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Partial Laryngectomy to Treat Early Glottic Cancer After Failure of Radiation Therapy
Makiko Toma, MD;
Ken-ichi Nibu, PhD;
Kazunari Nakao, MD;
Masaki Matsuzaki, MD;
Masato Mochiki, MD;
Tadashi Yuge, MD;
Atsuro Terahara, PhD;
Masashi Sugasawa, PhD
Arch Otolaryngol Head Neck Surg. 2002;128:909-912.
ABSTRACT
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Objective To evaluate the role of partial laryngectomy to treat glottic cancer
after failure of radiation therapy.
Design A 12-year retrospective outcome analysis.
Setting University referral center.
Patients A total of 19 patients who underwent partial laryngectomy to treat glottic
cancer after failure of radiation therapy.
Results The follow-up period in this group ranged from 31 to 144 months. After
surgery, a laryngocutaneous fistula was observed in 4 cases, and flap necrosis
occurred in 2, but these complications were successfully managed. Maximum
phonation time after surgery ranged from 3 to 28 seconds (median phonation
time, 10.2 seconds). Of these 19 patients, 3 developed local recurrence. These
cases were successfully treated with total laryngectomy. A surgical margin
of less than 1 mm was found to be a significant risk factor for local recurrence
after partial laryngectomy.
Conclusions These results indicate that partial laryngectomy is a useful option
for the treatment of irradiation failure in the treatment of stage I and stage
II vocal cord carcinomas. However, careful follow-up is mandatory for patients
with a small surgical margin.
INTRODUCTION
THE TREATMENT of T1 and T2 squamous cell carcinoma of the glottis is
controversial because early vocal cord cancers can be effectively treated
with either surgery or radiotherapy.1-11
In Japan, voice quality after radiation is clearly superior to that after
any type of surgical resection,8, 11-12
so irradiation remains the most common treatment option. The rate of recurrence
following irradiation ranges from 6% to 41%.1-10
Surgery is often reserved as a salvage option for patients with early glottic
cancer in whom the cancer recurs after radiation. While total laryngectomy
is usually used to treat recurrent tumors, in selected cases conservation
surgery with preservation of a portion of the larynx is feasible.1-7,9-10
This study reviews the functional results, complications, larynx conservation
rates, and survival rates of patients who underwent conservation surgery for
squamous cell carcinoma of the larynx as a salvage procedure for recurrent
tumors resistant to radiotherapy.
MATERIALS AND METHODS
Between January 1989 and December 1998, 91 patients with previously
untreated T1 and T2 invasive squamous cell carcinoma of the glottis were treated
with radiotherapy with curative intent at the Department of Otolaryngology,
The University of Tokyo Hospital, Tokyo, Japan. Local recurrence developed
in 32 (35%) of 91 patients (Table 1).
The local recurrence rates within T classifications were 12 (30%) of 40 in
T1, and 20 (39%) of 51 in T2. All 32 patients subsequently underwent salvage
surgery, including 19 patients who had a partial laryngectomy.
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Table 1. Local Recurrence After Radiotherapy and Results of Salvage
Surgery
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This article will document the clinical course of the 19 patients who
underwent partial laryngectomy. Clinical data were obtained from patient medical
records. Pathology reports were reviewed for the assessment of the results
of the histologic examination of the larynx. The follow-up period ranged from
31 to 144 months. All patients were men, with an average age of 62 years (age
range, 49-72 years). The total dose of radiotherapy ranged from 6000 to 7000
rad (60 to 70 Gy) (median dose, 6300 rad [63 Gy]). The disease-free interval
after radiotherapy ranged from 1 to 67 months (median interval, 21 months).
Nine patients had T1 tumors and 10 patients had T2 at the initial treatment
according to the International Union Against Cancer criteria.13
In 2 cases, the recurrent tumor extended beyond its original site. At the
time of postirradiation recurrences, 13 cases were staged as recurrent (r)
T1, 5 as rT2, and 1 as rT3. Computed tomographic scans were done for every
patient before partial laryngectomy. Cartilage invasion was not detected in
any patient. Squamous cell carcinoma was diagnosed in all cases both at the
initial treatment and at the diagnosis of recurrence.
A total of 19 patients who had a partial laryngectomy met the criteria
set by Biller et al14 for partial laryngectomy.
Our criteria included the following: (1) the thyroid cartilage should not
be invaded; (2) the arytenoid, except for the vocal process, should be free
of tumor; (3) the supraglottic extension should extend no further than the
lateral extension of the sinus of Morgagni; and (4) the recurrence should
correlate with the primary tumor previously treated with radiotherapy. We
performed a frontolateral laryngectomy in 4 patients, an extended frontolateral
laryngectomy in 13 patients, and a hemilaryngectomy in 2 patients. Frontolateral
laryngectomy consisted of removal of the frontolateral part of the ala of
the thyroid cartilage with the anterior commissure and the ipsilateral vocal
cord, including the paraglottic lesions. Additional excision of part of the
opposite vocal cord was performed according to the extent of the tumor. In
the extended frontolateral laryngectomy, part or all of the arytenoids was
removed in addition to that described for the frontolateral laryngectomy.
Fourteen patients had a 1-stage surgery and 5 underwent a 2-stage operation.15 Following the partial laryngectomy, the larynx was
reconstructed using a cervical skin flap15
in 4 patients and a combination of cervical skin flap and sternohyoid muscular
flap16 in 15 patients. The maximum phonation
time (MPT)12, 17 after the partial
laryngectomy was measured in 13 patients at least 6 months after surgery.
Patients were asked to phonate a sustained vowel sound ("a") at a comfortable
pitch and intensity level for as long as they could.
The Kaplan-Meier method18 was used to
calculate larynx conservation rates. Several prognostic factors for local
control were examined using the Fisher exact test.
RESULTS
There was no postoperative mortality among the 19 patients of this study.
All patients received a tracheostomy during the operative procedure. The time
from operation to the closure of the tracheostoma and the thyrostome ranged
from 14 to 80 days. All patients were able to swallow without aspiration within
9 to 29 days after the operation (median, 17 days). Aspiration pneumonia did
not occur in any patient. A laryngocutaneous fistula was observed in 4 cases
and partial flap necrosis occurred in 2 cases, but all of these complications
were successfully managed without surgical closure. Of these 19 patients,
3 (16%) developed local recurrence (2 rT1 and 1 rT2 at the time of postirradiation
recurrences). These patients ultimately underwent successful total laryngectomy.
In these 3 patients only, the surgical margin was less than 1 mm (Table 2). Such small surgical margins were
a significant risk factor for local recurrence (P<.01).
Analysis of other factors did not reveal significant differences between local
failure and local control groups; these factors included T classification,
disease-free interval, dose of radiation at the initial treatment, involvement
of the vocal process, involvement of the vocal muscle, and invasion of the
contralateral vocal cord (Table 2).
Cartilage invasion was not observed in any patient on histopathologic examination.
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Table 2. Factors Affecting Local Recurrence
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Cervical lymph node metastasis occurred in 3 patients. One was diagnosed
as having recurrence after radiotherapy and underwent a modified radical neck
dissection simultaneously at the time of salvage surgery, and the others were
diagnosed during the follow-up period after the salvage surgery and were successfully
treated with radical neck dissection. No patients died during the observation
periods.
The overall 5-year larynx conservation rates of T1 and T2 squamous cell
carcinoma of the glottis were as follows: T1a, 90%; T1b, 93%; and T2, 72%
(Figure 1). Of 32 patients with
irradiation failure for carcinoma of the glottis, laryngeal function was preserved
in 18 (56%): 2 by carbon dioxide laser microsurgery and 16 by partial laryngectomy.
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Figure 1. Larynx conservation rates of T1
and T2 squamous cell carcinoma of the glottis (N = 91).
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The MPT was measured in 13 patients. In all cases, the MPT was measured
at least 6 months after the operation and ranged from 3 to 28 seconds (median
MPT, 10.2 seconds). The MPT did not correlate either with T classification
or surgical procedures (Figure 2).
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Figure 2. Maximum phonation time (MPT) at
6 months after partial laryngectomy (n = 13). There was no correlation between
MPT and T classification (A) or surgical procedures (B).
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COMMENT
Treatment of irradiation-resistant T1 and T2 glottic carcinoma with
conservation surgery was first described in 1951.19
Since then, many reports about the efficacy of vertical partial laryngectomy
against recurrent disease after radiotherapy have been published.1-11
These studies confirm that a good cure rate and conservation of function can
result from vertical partial laryngectomies that are performed to treat recurrent
glottic carcinoma. Biller et al14 proposed
several contraindications for partial laryngectomy after radiotherapy: (1)
vocal cord immobility; (2) extension of the tumor to the contralateral vocal
cord or subglottic lesion; and (3) extension of the tumor beyond its original
site. In our study, 7 patients exhibited at least 1 of these contraindications.
However, local recurrence after salvage surgery was observed in only 1 patient
whose recurrent tumor after radiotherapy extended to the subglottic lesion.
Encouraged by the results of the present study and reports by Lavey and Calcaterra,3 we suggest expanding the criteria for salvage partial
laryngectomy as follows: A patient with persistent or locally recurrent glottic
cancer should be considered for a partial laryngectomy unless the tumor invades
(1) the arytenoid cartilage except vocal processes, (2) beyond the anterior
half of the contralateral vocal cord, (3) subglottically more than 10 mm in
the anterior half or 5 mm in the posterior half of the larynx, or (4) into
the thyroid or cricoid cartilage.
Prior to the performance of a partial laryngectomy, we routinely performed
thin-sliced computed tomographic scans of the neck to determine whether the
tumor extended into subglottic, paraglottic, preepiglottic, or supraglottic
spaces. In addition, we performed preoperative microlaryngoscopic examination
under general anesthesia to study the precise extension of tumor. All anatomic
sites containing tumor either before or after radiotherapy were included in
the partial laryngectomy specimen. With these efforts, we believe that a partial
laryngectomy can be performed for the salvage surgery of a T3 tumor causing
vocal cord fixation, as long as the tumor is confined to the paraglottic region
and meets the 4 proposed criteria.
In this study, the frequency of local recurrence after the salvage operation
did not significantly correlate with the involvement of the vocal process
and vocal muscles. On the other hand, patients with a small surgical margin
had a significantly higher recurrence rate than those with surgical margins
of 1 mm or more, which agrees with findings reported by Shah et al.20 These results suggest that an intraoperative examination
to determine the surgical margin is essential to the decision-making process.20 Fortunately, all 3 patients with local recurrence
after partial laryngectomy underwent successful total laryngectomy. Thus,
careful follow-up after conservation surgery for radiation failure is essential
to detect local recurrence and enable successful salvage by total laryngectomy.21
Although a number of authors have reported an increased incidence of
infectious and healing complications in patients who underwent frontolateral
laryngectomy for salvage of radiation failures,22-24
our incidence of fistula formation was similar to those of partial laryngectomy
performed at the initial treatment.8, 10
In most cases, we reconstructed the larynx using a combination of regional
skin flap15 and the sternohyoid muscles16 to cover the thyroid cartilage and to avoid occurrence
of dead space in the wound. This method of reconstruction may be favorable
for reconstruction after partial laryngectomy in patients who have undergone
radiotherapy. In addition, we performed a 2-stage operation to avoid fistula
formation by resecting a large area of the larynx. This method seemed to decrease
complications. The indications, effectiveness, and complications of salvage
partial laryngectomy after radiation failure are very similar to those of
partial laryngectomy performed at the initial treatment.8, 10-11
Thus, primary radiotherapy may be prescribed for early glottic cancers without
concern that it precludes the future use of larynx-conserving surgery.
The MPT after frontolateral laryngectomy ranged from 3 to 28 seconds,
with an average of 10.2 seconds. Of course, these values were slightly lower
than those obtained preoperatively (14 seconds),12
but similar to values obtained after partial laryngectomy (9.4-11 seconds).5, 12, 17 Although the number
of patients in this study was limited, we did not find a correlation between
MPT and T classification or surgical procedures. Interestingly, some patients
with T2 tumors kept good phonatory function, despite having a large area of
the larynx resected. This conservation of phonation may result from the bulk
of the skin flap for augmentation.
In summary, laryngeal function was preserved in 18 (56%) of 32 patients
who received salvage laser microsurgery or partial laryngectomy to treat glottic
carcinoma after irradiation failure. We believe that precise evaluation of
each case, including preoperative computed tomography studies, microlaryngoscopic
examination, intraoperative examination to determine surgical margin, and
close follow-up to detect the recurrence in the early stages, is essential
to successfully treat glottic carcinoma after irradiation failure and also
to preserve laryngeal function.
AUTHOR INFORMATION
Accepted for publication January 8, 2002.
This study was presented as a poster at the Fifth International Conference
on Head and Neck Cancer, San Francisco, Calif, July 30 through August 2, 2000.
Corresponding author and reprints: Makiko Toma, MD, Department of
Otolaryngology, Kanto Medical Center NTT E. C., 5-9-22 Higashi-Gotanda, Shinagawa-Ku,
Tokyo 141-8625, Japan (e-mail: makiko{at}jd5.so-net.ne.jp).
From the Departments of Otolaryngology–Head and Neck Surgery
(Drs Toma, Nibu, Nakao, Matsuzaki, Mochiki, Yuge, and Sugasawa) and Radiology
(Dr Terahara), Graduate School of Medicine, University of Tokyo; and the Department
of Otolaryngology, Kanto Medical Center (Dr Toma), Tokyo, Japan.
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