Five-year results of 1000 patients operated on for cancer of the larynx

The five-year results of 1000 consecutive cases of cancer of the larynx operated on at the Clinic of Otolaryngology of the University of Florence are presented. The treatment was cordectomy for T1a glottic cancers and total laryngectomy for the other cases. The five year cure rate is 66.5% of the 606 supraglottic cancers, 76.9% of the 294 glottic cancers and 54% of the 100 subglottic cancers. These crude survival rates consider the 7.6% of patients who died from non-tumoral causes and the 1.1% of untraced patients.     

Extended vertical partial laryngectomy for treatment of the glottic cancer with T3 category]

From June 1981 to December 1992, 32 patients of glottic cancer with T3 category were treated by extended vertical partial laryngectomy, i.e. vertical laryngectomy plus the resection of the arytenoid and part of the cricoid plate. The laryngeal defect was reconstructed by an osteomuscular flap. The 3- and 5-year survival rates were 78.1% and 73.9% respectively. The decannulation rate was 81.3%. The voice was satisfactory in 84.3%. All patients resumed mouth-food-taking. The authors conclude that selective glottic cancer of T3 category treated with extended vertical partial laryngectomy, which preserves the functions of the larynx and improves the quality of the life, is feasible and acceptable.     

Laryngeal reconstruction and survival after function-sparing laryngectomy for selected T3 and T4 lesions

Most patients lost their vocal ability after ablative surgery for the laryngeal cancer. Total laryngectomy has a history of over 100 years, hence many surgeons are accustomed to the en bloc organ resection and the loss of ability for communication after surgery. The recent advance of surgery introduces the concept and technique of radical cure and functional preservation of the cancer-afflicted-organ at the same setting. For lesions of late T categories (T3, T4), the maintenance of normal function after wide resection to ensure radicality demands a special technique to repair the crippled larynx. For this purpose a local osteomuscular flap was designed to reconstruct a functioning larynx. The surgical manoeuvre was described and the result proved to be successful. The outcome of 138 patients with T3 and T4 laryngeal carcinomas following conservation laryngectomy was analyzed. The five-year survival rate was 69% for supraglottic type and 75% for glottic type. The quality of life was much improved.     

Psychosocial and physical correlates of survival and recurrence in patients with head and neck carcinoma: results of a 6-year longitudinal study

BACKGROUND: Studies that have examined correlations between psychosocial factors and survival in cancer patients do not permit any definitive conclusions. To the authors' knowledge, to date no study has examined the relation between medical as well as quality of life variables and survival in head and neck carcinoma patients. The current study focused on the complex interactions among psychosocial, medical, behavioral, and demographic variables as they relate to prognosis in these patients. METHODS: A total of 133 consecutive head and neck carcinoma patients were included in a prospective study at pretreatment. In addition to clinical variables, psychosocial and physical functioning was assessed by means of a self-report questionnaire. RESULTS: During the observation period 57 patients died whereas 76 were still alive at 6 years after treatment. Results of the multivariate survival analysis indicated that patients without head and neck metastasis had a better prognosis than patients with positive cervical lymph nodes. Pretreatment smoking showed a negative correlation with overall survival. Patients who were more physically self-efficacious (i.e., higher perceived physical abilities) were more likely to survive and less likely to develop a recurrence. In addition, patients who expressed intense psychosocial complaints prior to treatment had a better prognosis than had those who did not express such negative feelings. CONCLUSIONS: The current findings linking physical self-efficacy and prognosis are promising, but clinical trials are necessary to examine the direct and indirect mediational pathways of the variables that underlie physical efficacy and influence survival and recurrence. Also, the negative correlation between pretreatment smoking and survival suggests a need for increased efforts to address smoking in newly diagnosed patients.     

CD8+ T cells in atopic disease

Refinements in radiographic techniques have resulted in increased use of radiographic studies in the evaluation of patients with head and neck cancer over the past 20 years. To assess the impact of such studies, we compared tumor clinical stages based solely on physical-examination findings with those obtained with the addition of CT findings. This study was accomplished through case review of 81 head and neck cancer patients who underwent CT after preliminary TNM-stage assignment as determined on the basis of physical examination alone. In this cohort, 44 patients (54%) had a change in assigned clinical stage. We reviewed individual anatomic sites to determine where CT was found to be most useful in modifying tumor stage. Changes in tumor and nodal stage were found across all major sites of the head and neck. Tumors of the hypopharynx were the most likely to change stage (90%) on the basis of CT findings, whereas tumors of the glottic larynx were least likely to undergo a change in stage (16%). The therapeutic implications of these findings are discussed in the context of the published literature.     

Late local recurrence after radiotherapy for tongue and early glottic carcinoma

BACKGROUND/AIM: Late local recurrence after radiotherapy for tongue and early glottic carcinoma is rarely discussed. In the head and neck cancer, approximately 90% of local recurrence occurred within 2 years after radiotherapy. However, we found that late local recurrence after radiotherapy for glottic cancer was not rare. Our aim was to evaluate the late local recurrence after radiotherapy for early glottic and tongue cancer. PATIENTS AND METHODS: From 1967 through 1982, 633 patients with tongue carcinoma and 330 patients with early (T1T2N0) glottic carcinomas were treated at the Department of Radiology, Osaka University Hospital. Of these 821 patients, 329 patients with tongue carcinoma and 221 patients with early glottic carcinoma survived at 5 years after radiotherapy without local recurrence. For tongue carcinoma, patients were divided by T category. For early glottic carcinoma, patients were divided by the tumor response at 40 Gy. RESULTS: Late local recurrence occurred in 23 of 329 patients (7%) with tongue carcinoma, and in 9 of 221 (4%) with early glottic carcinoma. For tongue carcinoma, late recurrence occurred in 19 of 249 patients (8%) in stage I and II, and 4 of 80 patients (5%) in stage III and IV. For glottic carcinoma, late recurrence occurred in 8 of 137 patients (6%) with tumor clearance at 40 Gy and 1 of 63 patients (2%) with tumor persistence at 40 Gy. The incidence of double cancer was also evaluated. Of 329 5-year survivors with tongue carcinoma, 39 patients (12%) had another malignancy, and 26 patients of 221 5-year survivors with early glottic carcinoma (12%) had also another malignancy. Of 39 double primaries of tongue carcinoma, 10 patients (26%) had head and neck malignancies, and none of 26 double primaries of early glottic carcinoma. CONCLUSION: Late local recurrence was not rare in tongue and early glottic cancer. Poor prognostic group showed lower incidence of late recurrence than good prognostic group. This result suggests that secondary tumor at the same site of primary tumor is late local recurrence.     

A sensitive assay for studying dopaminergic activity in cultures of rat pituitary cells

Nine male patients with separate primary cancers of the esophagus and head and neck (pharynx, larynx) presented with a mean age of 56 years (41-69). They included 7 pharyngeal cancer patients and 2 laryngeal ones. Esophageal cancer was discovered synchronously in 6 patients and metachronously in 3 (1, 4, and 11 years later, respectively). The head and neck cancer was stage-I in one patient, stage-II in 4 and stage-IV in 4. The esophageal cancer was cervical in 2, thoracic in 6 and abdominal in 1. It was early cancer (stage-0) in 6 patients and advanced (stage-IV) in 3. The esophageal cancer was more advanced in the metachronous group, while it was early in the synchronous group. Since the head and neck cancer was advanced, all patients underwent a total laryngectomy for their head and neck cancers. As for esophageal surgery, a transhiatal esophagectomy was, in principle, performed for early cancers while a total thoracic esophagectomy was done for advanced cancers. For the reconstruction of the esophagus, a gastric tube was used. Four patients are still alive with a mean survival time of 25 months, whereas five died of cancer recurrence of either type a mean of 19 months after surgery. As compared with the survival rates of the patients with esophageal cancer alone, the 5-year survival rate was 18.2% for patients with double cancers in this series and 27.9% for those with esophageal cancer alone.     

Quality of life after treatment in patients with laryngeal carcinoma]

Today laryngeal cancer can be cured by means of a variety of treatments (nearly 60% of the patients in an unselected population are still alive after 5 years). Despite the low incidence, this form of cancer can present a significant social problem because the form of treatment can have an impact on the esthetic, functional and emotional aspects affecting the quality of life (QOL). In the present study 690 laryngeal cancer patients treated with 6 different forms of therapy (total laryngectomy, partial laryngectomy, cordectomy, radiotherapy alone, total laryngectomy plus post-operative radiotherapy, partial laryngectomy plus post-operative radiotherapy) were asked to fill out a specific EORTC CORE QOL Questionnaire (EORTC QLQ C-30) as well as a specific head and neck questionnaire. Six multi-item function scales, 3 symptom scales and 6 individual items assessing both symptoms and economic consequences of the disease were evaluated. A total of 517 patients (74.92%) filled out the questionnaire. For each form of therapy the patients were divided by age (under and over 65 years of age). The results indicate that the quality of life is better in those patients who underwent a single form of treatment (i.e. radiotherapy alone, partial laryngectomy, total laryngectomy) than in those who underwent combination treatments (i.e. surgery plus radiotherapy). Moreover, the results were better in the older patients. Quite often laryngeal cancer patients are subject to psychosocial problems although this did not show up in the present study where the patients tended to consider surgery as a liberation. The social-cultural level of the patient has a significant effect on the quality of life as it proved better in those social classes were physical strength is of prime importance as opposed to those dominated by social parameters such as socialization, communication and aesthetics.     

Head and neck cancer: guidelines for chemotherapy

Head and neck cancer is estimated to be one of the most prevalent cancers in the world. This tumour type accounts for 5% of all new cancer cases in the US and Europe each year. Patients with locally recurrent or metastatic squamous cell carcinoma of the head and neck have a poor prognosis, with a median duration of survival between 4 and 6 months. During the past few years, screening for potentially active new compounds, new associations and new modalities of chemotherapy administration have had some degree of success. Clinical investigations have also focused on the addition of chemotherapy to locoregional treatment for patients with locally advanced disease. Induction chemotherapy or concomitant chemo- and radiation therapy can result in high response rates, and reduced incidence of distant metastases. However, there is no clear demonstration of any benefit from the addition of chemotherapy to locoregional therapy on overall survival in patients with resectable disease. In patients with resectable laryngeal or hypopharyngeal cancer, chemotherapy combined with radiotherapy can be considered as a standard treatment option for larynx preservation, keeping total laryngectomy reserved for salvage therapy. In patients with unresectable head and neck cancer, simultaneous chemoradiotherapy has been shown to improve locoregional control and survival, at the cost of greater toxicity. Outside clinical trials, this approach can also be considered as a standard therapy for unresectable disease.     

The Calvin cycle enzyme sedoheptulose-1,7-bisphosphatase is encoded by a light-regulated gene in Chlamydomonas reinhardtii

OBJECTIVES: Current surgical treatment for a glottic cancer with significant subglottic extension is a total laryngectomy. The objective of this study was to expand laryngeal conservation procedures by using a reconstructive technique that allows for the repair of hemicricolaryngectomy defects. STUDY DESIGN: After resection of the ipsilateral thyroid, cricoid, and arytenoid for advanced T3 glottic cancer, the laryngeal defect was reconstructed by means of an autotransplanted segment of trachea in four patients. The reconstruction consisted of a transferable patch that was constructed from a segment of revascularized cervical trachea. METHODS: During a 14-day period, a 4-cm segment of cervical trachea was wrapped by a free radial forearm fascial flap. In the second stage, the glottic cancer was removed and the cervical trachea was isolated on its fascial blood supply and transformed into a patch that was used to repair the extended hemilaryngectomy defect. Two different patch designs were used. Two patients underwent reconstruction with a patch augmented at the glottic level (group A); two patients underwent reconstruction without glottic augmentation on the patch (group B). Tracheal continuity was restored by an end-to-end reanastomosis. The postreconstruction morphology of the two patch designs was compared with the preoperative laryngeal morphology. RESULTS: The autotransplantation technique led to complete restoration of the subglottic airway lumen in all four patients. Although the anterior-posterior glottic diameter was reduced by 36% in group A patients and by 43.5% in group B patients, a sufficient glottic airway lumen was obtained. The glottic sphincteric function was restored in both groups. CONCLUSIONS: Tracheal autotransplantation may be used reliably to repair hemicricolaryngectomy defects. Augmentation of the patch at the level of the glottis is not essential for successful rehabilitation.     

Significance of DNA ploidy in the treatment of T1 glottic carcinoma

OBJECTIVE: To assess the role of DNA ploidy as a predictor of radioresistance in T1 glottic carcinoma. DESIGN: Case-control study. Flow cytometric DNA ploidy measurements were performed on formalin-fixed paraffin-embedded tumor specimens from 15 patients with T1 glottic laryngeal carcinomas in whom radiotherapy had failed and from a matched group of 15 patients in whom an identical radiotherapy regimen was curative. Analysis of DNA content was performed blind to outcome of treatment. SETTING: Academic tertiary referral medical center. PARTICIPANTS: Thirty patients with clinically staged T1, N0, M0 glottic carcinoma. INTERVENTION: All patients received radiation to the larynx through opposed lateral ports at a total dose of 64 to 70 Gy. RESULTS: Ten diploid and five aneuploid histograms were found in the resistant group, and six diploid and nine aneuploid histograms were found in the radiosensitive group. This difference was not statistically significant. A trend toward a higher relapse rate after radiotherapy (62.5%) among patients with diploid tumor compared with those with aneuploid tumor (35.7%) was noted. CONCLUSIONS: DNA ploidy did not predict response to radiotherapy in patients with T1 glottic cancer, probably because of the small number of patients. A trend toward lower risk of local recurrence after radiotherapy in aneuploid tumors was noted. A larger prospective study is needed to assess the value of DNA ploidy in the treatment of early laryngeal cancer.     

Radiation therapy for early stage (T1-T2) sarcomatoid carcinoma of true vocal cords: outcomes and patterns of failure

Sarcomatoid carcinoma of head and neck mucosal sites is a rare high-grade malignancy that may cause diagnostic and therapeutic controversies. A characteristic of this entity consistently reported but not entirely validated is its relative radioresistance and the general belief is that surgery is the treatment of choice. The objective of this retrospective study was to determine if patients treated with radiation for early glottic sarcomatoid carcinoma had worse outcomes than those achieved with irradiation for the more typical squamous cell carcinoma. Twenty-eight cases of early stage (T1-T2) sarcomatoid carcinoma of the larynx treated with definitive doses of megavoltage irradiation between 1969 and 1995 at The University of Texas M. D. Anderson Cancer Center form the cohort for this analysis. All pathologic material was reviewed to confirm the diagnosis. All tumors manifested spindle cell features with marked cytomorphologic abnormalities characteristic of this entity. Sixteen tumors (57%) had the more typical polypoid gross morphology of sarcomatoid carcinoma. Twenty-one patients (75%) were staged T1 and seven patients (25%) had stage T2 disease. All patients were treated with small laryngeal fields, median size 20 cm2, and to a median dose of 65 Gy. Follow-up ranged from 1.5 to 24 years (median, 10 years). Four patients (14%) had local disease recurrence, and all had salvage total laryngectomies and remained free of local disease. The 5-year actuarial local control rates for patients with T1 and T2 lesions were 94% and 54%, respectively. Only one patient developed regional and distant disease. The 10-year actuarial disease-specific and overall survival rates were 92% and 63%, respectively. Patients with early stage sarcomatoid carcinoma of the glottis treated with radiation had similar control rates to irradiated patients with similar volume disease with the more typical squamous cell carcinoma. The authors contend that the histologic diagnosis of sarcomatoid carcinoma by itself should not influence the decision to treat a patient with early stage glottic disease with irradiation.     

Endoscopic laser excisional biopsy for selected glottic carcinomas

From January 1988 to December 1990, 44 previously untreated patients with squamous cell carcinomas (SCCs) of the true vocal cord (33 T1a, 11 Tis) underwent carbon dioxide laser excision. The mean follow-up was 28 months (range, 12 to 44 months). Endoscopic excisional biopsy was the primary treatment in 38 of the 44 patients, whereas postoperative radiotherapy was added in 6 cases in which the pathology report showed positive margins. Recurrent vocal cord SCC developed in 8 (18%) of the cases, with an average interval of 17.8 months. Re-treatment consisted of a second laser excision in 4 cases, radiotherapy in 1, hemilaryngectomy in 1, and total laryngectomy in 2. The definitive cure rate with endoscopic excisional biopsy for the patients originally treated with laser excision alone was 94.7% (36/38). Endoscopic laser treatment for selected glottic SCC proves to be an excellent alternative to radiotherapy or open neck surgery.     

Can pretreatment computed tomography predict local control in T3 squamous cell carcinoma of the glottic larynx treated with definitive radiotherapy?

PURPOSE: To determine if pretreatment computed tomography (CT) can predict local control in T3 squamous cell carcinoma of the glottic larynx treated with definitive radiotherapy (RT). METHODS AND MATERIALS: Forty-two patients with previously untreated T3 squamous cell carcinoma of the glottic larynx were treated for cure with RT alone; all had a minimum 2-year follow-up. Tumor volumes and extent were determined by consensus of two head and neck radiologists on pretreatment CT studies. A tumor score was calculated and assigned to each primary lesion depending on the extent of laryngeal spread. Sclerosis of any laryngeal cartilage was recorded. The specific CT parameters assessed were correlated with local control. RESULTS: Tumor volume was a significant predictor of local control. For tumors measuring < 3.5 cm3, local control was achieved in 22 of 26 patients (85%), whereas for tumors > or = 3.5 cm3, local control was achieved in 4 of 16 patients (25%) (p = 0.0002). Sensitivity and specificity using this cutpoint were 85% and 75%, respectively. Tumor score as a measure of anatomic extent was also found to be a significant predictor of local control. The local control rate for tumors assigned a low tumor score (< or = 5) was 78% (21 of 27) compared to 33% (5 of 15) for tumors assigned a high tumor score (6, 7, or 8) (p = 0.008). A significant decrease in the local control rate was observed for cancers involving the paraglottic space at the false vocal cord level (14 of 16 [88%] vs. 12/26 [46%]) (p = 0.010), cancers involving the face of the arytenoid (15 of 18 [83%] vs. 11 of 24 [46%]) (p = 0.024), and tumors involving the interarytenoid region (25 of 36 [69%] vs. 1 of 6 [17%]; p = 0.020). There were 12 patients with sclerosis of both the ipsilateral arytenoid and the adjacent cricoid cartilage. These patients showed a significant decrease in local control (4 of 12 [33%]). CONCLUSION: Pretreatment CT can stratify patients with T3 glottic carcinoma into groups more or less likely to be locally controlled with definitive RT. The local control rate for these tumors can be improved using a CT-based tumor profile; the ideal CT profile for a radiocurable T3 glottic larynx carcinoma is volume < 3.5 cm3 and no or single laryngeal cartilage sclerosis.     

A case of laryngeal carcinoma recurrence in the neck lymphatic system after total laryngectomy and combined method treatment

A patient with inoperable recurrence of the larynx carcinoma in lymphatic neck system after total laryngectomy was described. Nonradical surgical treatment combined with radical radiotherapy allowed to achieve a five-year symptom-free survival in this case.     

Nodal disease in purely glottic carcinoma: is elective neck treatment worthwhile?

OBJECTIVE: Although there is a generalized understanding of the relatively low overall incidence of nodal disease from purely glottic carcinoma, the exact role for elective neck treatment in the management of this disease remains controversial. The purpose of this study was to identify the incidence of occult nodal disease (including paratracheal) in patients who have glottic carcinoma without significant extraglottic extension and to identify which patients are at risk for this. A retrospective chart review of 92 such patients who had either undergone neck dissection or been observed for a minimum of 2 years was performed. RESULTS: For the 92 patients, neck treatment consisted of observation in 68 patients, paratracheal node dissection in four, unilateral neck dissection in four, unilateral neck dissection and excision of paratracheal nodes in 14, and bilateral neck dissection with paratracheal node excision in two. Of the 24 nodal dissections performed, four were positive for occult metastatic disease. No patient in the observation group developed nodal disease. CONCLUSION: The incidence of occult nodal disease in NO glottic carcinoma is low, 0% in early stage disease (T1-T2) and 19% in late stage disease (T3-T4). Nodes at highest risk included only the paratracheal, level II, and level III. Elective neck treatment should only be undertaken for advanced (T3-T4) disease and even then is of questionable benefit. If undertaken, it should have a low potential morbidity, such as selective neck dissection or radiation. Computed tomography was not useful in staging the neck for this subset of patients.     

Pretreatment hemoglobin level influences local control and survival of T1-T2 squamous cell carcinomas of the glottic larynx

PURPOSE: A number of reports have documented the relationship between pretreatment hemoglobin level and local control and/or survival in the treatment of cervix, bladder, and advanced head and neck tumors. Consideration of correcting anemia before initiation of radiation therapy may prove increasingly important as clinical trials use intensive induction chemotherapy in the treatment of head and neck carcinomas. Neoadjuvant chemotherapy may produce anemia, which in turn may reduce the effectiveness of subsequent irradiation. MATERIALS AND METHODS: One hundred nine patients with T1-2N0 squamous cell carcinoma of the glottic larynx were treated with definitive radiotherapy at the Fox Chase Cancer Center between June 1980 and November 1990. Follow-up times ranged from 26 to 165 months (median, 82). RESULTS: The 2-year local control rate for patients who presented with a hemoglobin level < or = 13 g/dL was 66%, compared with 95% for patients with a hemoglobin level more than 13 g/dL (P = .0018). The 2-year survival rate for patients with a hemoglobin level < or = 13 g/dL was 46%, compared with 88% for patients with a hemoglobin level more than 13 g/dL (P < .001). Cox proportional hazards regression analysis showed that hemoglobin level (P = .0016) was the only variable that significantly influenced local control (P = .0016) and survival (P < .0001). CONCLUSION: Patients who presented with hemoglobin levels more than 13 g/dL had significantly higher local control and survival rates. The strong apparent correlation between hemoglobin level, local control, and survival supports consideration of correcting anemia before initiation of radiation therapy.     

Immunosuppressive therapy of lupus nephritis

Supracricoid laryngectomy is a new development in the treatment of laryngeal cancer in Australia. It allows the removal of both vocal cords, vestibular folds, and the entire thyroid cartilage including the paraglottic space without the loss of laryngeal function. This technique may offer a significant advance in the treatment of squamous cell carcinoma of the larynx. This paper reviews the surgical management of laryngeal cancer and discusses this new technique with modifications, indications for its use and the advantages of supracricoid laryngectomy. Case reports of seven patients operated on in our institution are included.     

Four cholesterol-sensing proteins

103 patients with cancer of the larynx treated with partial laryngectomy were presented. Voice quality before and after surgery was compared. Voice was analysed by subjective and objective-spectrographic methods. Partial laryngectomies consisted of: vertical, horizontal and supraglottic subtotal procedures. The least dysphony was found in horizontal laryngectomy, the biggest--in supraglottic subtotal laryngectomy.