CURRENT TREATMENT OF LARYNGEAL CARCINOMA
7. Radical neck dissection should be avoided in association with laryngectomy following radiotherapy. When necessary a planned fistula is the safest method of avoiding major postoperative complications. ACKNOWLEDGEMENTS Acknowledgement is made to Drs R.C. Kerr and J.P. Madigan, Radiotherapists of the Head and Neck Clinic of the Peter MacCallum Hospital, and to Dr Peter Freeman of the Alfred Hospital, whose patients are included in this study; also, to Dr P. Ilbery, Ex Medical Director, Peter MacCallum Hospital, who provided facilities and sessional time for the study. REFERENCES BALLANTYNE. A. J. (1974), Neoplasia of Head and Neck, University of Texas M. D. Anderson Hospital and Tumor Institute. Year Book Medical Publishers I n c . (Chicago): 89.
MILLAR Clinical Staging System for Carcinoma of the Larynx in T.N.M. (1972), Classification of Malignant Tumours of Breast, Larynx, Stomach, Cervix Uteri, Corpus Uteri, U.I.C.C. Geneva, Switzerland: 13 DE Santo. L. W. (1974). Workshop No. 2. Centennial Conference on Laryngeal Cancer (Toronto), edited by Alberti, P. W. a n d B r y c e , D . P., A p p l e t o n - C e n t u r y - C r o f t , New York: 146. FLETCHER. G. H., JESSE. R. H., LINDBERG. R. D. and KOONS. C. R. (1970), Amer. J. Roentgenol, 58: 19. KENNEDY. J. T. and KRAUSE. C. J. (1974) Arch. Otolaryng, 99: 274. KERR. R . C., MADIGAN. J. P.and MILLAR. H.S. (1970),AUST. N.Z.J. SURG.. 40: 19. LATWROP. F. D. (1968). Ann. Otol. (St Louis), 77: 493. LEDERMAN. M. (1961), Brit. med. J. 1: 1639. LOWRY. L. D., MARKS. J. E. and POWELL. W. J. (1973), Arch. Otolaryng., 98: 147. MARCIUEZ. A. (1967), in Cancer of the Head and Neck (International Workshop), edited by Conley J., Butterworths. Washington: 56. OGURA. J. H. and BILLER.H. F. (1969), Otolaryng. Clin. N. Amer.. 2: 641. SESSIONS. D. G. and OGURA. J. H. (1974), Workshop No. 7, Centennial Conference on Laryngeal Cancer (Toronto). edited by Alberti, P. W. and Bryce, D. P., AppletonCentury-Crofts, New York: 86.
CARCINOMA OF THE LARYNX: EXPERIENCE AT ST VINCENT’S HOSPITAL, SYDNEY F. W. DE WILDE AND B. F. SHERIDAN St Vincent’s Hospital, Sydney Two hundred and twenty-nine patients with carcinoma of the larynx were treated at St Vincent‘s Hospital, Sydney, during the years 1958 to 1973. A crude cumulative five-year survival of 76% in Stage I and 62% instage ii was obtained using radiotherapy as the first treatment in these stages, reserving surgery, consisting of iaryngectomy, for radiotherapy failures. A 63%, flve-year survival was achieved in Stage 111 by using Iaryngectomy as the first definitive treatment.
THE purpose of this paper is to report the results of treatment of 229 consecutive patients with laryngeal carcinoma treated at St Vincent’s Hopital during the years 1958 to 1973. In particular, it is to examine the role of surgery in Stage Ill of the disease. PATIENTS AND METHODS There were 229 patients in the series. Their ages ranged between 35 and 87 years, with a preponderance in the sixth and seventh decades. Themale: female ratiowas7:1.Therewere59cases in Stage I, 68 in Stage 11, 83 in Stage Ill and 19 in Stage IV. The staging used was the one advocated by Lederman (1952), namely:
Reprints: Dr F.W. de Wilde, Radiotherapy Department. St Vincent‘s Hospital, Darlinghunt. N.S.W. 2010.
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Stage I includes the very early cases where the tumour is limited to its tissue of origin, laryngeal mobility is unaffected, and there are no lymph-node metastases; Stage I1 includes the more advanced tumours where local spread has taken place, but the larynx is not fixed and lymph nodes are not involved; Stage Ill includes tumours accompanied by fixation of the larynx or homolateral mobile lymph-node metastases, or where extralaryngeal spread has occurred; Stage IV includes the very advanced cancers associated with bilateral or fixed lymphnode deposits or distant metastases. Only frankly inasive squamous cell carcinoma cases are included in this series. The treatment 619
LARYNGEAL CARCINOMA AT ST VINCENT'S HOSPITAL, SYDNEY
Policy consisted of megavoltage irradiation, namely external Cobalt 60, for Stages Iand II,surgery being reserved for radiation failures. The dose of irradiation used* consisted of a 6,000 rad tumour dose in six weeks in 30 fractions. For Stage Ill radiation was used during the earlier years of this survey, with surgery as salvage. The majority of patients, however, underwent laryngectomy as planned definitive treatment. For Stage IV, surgery by laryngectomy was used where such a procedure offered some hope of cure. Neck dissection was performed in all patients undergoing laryngectomy on the side of the larynx mainly affected and on both sides where bilateral nodes were clinically present. To analyse the results of treatment the fiveyear crude cumulative survival ratio was used. All deaths from whatever cause were deemed to be due to carcinoma. All cases were followed by us at regular intervals in our combined head and neck oncology clinic. The follow-up success rate was 93%. RESULTS The overall five-year survival of the 229 patients in Stages I to IV was 59%. In the individual stages, Stage I showed a 76% five-year survival, Stage II 62%, and all cases in Stage II, irrespective of treatment, 56%. In Stage IV two patients out of 19 survived three years, and only one longer than five years. Of the 59 patients in Stage I, 13 had failed radiotherapy and underwent salvage surgery by laryngectomy. Nine of these survived five years or more. Similarly, in Stage II. 21 out of 68 patients underwent laryngectomy for failed radiotherapy. Eleven ofthesesurvivedfiveyearsor more. Of the83 patients in Stage I l l , 24 were treated with irradiation initially and surgery as salvage. Of these 24 patients only seven survived five years, i.e. 29%. Of these seven, only one survived with an intact larynx. The remainder of the 83 patients, namely 59, were treated by total taryngectomy. The five-year survival in this category was 63Oh. Among the 229 cases of carcinoma of the larynx there were 32 cases of supraglottic carcinoma. The distribution according to staging wasonein Stage I, eight in Stage I I . 15 in Stage Ill,and eight in Stage IV. The one patient in Stage I died after two years. Of the eight patients in Stage 11, four survived five years. Of the 15 in Stage Ill, 10 had surgery as the initial treatment. Seven of these survived five years. Five patients had irradiation as their primary treatment. Of these five, two survived more than five years. Both had laryngectomy and block dissection of the neck after failed radiotherapy. Of the eight 620
DE WILDE AND SHERIDAN
patients in Stage IV only one survived five years. This patient had irradiation as the only treatment. DISCUSSION De Santo et alii (1977), reporting a large series of patients with glottic cancer treated at the Mayo Clinic, advocate a surgical approach in Stages I and II, uoting a radiation failure rate necessitating salvage surgery of 63% and 58% respectively. In a preceding article the same authors (1976) quoted a five-year survival for surgical salvage after failed radiotherapy of 58%. Our figures show a radiation failure rate of 13/59, i.e., 22% in Stage I, and 21/68, i.e., 31% in Stage II. I f we further consider that of the 13 patients undergoing salvage operation in Stage I, nine survived five years or more and in Stage II, 11 out of 21 we arrive at a combined total of 20 out of 34, i.e., 58%, five-year salvage after failed radiotherapy. If we bring this salvage rate of 58% in relation to a radiation failure rate of 22% and 31%, together with crude survival of 76% and 62% in Stage I and II, the conclusion is that radiotherapyshould be offered as the first definitive treatment in Stage I and I\glottic cancer. It has been said that all patients with carcinoma of the larynx Stage Ill should be offered radiotherapy as first line of treatment with the object of saving the voice if at all possible, Lederman (1961). However the analyses of our cases show that only seven out of 24, i.e. 29%, of patients so treated survived more than five years, and only one of these survived with an intact larynx. On the other hand, 63% survived of the 59 patients who had laryngectomy as the initial treatment in Stage Ill.InStages I and I I radiotherapy failures can usually be detected fairly readily, with the exception of those cases where the disease subsequently penetrates the preepiglottic space. In Stage Ill cases, however, there is often extensive persistent swelling and oedema of the glottis, and intact epithelium is no guarantee that the disease has been eradicated. Our experience leads us to believe that Stage Ill disease can rarely be cured by radiotherapy, and that furthermore, even with the most meticulous follow-up examinations, the realization that radiotherapy has failed comes usually at a time when the patient is beyond surgical cure. The obvious conclusion therefore is that laryngeal cancer Stage Ill should receivesurgery as the first definitive treatment. REFERENCES DE SANTO. L. W.,LILLIE. J . C. and DEVINE K. D. (196). Laryngoscope, 86: 649. DE SANTO. L. W., DEVINE,K. D. and LILLIE J . C . (1977), Surg. Clin. N. Amer., 57: 611. LEDERMAN. M. (1952), Brit. J. Radio/., 25: 462. LEDERMAN. M.(1961),Brit. med. J., 1: 1639.
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7. Radical neck dissection should be avoided in association with laryngectomy following radiotherapy. When necessary a planned fistula is the safest method of avoiding major postoperative complications. ACKNOWLEDGEMENTS Acknowledgement is made to Drs R.C. Kerr and J.P. Madigan, Radiotherapists of the Head and Neck Clinic of the Peter MacCallum Hospital, and to Dr Peter Freeman of the Alfred Hospital, whose patients are included in this study; also, to Dr P. Ilbery, Ex Medical Director, Peter MacCallum Hospital, who provided facilities and sessional time for the study. REFERENCES BALLANTYNE. A. J. (1974), Neoplasia of Head and Neck, University of Texas M. D. Anderson Hospital and Tumor Institute. Year Book Medical Publishers I n c . (Chicago): 89.
MILLAR Clinical Staging System for Carcinoma of the Larynx in T.N.M. (1972), Classification of Malignant Tumours of Breast, Larynx, Stomach, Cervix Uteri, Corpus Uteri, U.I.C.C. Geneva, Switzerland: 13 DE Santo. L. W. (1974). Workshop No. 2. Centennial Conference on Laryngeal Cancer (Toronto), edited by Alberti, P. W. a n d B r y c e , D . P., A p p l e t o n - C e n t u r y - C r o f t , New York: 146. FLETCHER. G. H., JESSE. R. H., LINDBERG. R. D. and KOONS. C. R. (1970), Amer. J. Roentgenol, 58: 19. KENNEDY. J. T. and KRAUSE. C. J. (1974) Arch. Otolaryng, 99: 274. KERR. R . C., MADIGAN. J. P.and MILLAR. H.S. (1970),AUST. N.Z.J. SURG.. 40: 19. LATWROP. F. D. (1968). Ann. Otol. (St Louis), 77: 493. LEDERMAN. M. (1961), Brit. med. J. 1: 1639. LOWRY. L. D., MARKS. J. E. and POWELL. W. J. (1973), Arch. Otolaryng., 98: 147. MARCIUEZ. A. (1967), in Cancer of the Head and Neck (International Workshop), edited by Conley J., Butterworths. Washington: 56. OGURA. J. H. and BILLER.H. F. (1969), Otolaryng. Clin. N. Amer.. 2: 641. SESSIONS. D. G. and OGURA. J. H. (1974), Workshop No. 7, Centennial Conference on Laryngeal Cancer (Toronto). edited by Alberti, P. W. and Bryce, D. P., AppletonCentury-Crofts, New York: 86.
CARCINOMA OF THE LARYNX: EXPERIENCE AT ST VINCENT’S HOSPITAL, SYDNEY F. W. DE WILDE AND B. F. SHERIDAN St Vincent’s Hospital, Sydney Two hundred and twenty-nine patients with carcinoma of the larynx were treated at St Vincent‘s Hospital, Sydney, during the years 1958 to 1973. A crude cumulative five-year survival of 76% in Stage I and 62% instage ii was obtained using radiotherapy as the first treatment in these stages, reserving surgery, consisting of iaryngectomy, for radiotherapy failures. A 63%, flve-year survival was achieved in Stage 111 by using Iaryngectomy as the first definitive treatment.
THE purpose of this paper is to report the results of treatment of 229 consecutive patients with laryngeal carcinoma treated at St Vincent’s Hopital during the years 1958 to 1973. In particular, it is to examine the role of surgery in Stage Ill of the disease. PATIENTS AND METHODS There were 229 patients in the series. Their ages ranged between 35 and 87 years, with a preponderance in the sixth and seventh decades. Themale: female ratiowas7:1.Therewere59cases in Stage I, 68 in Stage 11, 83 in Stage Ill and 19 in Stage IV. The staging used was the one advocated by Lederman (1952), namely:
Reprints: Dr F.W. de Wilde, Radiotherapy Department. St Vincent‘s Hospital, Darlinghunt. N.S.W. 2010.
AUST. N.Z. J. SURG..VOL. 48
- No. 6, DECEMBER, 1978
Stage I includes the very early cases where the tumour is limited to its tissue of origin, laryngeal mobility is unaffected, and there are no lymph-node metastases; Stage I1 includes the more advanced tumours where local spread has taken place, but the larynx is not fixed and lymph nodes are not involved; Stage Ill includes tumours accompanied by fixation of the larynx or homolateral mobile lymph-node metastases, or where extralaryngeal spread has occurred; Stage IV includes the very advanced cancers associated with bilateral or fixed lymphnode deposits or distant metastases. Only frankly inasive squamous cell carcinoma cases are included in this series. The treatment 619
LARYNGEAL CARCINOMA AT ST VINCENT'S HOSPITAL, SYDNEY
Policy consisted of megavoltage irradiation, namely external Cobalt 60, for Stages Iand II,surgery being reserved for radiation failures. The dose of irradiation used* consisted of a 6,000 rad tumour dose in six weeks in 30 fractions. For Stage Ill radiation was used during the earlier years of this survey, with surgery as salvage. The majority of patients, however, underwent laryngectomy as planned definitive treatment. For Stage IV, surgery by laryngectomy was used where such a procedure offered some hope of cure. Neck dissection was performed in all patients undergoing laryngectomy on the side of the larynx mainly affected and on both sides where bilateral nodes were clinically present. To analyse the results of treatment the fiveyear crude cumulative survival ratio was used. All deaths from whatever cause were deemed to be due to carcinoma. All cases were followed by us at regular intervals in our combined head and neck oncology clinic. The follow-up success rate was 93%. RESULTS The overall five-year survival of the 229 patients in Stages I to IV was 59%. In the individual stages, Stage I showed a 76% five-year survival, Stage II 62%, and all cases in Stage II, irrespective of treatment, 56%. In Stage IV two patients out of 19 survived three years, and only one longer than five years. Of the 59 patients in Stage I, 13 had failed radiotherapy and underwent salvage surgery by laryngectomy. Nine of these survived five years or more. Similarly, in Stage II. 21 out of 68 patients underwent laryngectomy for failed radiotherapy. Eleven ofthesesurvivedfiveyearsor more. Of the83 patients in Stage I l l , 24 were treated with irradiation initially and surgery as salvage. Of these 24 patients only seven survived five years, i.e. 29%. Of these seven, only one survived with an intact larynx. The remainder of the 83 patients, namely 59, were treated by total taryngectomy. The five-year survival in this category was 63Oh. Among the 229 cases of carcinoma of the larynx there were 32 cases of supraglottic carcinoma. The distribution according to staging wasonein Stage I, eight in Stage I I . 15 in Stage Ill,and eight in Stage IV. The one patient in Stage I died after two years. Of the eight patients in Stage 11, four survived five years. Of the 15 in Stage Ill, 10 had surgery as the initial treatment. Seven of these survived five years. Five patients had irradiation as their primary treatment. Of these five, two survived more than five years. Both had laryngectomy and block dissection of the neck after failed radiotherapy. Of the eight 620
DE WILDE AND SHERIDAN
patients in Stage IV only one survived five years. This patient had irradiation as the only treatment. DISCUSSION De Santo et alii (1977), reporting a large series of patients with glottic cancer treated at the Mayo Clinic, advocate a surgical approach in Stages I and II, uoting a radiation failure rate necessitating salvage surgery of 63% and 58% respectively. In a preceding article the same authors (1976) quoted a five-year survival for surgical salvage after failed radiotherapy of 58%. Our figures show a radiation failure rate of 13/59, i.e., 22% in Stage I, and 21/68, i.e., 31% in Stage II. I f we further consider that of the 13 patients undergoing salvage operation in Stage I, nine survived five years or more and in Stage II, 11 out of 21 we arrive at a combined total of 20 out of 34, i.e., 58%, five-year salvage after failed radiotherapy. If we bring this salvage rate of 58% in relation to a radiation failure rate of 22% and 31%, together with crude survival of 76% and 62% in Stage I and II, the conclusion is that radiotherapyshould be offered as the first definitive treatment in Stage I and I\glottic cancer. It has been said that all patients with carcinoma of the larynx Stage Ill should be offered radiotherapy as first line of treatment with the object of saving the voice if at all possible, Lederman (1961). However the analyses of our cases show that only seven out of 24, i.e. 29%, of patients so treated survived more than five years, and only one of these survived with an intact larynx. On the other hand, 63% survived of the 59 patients who had laryngectomy as the initial treatment in Stage Ill.InStages I and I I radiotherapy failures can usually be detected fairly readily, with the exception of those cases where the disease subsequently penetrates the preepiglottic space. In Stage Ill cases, however, there is often extensive persistent swelling and oedema of the glottis, and intact epithelium is no guarantee that the disease has been eradicated. Our experience leads us to believe that Stage Ill disease can rarely be cured by radiotherapy, and that furthermore, even with the most meticulous follow-up examinations, the realization that radiotherapy has failed comes usually at a time when the patient is beyond surgical cure. The obvious conclusion therefore is that laryngeal cancer Stage Ill should receivesurgery as the first definitive treatment. REFERENCES DE SANTO. L. W.,LILLIE. J . C. and DEVINE K. D. (196). Laryngoscope, 86: 649. DE SANTO. L. W., DEVINE,K. D. and LILLIE J . C . (1977), Surg. Clin. N. Amer., 57: 611. LEDERMAN. M. (1952), Brit. J. Radio/., 25: 462. LEDERMAN. M.(1961),Brit. med. J., 1: 1639.
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