T1 Glottic Carcinoma Research Articles

Vocal changes in patients undergoing radiation therapy for glottic carcinoma

A prospective evaluation of vocal changes in patients receiving radiation therapy for T1 and T2 (AJC) glottic carcinoma was undertaken in January 1987. Vocal analysis was performed prior to radiotherapy and at specific intervals throughout the radiation treatment program. The voicing ratio was extrapolated from a sustained vowel phonation using the Visipitch interfaced with the IBM-PC. Preliminary observations suggested three distinct patterns of vocal behavior: 1. reduced voicing ratio with precipitous improvement within the course of treatment, 2. high initial voicing ratio with reduction secondary to radiation induced edema, with rapid improvement in the voicing component after the edema subsided, and 3. fluctuating voicing ratio during and following treatment. Enrollment of new patients and a 2-year follow-up of current patients was undertaken.

Stage T1 glottic carcinoma: results of radiation therapy or laser excision.

A retrospective analysis was made of the data on 60 patients with stage T1 glottic carcinoma (43 T1a, 17 T1b) who received radiation therapy and 17 patients with T1a disease who underwent laser excision as the primary treatment modality. Patients who received radiation therapy achieved 3- and 5-year actuarial local control rates of 92% and 89% for T1a and 77% and 77% for T1b disease, respectively. In patients who underwent laser excision (all with T1a disease), the 3-year local control rate was 77%. Of the 42 evaluable irradiated T1a patients, 31 (74%) had a normal to near-normal voice, eight (19%) had mild or intermittent hoarseness, and three (7%) had persistent hoarseness. Of the 13 evaluable patients in the laser-excision group, four (31%) had a normal to near-normal voice, five (38%) had mild or intermittent hoarseness, and four (31%) had persistent hoarseness. The difference in the quality of voice between these two groups is statistically significant (P = .012), although the ultimate local control rate after salvage therapy for irradiated patients (97%) was similar to that for laser-excision patients (94%).

Fat graft laryngoplasty after vertical partial laryngectomy

The goals of laryngeal reconstruction after vertical partial laryngectomy are to prevent aspiration and to achieve an adequate airway with satisfactory phonation. For the past 7 years, reconstruction using a free fat graft-pyriform sinus mucosal pedicle flap has been our major reconstructive technique at the Lahey Clinic Medical Center. In our series, 10 patients have had reconstruction using a fat graft, with a minimum follow-up of 2 years. Nine patients had T2 and two patients had T3 glottic carcinoma. Radiation therapy had failed in 7 of 11 patients. No recurrence of tumor has been reported during follow-ups of between 2 and 5 years. The voice was considered satisfactory to good in 10 patients and poor in one patient. Tracheotomy decannulation was performed at 6 weeks to 4 months. Complications occurred in five patients. The goals of laryngeal reconstruction after vertical partial laryngectomy are to prevent aspiration and to achieve an adequate airway with satisfactory phonation. For the past 7 years, reconstruction using a free fat graft-pyriform sinus mucosal pedicle flap has been our major reconstructive technique at the Lahey Clinic Medical Center. In our series, 10 patients have had reconstruction using a fat graft, with a minimum follow-up of 2 years. Nine patients had T2 and two patients had T3 glottic carcinoma. Radiation therapy had failed in 7 of 11 patients. No recurrence of tumor has been reported during follow-ups of between 2 and 5 years. The voice was considered satisfactory to good in 10 patients and poor in one patient. Tracheotomy decannulation was performed at 6 weeks to 4 months. Complications occurred in five patients.

Our experience in the surgical treatment of T1 carcinoma of the vocal cord

From 1971 to 1986, 94 patients suffering from T1 glottic carcinoma underwent cordectomy at the University ENT Clinic of Thessaloniki, Greece. There were five female and 89 male patients with a median age of 61.7 years. Two year survival rate was 93.7 per cent; five year survival rate was 93.2 per cent. Seventeen of the patients suffered recurrence, but 11 of them after laryngectomy or radiotherapy are alive with no sign of the disease. Tracheostomy was not performed in the majority of our cases. The relationship between the site of recurrence and survival as well as the role of radiotherapy before and after cordectomy in some of our patients are discussed. We believe that despite the good results of radiotherapy in T1 carcinoma of the vocal cord and the introduction of other treatment modalities such as CO2 laser, cordectomy by laryngofissure is still of value with very good survival results and minimal discomfort for the patient.

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The stage classification is most frequently used at the present in predicting the outcome of laryngeal carcinoma. Recently, DNA ploidy pattern as detected by DNA flow cytometry and cytofluorometry has been also shown to be predictive. In this study, DNA cytofluorometry was performed on formalin-fixed paraffin-embedded tissues from 18 patients with T1 and T2 glottic squamous cell carcinoma for whom long-term follow-up data were available. The DNA ploidy pattern was classified into three types, diploid, diploid + tetraploid and aneuploid according to the DNA content of Go/G1 cells and mitotic cells. In these 18 cases, 8 cases (44%) had diploid pattern, 3 cases (17%) had the diploid + tetraploid pattern and 7 cases (39%) had the aneuploid pattern. The ploidy pattern was significantly associated with the relapse-free rate, but did not correlate with the stage of the carcinoma and differentiation of the cancer cells. Distribution of the patients by histology, stage and therapy was almost equal among the diploid, diploid + tetraploid and aneuploid groups. All the patients were treated with irradiation (60Gy). In the group as a whole, no patient died of glottic carcinoma. Relapse-free survival rates for diploid, diploid + tetraploid and aneupoid were 88%, 33% and 29% respectively. This retrospective study of glottic cancer treated with radiation therapy suggests the possibility that the DNA ploidy pattern would significantly predict patient outcome and would be useful for selecting patients whose poor prognosis demands more aggressive therapy.

The treatment of T3 glottic carcinoma with vertical partial laryngectomy.

Total laryngectomy has traditionally been considered the optimal treatment for patients with advanced glottic carcinoma who present with a fixed true vocal cord. However, using whole-organ sectioning techniques, it has been demonstrated that vertical partial laryngectomy is a sound oncologic procedure for selected fixed vocal cord lesions. During the period 1969 to 1984, 27 patients who presented at UCLA with T3 glottic carcinoma were treated using vertical partial laryngectomy. Follow-up for these patients averaged 4.0 years. The absolute two-year disease-free survival rate for this group was 85% (23 of 27 patients), and the local cancer recurrence rate during a two-year postoperative interval was 11% (three of 27 patients). These encouraging results support the continued use of partial laryngeal surgery for a subgroup of patients with T3 glottic cancer. Successful patient selection requires a careful analysis of disease extent based on data obtained from physical examination, magnetic resonance imaging or computed tomographic scanning, and direct laryngoscopy.

The Treatment of T3 Glottic Carcinoma With Vertical Partial Laryngectomy

The treatment of T3glottic carcinoma with vertical partial laryngectomy was reviewed by David Kessler, MD, and associates of the UCLA School of Medicine at the American Society of Head and Neck Surgery meeting, Denver. On the basis of their findings in 27 patients, they questioned the traditional concept that conservation vertical laryngectomy is contraindicated in the presence of vocal cord fixation. Their study population was critically chosen from a composite surgical population of 585 patients with laryngeal cancer at various stages. One hundred fifteen of these 585 patients were treated by vertical partial laryngectomy, including the 27 patients having a fixed vocal cord who comprised this study group. Their criteria for vertical partial laryngectomy in patients with a fixed vocal cord included: no subglottic extension (

Factors influencing the success of radiation therapy for T2 and T3 glottic carcinomas. Importance of cord mobility and sex.

One hundred ninety patients with T2 and 70 patients with T3 carcinoma of the glottis were treated by definitive radiation therapy at the Massachusetts General Hospital from 1952 to 1978; the results were analyzed. The 5-year actuarial no evidence of disease (NED) rate for the T2 lesions was 71%; including salvage surgery, 85%. The rate for T3 lesions was 36%; including surgical salvage, 57%. The most significant factors influencing the radiotherapeutic results included the mobility of the diseased cord and the sex of the patient. Those patients with impaired cord mobility, designated as T2b, and fixed cord, T3, had a poor prognosis. The female patients had a more favorable outlook stage for stage. Therefore, these factors must be taken into consideration in the management of T2 and T3 lesions if optimum therapeutic results and preservation of voice are the goals. A proposed treatment policy for carcinoma of the glottic larynx is presented.

Laser therapy for T1 glottic carcinoma of the larynx.

We treated 21 previously untreated T1 or tumor in situ squamous cell carcinomas of the true vocal cords by carbon dioxide laser excision. The mean follow-up was 42 months, with a range of 26 to 64 months. Recurrent vocal cord carcinomas, with an average interval to recurrence of 21 months developed in four patients. Three of the four recurrences involved the anterior portion of the true vocal cord, including the anterior commissure. One of the patients with recurrence was treated again with the laser, and the other three underwent radiotherapy. All four patients are alive and have retained their larynges. Laser excision of selected T1 and in situ carcinomas of the true vocal cords is a cost-effective and viable alternative to radiotherapy or more radical surgical therapy.

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.

Early glottic carcinoma: Factors affecting radiation failure, results of treatment and sequelae

The radiotherapy failure rate of 101 patients with T1, T2 and T3 glottic squamous carcinoma was analyzed with respect to age, race, sex, pathological grade, radiation dose, radiation treatment-field arrangement and surgical salvage rate. All patients who received telecobalt therapy for glottic disease were included. The group comprised 25% of 400 intrinsic squamous carcinomas of the larynx, treated in the Radiotherapy Department, Groote Schuur Hospital, from 1968 to 1975. Ninety-six patients were assessable. In all, disease was Stage N.0 at presentation; 33 failed locally, 6% developed nodal recurrence, 7% developed second primaries, 2% had distant metastases and 8% died of unrelated causes. Radiation sequelae and the importance of pathologic grade are discussed.

Replacement of the arytenoid following vertical hemilaryngectomy.

A considerable body of literature advocates and defines treatment of vocal cord cancer with posterior extension by hemilaryngectomy. The present study was carried out to determine the feasibility of using a newly devised pedicle flap, composed of thyroid cartilage and inferior constrictor muscle, to replace the ablated arytenoid cartilage. Animal investigation revealed satisfactory viability of the pedicle flap in canines, and in humans, five patients with T2 glottic carcinoma demonstrated excellent postoperative deglutition and return of voice. The results of the study indicate that this surgical technique merits consideration for its use in minimizing protracted glottic incompetence following hemilaryngectomy. The thyroid cartilage-inferior constrictor muscle pedicle flap may also prove useful as partial cricoid replacement in selected cases of subglottic extension and in cricoid reconstruction following trauma.