Irradiation of early carcinoma of the larynx. Significance of tumor extent

Early Glottic Cancer: Surgery or Radiation Therapy?

From 1970 to 1979 at the University Otorhinolaryngological Clinic, at the Radiology Institute of the University and at the Radiation Therapy Department of the Hospital of Florence, 385 early glottic cancers were treated: 300 by surgery and 85 with radiation therapy as the primary therapy. The policy of treatment in this period was in most cases surgery; those patients who could not be operated were treated with radiation therapy. The local control actuarial rates at 5 years were 85 %, 70 % and 65 % for the T1a, T1b and T2 patients treated by surgery, and 86 %, 83 % and 57 % for those treated with radiation therapy. Considering the surgical salvage, the actuarial results at 5 years were 95 %, 86 % and 71 % for the group treated by surgery, and 86 %, 90 % and 69 % for the one treated with radiotherapy. The crude results at 3 and 5 years with an analysis of failures according to treatment modalities are also reported. In our experience, cordectomy can be the treatment of choice in T1a glottic cancer, whereas radiation therapy offers better results in the T1b forms. Tratment policy is more questionable in the T2 cases.

Structures constituting the sound source after the treatment of early glottic cancer

INTRODUCTION

We indicate the exclusive radiation therapy as initial approach for T1a glottic tumors, and the frontolateral laryngectomy for the tumors staged as T1b and selected T2 glottic tumors. The videolaryngostroboscopy is a useful tool to analyze the laryngeal structural changes and compensatory motion after the therapeutic approach.

OBJECTIVES

To evaluate the endolaryngeal structures of patients who participate in the vibratory sound source after the early glottic cancer treatment through the videolaryngostroboscopy.

METHODS

It was a retrospective transversal study in which 20 patients who underwent exclusive radiation therapy and 25 patients who underwent frontolateral laryngectomy were analyzed by means of videolaryngostroboscopy. The radiation doses ranged from 5000 to 7020 cGy in the radiation therapy group. The mucosal wave and the vibratory source components were evaluated.

RESULTS

All of the irradiated patients presented vibratory behavior, and hyperfunction was occasionally observed in four cases. The mucosal wave source was glottic in 18 cases and mixed in two cases. In the laryngectomy group, 10 supraglottic sources, 10 glottic sources, and five mixed sources were identified. Among the 10 cases of supraglottic source, eight patients presented global constriction and two patients presented medial constriction. Among the five cases of mixed source, two patients presented global constriction, one patient presented medial constriction, and one patient presented anteroposterior constriction. Regarding the number of anatomical structures presenting vibratory pattern, five patients had two structures, four patients had three structures, and one patient had four structures.

CONCLUSION

Patients who underwent radiation therapy recruit less supraglottic structures as vibratory source than the patients undergoing vertical laryngectomy.

Acoustic voice analysis in different phonetic contexts after larynx radiotherapy for T1 vocal cord carcinoma

INTRODUCTION

Radiotherapy for early vocal cord carcinoma affects quality of voice. Nevertheless, most patients refer to having a high satisfaction level with their voice. The few acoustic studies on quality of voice have been performed only in prolonged vowel production, which is not a usual speech situation. The present study has been done with the aim of establishing which phonetic situations reflect a greater alteration in voice production related to irradiation.

MATERIAL AND METHODS

Eighteen male patients irradiated for Tis-T1 vocal cord carcinoma and a control group of 31 non-irradiated subjects were included in a study of acoustic voice analysis. This analysis was performed one year after radiotherapy. Patients and control group voices were tape recorded in extended vowel production, oral reading of a standard paragraph, spontaneous speech and in a song. Acoustic analysis was performed by a Kay Elemetric's Computerized Speech Lab (model CSL #4300). Fundamental frequency, jitter, shimmer and harmonics-to-noise ratio were obtained in both groups. Statistical test: Lin concordance coefficient and Pearson's correlation coefficient, Student's t-test and ROC curves.

RESULTS

Concordance and correlation studies did not allow selection of any subgroup in acoustic parameters and different acoustic situations. Acoustic parameters had higher median values in irradiated patients. Student's t-test showed significant differences for fundamental frequency in sustained vowel production and spontaneous speech; for jitter there was statistical significance in all the acoustic situations and for shimmer in oral reading and song. Jitter showed a cut-off of 2.02% with a sensitivity of 89% and specificity of 97% in classifying irradiated and non-irradiated groups. The ROC curve for jitter correctly classified 94% of subjects into irradiated or non-irradiated groups.

CONCLUSIONS

The present study showed that jitter obtained from spontaneous speech was the most relevant parameter in discriminating voice in irradiated patients by acoustic analysis. Jitter in spontaneous speech is in need of more analysis in bigger series and in more advanced stages of larynx cancer as its relevance has been demonstrated.

Acoustic analysis after radiotherapy in T1 vocal cord carcinoma: a new approach to the analysis of voice quality

PURPOSE

The study of acoustic voice parameters (fundamental frequency, jitter, shimmer, and harmonics-to-noise ratio) in extended vowel production, oral reading of a standard paragraph, spontaneous speech and a song in irradiated patients for Tis-T1 vocal cord carcinoma.

METHODS AND MATERIALS

Eighteen male patients irradiated for Tis-T1 vocal cord carcinoma and a control group of 31 nonirradiated subjects of the same age were included in a study of acoustic voice analysis. The control group had been rigorously selected for voice quality and the irradiated group had previous history of smoking in two-thirds of the cases and a vocal cord biopsy. Radiotherapy patients were treated with a 6MV Linac receiving a total dose of 66 Gy, 2 Gy/day, with median treatment areas of 28 cm(2). Acoustic voice analysis was performed 1 year after radiotherapy, the voice of patients in extended vowel production, oral reading of a standard paragraph, spontaneous speech, and in a song was tape registered and analyzed by a Kay Elemetric's Computerized Speech Lab (model CSL# 4300). Fundamental frequency, jitter, shimmer, and harmonics-to-noise ratio were obtained in each case. Mann Whitney analysis was used for statistical tests.

RESULTS

The irradiated group presented higher values of fundamental frequency, jitter, shimmer, and harmonics-to-noise ratio. Mann-Whitney analysis showed significant differences for fundamental frequency and jitter in vowel production, oral reading, spontaneous speech, and song. Shimmer only showed differences in vowel production and harmonics-to-noise ratio in oral reading and song.

CONCLUSIONS

In our study only fundamental frequency and jitter showed significant increased values to the control group in all the acoustic situations. Sustained vowel production showed the worst values of the acoustic parameters in comparison with the other acoustic situations. This study seems to suggest that more work should be done in this field.

Management of stage II (T2N0M0) glottic carcinoma by radiotherapy and conservation surgery

BACKGROUND

The best therapeutic approach for the treatment of stage II (T2N0M0) glottic carcinoma is controversial.

METHODS

A retrospective tumor registry data retrieval of patients with stage II glottic carcinoma treated with curative intent at Washington University Medical Center-Barnes Hospital between January 1971 and December 1989 (surgery) and December 1995 (radiotherapy) was performed.

RESULTS

Among 134 patients with stage II glottic carcinomas treated with curative intent and function preservation, there were 47 patients treated with low dose radiotherapy (median dose, 58.5 Gy at 1.5-1.8 Gy daily fractions), 16 patients with high dose radiotherapy (67.5-70 Gy) at higher daily fractionation doses (2-2.25 Gy), and 71 patients underwent conservation surgery. The overall local control rate was 85%. The overall salvage rate was 68%. The 5-year actuarial and disease specific survivals were 81.5% and 92%, respectively. Unaided phonation was achieved in 84.4% of the patients. An incidence of 10.4% regional metastases, 2.2% distant metastases, and 6% second primary tumors was documented. There were no statistical differences in local control, voice preservation, and 5-year actuarial and disease specific cure rates between conservation surgery and high dose radiation (p = .89). Low dose radiation had statistically lower local controls, 5-year survival, and voice preservation (p = .014). In advanced T2B disease, treating the ipsilateral neck nodes reduced regional metastases (p = .02).

CONCLUSIONS

High dose and daily fractionation (70 Gy at 2 Gy daily fraction doses) radiation achieved results equivalent to those of conservation surgery in 5-year local control, survival, and voice preservation. In advanced T2B disease, treatment of the ipsilateral neck nodes by radiotherapy or functional neck dissection reduced regional metastases.

Radiotherapy in T1 laryngeal cancer: prognostic factors for locoregional control and survival, uni- and multivariate analysis

From 1975 through 1985, 194 patients with T1 glottic, 37 patients with T1 supraglottic, and 3 patients with T1 subglottic cancer were treated with radiotherapy. Local control and ultimate locoregional control (after salvage surgery) was 91% and 97% for T1 glottic, 84% and 81% for T1 supraglottic, and 2/3 and 3/3, respectively for subglottic tumors. In uni- and multivariate analysis local control for glottic tumors was associated with extension of the tumor on the vocal cord (entire length of vocal cord vs others, p = 0.01) and continuation of smoking after therapy (yes/no, p = 0.03). No prognostic factor for local control was found in supraglottic tumors. However, regional control and survival were impaired by N stage (N0 vs N+, p less than 0.0005), local recurrence (yes/no, p less than 0.0005), and extension of the tumor (one supraglottic subsite vs more than one, p less than 0.05). Mild late complications were seen in 13% of patients without salvage therapy. Following univariate analysis, field size, fraction size (greater than 2 Gy), maximum tumor dose (greater than 70 Gy), age, post-treatment biopsy, and tumor site were associated with complication rate. Following multivariate analysis, site, fraction size, maximum tumor dose, and continuation of smoking after therapy were independent prognostic factors for mild late complications (mostly arytenoid edema).

Management of advanced glottic carcinomas

One hundred twenty-eight patients with T3 or T4 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 forty-nine percent of the total laryngectomy with neck dissection group remained free of disease for 5 or more years. Forty-seven percent (60 of 128 patients) treated surgically developed regional recurrences requiring 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.

Natural history of treated T1N0 squamous carcinoma of the glottis

The records of 373 patients with T1N0 squamous carcinoma of the glottis were examined. Of these, 271 underwent initial hemilaryngectomy; 102 had full-course irradiation for cure. While the overall survival rates of the two initial therapies were similar, failure of the initial treatment modality was approximately twice as frequent in the irradiated patients (34.4%) as in the patients undergoing hemilaryngectomy (16.9%). The effect of this difference in initial failure rate on quality of life and on cost of overall therapy will be discussed.

Surgical salvage for recurrent "early" glottic cancers

A 25-year retrospective study of 143 early (T1 and T2 N0) glottic cancer, patients was done to determine the recurrence rate following initial radiation therapy, the surgical salvage rate, and incidence of cervical lymph node metastases. Radiation therapy gave a 5-year cure rate of 78% for stage I and 57% for stage II. Total laryngectomy for recurrent squamous cell carcinoma had a 5-year salvage rate of 66% for stage I and 61% for stage II recurrent tumors. The overall 5-year cure rate with initial and second therapy for stage I and stage II glottic cancers was 93% and 83%, respectively.

The quality of voice in patients irradiated for laryngeal carcinoma

Data from 150 patients with laryngeal carcinoma, consecutively treated primarily by radiotherapy from 1965 through 1974 was analyzed to assess the quality of voice. The voice appears to improve in majority of the successfully irradiated patients. In 76% of the evaluable patients in this group, the quality of voice appears to have attained normalcy or near normalcy. Smoking appears to have a negative influence. High incidence of bronchogenic carcinoma along with the negative influence of smoking on the quality of voice in this series of patients indicate that the patients should be advised against smoking in day-to-day clinical practice.

The results of treatment of laryngeal cancer in Auckland New Zealand 1965-1979

A retrospective review of laryngeal cancer in Auckland over the period 1965-1979 has revealed a generally poorer prognosis for supraglottic cancer than for glottic cancer. The use of radiotherapy for supraglottic cancer and for advanced glottic cancer has not been as successful as primary surgery but has yielded good results in early glottic carcinoma. Salvage surgery after failed radiotherapy was significantly more successful for glottic tumours than supraglottic. Stomal recurrence was more likely if a patient had required an emergency tracheotomy for airway obstruction.

Glottic carcinoma limited to the vocal cords

Radiation therapy is generally considered to be the best primary treatment for early glottic carcinoma, with surgery reserved for local failure. In a series of 150 cases of T1 glottic carcinoma 138 were given radiation alone. In these patients the survival was 88 per cent at 3 years and 77 per cent at 5 years. Local control remained unchanged at 82 per cent after 6 years. When the results of surgery are included, local control was raised to 93 per cent. Preservation of the larynx was obtained in 92 per cent of survivors. Local extension or radiation dose levels had no influence on local control. The optimum dose could be lower than generally recommended. Voice quality after radiation therapy is superior to postsurgical laryngeal function. Since survival rates are identical, radiation therapy alone is the treatment of choice in all early glottic carcinomas.

Carcinoma of the endolarynx: results of irradiation

Irradiation at the University of Michgan in the 1960's was carried out in 192patients with endolaryngeal carcinoma. Thirty-two and 66% of the cases were located inthe supreaglottic and glottic regions respectively. Cases were classified in stages appropiate TNM GROUPING. Results were analyzed with respect to tumor location, size, anddose-time relationship. Early lesions were controlled more often than advanced ones. Radical surgery to the primary and/or neck improved overall survival, which was 89% at 5years for 127 glottic carcinoma cases and 61% for 61 patients with supraglottic tumors. No significant complications were found following radiation therapy.