Auris·Nasus·Larynx (Tokyo) 19, 37-44 (1992)
THE PLACE OF CONSERVATION SURGERY FOR T 3 LARYNGEAL CARCINOMAS WITH FIXATION Behbut CEVAN~iR, M.D., Orban OzTURAN, M.D., Nermin BA~ERER, M.D., and Engin YAZICIOGLU, M.D. Department of Otolaryngology, Istanbul Medical Faculty, University of Istanbul, Istanbul, Turkey
Although the traditional surgical treatment of T 3 laryngeal carcinomas is total laryngectomy, we have obtained favorable survival results for selected cases with partial laryngectomy, as exemplified in the literature. Extending the indications up to ultimate limits by partial, but radical surgical techniques is the recent trend in the world, for the conservation surgery of laryngeal cancers. The primary treatment of T 3 laryngeal cancers, instead of irradiation, should be surgical and, for select cases partial laryngectomy, depending on laryngeal embryological development and lymphatic drainage, may be carried out. We have performed partial laryngectomy with elective or therapeutic and radical or modified radical neck dissection for 43 T 3 laryngeal carcinomas at the Department of Otolaryngology, Istanbul Medical Faculty, University of Istanbul in the years 1978-1991 and obtained 2, 3, and 5 years of survival rates, which are 89, 79.4, and 73%, respectively. Although the optimal surgical treatment ofT3 laryngeal cancer is traditionally total laryngectomy (TL), when the embryological development and lymphatic drainage of the larynx, inadequacy of classification system, and sociocultural status of the patients are taken into account, partial laryngectomy can be performed in select cases, as suggested by many authors. Conservation surgery for laryngeal cancers involves complete resection of the malignant tumor and reconstruction of the remaining part of the larynx to maintain sphincteric, phonatory, and respiratory functions (BILLER, 1987; SESSION, 1980). TL is a severe operation from the physiological and especially psychological viewpoint for the patient. The first TL applied in America in 1879 is one of the most striking examples for unavoidable effects of this operation. ~he patient had committed suicide a week after having a successful operation, because he was not able to endure the deprivation of the laryngeal functions (MILLION and CASSIS!, Received for publication
December 7, 1990 37
38
B.
CEVAN~iR et al.
1984). These reasons have made laryngologists work diligently for over 100 years on developing conservation surgery techniques. There have been attempts to extend the indication limits of these techniques without compromising the oncological principles. KIRCHNER (1989) has made major contributions concerning intralaryngeal tumor extension patterns, pathways, compartments and, easy and hard infiltration borders which have permitted millimetric surgery on the larynx safely. All the knowledge we have acquired from biological potential of tumor, intralaryngeal tumor extension patterns, an adequate physical examination, direct laryngoscopy, intraoperative tumor inspection, and, if possible from CAT and MRI, should be analyzed very carefully to select the most suitable cases that could undergo a partial laryngectomy. Well-differentiated epidermoid cancers are preferable for conservation surgery. Surgeons should not rely on the current classification system (TNM) excessively, because the clinical classification system, which has been established by American Joint Committee on Cancer (1983), frequently delineates the pathology less than its exact dimensions and does not take into account all the measures of the tumor extension, especially it does not clarify sufficiently the fixation concept and the histological differentiation of the tumor; hence, a much wider new classification is necessary (FERLITO, 1976; GLANZ, 1984; JACOPSON, 1976; KIRCHNER, 1989; BAILEY, 1991). For these limitations of the clinical classification system, our attitude should depend on the extension of the tumor and its oncological behavior. But TNM expression of the lesion is the only way to present our cases and compare with others'. Undoubtedly, all of us have certain experiences and observations that similarly located tumors of different patients do not progress uniformly and do reach disparate prognosis. Although vocal cord fixation has been regarded as a sign of deep tumor extension, it is not an absolute indication for TL (KESSLER, TRAPP, and CALCATERRA, 1987). Invasion of the thyroarytenoideus muscle, the cricoarytenoideus muscle, the arytenoideus muscle, the arytenoideus cartilage, and the cricoarytenoideus joint are the most common causes of vocal cord fixation in T 3 glottic cancers. Less frequently there may be invasion of recurrent nerve and fixation of vocal cord to internal perichondrium of the thyroid cartilage. PATIENTS AND METHODS We have carried out partial laryngectomy in 43 ( 1 glottic, 5 supraglottic, and 37 transglottic) T 3 laryngeal cancers with vocal cord fixation in Department of Otolaryngology, Istanbul Medical Faculty, the University of Istanbul. Patients whose vocal cord functions were described as paretic, partially immobile or patients
CONSERVATION SURGERY FOR T3 LARYNGEAL CARCINOMA
39
with impaired mobility were not included in our study. Preoperative indirect and direct laryngoscopy were performed as well as intraoperative inspection for ultimate decision to ensure the adequacy of conservation surgery. We had 1 female and 42 male patients, whose ages were between 31 and 72 with an average of 55. The extent of the lesions in the present study was as follows: 31 T 3N0 M0 , 11 T 3N 10 0, and 1 T 3N 2M0 • All of them had undergone elective or therapeutic, radical or modified radical neck dissection unilaterally, except for one N 2 patient who had a staged bilateral therapeutic neck dissection. We have applied vertical partial laryngectomy (VPL) in 20 cases (47%), horizonto-verticallaryngectomy (HVL) in 18 cases ( 42%), and supraglottic laryngectomy with arytenoidectomy (SL+A) in 5 cases (11%). The indications of VPL for T 3 laryngeal cancers are the lesions involving one hemilarynx with fixation, possibly subglottic extension, but not more than 10 mm anteriorly and 4 mm posteriorly. Paraglottic region can be infiltrated without invading the thyroid cartilage. The indications of HVL for T 3 laryngeal cancers are the lesions involving one side of the hemilarynx vertically with fixation and other side of the supraglottic sites. Paraglottic region invasion in the vertically involved side and preepiglottic region invasion does not preclude this technique, providing that the thyroid cartilage is not infiltrated. The indications of SL +A for T 3 laryngeal cancers are the lesions involving supraglottis and extension to the arytenoideus cartilage unilaterally with fixation. RESULTS
Postoperative 2 years of duration has not been completed by 6 of 43 cases, so that 37 cases were taken into account for survival rate calculations. Two cases have been lost follow-up shortly after operation and two more cases in the later period of study. Local recurrence has happened to three cases 7, 8, and 13 months after operation, respectively, and TL had to be carried out. One of these has died 11 months after TL. Local recurrence suggests suspect margins and inadequate evaluation. Operation years of these cases were 1979, 1980, and 1987. The local recurrences in the first two cases might be attributed to the inefficiency of the available diagnostic modalities and being less experienced in the initial years of study. Two regional neck recurrences have taken place, who have been operated by neck dissection. One of these patients has died of an unremitting regional neck metastasis with carotid artery infiltration which happened 12 months after the first operation. Carotid artery resection with regional tumor metastasis did not help. Two patients have suffered from lung metastasis after 34 and 36 months postoperatively.
B. CEVAN~iR et al.
40 Table I.
Two years of follow-up and survival rate.
The duration of the study: 1978-1991 Not completed 2 years of period Completed 2 years of period Lost follow-up Exitus due to local recurrence Exitus due to regional recurrence Exitus due to distant metastasis Exitus due to nonlaryngeal reasons Two years of survival rate (33/37)
Table 2.
cases cases cases cases case case None None 89%
Three years of follow-up and survival rate.
The duration of the study: 1978-1991 Not completed 3 years of period Completed 3 years of period Lost follow-up Exitus due to local recurrence Exitus due to regional recurrence Exitus due to distant metastasis Exitus due to nonlaryngeal reasons Three years of survival rate (27/34)
Table 3.
43 6 37 2
43 9 34 4
cases cases cases cases case case case None 79.4%
Five years of follow-up and survival rate.
The duration of the study: 1978-1991 Not completed 5 years of period Completed 5 years of period Lost follow-up Exitus due to local recurrence Exitus due to regional recurrence Exitus due to distant metastasis Exitus due to nonlaryngeal reasons Five years of survival rate ( 19/26)
cases cases cases cases case None 2 cases 1 case 73%
43 17 26 3 1
A patient has died of cardiac reason 3 years and 4 months after the operation. Four lost patients from follow-up and 1 nonlaryngeal death were considered as failure for pessimistic survival rate calculations. Two, 3, and 5 years of follow-ups and pessimistic survival rates have been summarized in simplified tables (Tables I, 2, and 3). DISCUSSION
The desired treatment of the laryngeal cancers is not only eradicating the tumor, but also conserving the precious functions of the larynx. In the light of this reality, the introduction of the first vertical hemilaryngectomy into the medical literature in 1878 by BILLROTH and development of this technique by GLUCK in
CONSERVATION SURGERY FOR T3 LARYNGEAL CARCINOMA
41
1903 have aroused the partial laryngectomy concept (BILLER, 1987). BILLER and LAWSON (1986) and KIRCHNER and SoM (1971) extended the partial laryngectomy resection limits to an extent enabling it to be applied even to cases with T 3 laryngeal cancer. Meanwhile we would like to emphasize that classical techniques are inadequate for T 3 laryngeal cancers, whereas special techniques are necessary indeed, to resect a greater part and to reconstruct the remainder functionally. Transglottic tumors had been introduced by Me GAVRAN, OGURA, and BAUER in 1961. These tumors involve both structures of the larynx originating from buccopharyngeal and tracheobronchial anlage. The site of origin is no longer possible to determine in transglottic tumors, which comprised 86% of our cases. Naturally those tumors have worse prognosis than supraglottic and glottic tumors. Unfortunately, current TNM classification does not include this subject. While our 2 years of survival rate is 89%, BILLER and LAWSON (1986) reported that they had operated on 26 vocal cord cancer cases with fixed or partially immobile cord with extended VPL and had obtained a 2 years survival rate of 72%. KESSLER et al. (1987) performed VPL on 27 T 3 glottic cancers and obtained a 2 years survival ra~ of 85%. Our 3 years of survival rate is 79.4%. COATES et al. (1976) carried out partial laryngectomy for stage 3 laryngeal cancers and reported a 3 years survival rate of 70%. LEROUX-ROBERT (1975) has obtained a 5 years survival rate of 61% by performing frontolaterallaryngectomy in 127 patients with T 3 lesions. LESINSKI, BAUER, and OGURA (1976) have accomplished a 5 years survival rates of 85% in 18 patients by hemilaryngectomy. Our 5 years survival rate is 73%. We believe that as long as 5 years of survival rates are above 6o-65% after conservation surgery of the T 3 laryngeal cancers, it should be regarded as a success, since for such tumors 5 years of survival rates after TL are usually 6o-70% (SASAKI and CARLSON, 1986). Disease control rates with primary irradiation therapy in T 3 laryngeal cancers are between 2o-50% in the literature. Nevertheless, all of the failures have been salvaged with TL and these salvaged cases have been reported as a success of irradiation therapy alone and total survival rates were reported approximately as 7o-75% (HARWOOD, DOUGLAS, and WALTER, 1980). WANG (1987) has presented 5 years of survival rate after irradiation for T 3 laryngeal cancers as 37%, which has been increased to 46% after salvage surgery. The disadvantages of initial irradiation therapy is that, in case of failure the salvage surgery cannot be performed as conservation surgery due to irradiation edema, inadequate wound healing, and disappearing of the surgical boundaries; consequently, we have to carry out TL (KESSLER et al., 1987). HARWOOD et al. ( 1980) from Toronto reported that after radical irradia-
42
B.
CEV AN~iR et a/.
tion, out of 37 patients with T 3N 0M0 glottic cancers, 57% were alive with their own larynx, 27% were alive without larynx, and 16% were dead. After salvage surgery, a 3 years survival rate of 84% has been attained. Of these alive patients 32% were without larynx. Whereas our 3 years survival rate is 79.4% in 34 patients, the 27 living patients out of 34 are alive with a functioning larynx, except 2 (7.4%) of them are total laryngectomized due to local recurrence. ScHESTER (1984), made an interesting remark in Symposium on Larynx of Otolaryngologic Clinics of North America that the alignment and dosimetry devices which are essential for primary irradiation of larynx cancers are available in only 40% of the radiotherapy centers in the U.S.A. Our opinion on indication of postoperative irradiation therapy is as follows: the histological evidence of tumor extension on the resection border, extension to pharyngeal walls, valleculae, root of the tongue and pyriform sinus, perineural invasion, intralymphatic invasion and direct extension to neck, 2 or more histologically positive lymph nodes (especially when more than one nodal region are involved), presence of extracapsular disease, and invasion to the soft tissue. When the tumor is noticed in intraoperative inspection to be unexpectedly large for conservation surgery, extending to the other arytenoideus cartilage by way of posterior commissure, exteriorized position, invasion of the subglottis more than 10 mm anteriorly and 4 mm posteriorly, invasion of the cartilage, cardiopulmonary insufficiency, and general debility necessitate TL (KESSLER eta/., 1987). BILLER and LAWSON (1986) reported that after partial laryngectomy of the lesions that were invading subglottis more than 4 mm, there would be considerable increase in local recurrences. KIRCHNER and SoM ( 1971) reported that 4 of the 5 patients with subglottic extension had developed local recurrences. CONCLUSIONS As CAT, MRI, and other facilities become routine and the abilities of these diagnostic modalities to detect the tumoral extensions in the larynx are enhanced, we will be able to select the more suitable patients efficiently for partial laryngectomy and consequently attain a much better local disease control rate. Since carefully performed conservation surgery in adequate patients provides more than satisfactory survival rates according to TL, we should not change our mind unless there is a contraindication in intraoperative inspection for partial laryngectomy, and should maintain patients' laryngeal functions depending on inherent features of this organ. This will gratify us and make our patients happy. Surgical approach is undoubtedly the primary treatment for T 3 laryngeal cancers. Postoperative irradiation is necessary for certain cases to increase prognosis. Our survival rates for 2, 3, and 5 years are 89, 79.4, and 73%, respectively. These results should encourage surgeons and inspire them to perform partial laryngectomy.
CONSERVATION SURGERY FOR T 3 LARYNGEAL CARCINOMA
43
The scientific challenge is toward extending the limits of conservation surgery with better reconstructive techniques. By this challenge we attained a reconstructive conservation level at which only an arytenoid unit remains as larynx and a laryngostoma which will be closed later on (BILLER, 1987). There is no doubt that there will be surgeons who are aware of historical development of laryngeal cancer surgery and have a strong imagination to develop further the conservation laryngeal surgery. REFERENCES American Joint Committee on Cancer: Manual for Staging of Head and Neck Sites, J. B. Lippincott, Philadelphia, 1983. BAILEY, B. J.: Beyond the 'New' TNM classification (Editorial). Arch. Otolaryngol. Head Neck Surg. 117: 369-370, 1991. BILLER, H. F.: The Joseph H. Ogura Memorial Lecture: Conservation surgery: Past, present and future. Laryngoscope 97: 36-40, 1987. BILLER, H. F., and LAWSON, W.: Partial laryngectomy for vocal cord cancer with marked limitation of fixation of the vocal cord. Laryngoscope 96: 61-64, 1986. CoATES, H. L. et al.: Carcinoma of the supraglottic larynx. Arch. Otolaryngol. 102: 686, 1976. FERLITO, A.: Histological classification of larynx and hypopharynx cancers and their clinical implications. Acta Otolaryngol. Suppl. 342, 1976. GLANZ, H.: Growth, P-classification and grading of squamous cell carcinoma of the vocal cord. Adv. Otorhinolaryngol. 32: 1, 1984. HARWOOD, A. R., DOUGLAS, P. B., and WALTER, D. R.: Management of T 3 glottic cancer. Arch. Otolaryngol. Head Neck Surg. 106: 697-688, 1980. JACOPSON, P. A.: Histologic grading of malignancy and prognosis in glottic carcinoma of the larynx. In Centennial Conference on Laryngeal Cancer (Alberti, P. W., and Bryce, D. F., eds.), Appleton-Century Crofts, New York, 1976. KESSLER, D. J., TRAPP, K. T., and CALCATERRA, T. C.: Treatment of T 3 glottic carcinoma with vertical partial laryngectomy. Arch. Otolaryngol. 113: 1196-1199, 1987. KIRCHNER, J. A.: Fifteenth Daniel C. Baker, Jr., Memorial Lecture: What have whole organ sections contributed to the treatment of laryngeal cancer. Ann. Otol. Rhino/. Laryngol. 98: 661-667, 1989. KIRCHNER, J. A., and SoM, M.: Clinical significance of fixed vocal cord. Laryngoscope 81: 1029-1044, 1971. LEROUX-ROBERT, J.: Panel discussion on glottic tumors IV. A. Statistical study of 620 laryngeal carcinomas of the glottic region personally operated upon more than 5 years ago. Laryngoscope 85: 1440, 1975. LESINSKI, S. G., BAUER, W. C., and OGURA, J. H.: Hemilaryngectomy for T 3 (fixed cord) epidermoid carcinoma of the larynx. Laryngoscope 86: 1563-1571, 1976. Me GAVRAN, H. M., BAUER, W. C., and OGURA, J. H.: The incidence of cervical lymph node metastases from epidermoid carcinoma of the larynx and their relationship to certain characteristics of the primary tumor. Cancer 14: 55, 1961. MILLION, R. R., and CASSIS!, N. J.: Management of Head and Neck Cancer. A. Multidisciplinary Approach, pp. 13-15, J.P. Lippincott Company, Philadelphia, 1984. SASAKI, C. T., and CARLSON, R. D.: Malignant neoplasms of the larynx. In Otolaryngology-Head and Neck Surgery (Cummings, C. W., and Frederickson, J. M., eds.), p. 1987, The C. V. Mosby Company, St. Louis, 1986. SCHESTER, G. L.: Conservation surgery of the larynx-When? Otol. Clin. North Am. 17: 215-225,
44
B. CEVAN~iR et al.
1984. SESSION, D. G.: Extended partial laryngectomy. Ann. Otol. 89: 556-557, 1980. SHAMBOUL, K., DOYLE-KELLY, W., and BAILEY, D.: Results of salvage surgery following radical radiotherapy for laryngeal carcinoma. J. Laryngol. Otol. 98: 905-907, 1984. WANG, C. C.: Radiation therapy of laryngeal tumors. In Comprehensive Management of Head and Neck Tumors (Thawley, S. E., and Panje, W. R., eds.), pp. 906-919, W. B. Saunders Company, Philadelphia, 1987.
Request reprints to:
Dr. B. Cevan~ir, Department of Otolaryngology, Istanbul Medical Faculty, University of Istanbul,
THE PLACE OF CONSERVATION SURGERY FOR T 3 LARYNGEAL CARCINOMAS WITH FIXATION Behbut CEVAN~iR, M.D., Orban OzTURAN, M.D., Nermin BA~ERER, M.D., and Engin YAZICIOGLU, M.D. Department of Otolaryngology, Istanbul Medical Faculty, University of Istanbul, Istanbul, Turkey
Although the traditional surgical treatment of T 3 laryngeal carcinomas is total laryngectomy, we have obtained favorable survival results for selected cases with partial laryngectomy, as exemplified in the literature. Extending the indications up to ultimate limits by partial, but radical surgical techniques is the recent trend in the world, for the conservation surgery of laryngeal cancers. The primary treatment of T 3 laryngeal cancers, instead of irradiation, should be surgical and, for select cases partial laryngectomy, depending on laryngeal embryological development and lymphatic drainage, may be carried out. We have performed partial laryngectomy with elective or therapeutic and radical or modified radical neck dissection for 43 T 3 laryngeal carcinomas at the Department of Otolaryngology, Istanbul Medical Faculty, University of Istanbul in the years 1978-1991 and obtained 2, 3, and 5 years of survival rates, which are 89, 79.4, and 73%, respectively. Although the optimal surgical treatment ofT3 laryngeal cancer is traditionally total laryngectomy (TL), when the embryological development and lymphatic drainage of the larynx, inadequacy of classification system, and sociocultural status of the patients are taken into account, partial laryngectomy can be performed in select cases, as suggested by many authors. Conservation surgery for laryngeal cancers involves complete resection of the malignant tumor and reconstruction of the remaining part of the larynx to maintain sphincteric, phonatory, and respiratory functions (BILLER, 1987; SESSION, 1980). TL is a severe operation from the physiological and especially psychological viewpoint for the patient. The first TL applied in America in 1879 is one of the most striking examples for unavoidable effects of this operation. ~he patient had committed suicide a week after having a successful operation, because he was not able to endure the deprivation of the laryngeal functions (MILLION and CASSIS!, Received for publication
December 7, 1990 37
38
B.
CEVAN~iR et al.
1984). These reasons have made laryngologists work diligently for over 100 years on developing conservation surgery techniques. There have been attempts to extend the indication limits of these techniques without compromising the oncological principles. KIRCHNER (1989) has made major contributions concerning intralaryngeal tumor extension patterns, pathways, compartments and, easy and hard infiltration borders which have permitted millimetric surgery on the larynx safely. All the knowledge we have acquired from biological potential of tumor, intralaryngeal tumor extension patterns, an adequate physical examination, direct laryngoscopy, intraoperative tumor inspection, and, if possible from CAT and MRI, should be analyzed very carefully to select the most suitable cases that could undergo a partial laryngectomy. Well-differentiated epidermoid cancers are preferable for conservation surgery. Surgeons should not rely on the current classification system (TNM) excessively, because the clinical classification system, which has been established by American Joint Committee on Cancer (1983), frequently delineates the pathology less than its exact dimensions and does not take into account all the measures of the tumor extension, especially it does not clarify sufficiently the fixation concept and the histological differentiation of the tumor; hence, a much wider new classification is necessary (FERLITO, 1976; GLANZ, 1984; JACOPSON, 1976; KIRCHNER, 1989; BAILEY, 1991). For these limitations of the clinical classification system, our attitude should depend on the extension of the tumor and its oncological behavior. But TNM expression of the lesion is the only way to present our cases and compare with others'. Undoubtedly, all of us have certain experiences and observations that similarly located tumors of different patients do not progress uniformly and do reach disparate prognosis. Although vocal cord fixation has been regarded as a sign of deep tumor extension, it is not an absolute indication for TL (KESSLER, TRAPP, and CALCATERRA, 1987). Invasion of the thyroarytenoideus muscle, the cricoarytenoideus muscle, the arytenoideus muscle, the arytenoideus cartilage, and the cricoarytenoideus joint are the most common causes of vocal cord fixation in T 3 glottic cancers. Less frequently there may be invasion of recurrent nerve and fixation of vocal cord to internal perichondrium of the thyroid cartilage. PATIENTS AND METHODS We have carried out partial laryngectomy in 43 ( 1 glottic, 5 supraglottic, and 37 transglottic) T 3 laryngeal cancers with vocal cord fixation in Department of Otolaryngology, Istanbul Medical Faculty, the University of Istanbul. Patients whose vocal cord functions were described as paretic, partially immobile or patients
CONSERVATION SURGERY FOR T3 LARYNGEAL CARCINOMA
39
with impaired mobility were not included in our study. Preoperative indirect and direct laryngoscopy were performed as well as intraoperative inspection for ultimate decision to ensure the adequacy of conservation surgery. We had 1 female and 42 male patients, whose ages were between 31 and 72 with an average of 55. The extent of the lesions in the present study was as follows: 31 T 3N0 M0 , 11 T 3N 10 0, and 1 T 3N 2M0 • All of them had undergone elective or therapeutic, radical or modified radical neck dissection unilaterally, except for one N 2 patient who had a staged bilateral therapeutic neck dissection. We have applied vertical partial laryngectomy (VPL) in 20 cases (47%), horizonto-verticallaryngectomy (HVL) in 18 cases ( 42%), and supraglottic laryngectomy with arytenoidectomy (SL+A) in 5 cases (11%). The indications of VPL for T 3 laryngeal cancers are the lesions involving one hemilarynx with fixation, possibly subglottic extension, but not more than 10 mm anteriorly and 4 mm posteriorly. Paraglottic region can be infiltrated without invading the thyroid cartilage. The indications of HVL for T 3 laryngeal cancers are the lesions involving one side of the hemilarynx vertically with fixation and other side of the supraglottic sites. Paraglottic region invasion in the vertically involved side and preepiglottic region invasion does not preclude this technique, providing that the thyroid cartilage is not infiltrated. The indications of SL +A for T 3 laryngeal cancers are the lesions involving supraglottis and extension to the arytenoideus cartilage unilaterally with fixation. RESULTS
Postoperative 2 years of duration has not been completed by 6 of 43 cases, so that 37 cases were taken into account for survival rate calculations. Two cases have been lost follow-up shortly after operation and two more cases in the later period of study. Local recurrence has happened to three cases 7, 8, and 13 months after operation, respectively, and TL had to be carried out. One of these has died 11 months after TL. Local recurrence suggests suspect margins and inadequate evaluation. Operation years of these cases were 1979, 1980, and 1987. The local recurrences in the first two cases might be attributed to the inefficiency of the available diagnostic modalities and being less experienced in the initial years of study. Two regional neck recurrences have taken place, who have been operated by neck dissection. One of these patients has died of an unremitting regional neck metastasis with carotid artery infiltration which happened 12 months after the first operation. Carotid artery resection with regional tumor metastasis did not help. Two patients have suffered from lung metastasis after 34 and 36 months postoperatively.
B. CEVAN~iR et al.
40 Table I.
Two years of follow-up and survival rate.
The duration of the study: 1978-1991 Not completed 2 years of period Completed 2 years of period Lost follow-up Exitus due to local recurrence Exitus due to regional recurrence Exitus due to distant metastasis Exitus due to nonlaryngeal reasons Two years of survival rate (33/37)
Table 2.
cases cases cases cases case case None None 89%
Three years of follow-up and survival rate.
The duration of the study: 1978-1991 Not completed 3 years of period Completed 3 years of period Lost follow-up Exitus due to local recurrence Exitus due to regional recurrence Exitus due to distant metastasis Exitus due to nonlaryngeal reasons Three years of survival rate (27/34)
Table 3.
43 6 37 2
43 9 34 4
cases cases cases cases case case case None 79.4%
Five years of follow-up and survival rate.
The duration of the study: 1978-1991 Not completed 5 years of period Completed 5 years of period Lost follow-up Exitus due to local recurrence Exitus due to regional recurrence Exitus due to distant metastasis Exitus due to nonlaryngeal reasons Five years of survival rate ( 19/26)
cases cases cases cases case None 2 cases 1 case 73%
43 17 26 3 1
A patient has died of cardiac reason 3 years and 4 months after the operation. Four lost patients from follow-up and 1 nonlaryngeal death were considered as failure for pessimistic survival rate calculations. Two, 3, and 5 years of follow-ups and pessimistic survival rates have been summarized in simplified tables (Tables I, 2, and 3). DISCUSSION
The desired treatment of the laryngeal cancers is not only eradicating the tumor, but also conserving the precious functions of the larynx. In the light of this reality, the introduction of the first vertical hemilaryngectomy into the medical literature in 1878 by BILLROTH and development of this technique by GLUCK in
CONSERVATION SURGERY FOR T3 LARYNGEAL CARCINOMA
41
1903 have aroused the partial laryngectomy concept (BILLER, 1987). BILLER and LAWSON (1986) and KIRCHNER and SoM (1971) extended the partial laryngectomy resection limits to an extent enabling it to be applied even to cases with T 3 laryngeal cancer. Meanwhile we would like to emphasize that classical techniques are inadequate for T 3 laryngeal cancers, whereas special techniques are necessary indeed, to resect a greater part and to reconstruct the remainder functionally. Transglottic tumors had been introduced by Me GAVRAN, OGURA, and BAUER in 1961. These tumors involve both structures of the larynx originating from buccopharyngeal and tracheobronchial anlage. The site of origin is no longer possible to determine in transglottic tumors, which comprised 86% of our cases. Naturally those tumors have worse prognosis than supraglottic and glottic tumors. Unfortunately, current TNM classification does not include this subject. While our 2 years of survival rate is 89%, BILLER and LAWSON (1986) reported that they had operated on 26 vocal cord cancer cases with fixed or partially immobile cord with extended VPL and had obtained a 2 years survival rate of 72%. KESSLER et al. (1987) performed VPL on 27 T 3 glottic cancers and obtained a 2 years survival ra~ of 85%. Our 3 years of survival rate is 79.4%. COATES et al. (1976) carried out partial laryngectomy for stage 3 laryngeal cancers and reported a 3 years survival rate of 70%. LEROUX-ROBERT (1975) has obtained a 5 years survival rate of 61% by performing frontolaterallaryngectomy in 127 patients with T 3 lesions. LESINSKI, BAUER, and OGURA (1976) have accomplished a 5 years survival rates of 85% in 18 patients by hemilaryngectomy. Our 5 years survival rate is 73%. We believe that as long as 5 years of survival rates are above 6o-65% after conservation surgery of the T 3 laryngeal cancers, it should be regarded as a success, since for such tumors 5 years of survival rates after TL are usually 6o-70% (SASAKI and CARLSON, 1986). Disease control rates with primary irradiation therapy in T 3 laryngeal cancers are between 2o-50% in the literature. Nevertheless, all of the failures have been salvaged with TL and these salvaged cases have been reported as a success of irradiation therapy alone and total survival rates were reported approximately as 7o-75% (HARWOOD, DOUGLAS, and WALTER, 1980). WANG (1987) has presented 5 years of survival rate after irradiation for T 3 laryngeal cancers as 37%, which has been increased to 46% after salvage surgery. The disadvantages of initial irradiation therapy is that, in case of failure the salvage surgery cannot be performed as conservation surgery due to irradiation edema, inadequate wound healing, and disappearing of the surgical boundaries; consequently, we have to carry out TL (KESSLER et al., 1987). HARWOOD et al. ( 1980) from Toronto reported that after radical irradia-
42
B.
CEV AN~iR et a/.
tion, out of 37 patients with T 3N 0M0 glottic cancers, 57% were alive with their own larynx, 27% were alive without larynx, and 16% were dead. After salvage surgery, a 3 years survival rate of 84% has been attained. Of these alive patients 32% were without larynx. Whereas our 3 years survival rate is 79.4% in 34 patients, the 27 living patients out of 34 are alive with a functioning larynx, except 2 (7.4%) of them are total laryngectomized due to local recurrence. ScHESTER (1984), made an interesting remark in Symposium on Larynx of Otolaryngologic Clinics of North America that the alignment and dosimetry devices which are essential for primary irradiation of larynx cancers are available in only 40% of the radiotherapy centers in the U.S.A. Our opinion on indication of postoperative irradiation therapy is as follows: the histological evidence of tumor extension on the resection border, extension to pharyngeal walls, valleculae, root of the tongue and pyriform sinus, perineural invasion, intralymphatic invasion and direct extension to neck, 2 or more histologically positive lymph nodes (especially when more than one nodal region are involved), presence of extracapsular disease, and invasion to the soft tissue. When the tumor is noticed in intraoperative inspection to be unexpectedly large for conservation surgery, extending to the other arytenoideus cartilage by way of posterior commissure, exteriorized position, invasion of the subglottis more than 10 mm anteriorly and 4 mm posteriorly, invasion of the cartilage, cardiopulmonary insufficiency, and general debility necessitate TL (KESSLER eta/., 1987). BILLER and LAWSON (1986) reported that after partial laryngectomy of the lesions that were invading subglottis more than 4 mm, there would be considerable increase in local recurrences. KIRCHNER and SoM ( 1971) reported that 4 of the 5 patients with subglottic extension had developed local recurrences. CONCLUSIONS As CAT, MRI, and other facilities become routine and the abilities of these diagnostic modalities to detect the tumoral extensions in the larynx are enhanced, we will be able to select the more suitable patients efficiently for partial laryngectomy and consequently attain a much better local disease control rate. Since carefully performed conservation surgery in adequate patients provides more than satisfactory survival rates according to TL, we should not change our mind unless there is a contraindication in intraoperative inspection for partial laryngectomy, and should maintain patients' laryngeal functions depending on inherent features of this organ. This will gratify us and make our patients happy. Surgical approach is undoubtedly the primary treatment for T 3 laryngeal cancers. Postoperative irradiation is necessary for certain cases to increase prognosis. Our survival rates for 2, 3, and 5 years are 89, 79.4, and 73%, respectively. These results should encourage surgeons and inspire them to perform partial laryngectomy.
CONSERVATION SURGERY FOR T 3 LARYNGEAL CARCINOMA
43
The scientific challenge is toward extending the limits of conservation surgery with better reconstructive techniques. By this challenge we attained a reconstructive conservation level at which only an arytenoid unit remains as larynx and a laryngostoma which will be closed later on (BILLER, 1987). There is no doubt that there will be surgeons who are aware of historical development of laryngeal cancer surgery and have a strong imagination to develop further the conservation laryngeal surgery. REFERENCES American Joint Committee on Cancer: Manual for Staging of Head and Neck Sites, J. B. Lippincott, Philadelphia, 1983. BAILEY, B. J.: Beyond the 'New' TNM classification (Editorial). Arch. Otolaryngol. Head Neck Surg. 117: 369-370, 1991. BILLER, H. F.: The Joseph H. Ogura Memorial Lecture: Conservation surgery: Past, present and future. Laryngoscope 97: 36-40, 1987. BILLER, H. F., and LAWSON, W.: Partial laryngectomy for vocal cord cancer with marked limitation of fixation of the vocal cord. Laryngoscope 96: 61-64, 1986. CoATES, H. L. et al.: Carcinoma of the supraglottic larynx. Arch. Otolaryngol. 102: 686, 1976. FERLITO, A.: Histological classification of larynx and hypopharynx cancers and their clinical implications. Acta Otolaryngol. Suppl. 342, 1976. GLANZ, H.: Growth, P-classification and grading of squamous cell carcinoma of the vocal cord. Adv. Otorhinolaryngol. 32: 1, 1984. HARWOOD, A. R., DOUGLAS, P. B., and WALTER, D. R.: Management of T 3 glottic cancer. Arch. Otolaryngol. Head Neck Surg. 106: 697-688, 1980. JACOPSON, P. A.: Histologic grading of malignancy and prognosis in glottic carcinoma of the larynx. In Centennial Conference on Laryngeal Cancer (Alberti, P. W., and Bryce, D. F., eds.), Appleton-Century Crofts, New York, 1976. KESSLER, D. J., TRAPP, K. T., and CALCATERRA, T. C.: Treatment of T 3 glottic carcinoma with vertical partial laryngectomy. Arch. Otolaryngol. 113: 1196-1199, 1987. KIRCHNER, J. A.: Fifteenth Daniel C. Baker, Jr., Memorial Lecture: What have whole organ sections contributed to the treatment of laryngeal cancer. Ann. Otol. Rhino/. Laryngol. 98: 661-667, 1989. KIRCHNER, J. A., and SoM, M.: Clinical significance of fixed vocal cord. Laryngoscope 81: 1029-1044, 1971. LEROUX-ROBERT, J.: Panel discussion on glottic tumors IV. A. Statistical study of 620 laryngeal carcinomas of the glottic region personally operated upon more than 5 years ago. Laryngoscope 85: 1440, 1975. LESINSKI, S. G., BAUER, W. C., and OGURA, J. H.: Hemilaryngectomy for T 3 (fixed cord) epidermoid carcinoma of the larynx. Laryngoscope 86: 1563-1571, 1976. Me GAVRAN, H. M., BAUER, W. C., and OGURA, J. H.: The incidence of cervical lymph node metastases from epidermoid carcinoma of the larynx and their relationship to certain characteristics of the primary tumor. Cancer 14: 55, 1961. MILLION, R. R., and CASSIS!, N. J.: Management of Head and Neck Cancer. A. Multidisciplinary Approach, pp. 13-15, J.P. Lippincott Company, Philadelphia, 1984. SASAKI, C. T., and CARLSON, R. D.: Malignant neoplasms of the larynx. In Otolaryngology-Head and Neck Surgery (Cummings, C. W., and Frederickson, J. M., eds.), p. 1987, The C. V. Mosby Company, St. Louis, 1986. SCHESTER, G. L.: Conservation surgery of the larynx-When? Otol. Clin. North Am. 17: 215-225,
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1984. SESSION, D. G.: Extended partial laryngectomy. Ann. Otol. 89: 556-557, 1980. SHAMBOUL, K., DOYLE-KELLY, W., and BAILEY, D.: Results of salvage surgery following radical radiotherapy for laryngeal carcinoma. J. Laryngol. Otol. 98: 905-907, 1984. WANG, C. C.: Radiation therapy of laryngeal tumors. In Comprehensive Management of Head and Neck Tumors (Thawley, S. E., and Panje, W. R., eds.), pp. 906-919, W. B. Saunders Company, Philadelphia, 1987.
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Dr. B. Cevan~ir, Department of Otolaryngology, Istanbul Medical Faculty, University of Istanbul,
