Editorial Management of Tl and T2 Squamous Cell Carcinoma of the Glottic Larynx
are not candidates for operative treatment that conserves the larynx because of the anatomic extent of the tumor or because of medical problems such as heart disease or chronic obstructive pulmonary disease. Endoscopic laser excision is probably appropriate only for well-defined Tl lesions limTreatment Options.-Previously untreated Tl and T2 ited to the middle third of one true vocal cord. The likelihood of a major complication is higher after squamous cell carcinoma of the glottic larynx can be effectively managed by a surgical procedure or irradiation.' Sur- surgical treatment than after radiotherapy.'> Neel and assogical alternatives include endoscopic laser excision, cordec- ciates' reported that major complications occurred in 47 of tomy, and hemilaryngectomy. Although total laryngectomy 182 patients (25.8%) who underwent laryngofissure and coris occasionally used as the initial treatment of early vocal dectomy for early vocal cord cancer. Similarly, Gall and cord cancer at some institutions, we think that its application colleagues' noted that 38 of 237 patients (16.0%) who underis inappropriate in this setting because of the relatively high went hemilaryngectomy experienced serious complications, probability of local control with use of irradiation only. One 2 (0.8%) of which were fatal. In contrast, only 5 of 304 might argue that rehabilitation of the voice after totallaryn- patients (1.6%) treated with only irradiation for Tl or T2 gectomy can be accomplished in most patients by various glottic cancer at the University of Florida experienced major techniques such as use of a voice prosthesis (for example, complications, none of which was fatal.' Irradiation is less Blom-Singer prosthesis or Panje button), electrolarynx, or expensive than hemilaryngectomy and more expensive than esophageal speech. Nevertheless, only 60% of patients with endoscopic laser excision. Because radiation therapy is the a voice prosthesis will have long-term success (that is, 2 preferred management for previously untreated Tl and T2 years or more postoperativelyj.' The rest of the patients are true vocal cord cancer at the University of Florida, our data rehabilitated with an electrolarynx or esophageal speech, represent an unselected series.' Situations in which we both of which result in a quality of voice that is clearly would recommend surgical treatment include verrucous carinferior to that obtained after either irradiation or partial cinoma suitable for a conservative operation, a history of laryngectomy. Although the voice may be restored in most prior irradiation to the larynx, and refusal of the patient to patients who undergo a total laryngectomy , the quality of life undergo irradiation. is often compromised by such factors as difficulty communiPersonal Series of Patients.-Between 1964 and 1984, cating by telephone and the necessity of using one hand to 304 patients with invasive previously untreated squamous communicate (for example, with an electrolarynx or Blom- cell carcinoma of the glottic larynx were managed with only Singer prosthesis). Adjuvant chemotherapy has no role in irradiation at the University of Florida.' Because most recurthe initial treatment of Tl and T2 laryngeal cancer. rences are noted within 2 years after treatment, all patients Preservation ofthe Larynx.-For patients who are suit- underwent follow-up for at least 2 years, and those who died able candidates for a laryngeal conservation surgical proce- within 2 years after irradiation with the primary site continudure, the likelihood of cure with preservation of laryngeal ously disease-free were excluded from the analysis of local voice is similar after either irradiation or an operation.' The control." Local control after irradiation was as follows: Tla, choice of treatment depends on physician availability, physi- 93%; Tlb, 94%; T2a, 77%; and T2b, 72%. Thirty-eight cian preference, and the wishes of the patient and the family patients underwent a salvage operation for local recurrence members. The advantage of a partial laryngectomy over after irradiation, which was successful in 27 (71%): 6 of 10 irradiation is that it involves a briefer period, particularly (60%) who underwent a hemilaryngectomy and 21 of 28 with use of endoscopic laser excision. The advantages of (75%) who underwent a total laryngectomy. Four patients irradiation are that a major operation can be avoided (if the who had been unsuitable for a hemilaryngectomy before surgical alternative is a hemilaryngectomy), the final quality irradiation subsequently underwent a hemilaryngectomy for of the voice is better, and the modality is appropriate for a local recurrence; the procedure was successful in two of the almost all patients with Tl or T2 vocal cord cancer. In four patients. Ultimate local control was as follows: T'Ia, contrast, a subset of patients with T 1 or T2 vocal cord cancer 98%; Tlb, 94%; T2a, 97%; and T2b, 88%. Majorcomplications were observed in 5 patients-l of 184 (0.5%) with Tl lesions and 4 of 120 (3.3%) with T21esions. At 5 years, the Address reprint requests to Dr. W. M. Mendenhall, Department of cause-specific survival was as follows: TIaNO, 97%; Radiation Oncology, University of Florida Health Science Center, TlbNO, 96%; T2aNO, 93%; and T2bNO, 88%. P.O. Box 100385, Gainesville, FL 32610-0385. Mayo Clin Proc 67:703-705, 1992
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EDITORIAL
Mayo Clio Proc, July 1992, Vol 67
Local Control After Irradiation»-« Various investigators associates report that local control was achieved with use of have suggested that numerous factors, including involve- 6-MV irradiation in all 16 patients with early-stage vocal ment of the anterior commissure, obesity, gender, impaired cord cancers. Nonetheless, concern exists that the use of a 6mobility of the vocal cords, andT stage, influence the likeli- MV photon beam may undertreat the tumor at the anterior hood of local control after use of irradiation only.' The commissure, particularly in patients with a thin neck and argument follows that patients with one or more of these little subcutaneous tissue. Recently, Akine and colleagues" unfavorable characteristics are best managed by an operation described a series of 154 patients treated with only irradiarather than irradiation. Since 1977, patients treated at the tion (6 MV) for T1 true vocal cord cancer; local control at 5 University of Florida for Tl or T2 vocal cord cancer have years was 91 % if the anterior commissure was not involved received irradiation once daily at 225 cGy per fraction or, for and 81 % if such involvement was noted at diagnosis (P = some T2 lesions since 1987, twice daily at 120 cGy per 0.06). fraction. Only the surgical alternative (the operation that Essentially all patients with Tl orT2 squamous cell carciwould have been necessary had the patient been initially nomas of the glottic larynx are managed with only irradiatreated surgically) and the mobility of the vocal cords sig- tion at the University of Florida. Patients receive irradiation nificantly influenced the probability of local control after with cobalt-60 while in the lateral decubitus position; the irradiation." Involvement of the anterior commissure, obe- fields are individually determined daily by a physician.'? sity, gender, and T stage did not significantly predict the The lateral decubitus position is preferred, as opposed to the likelihood of local control. supine position, because the anatomic landmarks (particuSeveral treatment-related variables may also influence larly the posterior edge of the thyroid cartilage) are easier to the likelihood of control of the tumor by radiotherapy. Split- discern. Patients are treated once daily at 225 cGy per course irradiation for cancer of the head and neck gained fraction to a total of 6,300 cGy administered in 28 fractions widespread applicability 20 to 25 years ago because it was for T1 and T2a lesions and to 6,525 cGy in 29 fractions for associated with diminished acute effects in comparison with T2b cancers. Since 1987, patients with T2 lesions who are continuous-course radiotherapy. Subsequently, studies logistically able to be treated twice daily have received 120 demonstrated that it was also associated with a decreased cGy per fraction to a total of7,440 cGy. Thus far, 28 patients probability of local control and that, because most cancers with T2 glottic cancers have been treated with twice-daily tend to respond to irradiation like acutely responding normal irradiation and have participated in follow-up for 2 or more tissues, dose-fractionation maneuvers that reduce acute tox- years; local control after irradiation has been achieved in 26 icity also decrease the likelihood of control of the tumor." (93%).1 Evidence indicates that the probability of local control is William M. Mendenhall, M.D. related to dose per fraction in patients treated once daily and James T. Parsons, M.D. that control rates at 200 cGy per fraction are better than those obtained at 180 cGy per fraction.PP Field size does not Rodney R. Million, M.D. Department of Radiation Oncology seem to be related to the probability of local control as long University of Florida College as the irradiation portals adequately provide an appropriate margin beyond the tumor. Teshima and co-workers" deof Medicine Gainesville, Florida scribed a series of 87 patients with TINO vocal cord cancer who had been randomized to irradiation with either a 5- by 5em or a 6- by 6-cm field; no significant difference in local control was noted. The recommended approach is to use the smallest field size needed to treat the tumor adequately be- REFERENCES cause, particularly as dose per fraction is increased, the I. MillionRR: The larynx... so to speak: everythingI wantedto knowabout laryngealcancerI learnedin the last 32 years. Int frequencies of acute side effects and late complications inJ Radiat Oncol BioIPhys (in press) crease with field size. Furthermore, the risk of failure in the 2. Wetmore SJ, Krueger K, Wesson K, Blessing ML: Longneck is remote if the primary lesion is controlled; thus, even term results of the Blom-Singer speech rehabilitation procefor high-volume T2 lesions, enlargement of the irradiation dure. Arch Otolaryngol 111:106-109, 1985 portals for elective inclusion of the neck nodes is unneces3. Mendenhall WM, Parsons JT, Stringer SP, Cassisi NJ, Million RR: TI- T2 vocalcord carcinoma: a basis for comparing sary.'-' Finally, controversy exists about the optimal beam the results of radiotherapy and surgery. Head Neck Surg energy. Most of the published data pertaining to results of 10:373-377, 1988 irradiation of Tl or T2 glottic carcinoma are based on treat4. Neel HB III, Devine KD, DesantoLW: Laryngofissure and ment with cobalt-60 or 4-MV irradiation. In this issue of the cordectomy for early cordal carcinoma: outcome in 182 Mayo Clinic Proceedings (pages 629 to 636), Foote and patients. Otolaryngol Head Neck Surg 88:79-84,1980
Mayo Clio Proc, July 1992, Vol 67
5.
Gall AM, Sessions DG, Ogura JH: Complications following surgery for cancer of the larynx and hypopharynx. Cancer 39:624-631, 1977 6. Parsons JT, McCarty PJ, Rao PV, Mendenhall WM, Million RR: On the definition of local control (editorial). Int J Radiat Oncol BioI Phys 18:705-706, 1990 7. Rucci L, Gallo 0, Fini-Storchi 0: Glottic cancer involving anterior commissure: surgery vs radiotherapy. Head Neck 13:403-410, 1991 8. Fein DA, Mendenhall WM, Parsons JT, Million RR: Tl-T2 squamous cell carcinoma of the glottic larynx treated with radiotherapy: a multivariate analysis of variables potentially influencing local control (submitted for publication) 9. Parsons JT, Bova FJ, Million RR: A re-evaluation of split-course technique for squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 6:1645-1652, 1980 10. Mendenhall WM, Parsons IT, Million RR, fletcher GH: rr. T2 squamous cell carcinoma of the glottic larynx treated with
EDITORIAL
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radiation therapy: relationship of dose-fractionation factors to local control and complications. Int J Radiat Oncol Biol Phys 15:1267-1273,1988 11. Schwaibold F, Scariato A, Nunno M, Wallner PE, Lustig RA, Rouby E, Gorshein D, Wenger J: The effect of fraction size on control of early glottic cancer. Int J Radiat Oncol Biol Phys 14:451-454, 1988 12. Marks M, Kim R, Salter M: Importance of dose-fractionation in the radiotherapeutic management of early stage glottic cancer (abstract). Int J Radiat Oncol Biol Phys 19 (Suppl 1):241, 1990 13. Teshima T, Chatani M, Inoue T: Radiation therapy for early glottic cancer (TlNOMO). II. Prospective randomized study concerning radiation field. Int J Radiat Oncol Biol Phys 18:119-123, 1990 14. Akine Y, Tokita N, Ogino T, Tsukiyama I, Egawa S, Saikawa M, Ohyama W, Yoshizumi T, Ebihara S: Radiotherapy ofTl glottic cancer with 6 MeV x rays. Int J Radiat Oncol Biol Phys 20:1215-1218, 1991
are not candidates for operative treatment that conserves the larynx because of the anatomic extent of the tumor or because of medical problems such as heart disease or chronic obstructive pulmonary disease. Endoscopic laser excision is probably appropriate only for well-defined Tl lesions limTreatment Options.-Previously untreated Tl and T2 ited to the middle third of one true vocal cord. The likelihood of a major complication is higher after squamous cell carcinoma of the glottic larynx can be effectively managed by a surgical procedure or irradiation.' Sur- surgical treatment than after radiotherapy.'> Neel and assogical alternatives include endoscopic laser excision, cordec- ciates' reported that major complications occurred in 47 of tomy, and hemilaryngectomy. Although total laryngectomy 182 patients (25.8%) who underwent laryngofissure and coris occasionally used as the initial treatment of early vocal dectomy for early vocal cord cancer. Similarly, Gall and cord cancer at some institutions, we think that its application colleagues' noted that 38 of 237 patients (16.0%) who underis inappropriate in this setting because of the relatively high went hemilaryngectomy experienced serious complications, probability of local control with use of irradiation only. One 2 (0.8%) of which were fatal. In contrast, only 5 of 304 might argue that rehabilitation of the voice after totallaryn- patients (1.6%) treated with only irradiation for Tl or T2 gectomy can be accomplished in most patients by various glottic cancer at the University of Florida experienced major techniques such as use of a voice prosthesis (for example, complications, none of which was fatal.' Irradiation is less Blom-Singer prosthesis or Panje button), electrolarynx, or expensive than hemilaryngectomy and more expensive than esophageal speech. Nevertheless, only 60% of patients with endoscopic laser excision. Because radiation therapy is the a voice prosthesis will have long-term success (that is, 2 preferred management for previously untreated Tl and T2 years or more postoperativelyj.' The rest of the patients are true vocal cord cancer at the University of Florida, our data rehabilitated with an electrolarynx or esophageal speech, represent an unselected series.' Situations in which we both of which result in a quality of voice that is clearly would recommend surgical treatment include verrucous carinferior to that obtained after either irradiation or partial cinoma suitable for a conservative operation, a history of laryngectomy. Although the voice may be restored in most prior irradiation to the larynx, and refusal of the patient to patients who undergo a total laryngectomy , the quality of life undergo irradiation. is often compromised by such factors as difficulty communiPersonal Series of Patients.-Between 1964 and 1984, cating by telephone and the necessity of using one hand to 304 patients with invasive previously untreated squamous communicate (for example, with an electrolarynx or Blom- cell carcinoma of the glottic larynx were managed with only Singer prosthesis). Adjuvant chemotherapy has no role in irradiation at the University of Florida.' Because most recurthe initial treatment of Tl and T2 laryngeal cancer. rences are noted within 2 years after treatment, all patients Preservation ofthe Larynx.-For patients who are suit- underwent follow-up for at least 2 years, and those who died able candidates for a laryngeal conservation surgical proce- within 2 years after irradiation with the primary site continudure, the likelihood of cure with preservation of laryngeal ously disease-free were excluded from the analysis of local voice is similar after either irradiation or an operation.' The control." Local control after irradiation was as follows: Tla, choice of treatment depends on physician availability, physi- 93%; Tlb, 94%; T2a, 77%; and T2b, 72%. Thirty-eight cian preference, and the wishes of the patient and the family patients underwent a salvage operation for local recurrence members. The advantage of a partial laryngectomy over after irradiation, which was successful in 27 (71%): 6 of 10 irradiation is that it involves a briefer period, particularly (60%) who underwent a hemilaryngectomy and 21 of 28 with use of endoscopic laser excision. The advantages of (75%) who underwent a total laryngectomy. Four patients irradiation are that a major operation can be avoided (if the who had been unsuitable for a hemilaryngectomy before surgical alternative is a hemilaryngectomy), the final quality irradiation subsequently underwent a hemilaryngectomy for of the voice is better, and the modality is appropriate for a local recurrence; the procedure was successful in two of the almost all patients with Tl or T2 vocal cord cancer. In four patients. Ultimate local control was as follows: T'Ia, contrast, a subset of patients with T 1 or T2 vocal cord cancer 98%; Tlb, 94%; T2a, 97%; and T2b, 88%. Majorcomplications were observed in 5 patients-l of 184 (0.5%) with Tl lesions and 4 of 120 (3.3%) with T21esions. At 5 years, the Address reprint requests to Dr. W. M. Mendenhall, Department of cause-specific survival was as follows: TIaNO, 97%; Radiation Oncology, University of Florida Health Science Center, TlbNO, 96%; T2aNO, 93%; and T2bNO, 88%. P.O. Box 100385, Gainesville, FL 32610-0385. Mayo Clin Proc 67:703-705, 1992
703
704
EDITORIAL
Mayo Clio Proc, July 1992, Vol 67
Local Control After Irradiation»-« Various investigators associates report that local control was achieved with use of have suggested that numerous factors, including involve- 6-MV irradiation in all 16 patients with early-stage vocal ment of the anterior commissure, obesity, gender, impaired cord cancers. Nonetheless, concern exists that the use of a 6mobility of the vocal cords, andT stage, influence the likeli- MV photon beam may undertreat the tumor at the anterior hood of local control after use of irradiation only.' The commissure, particularly in patients with a thin neck and argument follows that patients with one or more of these little subcutaneous tissue. Recently, Akine and colleagues" unfavorable characteristics are best managed by an operation described a series of 154 patients treated with only irradiarather than irradiation. Since 1977, patients treated at the tion (6 MV) for T1 true vocal cord cancer; local control at 5 University of Florida for Tl or T2 vocal cord cancer have years was 91 % if the anterior commissure was not involved received irradiation once daily at 225 cGy per fraction or, for and 81 % if such involvement was noted at diagnosis (P = some T2 lesions since 1987, twice daily at 120 cGy per 0.06). fraction. Only the surgical alternative (the operation that Essentially all patients with Tl orT2 squamous cell carciwould have been necessary had the patient been initially nomas of the glottic larynx are managed with only irradiatreated surgically) and the mobility of the vocal cords sig- tion at the University of Florida. Patients receive irradiation nificantly influenced the probability of local control after with cobalt-60 while in the lateral decubitus position; the irradiation." Involvement of the anterior commissure, obe- fields are individually determined daily by a physician.'? sity, gender, and T stage did not significantly predict the The lateral decubitus position is preferred, as opposed to the likelihood of local control. supine position, because the anatomic landmarks (particuSeveral treatment-related variables may also influence larly the posterior edge of the thyroid cartilage) are easier to the likelihood of control of the tumor by radiotherapy. Split- discern. Patients are treated once daily at 225 cGy per course irradiation for cancer of the head and neck gained fraction to a total of 6,300 cGy administered in 28 fractions widespread applicability 20 to 25 years ago because it was for T1 and T2a lesions and to 6,525 cGy in 29 fractions for associated with diminished acute effects in comparison with T2b cancers. Since 1987, patients with T2 lesions who are continuous-course radiotherapy. Subsequently, studies logistically able to be treated twice daily have received 120 demonstrated that it was also associated with a decreased cGy per fraction to a total of7,440 cGy. Thus far, 28 patients probability of local control and that, because most cancers with T2 glottic cancers have been treated with twice-daily tend to respond to irradiation like acutely responding normal irradiation and have participated in follow-up for 2 or more tissues, dose-fractionation maneuvers that reduce acute tox- years; local control after irradiation has been achieved in 26 icity also decrease the likelihood of control of the tumor." (93%).1 Evidence indicates that the probability of local control is William M. Mendenhall, M.D. related to dose per fraction in patients treated once daily and James T. Parsons, M.D. that control rates at 200 cGy per fraction are better than those obtained at 180 cGy per fraction.PP Field size does not Rodney R. Million, M.D. Department of Radiation Oncology seem to be related to the probability of local control as long University of Florida College as the irradiation portals adequately provide an appropriate margin beyond the tumor. Teshima and co-workers" deof Medicine Gainesville, Florida scribed a series of 87 patients with TINO vocal cord cancer who had been randomized to irradiation with either a 5- by 5em or a 6- by 6-cm field; no significant difference in local control was noted. The recommended approach is to use the smallest field size needed to treat the tumor adequately be- REFERENCES cause, particularly as dose per fraction is increased, the I. MillionRR: The larynx... so to speak: everythingI wantedto knowabout laryngealcancerI learnedin the last 32 years. Int frequencies of acute side effects and late complications inJ Radiat Oncol BioIPhys (in press) crease with field size. Furthermore, the risk of failure in the 2. Wetmore SJ, Krueger K, Wesson K, Blessing ML: Longneck is remote if the primary lesion is controlled; thus, even term results of the Blom-Singer speech rehabilitation procefor high-volume T2 lesions, enlargement of the irradiation dure. Arch Otolaryngol 111:106-109, 1985 portals for elective inclusion of the neck nodes is unneces3. Mendenhall WM, Parsons JT, Stringer SP, Cassisi NJ, Million RR: TI- T2 vocalcord carcinoma: a basis for comparing sary.'-' Finally, controversy exists about the optimal beam the results of radiotherapy and surgery. Head Neck Surg energy. Most of the published data pertaining to results of 10:373-377, 1988 irradiation of Tl or T2 glottic carcinoma are based on treat4. Neel HB III, Devine KD, DesantoLW: Laryngofissure and ment with cobalt-60 or 4-MV irradiation. In this issue of the cordectomy for early cordal carcinoma: outcome in 182 Mayo Clinic Proceedings (pages 629 to 636), Foote and patients. Otolaryngol Head Neck Surg 88:79-84,1980
Mayo Clio Proc, July 1992, Vol 67
5.
Gall AM, Sessions DG, Ogura JH: Complications following surgery for cancer of the larynx and hypopharynx. Cancer 39:624-631, 1977 6. Parsons JT, McCarty PJ, Rao PV, Mendenhall WM, Million RR: On the definition of local control (editorial). Int J Radiat Oncol BioI Phys 18:705-706, 1990 7. Rucci L, Gallo 0, Fini-Storchi 0: Glottic cancer involving anterior commissure: surgery vs radiotherapy. Head Neck 13:403-410, 1991 8. Fein DA, Mendenhall WM, Parsons JT, Million RR: Tl-T2 squamous cell carcinoma of the glottic larynx treated with radiotherapy: a multivariate analysis of variables potentially influencing local control (submitted for publication) 9. Parsons JT, Bova FJ, Million RR: A re-evaluation of split-course technique for squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 6:1645-1652, 1980 10. Mendenhall WM, Parsons IT, Million RR, fletcher GH: rr. T2 squamous cell carcinoma of the glottic larynx treated with
EDITORIAL
705
radiation therapy: relationship of dose-fractionation factors to local control and complications. Int J Radiat Oncol Biol Phys 15:1267-1273,1988 11. Schwaibold F, Scariato A, Nunno M, Wallner PE, Lustig RA, Rouby E, Gorshein D, Wenger J: The effect of fraction size on control of early glottic cancer. Int J Radiat Oncol Biol Phys 14:451-454, 1988 12. Marks M, Kim R, Salter M: Importance of dose-fractionation in the radiotherapeutic management of early stage glottic cancer (abstract). Int J Radiat Oncol Biol Phys 19 (Suppl 1):241, 1990 13. Teshima T, Chatani M, Inoue T: Radiation therapy for early glottic cancer (TlNOMO). II. Prospective randomized study concerning radiation field. Int J Radiat Oncol Biol Phys 18:119-123, 1990 14. Akine Y, Tokita N, Ogino T, Tsukiyama I, Egawa S, Saikawa M, Ohyama W, Yoshizumi T, Ebihara S: Radiotherapy ofTl glottic cancer with 6 MeV x rays. Int J Radiat Oncol Biol Phys 20:1215-1218, 1991
