3／25)。生存率随分期下降，T1 T2与13 T4和N0 N1与N2 N3的生存率差异分别有显著性(χ^2=4．942，P=0．026；χ^2=4．306，P=0．038)。单纯手术与手术结合放射治疗的生存率差异无显著性，N2和N3患者的手术结合放射治疗相对优于单纯手术。结论 喉声门上型低分化鳞癌患者以晚期病变为主，易较早发生淋巴结转移，颈部转移和远处转移率较高，治疗仍以手术为主，喉部分切除术是可行的，T3病变的喉部分切除和颈部N分级较晚的患者应手术结合放射治疗。     

Clinical study of early laryngeal cancer

We retrospectively analyzed 71 consecutive cases of early laryngeal cancer (stage I or II) that had undergone primary treatment in our department between 1999 and 2004. There were 68 males and 3 females, and their ages ranged from 40 to 85 years of age (average; 67.7 years). Eight patients had the supraglottic type, 61 had the glottic type, and 2 had the subglottic type. Chemoradiotherapy was performed as the primary treatment except in the patients with glottic T1a cancer, who received radiotherapy alone. The 5-year survival rates was 91.1% for glottic cancer (T1a: 100%, T1b: 92.3%, T2: 85.8%) and 75.0% for supraglottic cancer. The local control rate of glottic cancer was 79.6% (T1a: 80.0%, T1b: 74.0%, T2: 85.2%), and significantly higher than that of supraglottic cancer (56.2%, p < 0.05). The laryngeal preservation rate was 84.4% in glottic cancer (T1a: 100%, T1b: 76.9%, T2: 77.5%) and 58.3% in supraglottic cancer, and the difference between T1a and T2 glottic cancer was significant (p < 0.05). Local recurrence and cervical lymph node metastasis were seen in 9 patients and 6 patients, respectively. Distant metastasis occurred in 4 patients, all of whom had the glottic type. Four patients died of their disease, and distant metastasis was the major cause of death in 3 of them. These results indicate that additional treatment should be performed in cases in which radiotherapy/chemoradiotherapy is ineffective and that both in the early stages glottic and supraglottic cancers can be successfully treated by radiotherapy/chemoradiotherapy. The results also suggested that the survival of patients with early laryngeal cancer depends on whether they develop distant metastasis. Introduction of adjuvant chemotherapy to improve their prognosis remains to be assessed.     

Transoral carbon dioxide laser supraglottic laryngectomy and irradiation in stage I, II, and III squamous cell carcinoma of the supraglottic larynx: report of Southwest Oncology Group Phase 2 Trial S9709

OBJECTIVE: To evaluate feasibility, functional outcome, and disease control of endoscopic surgery and irradiation in patients with squamous cell carcinoma of the supraglottic larynx. DESIGN: Prospective, single-arm, phase 2 multi-institutional trial. SETTING: Southwest Oncology Group trial S9709. PATIENTS: Thirty-four patients diagnosed as having stage I, stage II, or selected stage III (T1-2N1M0) supraglottic laryngeal carcinoma enrolled from September 15, 1997, to December 1, 2001. INTERVENTIONS: Transoral supraglottic laryngectomy by carbon dioxide laser followed by planned postoperative radiotherapy. MAIN OUTCOME MEASURES: Three-year progression-free survival, proportion of patients requiring tracheostomy as a result of surgery, and time to adequate oral intake. RESULTS: All 34 patients underwent surgery without major protocol deviation. Thirty-two patients (94%) completed planned postoperative radiotherapy without major deviation. At the time of analysis, only 1 patient (3%) had documented local disease recurrence at the primary disease site and required salvage total laryngectomy, and 2 patients (6%) had documented regional recurrence and required salvage neck dissection. Estimated 3-year progression-free survival and overall survival were 79% and 88%, respectively. No subjects required tracheostomy as a direct consequence of endoscopic resection. Patients who required tracheostomy before endoscopic resection due to either obstructive tumor bulk or unfavorable anatomy that precluded safe intubation (4 patients [12%]) were all decannulated in the early postoperative period (相似文献   

Results of treatment of 584 laryngeal cancers at the Ear-Nose-Throat Clinic of Marburg University

The results in the management of 460 vocal cord carcinomas and 124 supraglottic carcinomas are reported. Of the vocal cord carcinomas, 63.3% were diagnosed in the early Tis and T1 stage. Seventy-six tumors were resected endoscopically, 128 by laryngofissure and chordectomy. Not one of these patients has lost his life, larynx or voice. In bilateral tumors of the T1b category, 2 patients developed local recurrences and lost their larynx. Sixty-two carcinomas of the Tis, T1a and T1b categories were irradiated primarily. Two of these patients died and 14 underwent laryngectomy for local recurrence. In T2 carcinomas a 5-year cure rate of 87.5% was achieved by vertical partial resection. The 5-year cure rate after laryngectomy or laryngectomy with neck dissection for T2N0 and T2N+ carcinoma was 86.2% and 75.0% respectively. Most treatment failures were due to late metastases which could not be controlled. In T3 carcinomas with a 5-year cure rate of 71.4% (N0) and 70.0% (N+) respectively, treatment failures were also mainly seen in patients with N0 necks where we did not carry out a prophylactic neck dissection. Five-year survival rates for primary surgery in supraglottic T1-T4 carcinomas were 100%, 82.4%, 84% and 58.3%. The widely hel opinion that laryngeal carcinoma should only be subjected to surgery for irradiation failure can no longer be sustained. More patients lose their larynx or their life after irradiation of small carcinomas than after primary surgery. Furthermore, too many patients have to undergo two major cancer treatments (irradiation and salvage surgery). In larger carcinomas radiotherapy produces a lower survival rate and too many patients require two stressful cancer therapies. The number of retained larynges is not substantially higher than with primary surgery. Primary irradiation for selected cases should be part of every therapy concept that aims at an adequate and individual treatment of every patient.     

保留杓状软骨喉次全切除喉功能重建的体会

探讨应用保留杓状软骨的喉次全切除喉功能重建术治疗Ｔ３喉癌的拔管率和３、５年生存率。方法对２０例Ｔ３级喉癌,其中声门型３例,声门上型１７例,根据病变范围行保留单侧或双侧杓状软骨喉次全切除及功能重建术,并设计环咽吻合术式。     

205例喉癌的手术方式与远期疗效分析

目的分析1990年以来喉癌手术治疗的方法及其远期疗效，以改进治疗并提高生存率。方法对1990年1月-2004年10月间手术治疗的205例病例进行临床随访、病历资料分析。其中声门上型52例，声门型149例，声门下型4例；按UICC 1997年分期标准Ⅰ期48例，Ⅱ期88例，Ⅲ期44例，Ⅳ期25例。行支撑喉镜下声带切除术1例，撕皮术2例，喉裂开声带切除术9例，未行气管切开的喉垂直部分切除术16例，喉垂直部分切除术25例，水平半喉切除术7例，Arslan（咽气管吻合）手术15例，环舌骨会套固定术（criicohyoidoepidottopexy，CHEP）57例，喉次全切除术16例，喉全切除术57例。结果205例仅4例失访，Kaplan—Meier法统计总的1年生存率96．0％，3年生存率84．8％，5年生存率为79．4％，其中声门上型1年生存率88．3％，3年为67．5％，5年为65．0％；声门型1年生存率99．3％，3年为91．3％，5年为84．7％，喉功能保存率72．7％。早期肿瘤（Ⅰ、Ⅱ期）与晚期肿瘤（Ⅲ、Ⅳ期）患者之间生存率差异有统计学意义（P〈0．01），肿瘤不同发病部位（声门型、声门上型）患者之间生存率差异有统计学意义（P〈0．05）。结论喉癌手术治疗效果好，喉功能保存率高，其预后与肿瘤分期、发病部位有关。提倡严格掌握手术指征，在保证手术安全边缘的情况下，制定个体化治疗方案，运用最优的手术切除和功能重建方法，综合治疗，提高生存质量。     

喉环上部分切除术及其疗效

目的 探讨喉癌行喉次全切除术并重建喉功能的术式及其疗效。方法 １９７８～１９９８年行喉次全切除环－舌骨固定术或环－舌骨－会厌固定术２９例,其中男１８例,女１１例;年龄最大７０岁,最小３８岁,平均５５．４岁。按１９８７年ＵＩＣＣ分期,全部均为Ｍ０,声门上型１０例（Ｔ２Ｎ０ ３例、Ｔ２Ｎ１ １例、Ｔ３Ｎ０ ３例、Ｔ３Ｎ１ ２例,Ｔ３Ｎ２ １例）,声门型１９例（Ｔ２Ｎ０ １２例、Ｔ２Ｎ１ １例、Ｔ３Ｎ０     

Subtotal laryngectomy with cricohyoidopexy as first treatment procedure for supraglottic carcinoma: Institut Gustave-Roussy experience (146 cases, 1974–1997)

Patients and methods: Between 1974 and 1997, 297 patients underwent a subtotal laryngectomy at the Institut Gustave-Roussy; 146 of these patients underwent cricohyoidopexy (CHP) for a supraglottic primary as their first treatment. The majority of patients were men (137) aged from 33 to 78 years (median 54 years). The tumour stage at presentation was T1 in 2, T2 in 87, T3 in 53 (pre-epiglottic space involvement), and T4 (minimal thyroid cartilage invasion) in 4 patients. One hundred and twenty-five patients were N0 (86%) and 21 patients were Np (palpable); 98% had homolateral and 55% had bilateral neck dissections. Results: One patient died postoperatively of a myocardial infarction and 68% patients had an uneventful course. Aspiration was the commonest complication (23 patients, 19%). The median time to removal of the tracheotomy cannula was 10 days and for the nasogastric tube 21 days during the past 10 years. Completion of subtotal laryngectomy into total laryngectomy was done in 21 cases (15%): eight times because of oncological events [five local failures, two second primary (hypopharynx), one positive margin] and 13 times because of aspiration (9%). There were six local failures (4%) and eight nodal failures (5%). The rates of distant metastases and second primaries were 6% and 16% respectively. Half of the local and nodal failures were subsequently sterilized. Findings at death were two local recurrences, four nodal recurrences, eight distant metastases, and 11 second primaries. The 3- and 5-year overall survival rates were 92% and 88% respectively, with an overall laryngeal preservation rate of 86%. Conclusion: When supraglottic laryngectomy is not feasible for supraglottic cancer, subtotal laryngectomy with CHP is a safe and effective oncological procedure, with preservation of satisfactory laryngeal function. Received: 20 June 2000 / Accepted: 10 April 2001     

Oncological outcomes of surgical treatment for T3 supraglottic laryngeal squamous cell carcinoma patients

Abstract

Background: T3 supraglottic laryngeal carcinoma (LC) is a common advanced laryngeal cancer.

Objective: This study was conducted to assess the clinical results of pathological T3 (pT3) supraglottic LC patients who were amenable to laryngectomy treated with primary surgery and postoperative therapy.

Methods: Retrospective review of 202 pT3 cases of supraglottic laryngeal squamous cell carcinoma.

Results: The five-year cancer specific survival (CSS) rate was 63.7% and the overall survival rate (OS) was 62.8%. For T3 supraglottic patients who underwent total laryngectomy, the five-year disease-free survival (DFS) was 51.8%, and the CSS was 62.5%. For patients who underwent partial laryngectomy, the five-year DFS was 72.2%, and the CSS was 79.0%. High lymph node and stage status are predictors of mortality for these patients. No difference was found in the DFS and CSS rates between patients with negative margins and those with positive margins following postoperative radiotherapy and chemotherapy.

Conclusion: Surgical treatment of T3 supraglottic LC patients achieved satisfactory results. Postoperative radiotherapy and chemotherapy are an effective method of treatment for T3 supraglottic LC patients, especially for those with a positive margin.     

Conservation surgery for laryngeal and hypopharyngeal cancer

The charts of 173 patients treated by conservation laryngectomy and pharyngolaryngectomy were retrospectively reviewed. The patients treated by endoscopic laser resection were excluded of this study. Glottic carcinoma was diagnosed in 101 patients, supraglottic carcinoma in 44 patients, hypopharyngeal carcinoma in 24 patients and oropharyngeal carcinoma in 4 patients. The median follow-up period was 44 months, 84/101 glottic cancer, 34/44 supraglottic cancer, 23/24 hypopharyngeal cancer and 2/4 oropharyngeal cancer were staged as T1 and T2. A voice-sparing external approach was carried on in 20 patients with locally advanced tumor (T3-T4). At time of the last follow-up, 132 patients (77%) were alive when 41 patients (23%) died. Overall survival rates for patients treated for T1-T2 glottic cancer at 3, 5 and 10 years were 90, 90 and 78% respectively. Overall survival rates for patients treated for T1-T2 supralottic cancer at 3, 5 and 10 years were 73, 68 and 48% respectively. Overall survival rates for patients treated for T1-T2 hypopharyngeal cancer at 3 and 5 years were 74 and 37% respectively. The site of the primary tumor (glottic versus supraglottic or hypopharynx) showed significant impact on survival (P = 0.0025)). Regarding survival, T stage and N stage were not found statistically significant.     

Radiotherapy of early-stage glottic cancer: analysis of factors affecting prognosis

This study is a retrospective analysis of 134 patients treated with radiotherapy at our hospital. The sample included 88 stage T1 and 46 stage T2 patients. Sixty-two patients had anterior commissure involvement, 37 patients had impaired vocal cord mobility, and 24 patients had supraglottic or subglottic extension. Irradiation was given, with the dose ranging from 60 to 72 Gy. Laryngectomy was the main salvage treatment for local recurrence. The 5-year initial and final local control rates were 71% and 83%, and the 10-year initial and final local control rates were 69% and 80%, comparable to the results of other series. The 5-year rate of overall survival with final larynx preservation was 77%. Multivariate analysis revealed that anterior commissure involvement is prognostic of a poor outcome in patients with T1 glottic cancer. Further subgroup analysis revealed that a fraction size of > 200 cGy could overcome the negative impact of anterior commissure involvement and significantly improve the 5-year local control rate in T1 patients (100% at > 200 cGy versus 45% at < or = 200 cGy; p = .04). Subglottic extension of the glottic cancer predicted poor outcome in T2 patients. The 5-year local control rates of patients with and without subglottic extension were 9% and 77%, respectively (p < .001). According to our results, radiotherapy with a fraction size of > 200 cGy is recommended for T1 disease with anterior commissure involvement. For patients with T2 disease and subglottic extension, radiotherapy alone produces poor results. Further improvement of outcomes by other treatment strategies needs to be investigated.     

Early vocal cord carcinoma in obese patients: A surgical lesion

Early epidermoid carcinoma of the vocal cord is treated successfully by radiation therapy with high 5-year survival rates, low morbidity, and preservation of excellent voice quality in most cases. Typically, surgery is reserved for salvage of radiation failure and provides overall 5-year survival rates of 98% and 90% for T1 and T2 lesions, respectively. The extremely obese patient, often with a short neck and excessive amounts of subcutaneous fat, is difficult for both radiotherapist and surgeon to diagnose and treat. The recent observation of an unusually high rate of radiotherapy failure in a cluster of obese patients with early vocal cord cancer called attention to this problem. Because the larynx is near the thoracic inlet in obese patients, they are not suitable for administration of radiotherapy by accurate opposed lateral portals. The patients reported herein were treated entirely with anterior oblique portals. Of the five obese patients who underwent primary radiation therapy for early vocal cord cancer, three developed recurrent disease (60%) and a fourth developed a severe perichondritis requiring tracheostomy. Two patients with recurrent disease were successfully salvaged with total laryngectomy, while the third patient refused surgery and died 2 years later. The sixth patient was treated by partial laryngectomy with imbrication reconstruction and is alive and without evidence of disease 2 years following surgery. Recurrence rates and complication rates following primary radiation therapy for early vocal cord cancer appear to be unacceptably high in obese patients treated with anterior oblique portals. Therefore, we recommend primary conservation laryngeal surgery for obese patients with early vocal cancer who cannot undergo “standard” radiotherapeutic techniques.     

Horizontal partial laryngectomy for supraglottic squamous cell carcinoma

Between 1981–1999, 75 patients treated for supraglottic SCC with horizontal supraglottic laryngectomy (HSL) at the Otolaryngology Head and Neck Surgery Department of Lausanne University Hospital were retrospectively studied. There were 16 patients with T1, 46 with T2 and 13 with T3 tumors. Among these, 16 patients (21%) had clinical neck disease corresponding to stage I, II, III and IV in 12, 39, 18 and 6 patients, respectively. All patients had HSL. Most patients had either elective or therapeutic bilateral level II–IV selective neck dissection. Six patients (8%) with advanced neck disease had ipsilateral radical and controlateral elective II–IV selective neck dissections. Adjuvant radiotherapy was given to 25 patients (30%) for either positive surgical margins (n=8), pathological nodal status (n=14) or both (n=3). Median follow-up was 48 months (range, 24–199). Five-year disease-specific survival and locoregional and local control were 92, 90 and 92.5%, respectively. Among five patients who were diagnosed with local recurrence, one had a total laryngectomy (1.4%); the others were treated by endoscopic laser surgery. Two patients had both a local and regional recurrence. They were salvaged with combined surgery and radiotherapy, but eventually died of their disease. Cartilage infiltration seems to influence both local control (P=0.03) and disease-specific survival (P=0.06). There was a trend for worse survival with pathological node involvement (P=0.15) and extralaryngeal extension of the cancer (P=0.1). All patients except one recovered a close to normal function after the treatment. Aspiration was present in 16 patients (26%) in the early postoperative period. A median of 16 days (7–9) was necessary to recover a close to normal diet. Decannulation took a median of 17 days (8–93). Seven patients kept a tracheotomy tube for up to 3 months because of persistent aspiration. There was no permanent tracheostomy or total laryngectomy for functional purposes. Horizontal supraglottic laryngectomy remains an adequate therapeutic alternative for supraglottic squamous cell carcinoma, offering an excellent oncological outcome. The postoperative functional morbidity is substantial, indicating the need for careful patient selection, but good laryngeal function recovery is the rule. The surgical alternative is endoscopic laser surgery, which may offer comparable oncological results with less functional morbidity. Nevertheless, these two different techniques need to be compared prospectively.This paper was presented at the 2nd World Congress of the International Federation of Head and Neck Oncologic Societies, Rio de Janeiro, Brazil, 29 November–2 December 2002.     

Laryngeal long-term morbidity after supraglottic laryngectomy and postoperative radiation therapy

PURPOSE: This study was performed to investigate factors associated with laryngeal morbidity when postoperative radiation therapy (RT) is added to supraglottic laryngectomy. MATERIALS AND METHODS: From 1980 to 1994, 56 patients affected with T1 to 4 N0 to 2c supraglottic squamous cell carcinoma selected for standard (59%) or extended (41%) supraglottic laryngectomy at 2 different institutions were retrospectively analyzed. Most of the patients (91%) also underwent neck dissection. Approximately 80% of the patients had stage T4 primary lesions or N2 neck disease. Postoperative RT was added for presumed microscopic disease at the primary site (13 patients), regional nodes (23 patients), or both (20 patients). Median delivered doses to the larynx and to the neck were 50 Gy (range, 40 to 64 Gy) and 46 Gy (range, 40 to 64 Gy), respectively. Median follow-up for living patients is 11 years (range, 2.8 to 16.9 years). Laryngeal complication was defined as the appearance of grade 2 or higher toxicity according to the European Organization for Research and Treatment of Cancer (EORTC) and the Radiation Therapy Oncology Group (RTOG) scoring systems. RESULTS: Two- and 5-year actuarial locoregional control rates were 85+/-5% and 83+/-5%, respectively. Thirty patients (54%) developed laryngeal complications. However, just one patient experienced grade 4 laryngeal oedema requiring permanent tracheostomy. Estimated actuarial survival without laryngeal complications were 50+/-7%, 43+/-7%, and 39+/-7% at 2, 5, and 10 years, respectively. At univariate analysis, treated volumes (P = .03) and total dose to the larynx (P = .03) were significantly associated with local toxicity. A trend was observed also for the maximum dose to the neck (P = .06) and dose per fraction (P = .09). A multivariate Cox proportional hazards model showed total dose to the larynx to be the only independent predictor of toxicity (P = .03). The hazard ratio of laryngeal toxicity was 2.2 (95% confidence interval: 1.1/4.6), for a total dose to the larynx greater than 50 Gy. CONCLUSION: After supraglottic laryngectomy, postoperative RT to the neck does not affect local morbidity, but careful RT treatment planning is necessary to avoid delivering a total dose to the larynx greater than 50 Gy.