Advanced-Stage “Horseshoe” Anterior Commissure Laryngeal Cancers, Contemporary Management, and Long-Term (10-year) Outcomes

Abstract

Although treatment paradigms and modalities have changed significantly in the last two decades, total laryngectomy is still an option that is reserved for patients with primary laryngeal cancers portrayed as bulky tumor masses with extensive soft tissue or thyroid cartilage invasion on radiography. Optimal management of anterior commissure carcinoma remains a subject of discussion because of its juxtaposition to the thyroid cartilage. Few reports of advanced stage ‘horseshoe’ anterior commissure laryngeal carcinoma (HACLC) and the long-term outcome of patients after treatment exist in the literature. Herein, we present the results of a retrospective review of a 30-year experience of people treated for locally advanced HACLC using contemporary management strategies. Of 596 people diagnosed with laryngeal cancer between 1981 and 2010, 49 consecutive individuals were treated for stage III or IV HACLC. Twelve of these patients were treated by total laryngectomy alone, and 37 patients were treated with postoperative radiation therapy; five individuals in the latter group also received chemotherapy. The indications for adjuvant therapy included tumor-positive regional nodes/resection margins, invasion of the thyroid/cricoid cartilage or subglottic region and extralaryngeal neoplastic spread to soft tissues; postoperative irradiation was generally omitted in the absence of the preceding risk factors. The median follow-up time was 65 months. The chosen endpoints were 10-year survival and relapse rates. Overall, the median survival was 83 months. At 10 years, the survival rate was 37% and the recurrence rate was 16%. The local, regional and distant relapse rates were 0%, 4% and 12% respectively. Improved long-term prognosis was not observed in patients undergoing combined therapy compared to people treated with surgery alone in light of the corresponding 39% and 30% 10-year survival rates ( P = .30). The recurrence rate was 11% in the postoperative radiation therapy group and was 33% in the laryngectomy alone cohort (P = .09). Complications included tracheal stoma stricture (8%), hypothyroidism (4%) and esophageal stricture/carotid artery stenosis (2%). In advanced stage HACLC, definitive surgery followed by adjuvant radiation therapy (and chemotherapy as indicated) can potentially provide extended disease-free survival with minimal morbidity.