Abstract
Objective
The purpose of this study was to evaluate the appropriateness of the conservative surgery as the initial treatment of supraglottic cancer by the comparative study of supraglottic partial laryngectomy with radiation therapy.
Methods
We analyzed 48 patients diagnosed as having supraglottic cancer who underwent supraglottic partial laryngectomy and 20 patients treated with radiation therapy as initial treatment from 1991 to 2005. Oncologic safety was evaluated by comparison of survival rates. Swallowing test was performed with videoesophagofluoroscopy under the category of the pharyngeal phase and the presence or absence of aspiration. Phonologic analysis was performed with acoustic waveform analysis and stroboscopy.
Results
Positive resection margin was observed in 12 of the patients who received supraglottic partial laryngectomy (SPL), and its relationship with the primary subsite was evaluated. For the patients in stages I and II, the overall survival rate in each of the SPL group and the radiotherapy (RTx) group was 87% and 80%, respectively. For the patients in stages III and IV, the overall survival rate was 87% and 80%, respectively. On evaluation of swallowing and phonation function, no significant difference was noted between the SPL group and the RTx group.
Conclusion
This study suggests that for patients with supraglottic cancer, SPL provides acceptable survival, swallowing, and phonologic results in comparison with radiation therapy.
1
Introduction
Laryngeal tumors consist of 2% of all tumors and show the second highest incidence in the head and neck area . Among them, approximately one third occurs in the supraglottis, and 90% are pathologically squamous cell carcinomas . Similar to other tumors of the head and neck, the primary purpose of treatment of supraglottic carcinoma is the radical resection of tumor; nevertheless, the conservation of laryngeal function is also an important issue to be considered. The therapeutic modes of supraglottic carcinoma that could be applied to selective early-stage patients would be endoscopic resection, supraglottic partial laryngectomy (SPL), radiation therapy, and chemotherapy.
In early supraglottic carcinoma, high local control rates are anticipated with radiotherapy (RTx) or surgery alone; however, from the aspect of functional preservation, radiation therapy is advantageous, and so it has been generally adopted as the initial therapy . However, the impairment of swallowing and phonation caused by radiation therapy is being reported by many studies, and excellent treatment results of surgical methods that have been underevaluated in terms of functional preservation have been reported, and so, reevaluation of its appropriateness as the initial treatment of supraglottic carcinomas is considered necessary.
Supraglottic partial laryngectomy has been reported by Alonso in the 1940s for the first time, and it shows equal oncologic results with total laryngectomy, and also, functional preservation of swallowing and phonation is possible with this technique. To date, studies on the treatment effectiveness or the functional preservation after either conservation laryngeal surgery or radiation therapy alone have been conducted; nevertheless, comparative studies between the 2 treatment methods have hardly ever been conducted. In addition, the functional evaluation after SPL was limited to parameters such as the time of decannulation, aspiration, and the ability for oral intake.
Therefore, this study aims to compare the oncologic safety between SPL and radiation therapy, and from the functional comparison of swallowing and phonation after treatment, the appropriateness of SPL as the initial treatment of supraglottic carcinomas has been evaluated.
2
Materials and methods
2.1
Patients and characteristics
Patients who were diagnosed as having supraglottic carcinoma from May 1991 to May 2005 in the department of Otolaryngology, Head and Neck Cancer Clinic, Severance Hospital, were chosen for subjects of this study. The University of Yonsei Institutional Review Board has acknowledged the protocol, and informed consent was received from all patients. The subjects were confined to those patient groups where conservative surgery such as SPL or RTx were possible as initial treatment according to T stage, and those who were indicated for total laryngectomy or those who received chemotherapy were excluded. Sixty-eight patients were diagnosed as having supraglottic carcinoma, and among them, 48 patients received SPL and 20 were treated with radiation therapy as initial treatment. Subjects were divided into 2 groups according to the mode of initial treatment, and the average age of each group was 62 and 69 years. For each group, the number of patients diagnosed as stage I or II and whose treatment was completed by initial therapy was 15 in the SPL group and 10 in the radiation therapy group, and their mean age was 62 and 69 years. The clinical stage of all patient groups was analyzed according to the mode of initial treatment. In the SPL group, 25 patients were diagnosed as stage I or II (T1, T2), and for 3 patients diagnosed as T3, limited SPL was performed ( Table 2 A, B). In the RTx group, 10 patients were diagnosed as stage I or II (T1, T2), and it was also applied to 4 patients diagnosed as T3 ( Table 1 A, B). Medical records of each patient were retrospectively reviewed. In this study, the disease stage was determined according to the 2002 edition of the American Joint Committee on Cancer staging manual .
| cT | cN | T (n) | ||||
|---|---|---|---|---|---|---|
| N0 | N1 | N2a | N2b | N2c | ||
| T1 | 12 | 2 | – | 1 | – | 15 |
| T2 | 13 | 3 | 2 | 5 | 1 | 24 |
| T3 | 3 | – | – | 2 | 4 | 9 |
| Total | 28 | 5 | 2 | 8 | 5 | 48 |
| cT | cN | T (n) | ||||
|---|---|---|---|---|---|---|
| N0 | N1 | N2a | N2b | N2c | ||
| T1 | 2 | – | – | – | – | 2 |
| T2 | 8 | – | 2 | 1 | 1 | 12 |
| T3 | 4 | – | – | 1 | 1 | 6 |
| Total | 14 | – | 2 | 2 | 2 | 20 |
2.2
Treatment algorithm
Supraglottic partial laryngectomy or RTx was performed on patients with resectable supraglottic carcinoma regardless of the nodal stages. For those cases where RM(+) or pN(+) was confirmed after SPL, adjuvant RTx was performed. After close follow-up of patients whose treatment ended, salvage radical neck dissection or RTx was performed in primary or nodal recurrence cases, but 2 patients in each group refused treatment and so adjunctive treatment was not performed ( Fig. 1 ).
2.3
Evaluation of oncologic safety
To evaluate oncologic safety, the correlation of primary site and the resection margin was analyzed and survival rates of each group according to stage were compared.
2.4
Swallowing analysis
To exclude influences from other treatments, functional tests were performed only on the stage I and II patients whose treatment was completed by the initial treatment. Swallowing test was conducted in the Severace Rehabilitation Medicine Laboratory, using the TOSHIBA (Tokyo, Japan) Winscope 6000 videoesophagofluoroscopy. The examination compared the 2 groups under the category of the pharyngeal phase and the presence or absence of aspiration.
2.5
Phonologic analysis
For phonation examination, acoustic waveform analysis and KAY (Lincoln Park, NJ, USA) PENTAX RLS9100B stroboscopy were performed at the Severance Voice Diagnostic Laboratory. Acoustic wave form analysis by KAY CSL4400 evaluated the variance against frequency, the variance against amplitude, and the noise level; and stroboscopy analyzed specific categories of regularity, symmetry, glottic closure, mucosal wave, amplitude, and nonvibrating portion.
2.6
Statistical analysis
Survival rates were calculated by the Kaplan-Meier method, and their statistical significance was validated by log-rank test. For the functional tests, χ 2 test and t test were applied for comparison between the 2 groups. P value less than .05 was considered statistically significant.
2
Materials and methods
2.1
Patients and characteristics
Patients who were diagnosed as having supraglottic carcinoma from May 1991 to May 2005 in the department of Otolaryngology, Head and Neck Cancer Clinic, Severance Hospital, were chosen for subjects of this study. The University of Yonsei Institutional Review Board has acknowledged the protocol, and informed consent was received from all patients. The subjects were confined to those patient groups where conservative surgery such as SPL or RTx were possible as initial treatment according to T stage, and those who were indicated for total laryngectomy or those who received chemotherapy were excluded. Sixty-eight patients were diagnosed as having supraglottic carcinoma, and among them, 48 patients received SPL and 20 were treated with radiation therapy as initial treatment. Subjects were divided into 2 groups according to the mode of initial treatment, and the average age of each group was 62 and 69 years. For each group, the number of patients diagnosed as stage I or II and whose treatment was completed by initial therapy was 15 in the SPL group and 10 in the radiation therapy group, and their mean age was 62 and 69 years. The clinical stage of all patient groups was analyzed according to the mode of initial treatment. In the SPL group, 25 patients were diagnosed as stage I or II (T1, T2), and for 3 patients diagnosed as T3, limited SPL was performed ( Table 2 A, B). In the RTx group, 10 patients were diagnosed as stage I or II (T1, T2), and it was also applied to 4 patients diagnosed as T3 ( Table 1 A, B). Medical records of each patient were retrospectively reviewed. In this study, the disease stage was determined according to the 2002 edition of the American Joint Committee on Cancer staging manual .
| cT | cN | T (n) | ||||
|---|---|---|---|---|---|---|
| N0 | N1 | N2a | N2b | N2c | ||
| T1 | 12 | 2 | – | 1 | – | 15 |
| T2 | 13 | 3 | 2 | 5 | 1 | 24 |
| T3 | 3 | – | – | 2 | 4 | 9 |
| Total | 28 | 5 | 2 | 8 | 5 | 48 |
| cT | cN | T (n) | ||||
|---|---|---|---|---|---|---|
| N0 | N1 | N2a | N2b | N2c | ||
| T1 | 2 | – | – | – | – | 2 |
| T2 | 8 | – | 2 | 1 | 1 | 12 |
| T3 | 4 | – | – | 1 | 1 | 6 |
| Total | 14 | – | 2 | 2 | 2 | 20 |
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