Hemilaryngectomy for salvage of radiation therapy failures ROBERT E. ROTHFIELD, MD, JONAS T. JOHNSON, MD, EUGENE N. MYERS, MD, and ROBIN L. WAGNER, as, Pittsburgh, Pennsylvania
Radiation therapy has been the treatment most frequently used for early vocal cord cancer with surgery usually In the form of total laryngectomy held In reserve as a salvage option. We report our experience In selected patients who, having failed radiation therapy for their early vocal cord cancers, underwent frontolateral hemilaryngectomy as attempted salvage surgery. Between 1977 and 1986, fourteen patients at the Unl· verslty of Pittsburgh Eye and Ear Hospital underwent hemilaryngectomy for salvage of their stage I vocal cord squamous cell carcinoma after full-course radiation therapy had been unsuccessful. Over this same time period, 77 patients underwent total laryngectomy for salvage of radiation therapy failure. Three patients failed hemilaryngectomy, two of whom were Ultimately salvaged with total laryngectomy. Thus a 79% salvage rate was achieved with hemilaryngectomy with an average followup of 90 months. The overall cure rate was 93% (13 of 14) with voice preservation In 86% (12 of 14). Decannulatlon, postoperative Infection, and Initiation of oral Intake were not Influenced by age. Such problems occurred more often In patients undergoing radiation therapy compared to those undergoing hemilaryngectomy without previous radiation therapy. These results Indicate that hemilaryngectomy may be used for the salvage of radiation therapy failures of stage I vocal cord carcinoma with good success and without undue morbidity. (OTOlARYNGOL HEAD NECK SURG 1990;103:792,)
A
Ithough a variety of treatment modalities exist for stage I vocal cord cancer. radiation therapy remains the most common treatment option. Surgery is often reserved as a salvage option for patients in whom cancer recurs after radiation therapy. Unfortunately. total laryngectomy is often required. We report our experience in selected patients with recurrent cancer after radiation therapy for stage I vocal cord cancer. in whom frontolateral hemilaryngectomy was performed as attempted salvage surgery.
METHODS AND MATERIALS The medical charts of patients who had undergone hemilaryngectomy at the University of Pittsburgh Eye
From the Department of Otolaryngology. University of Pittsburgh School of Medicine. Eye and Ear Hospital of Pittsburgh, Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, New Orleans, La" Sept. 24-28, 1989, Received for publication Sept. 24, 1989; revision received Aug. 30, 1990; accepted Aug. 31, 1990. Reprint requests: Robert E, Rothfield, MD. Department of Otolaryngology, University of Pittsburgh School of Medicine, Eye and Ear Hospital of Pittsburgh, Suite 500,203 Lothrop St., Pittsburgh. PA 15213.
23/1/25133
and Ear Hospital for stage I squamous cell carcinoma of the vocal cord. after radiation therapy failed. between March 1977 and August 1986 were reviewed. Disease was staged retrospectively by means of criteria set forth in 1980 by the American Joint Committee on Cancer. and it was based on clinical descriptions at the time of laryngoscopy. at operation. and on review of pathologic specimens. I The standard frontolateral hemilaryngectomy technique was used in each patient. The anterior commissure was included in all specimens. whereas the extent of the posterior margin was dependent on the location of the tumor. Although the vocal process was frequently resected with the standard technique. the entire arytenoid was included with the specimen only in the two cases of extended frontolateral hemilaryngectomy. The cricothyroid membrane was the inferior margin. the aryepiglottic fold was the superior margin. and the thyroid cartilage was the lateral margin in every patient. The external thyroid perichondrium was preserved and used for closure. No attempt was made to reconstruct the resected true vocal cord. The anterior commissure was identified as involved or not involved. Voice quality was based subjectively on the ability to converse intelligibly. Infection was determined by gross salivary fistula. wound breakdown.
792
Downloaded from oto.sagepub.com at CORNELL UNIV on June 30, 2016
Volume 103 Number 5 Part 1 November 1990
Hemilaryngectomy for salvage of radiation therapy failures 793
and chest x-ray film demonstrating aspiration pneumonia. RESULTS
Fourteen patients were identified who underwent hemilaryngectomy for failure of radiation therapy during the study period. Over this same time period. 77 patients underwent total laryngectomy for salvage of radiation therapy failure. Followup for the patients undergoing hemilaryngectomy ranged from 37 to ISS months with an average of 90 months. All patients were men. The average age of the study patients was 65 years, with a range of 56 to 83 years. Average radiation dosage was 6065 rads, with a range of 5000 to 7000 rads. The average interval between radiation therapy and recurrent carcinoma was 23 months. with a range of 8 to 96 months. All patients undergoing hemilaryngectomy had stage I (T I or T 2) cancer. Twelve patients underwent standard frontolateral hemilaryngectomy and two underwent extended frontolateral hemilaryngectomy with resection of the ipsilateral arytenoid cartilage. Conservation surgery was unsuccessful in 3 of 14 (21%) patients. One patient died of lung metastases 32 months after surgery with no evidence of local recurrence or persistent disease. A second patient had undergone an extended frontolateral hemilaryngectomy requiring keel placement at the time of the initial surgery. Although results of pathologic examination showed clear margins, local recurrence at 18 months after surgery required salvage with a total laryngectomy. A third patient failed at the anterior commissure at 18 months after surgery and also was salvaged with a total laryngectomy. This patient was noted before hemilaryngectomy to have diminished vocal cord mobility. Two patients apparently cured of laryngeal cancer died of intercurrent disease; one patient at 69 months died of a myocardial infarction and one at 36 months died of colon carcinoma. The anterior commissure was involved in 7 of 14 (50%) of the study patients. Both patients with local recurrence after salvage surgery had anterior commissure involvement. Voice preservation was ultimately achieved in 12 of 14 (86%) patients (the two failures were the two patients salvaged by total laryngectomy); II of 12 (92%) patients were considered to have good voices. The single patient with a poor speech result had a serviceable but whisper-like voice. Patients were decannu1ated on average 13 days after surgery, with a range of 6 to 26 days. This excludes a single patient in whom keel placement at the time of surgery precluded decannulation at the time of his first
hospital discharge. Three patients required a second tracheotomy: (1) the patient in whom a keel was placed initially who ultimately underwent salvage total laryngectomy for persistent disease; (2) a patient with aspiration pneumonia; and (3) a patient with a laryngocutaneous fistula. The second and third patients were decannulated within 2 months of their initial surgery. The nasogastric tube was generally removed the day after decannulation, on average 14 days after surgery. with a range of 8 to 31 days. In two patients a fistula developed postoperatively. One patient, aged 56 years. had a recurrence of the tumor 12 months after completion of 6600 rads for a T2 vocal cord cancer. The other, aged 68 years, had a recurrence of the tumor 36 months after completion of 5940 rads for a T I vocal cord cancer. Aspiration pneumonia developed in three patients. Two of these patients had undergone standard frontolateral hemilaryngectomy. The third patient had undergone an extended frontolateral hemilaryngectomy with resection of the arytenoid cartilage. Eleven of the 14 patients had stage T, tumors. In this group of patients, two had aspiration pneumonia, one had a fistula. one had I local recurrence. and one died of metastatic disease. Of the three patients with T 2 tumors. one had a fistula and the other had a recurrence of local disease.
COMMENTS Conservation surgery for the salvage of radiation failures in early vocal cord cancer is not a new concept. Som' described the salvage of radiation failures by means of laryngofissure in the 1950s, and Biller 2 et a1. and Nichols et al..\reported on the use of hemilaryngectomy as a salvage option in the 1970s. Biller 2 et al. set forth a number of criteria that they thought would preclude salvage by hemilaryngectomy. These included: (I) subglottic extension greater than 5 mm; (2) cartilage invasion; (3) contralateral vocal cord involvement; (4) arytenoid (except for vocal process) in. volvement; (5) cord fixation; and (6) recurrence that did not correlate with the primary lesion previously treated with radiotherapy. Subsequently many authors have reported on their successes with conservation surgery for the salvage of radiation failures in early vocal cord cancer and have generally followed these precepts, 2 with varying modification. as set forth by Biller et al. and others.!" A number of authors have also reported an increased incidence of infectious and healing complications in patients undergoing hemilaryngectomy for salvage of radiation failures.r-" The experience in the Department of Otolaryngology at the University of Pittsburgh demonstrates that herni-
Downloaded from oto.sagepub.com at CORNELL UNIV on June 30, 2016
7M
OtolaryngologyHead ancl Neck Surgery
ROTHRELD at 01.
laryngectomy is an efficacious and safe salvage procedure for selected patients in whom radiation therapy for stage I vocal cord cancer has failed. In an uncontrolled experience with 91 patients treated for recurrence of cancer after high-dose radiation therapy, 14 (16%) were deemed candidates for conservation surgery. By use of hemilaryngectomy alone, we salvaged 79% (11 of 14) of these selected patients. Two patients with recurrent local cancer were both salvaged with total laryngectomy. Only one patient died of distant metastasis but without local or regional recurrence. Therefore our overall cure rate was 93% with voice preservation in 86% (12 of 14). Unfortunately, because of the nature of the referrals to tertiary care centers such as our own, it is not possible to estimate the number of patients treated for stage 1 disease with radiation therapy. One of the two patients with local recurrence had extension of tumor preoperatively, which involved more than one third of the opposite vocal cord. The second patient had preoperative tumor involving the anterior commissure associated with significantly diminished vocal cord mobility. These two patients demonstrate a basic premise of Biller's original idea; namely, that hemilaryngectomy salvage of radiation therapy failures is most applicable to stage I cancer. It is an interesting observation, although not one with statistical significance, that both patients with local recurrence had anterior commissure involvement. This finding is in contrast to our results in a recent study in which anterior commissure involvement in T 1 carcinoma of the vocal cord did not affect outcome. S The high percentage of patients with anterior commissure involvement (50%) suggests but does not prove the importance of anterior commissure involvement as a potential determinant in the initial treatment of patients with early vocal cord cancer, that is, radiation therapy vs. conservation surgery. Wound healing in our study population was only minimally delayed. The average time of decannulation in our patient population was 14 days. This is slightly longer than the 12-day average of patients undergoing hemilaryngectomy with no previous radiation therapy. Similarly, removal of the nasogastric tube occurred on an average of 13 days in our study population versus 11 days in nonradiated hemilaryngectomy patients. Three patients required retracheotomy. One patient required repeat tracheotomy for aspiration pneumonia and was ultimately decannulated. A second patient had chondritis 3 weeks after surgery and required 10-
cal debridement and reconstruction of the trachea. He too was eventually decannulated and maintains a good voice. The third patient underwent salvage total laryngectomy for persistent local disease. Although there were only three patients with more advanced lesions (T2), they had a higher rate of complications. Of the three patients with T2 lesions, one did well with no complications, one had a local recurrence, and one had a fistula. Comparatively, among 11 patients with T, lesions, there were two with aspiration pneumonia, one with a fistula, one local failure, and one distant failure. Patient age and radiotherapeutic dosage did not affect patient healing or survival in our study population. CONCLUSION
Hemilaryngectomy for radiation failures of stage I vocal cord cancer is an effective salvage procedure in selected patients. It offers voice preservation and good cure rates. Although healing and complication rates are slightly increased as compared to patients undergoing hemilaryngectomy with no previous irradiation, they are not excessive. It is evident that those patients who would best be served by this procedure are those patients with stage I tumors. In these patients cure rates are not compromised, voice is preserved, and totallaryngectomy remains a viable salvage option. REFERENCES
I. Som ML. Limited surgery after failure of radiotherapy and the treatment of carcinoma of the larynx. Ann Otol Rhinol Laryngol 1951;60:670-95. 2. Biller HF. Barnhill FR, Ogura JH. et al. Hemilaryngectomy following radiation failure for carcinoma of the vocal cords. Laryngoscope 1970;80:249-53. 3. Nichols RD, Stine PH, Greenwald KJ. Partial laryngectomy after radiation failure. Laryngoscope 1980;90:571-5. 4. Sorensen H. Hansen HS. Thomsen KA. Partial laryngectomy following irradiation. Laryngoscope 1980;90:1344-9. 5. Strauss M. Hemilaryngectomy rescue surgery for radiation failure in early glottic carcinoma. Laryngoscope 1988;98:317-20. 6. Bums H, Bryce BP, Van Nostrand P. Conservation surgery in laryngeal cancer and its role following radiotherapy: a histopathologic and clinical study of 32 cases. Arch Otolaryngol 1979;105:234-9. 7. Norris CM. Peale AR. Partial laryngectomy for radiation failure. Arch Otolaryngol 1966;84:112-16. 8. Rothfield RE. Johnson JT, Myers EN, et al. The role of hemilaryngectomy in the management of T , vocal cord cancer. Arch Otolaryngol Head Neck Surg 1989;115:677-80. 9. American Joint Committee tor Cancer Staging and End Results Reporting. Staging cancer of head and neck sites and of melanoma. Chicago: American Joint Committee on Cancer. 1980.
Downloaded from oto.sagepub.com at CORNELL UNIV on June 30, 2016
Radiation therapy has been the treatment most frequently used for early vocal cord cancer with surgery usually In the form of total laryngectomy held In reserve as a salvage option. We report our experience In selected patients who, having failed radiation therapy for their early vocal cord cancers, underwent frontolateral hemilaryngectomy as attempted salvage surgery. Between 1977 and 1986, fourteen patients at the Unl· verslty of Pittsburgh Eye and Ear Hospital underwent hemilaryngectomy for salvage of their stage I vocal cord squamous cell carcinoma after full-course radiation therapy had been unsuccessful. Over this same time period, 77 patients underwent total laryngectomy for salvage of radiation therapy failure. Three patients failed hemilaryngectomy, two of whom were Ultimately salvaged with total laryngectomy. Thus a 79% salvage rate was achieved with hemilaryngectomy with an average followup of 90 months. The overall cure rate was 93% (13 of 14) with voice preservation In 86% (12 of 14). Decannulatlon, postoperative Infection, and Initiation of oral Intake were not Influenced by age. Such problems occurred more often In patients undergoing radiation therapy compared to those undergoing hemilaryngectomy without previous radiation therapy. These results Indicate that hemilaryngectomy may be used for the salvage of radiation therapy failures of stage I vocal cord carcinoma with good success and without undue morbidity. (OTOlARYNGOL HEAD NECK SURG 1990;103:792,)
A
Ithough a variety of treatment modalities exist for stage I vocal cord cancer. radiation therapy remains the most common treatment option. Surgery is often reserved as a salvage option for patients in whom cancer recurs after radiation therapy. Unfortunately. total laryngectomy is often required. We report our experience in selected patients with recurrent cancer after radiation therapy for stage I vocal cord cancer. in whom frontolateral hemilaryngectomy was performed as attempted salvage surgery.
METHODS AND MATERIALS The medical charts of patients who had undergone hemilaryngectomy at the University of Pittsburgh Eye
From the Department of Otolaryngology. University of Pittsburgh School of Medicine. Eye and Ear Hospital of Pittsburgh, Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, New Orleans, La" Sept. 24-28, 1989, Received for publication Sept. 24, 1989; revision received Aug. 30, 1990; accepted Aug. 31, 1990. Reprint requests: Robert E, Rothfield, MD. Department of Otolaryngology, University of Pittsburgh School of Medicine, Eye and Ear Hospital of Pittsburgh, Suite 500,203 Lothrop St., Pittsburgh. PA 15213.
23/1/25133
and Ear Hospital for stage I squamous cell carcinoma of the vocal cord. after radiation therapy failed. between March 1977 and August 1986 were reviewed. Disease was staged retrospectively by means of criteria set forth in 1980 by the American Joint Committee on Cancer. and it was based on clinical descriptions at the time of laryngoscopy. at operation. and on review of pathologic specimens. I The standard frontolateral hemilaryngectomy technique was used in each patient. The anterior commissure was included in all specimens. whereas the extent of the posterior margin was dependent on the location of the tumor. Although the vocal process was frequently resected with the standard technique. the entire arytenoid was included with the specimen only in the two cases of extended frontolateral hemilaryngectomy. The cricothyroid membrane was the inferior margin. the aryepiglottic fold was the superior margin. and the thyroid cartilage was the lateral margin in every patient. The external thyroid perichondrium was preserved and used for closure. No attempt was made to reconstruct the resected true vocal cord. The anterior commissure was identified as involved or not involved. Voice quality was based subjectively on the ability to converse intelligibly. Infection was determined by gross salivary fistula. wound breakdown.
792
Downloaded from oto.sagepub.com at CORNELL UNIV on June 30, 2016
Volume 103 Number 5 Part 1 November 1990
Hemilaryngectomy for salvage of radiation therapy failures 793
and chest x-ray film demonstrating aspiration pneumonia. RESULTS
Fourteen patients were identified who underwent hemilaryngectomy for failure of radiation therapy during the study period. Over this same time period. 77 patients underwent total laryngectomy for salvage of radiation therapy failure. Followup for the patients undergoing hemilaryngectomy ranged from 37 to ISS months with an average of 90 months. All patients were men. The average age of the study patients was 65 years, with a range of 56 to 83 years. Average radiation dosage was 6065 rads, with a range of 5000 to 7000 rads. The average interval between radiation therapy and recurrent carcinoma was 23 months. with a range of 8 to 96 months. All patients undergoing hemilaryngectomy had stage I (T I or T 2) cancer. Twelve patients underwent standard frontolateral hemilaryngectomy and two underwent extended frontolateral hemilaryngectomy with resection of the ipsilateral arytenoid cartilage. Conservation surgery was unsuccessful in 3 of 14 (21%) patients. One patient died of lung metastases 32 months after surgery with no evidence of local recurrence or persistent disease. A second patient had undergone an extended frontolateral hemilaryngectomy requiring keel placement at the time of the initial surgery. Although results of pathologic examination showed clear margins, local recurrence at 18 months after surgery required salvage with a total laryngectomy. A third patient failed at the anterior commissure at 18 months after surgery and also was salvaged with a total laryngectomy. This patient was noted before hemilaryngectomy to have diminished vocal cord mobility. Two patients apparently cured of laryngeal cancer died of intercurrent disease; one patient at 69 months died of a myocardial infarction and one at 36 months died of colon carcinoma. The anterior commissure was involved in 7 of 14 (50%) of the study patients. Both patients with local recurrence after salvage surgery had anterior commissure involvement. Voice preservation was ultimately achieved in 12 of 14 (86%) patients (the two failures were the two patients salvaged by total laryngectomy); II of 12 (92%) patients were considered to have good voices. The single patient with a poor speech result had a serviceable but whisper-like voice. Patients were decannu1ated on average 13 days after surgery, with a range of 6 to 26 days. This excludes a single patient in whom keel placement at the time of surgery precluded decannulation at the time of his first
hospital discharge. Three patients required a second tracheotomy: (1) the patient in whom a keel was placed initially who ultimately underwent salvage total laryngectomy for persistent disease; (2) a patient with aspiration pneumonia; and (3) a patient with a laryngocutaneous fistula. The second and third patients were decannulated within 2 months of their initial surgery. The nasogastric tube was generally removed the day after decannulation, on average 14 days after surgery. with a range of 8 to 31 days. In two patients a fistula developed postoperatively. One patient, aged 56 years. had a recurrence of the tumor 12 months after completion of 6600 rads for a T2 vocal cord cancer. The other, aged 68 years, had a recurrence of the tumor 36 months after completion of 5940 rads for a T I vocal cord cancer. Aspiration pneumonia developed in three patients. Two of these patients had undergone standard frontolateral hemilaryngectomy. The third patient had undergone an extended frontolateral hemilaryngectomy with resection of the arytenoid cartilage. Eleven of the 14 patients had stage T, tumors. In this group of patients, two had aspiration pneumonia, one had a fistula. one had I local recurrence. and one died of metastatic disease. Of the three patients with T 2 tumors. one had a fistula and the other had a recurrence of local disease.
COMMENTS Conservation surgery for the salvage of radiation failures in early vocal cord cancer is not a new concept. Som' described the salvage of radiation failures by means of laryngofissure in the 1950s, and Biller 2 et a1. and Nichols et al..\reported on the use of hemilaryngectomy as a salvage option in the 1970s. Biller 2 et al. set forth a number of criteria that they thought would preclude salvage by hemilaryngectomy. These included: (I) subglottic extension greater than 5 mm; (2) cartilage invasion; (3) contralateral vocal cord involvement; (4) arytenoid (except for vocal process) in. volvement; (5) cord fixation; and (6) recurrence that did not correlate with the primary lesion previously treated with radiotherapy. Subsequently many authors have reported on their successes with conservation surgery for the salvage of radiation failures in early vocal cord cancer and have generally followed these precepts, 2 with varying modification. as set forth by Biller et al. and others.!" A number of authors have also reported an increased incidence of infectious and healing complications in patients undergoing hemilaryngectomy for salvage of radiation failures.r-" The experience in the Department of Otolaryngology at the University of Pittsburgh demonstrates that herni-
Downloaded from oto.sagepub.com at CORNELL UNIV on June 30, 2016
7M
OtolaryngologyHead ancl Neck Surgery
ROTHRELD at 01.
laryngectomy is an efficacious and safe salvage procedure for selected patients in whom radiation therapy for stage I vocal cord cancer has failed. In an uncontrolled experience with 91 patients treated for recurrence of cancer after high-dose radiation therapy, 14 (16%) were deemed candidates for conservation surgery. By use of hemilaryngectomy alone, we salvaged 79% (11 of 14) of these selected patients. Two patients with recurrent local cancer were both salvaged with total laryngectomy. Only one patient died of distant metastasis but without local or regional recurrence. Therefore our overall cure rate was 93% with voice preservation in 86% (12 of 14). Unfortunately, because of the nature of the referrals to tertiary care centers such as our own, it is not possible to estimate the number of patients treated for stage 1 disease with radiation therapy. One of the two patients with local recurrence had extension of tumor preoperatively, which involved more than one third of the opposite vocal cord. The second patient had preoperative tumor involving the anterior commissure associated with significantly diminished vocal cord mobility. These two patients demonstrate a basic premise of Biller's original idea; namely, that hemilaryngectomy salvage of radiation therapy failures is most applicable to stage I cancer. It is an interesting observation, although not one with statistical significance, that both patients with local recurrence had anterior commissure involvement. This finding is in contrast to our results in a recent study in which anterior commissure involvement in T 1 carcinoma of the vocal cord did not affect outcome. S The high percentage of patients with anterior commissure involvement (50%) suggests but does not prove the importance of anterior commissure involvement as a potential determinant in the initial treatment of patients with early vocal cord cancer, that is, radiation therapy vs. conservation surgery. Wound healing in our study population was only minimally delayed. The average time of decannulation in our patient population was 14 days. This is slightly longer than the 12-day average of patients undergoing hemilaryngectomy with no previous radiation therapy. Similarly, removal of the nasogastric tube occurred on an average of 13 days in our study population versus 11 days in nonradiated hemilaryngectomy patients. Three patients required retracheotomy. One patient required repeat tracheotomy for aspiration pneumonia and was ultimately decannulated. A second patient had chondritis 3 weeks after surgery and required 10-
cal debridement and reconstruction of the trachea. He too was eventually decannulated and maintains a good voice. The third patient underwent salvage total laryngectomy for persistent local disease. Although there were only three patients with more advanced lesions (T2), they had a higher rate of complications. Of the three patients with T2 lesions, one did well with no complications, one had a local recurrence, and one had a fistula. Comparatively, among 11 patients with T, lesions, there were two with aspiration pneumonia, one with a fistula, one local failure, and one distant failure. Patient age and radiotherapeutic dosage did not affect patient healing or survival in our study population. CONCLUSION
Hemilaryngectomy for radiation failures of stage I vocal cord cancer is an effective salvage procedure in selected patients. It offers voice preservation and good cure rates. Although healing and complication rates are slightly increased as compared to patients undergoing hemilaryngectomy with no previous irradiation, they are not excessive. It is evident that those patients who would best be served by this procedure are those patients with stage I tumors. In these patients cure rates are not compromised, voice is preserved, and totallaryngectomy remains a viable salvage option. REFERENCES
I. Som ML. Limited surgery after failure of radiotherapy and the treatment of carcinoma of the larynx. Ann Otol Rhinol Laryngol 1951;60:670-95. 2. Biller HF. Barnhill FR, Ogura JH. et al. Hemilaryngectomy following radiation failure for carcinoma of the vocal cords. Laryngoscope 1970;80:249-53. 3. Nichols RD, Stine PH, Greenwald KJ. Partial laryngectomy after radiation failure. Laryngoscope 1980;90:571-5. 4. Sorensen H. Hansen HS. Thomsen KA. Partial laryngectomy following irradiation. Laryngoscope 1980;90:1344-9. 5. Strauss M. Hemilaryngectomy rescue surgery for radiation failure in early glottic carcinoma. Laryngoscope 1988;98:317-20. 6. Bums H, Bryce BP, Van Nostrand P. Conservation surgery in laryngeal cancer and its role following radiotherapy: a histopathologic and clinical study of 32 cases. Arch Otolaryngol 1979;105:234-9. 7. Norris CM. Peale AR. Partial laryngectomy for radiation failure. Arch Otolaryngol 1966;84:112-16. 8. Rothfield RE. Johnson JT, Myers EN, et al. The role of hemilaryngectomy in the management of T , vocal cord cancer. Arch Otolaryngol Head Neck Surg 1989;115:677-80. 9. American Joint Committee tor Cancer Staging and End Results Reporting. Staging cancer of head and neck sites and of melanoma. Chicago: American Joint Committee on Cancer. 1980.
Downloaded from oto.sagepub.com at CORNELL UNIV on June 30, 2016
