Optimizing Primary Treatment for Advanced Laryngeal and Pyriform Sinus Carcinoma Leigh Hamby, MD, Patrick C. McGrath, MD, Edward A. Lute, MD, William Meekert, MD, Daniel E. Kenady, MD, Lexington,Kentucky
Advocates of chemotherapy pins radiation as the definitive treatment for patients with advanced laryngeal cancer often cite older studies that attribute cure rates of less than 50% to laryngectomy plus radiation. The outcomes of patients with stage III and IV laryngeal and pyriform sinns carcinoma from 1980 to 1989 ( 9 6 patients) were compare~I with those of patients treated from 1962 to 197~ (84 patients). Demographics, the extent of disease, and nodal involvement were similar between the groups. There were more operative complications (45% versns 22%; p < 0 . 0 1 ) and deaths (10% versns 2%; p < 0 . 0 1 ) in the patients who underwent irradiation preoperatively. Overall survival was improved in the recent group compared with the early group (73% versus 54% at 5 years; p < 0 . 0 3 ) , as was disease-free survival (64% versus 38% at 5 years; p < 0 . 0 2 ) . Results of treatment for advanced laryngeal and pyriform sinus carcinoma have improved significantly. These modern results should be nsed to evaluate newer treatment modalities.
Fromthe Divisionsof GeneralSurgery(LH, PCM, DEK) and Plastic Surgery (EAL). Departmentof Surgery (WM), Universityof Kentueky Collegeof Medicine.and LexingtonVeterans Administration MedicalCenter.Lexington,Kentucky. tDeceased. Requests for reprints should be addressedto Daniel E. Kenady, MD, Sectionof SurgicalOntology,Departmentof Surgery,University of KentuckyMedicalCenter, 800 Rose Street, Lexington,Kentucky 40536-0084. Presentedat the ThirdInternationalConferenceon HeadandNeck Cancer,San Francisco,California,July26-30, 1992.
ancer of the larynx and pyriform sinus affects approximately 12,000 patients in the United States annually, resulting in 3,500 cancer-related deaths [I]. Conventional treatment for patients with advanced cane.er has been laryngeetomy with or without radiation. Recent reports have advocated combinations of chemotherapy and radiation without laryngectomy as the evolving definitive treatment for patients with advanced carcinoma. These reports cite cure rates similar to those previously reported in older studies of resection combined with radiotherapy, ranging from 0% to 50% [2-7]. To evaluate newer methods of treatment, a review of contemporary results is necessary. We reviewed our experience regarding the recurrence and survival rates of patients with advanced laryngeal and pyriform sinus carcinoma who were treated with laryngectomy or the combination of laryngectomy and radiation.
C
PATIENTS AND METHODS Clinical and pathologic information from the charts of patients with stage III and IV laryngeal and pyriform sinus carcinoma treated at the University of Kentucky Medical Center and the Lexington Veterans Administration Medical Center was reviewed. To evaluate any historical change in results, patients were divided into two groups: group 1 consisted of patients treated from 1962 to 1977 (84 patients), and group 2 consisted of patients treated from 1980 to 1989 (96 patients). This division was made because of a change in our institutional philosophy. After 1977, scheduled preoperative radiation was no longer used routinely. Instead, radiation was administered postoperatively only to selected patients (those with metasta~;es to cervical nodes or close surgical margins [less than 5 mm]). Information collected from charts included age, sex, race, tumor and nodal status [8], histologic differentiation, presence of positive margins, radiation treatment, and outcome. Operative complications were def'med as those that prolonged hospitalization or required further operative intervention. Operative deaths were defined as those that occurred within 30 days after operation or as a result of complications directly related to treatment (i.e., rupture of the carotid artery or infection). All operations were performed or supervised by one of the authors (DEK, EAL, PCM, WM). Variations in techniques were common with regard to incisions used and the protection and reconstruction of the carotid artery, but a fairly standard "wide-field laryngectomy" technique was used in extirpation. In general, in patients with clinically involved nodes, neck dissection included resection of the sternocleidomastoid muscle and the internal jugular vein. For patients with T3 or T4 lesions with clinically uninvolved cervical nodes, neck dissection was
THE AMERICANJOURNAL OF SURGERY VOLUME164 DECEMBER1992 629
HAMBY ET AL
TABLE 1
Characteristics of Patients With Advanced Laryngeal and P y r i f o r m S i n u s Carcinoma Group 1 (n = 84) (1962-1977)
(%)
Tumor location Pyriform sinus Supraglottic larynx Glottic larynx Subglottic larynx Tumor status T2* T3 T4 NO N+ Stage III Stage N
13 40 28 3 9 53 22 31 53 49 35
(15) (48) (33) (5)
Group 2 (n = 96) (1980-1989)
(%)
21 37 35 3
(11) (63) (26) (37) (63) (56) (42)
(22) (39) (36) (3)
1 (1) 62 (65) 33 (34) 43 (45) 53 (55) 50 (52) 46 (43)
*p
Advocates of chemotherapy pins radiation as the definitive treatment for patients with advanced laryngeal cancer often cite older studies that attribute cure rates of less than 50% to laryngectomy plus radiation. The outcomes of patients with stage III and IV laryngeal and pyriform sinns carcinoma from 1980 to 1989 ( 9 6 patients) were compare~I with those of patients treated from 1962 to 197~ (84 patients). Demographics, the extent of disease, and nodal involvement were similar between the groups. There were more operative complications (45% versns 22%; p < 0 . 0 1 ) and deaths (10% versns 2%; p < 0 . 0 1 ) in the patients who underwent irradiation preoperatively. Overall survival was improved in the recent group compared with the early group (73% versus 54% at 5 years; p < 0 . 0 3 ) , as was disease-free survival (64% versus 38% at 5 years; p < 0 . 0 2 ) . Results of treatment for advanced laryngeal and pyriform sinus carcinoma have improved significantly. These modern results should be nsed to evaluate newer treatment modalities.
Fromthe Divisionsof GeneralSurgery(LH, PCM, DEK) and Plastic Surgery (EAL). Departmentof Surgery (WM), Universityof Kentueky Collegeof Medicine.and LexingtonVeterans Administration MedicalCenter.Lexington,Kentucky. tDeceased. Requests for reprints should be addressedto Daniel E. Kenady, MD, Sectionof SurgicalOntology,Departmentof Surgery,University of KentuckyMedicalCenter, 800 Rose Street, Lexington,Kentucky 40536-0084. Presentedat the ThirdInternationalConferenceon HeadandNeck Cancer,San Francisco,California,July26-30, 1992.
ancer of the larynx and pyriform sinus affects approximately 12,000 patients in the United States annually, resulting in 3,500 cancer-related deaths [I]. Conventional treatment for patients with advanced cane.er has been laryngeetomy with or without radiation. Recent reports have advocated combinations of chemotherapy and radiation without laryngectomy as the evolving definitive treatment for patients with advanced carcinoma. These reports cite cure rates similar to those previously reported in older studies of resection combined with radiotherapy, ranging from 0% to 50% [2-7]. To evaluate newer methods of treatment, a review of contemporary results is necessary. We reviewed our experience regarding the recurrence and survival rates of patients with advanced laryngeal and pyriform sinus carcinoma who were treated with laryngectomy or the combination of laryngectomy and radiation.
C
PATIENTS AND METHODS Clinical and pathologic information from the charts of patients with stage III and IV laryngeal and pyriform sinus carcinoma treated at the University of Kentucky Medical Center and the Lexington Veterans Administration Medical Center was reviewed. To evaluate any historical change in results, patients were divided into two groups: group 1 consisted of patients treated from 1962 to 1977 (84 patients), and group 2 consisted of patients treated from 1980 to 1989 (96 patients). This division was made because of a change in our institutional philosophy. After 1977, scheduled preoperative radiation was no longer used routinely. Instead, radiation was administered postoperatively only to selected patients (those with metasta~;es to cervical nodes or close surgical margins [less than 5 mm]). Information collected from charts included age, sex, race, tumor and nodal status [8], histologic differentiation, presence of positive margins, radiation treatment, and outcome. Operative complications were def'med as those that prolonged hospitalization or required further operative intervention. Operative deaths were defined as those that occurred within 30 days after operation or as a result of complications directly related to treatment (i.e., rupture of the carotid artery or infection). All operations were performed or supervised by one of the authors (DEK, EAL, PCM, WM). Variations in techniques were common with regard to incisions used and the protection and reconstruction of the carotid artery, but a fairly standard "wide-field laryngectomy" technique was used in extirpation. In general, in patients with clinically involved nodes, neck dissection included resection of the sternocleidomastoid muscle and the internal jugular vein. For patients with T3 or T4 lesions with clinically uninvolved cervical nodes, neck dissection was
THE AMERICANJOURNAL OF SURGERY VOLUME164 DECEMBER1992 629
HAMBY ET AL
TABLE 1
Characteristics of Patients With Advanced Laryngeal and P y r i f o r m S i n u s Carcinoma Group 1 (n = 84) (1962-1977)
(%)
Tumor location Pyriform sinus Supraglottic larynx Glottic larynx Subglottic larynx Tumor status T2* T3 T4 NO N+ Stage III Stage N
13 40 28 3 9 53 22 31 53 49 35
(15) (48) (33) (5)
Group 2 (n = 96) (1980-1989)
(%)
21 37 35 3
(11) (63) (26) (37) (63) (56) (42)
(22) (39) (36) (3)
1 (1) 62 (65) 33 (34) 43 (45) 53 (55) 50 (52) 46 (43)
*p
