Squamous Cell Carcinoma FR.+NI<
From the Head and Neck A Service, Memorial Institute, Bufalo, New York.
of the Larynx* WALTER
Clinically, this lesion was located on the vocal cord and was associated with normal cord mobility. Reddening or roughening of the vocal cord up to the anterior commissure was not an unusual finding, making it clinically impossible to know whether the changes were However, inflammatory or carcinomatous. with normal mobility of the cord and without gross erosive involvement of the commissure, the malignant disease was presumed to be superficial. Irradiation during the decade of the 1940’s provided an absolute five year survival of 25 per cent. (Fig. 1.) NED 60 after irradiation of the same class of lesion during the period 1950 to 1962 was 54 per cent. These figures were low when compared to those reported in the literature. When the figures were corrected and those patients with questionable clinical involvement of the anterior commissure were withdrawn, the five year survival with no evidence of disease was 59 per cent. NED 60 for cord mobile lesions with anterior commissure involvement was 20 per cent. Five patients in whom radiation therapy failed were subsequently treated with total laryngectomy: four for recurrent disease in the larynx and one for radionecrosis. One patient died postoperatively and four were alive and free of disease at five years. The surgical survival curves for the two periods provided reasonably good results (65 and 77 per cent, respectively). Laryngofissure was the surgical procedure most commonly performed. Total laryngectomy was performed when there was questionable In a few involvement of the commissure. instances excisional biopsy was curative.
study T HIS experience
represents a twenty-seven year of members of the Head and Neck X Service of the Roswell Park &Iemorial Institute. One of us was at this institution throughout the entire period of the study and one since 1950, thus allowing standardization of clinical classification and clinical evaluation of patients. No patients seen for the first time after 1962 were included, thus providing a minimum five-year follow-up study on all patients. Patients who had either received surgical or radiation therapy prior to admission or refused treatment were not included. This report is based on 541 patients with squamous cell carcinoma of the larynx examined and treated during the years 1940 to 1962. The ratio of male to female patients was 9: 1. This malignant lesion occurred with greatest frequency during the sixth decade. The clinical findings were confirmed by direct laryngoscopy. In all patients a biopsy positive for squamous cell carcinoma was obtained. Depending on its location and extent, the primary lesion was divided into four categories: mobile cord, cord fixed, extrinsic endolaryngeal, and extrinsic exolaryngeal. Lesions of the pyriform sinus and those originating primarily on the base of the tongue or in the vallecula were not included. The results of surgical and radiation therapy were compared and the decade of the 1940’s was compared with the subsequent period from 1956 to 1962. Results were expressed in absolute five year survival with no evidence of disease (NED 60).
* Presented at the Fourteenth Annual Meeting of The Society of Head and Neck Surgeons, Los Angeles, California, April 21-24, 1968. Vol. 116, October 1968
Marchetta, Sako, and Mattick
When laryngofissure was performed for mobile cord lesions, limited to the vocal cord with a normal appearing commissure, the five year survival with no evidence of disease was 74 per cent as compared to 59 per cent in patients treated with irradiation. Recurrence after laryngofissure occurred in 21 per cent of the patients. Five of these patients were successfully treated by additional surgery (total laryngectomy) with long-term survival free of disease. FIXED
The fixed cord lesion originated at the level of the vocal cords. Some degree of vocal cord
The extrinsic endolaryngeal lesion involved primarily the structures of the endolarynx above the level of the vocal cords but still confined to the larynx. During the decade of the 1940’s all patients with this lesion were treated with irradiation. Surgery was not performed and consequently the factor of selection was nonexistent. The five year survival with no evidence of disease during the early period (1940 to 1949) was 7 per cent. (Fig. 3.) Irradiation during the second period of study produced a five year survival of 10 per cent with no evidence of disease. CORD- FIXED 1940
2 3 YEARS
Radiolion 15 pafi*n(* t 3 2 YEARS
FIG. 2. Survival in patients with squamous cell carcinoma of the larynx (cord fixed lesion) between 1940 and 1962.
fixation, either partial or complete, existed, and reflected the degree or depth of tumor infiltration. The lesion extended into adjacent areas such as the anterior commissure, ventricle, subglottic area, and other cord. The comparative results of radiation in the two periods was 14 and 20 per cent, respectively. (Fig. 2.) Surgical results were 75 and 62 per cent, respectively. In most instances the procedure employed was total laryngectomy whereas in some, because of palpable nodes suspicious of metastatic disease, the procedure was total laryngectomy and radical neck dissection. Secondary neck dissection was performed when suspicious metastatic disease became clinically evident. The data indicated that surgery was the treatment of choice, resulting in improvements in survival rates of 40 per cent.
From 1950 to 1962, a large number of patients were surgically treated, generally employing total laryngectomy and radical neck dissection. In some patients, total laryngectomy only was performed, but was followed by a recurrence of 64 per cent. Recurrences usually presented as palpable cervical lymph nodes which were treated by radical neck dissection. The absolute five year survival with no evidence of disease was 51 per cent, an improvement of 40 per cent over radiation.
FIG. 1. Survival in patients with squamous cinoma of the larynx (cord mobile lesion) 1940 and 1962.
This lesion originated in the larynx but extended beyond the larynx into adjacent structures, such as the vallecula, tongue, laryngeal side of the pyriform sinus, and pharynx. During the 1940’s all patients in this cateThe American
Journal of Surwry
Squamous Cell Carcinoma of Larynx gory were treated with irradiation, again eliminating the factor of selection. The five year survival with no evidence of disease was 7 per cent. (Fig. 4.) During the second period, the survival after irradiation was 15 per cent, an improvement when results of irradiation in the two periods were compared. Surgery for extrinsic exolaryngeal lesions, performed only during the 1950 to 1962 period, produced an absolute five year survival with no evidence of disease of 44 per cent. Surgery in most instances was total laryngectomy and radical neck dissection. In some, a second or bilateral radical neck dissection was performed. Surgical therapy, when compared to irradia-
2 3 YEARS
The results, however, showed only a small improvement in survival. Some of this improvement was reflected in the better pre- and postirradiation care which the patient received during this later period. The serious complication of radionecrosis occurred infrequently and in many instances was treated surgically. Surgery on the other hand was a therapeutic modality which was less readily accepted by both patients and physicians. Complications in some instances were severe. The operative mortality computed from all operations performed for carcinoma of the larynx from 1950 to 1962 was 6 per cent. The results of surgery, however, produced improved survival
2 3 YEARS
2 3 YEARS
FIG. 3. Survival in patients with squamous cell carcinoma of the larynx (extrinsic endolaryngeal lesion) between 1940 and 1962.
FIG. 4. Survival in patients with squamous cell carcinoma of the larynx (extrinsic exolaryngeai lesion) between 1940 and 1962.
tion, improved survival by 30 per cent in these patients.
figures in patients in the last three categories (cord fixed, extrinsic endolaryngeal, a.nd extrinsic exolaryngeal lesions).
might be expected, radiation technics changed during the period of study. During the 1940’s, most patients were treated with either a 200 or 400 kv. generator with half value layer 0.9 or 5.0 mm. Cu, respectively, for four to five weeks with a total tumor dose of 5,000 to 6,000 r. By the late 1940’s and early 1950’s more patients were treated with the 400 kv. generator and some with the 1,000 kv. generator. During the late 1950’s many patients were treated with the 2,000 kv. generator with half value layer 7.6 mm. Pb, for a total tumor dose of 5,000 to 6,000 rads delivered in forty to fifty days. It was expected that the results of radiation during the years 1950 to 1962 would be better than those during the 1940 to 1949 year period. As
Vol. 116, October 1968
The period 1950 to 1962 has seen improved results for both radiation and surgery. Radiation will provide good survival results in patients with mobile cord lesions without involvement of the anterior commissure. Laryngectomy is the treatment of choice for anterior commissure involvement even when cord motion is normal. Surgery, however, is the treatment of choice for fixed cord, extrinsic endolaryngeal, and extrinsic exolaryngeal lesions. The absolute five year survival with no evidence of disease showed an improvement of 40, 40, and 30 per cent, respectively, over radiation in these categories.