High dosage pre-operative radiation and surgery for carcinoma of the larynx and laryngopharynx. A 14-year program.

Abstract

AbstractA carefully planned clinical program of combined pre‐operative radiation and surgery has been conducted by the Department of Otolaryngology at The Mount Sinai Hospital for the past 14 years in an effort to improve the survival rates for advanced cancer of the larynx and laryngopharynx.The Combined Therapy Program, introduced in 1958, encompassed three separate but interdependent phases. The first stage consisted of a strict protocol of 5,500 rads of Cobalt 60 teletherapy administered over a five to six‐week period. The second stage involved a rest period of three to six weeks to allow for proper healing of radiation reactions. The third stage comprised the radical procedure which included a wide field laryn‐gectomy, ipsilateral hemithyroidectomy and radical neck dissection. Whenever indicated, a contralateral neck dissection was performed as soon as feasible.The protocol described above was applied only to those patients who fit all the criteria that categorized them as having advanced cancer of the larynx and laryngopharynx. In this study all patients had a biopsy proven diagnosis of squamous cell carcinoma.A very careful statistical analysis has been made of the survival experience of this series of cases. The three and five‐year survival rates have been computed by the actuarial method,1 which when compared to the direct method, adds more reliability to the results. The direct method removes those cases not treated at least three and five years ago in computing three and five‐year survival rates, while the actuarial procedure includes all cases in the computation of survival rates.Between November, 1958, and March 1, 1972, 64 patients had been treated by combined therapy. According to the American Classification2 the 64 cases are composed of 20 Stage II (T2N0 excluded), 12 Stage III and 32 Stage IV cases. According to the actuarial method the absolute survival rates for all cases were 77 percent and 59 percent for three and five years respectively. The corresponding determinate rates were 88 percent and 86 percent. Analyzing the results according to stages, the three‐year determinate rates ranged from 100 percent for Stage II to 79 percent for Stage IV. The corresponding absolute rates ranged from 89 percent to 70 percent. The five‐year determinate rates ranged from 100 percent to 74 percent, while the absolute five‐year survival rates ranged from 50 percent for Stage II to 66 percent for Stage IV. This apparent reversal is far from being statistically significant because of considerable sampling error.The complications seen in patients treated with combined therapy have been essentially the same as those patients who undergo radical surgery without pre‐operative radiation. Several preventive measures have been utilized during surgery, and it is to be emphasized that there have been no deaths related to complications, and all patients ultimately healed completely.The important controversy which exists in the‐ combined method of therapy concerns the question of using low dosage pre‐operative radiation in the order of 1,000 to 3,000 rads or high dosages of radiation. It is our contention that serial section studies of biopsied laryngeal specimens labelled with tritiated thymidine tend to disprove the claims made favoring the value of low dosage radiation. The in vitro tritiated thymidine studies demonstrated that active DNA synthesis was observed in cancer cells in an appreciable number following dosages of 3,500 and also 5,500 rads.3 A further significant factor to be considered, we believe, is the effect of high dose pre‐operative radiation on the incidence of cervical recurrence. In this series, 44 patients had clinically palpable nodes pre‐operatively. There were six patients who developed local cervical recurrence, a rate of 14 percent.In conclusion, our statistics seem to indicate that our combined method of therapy has improved the survival rates of patients with advanced cancer of the larynx and laryngopharynx.