Vocal Cord Fixation in Laryngeal Carcinoma Thomas P. Belson, MD; James A.

Duncavage, MD;

\s=b\ The 1962 TNM classification (T, tumor and extent; N, regional lymph node metastasis, M, distant metastasis) did not emphasize vocal cord fixation in staging. In the revision of 1972, lesions with partial fixation were classified T2, stage II, and those causing fixation were T3, stage III. The therapeutic results in 39 patients with fixed cords revealed a determinate five\x=req-\ year survival of 41% and an absolute of 23%. These statistics support the validity of the 1972 classification. Careful evaluation of vocal cord mobility prior to selection of therapy is stressed.

(Arch Otolaryngol 102:281-283, 1976)

there has the on im¬ been paired vocal cord mobility in carcinoma. In 1953, Meurman1 stated "not too great significance should be attached to the degree of mobility of the vocal cord in intrinsic cancer." However, in more recent reports, the importance of impaired vocal cord mobility or fixation, or both, have

past decade, During increasing emphasis laryngeal

Accepted for publication Jan 13, 1976. From the Department of Otolaryngology, Medical College of Wisconsin, and the sections of otolaryngology, Veterans Administration Center and the Milwaukee County Medical Complex,

Milwaukee. Read before the Tri-State Otolaryngology Seminar, Wisconsin Otolaryngology Society, Ca-

ble, Wis, Aug 23, 1975. Reprint requests to Moreland Medical Center, 1111 Delafield, Waukesha, WI 53186 (Dr

Belson).

Robert J.

Toohill, MD; Roger H. Lehman, MD

been stressed. In the 1962 classifica¬ tion proposed by the American Joint Committee for Cancer Staging and End Results Reporting,- a tumor of both vocal cords with normal mobility, and a tumor of one or both cords with loss of mobility, were both classified as T2, stage II, lesions. In 1969, Holinger et al·' suggested a separation of these two groups because of the gratifying results obtained with ra¬ diotherapy and conservation surgery in vocal cord lesions with normal mobility. In the classification pro¬ posed by the American Joint Commit¬ tee in 1972,4 a tumor involving both cords with normal mobility was reclassified into a new grouping, ie, T,B. Tumors extending from the cords, either subglottically or supraglottically, with normal or impaired mobil¬ ity, were classified as T2, stage II, lesions. However, tumors that pro¬ duced vocal cord fixation were reclassified as T3, stage III, lesions. From the standpoint of prognosis, such clas¬ sification appears warranted since the presence of cord fixation indicates deeper penetration of the tumor. Kirchner3 studied 100 laryngés by serial section, and of the 11 glottic carcinomas that had exhibited vocal cord fixation, eight showed deep inva¬ sion of the thyroarytenoid muscle approaching the thyroid cartilage. In the remaining three cases, the tumor had invaded the thyroid cartilage. He

also studied six glottic lesions with partial fixation; four of these showed a lesser degree of thyroarytenoid

muscle invasion than cases with total fixation. In one case, the limited mobility was due to cancer surround¬ ing the arytenoid, and in another, it was due to infraglottic extension. Based on a serial section study, Kirchner and Som" believe that the cause of fixation is due to one or a combination of four patterns of

spread: 1. Replacement of the thyroarytenoideus muscle by tumor. 2. Invasion of cancer along the superior surface of the vocal cord with extension to the thyroid cartilage. 3. Subglottic extension posteriorly fixing the vocal cord to the underlying cricoid plate.

4. A combination of radiotherapy fibrosis and residual tumor. Norris et al7 also studied 100 carcinomatous laryngés by serial coronal section and classified them by assigning a series of values based on the extent of the tumor invasion perpendicular to the mucosal surface. His pathologic clas¬ sification was found to correlate more closely with the clinical course of the patient than the TNM classification. PATIENTS From 1960 to 1973, 141 patients with laryngeal carcinoma were seen. In review¬ ing the charts of these patients, 39 were

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complete vocal cord fixation. They were analyzed in detail and form the basis of this study. The age, sex, location of found with

the lesions, presence or absence of metas¬ tasis, and mode and results of therapy were recorded. All cases were classified accord¬ ing to the 1962 and the 1972 American Joint Committee classifications. Five-year survival rates were calculated by absolute and determinate computer methods.

Table 1.—Comparison of Joint Committee TNM Classifications 1972

1962

Tumor/ No. of Patients

T,/6

T3/2I y12

Tumor/ No. of Patients

Stage/ No. of Patients II/29 Ml/5 IV/5

T,/0 T,/25

y 14

Stage/

No. of Patients I I/O III/38 IV/1

RESULTS Patients included two women and 37 men, ranging in age from 41 to 87 years, with a mean of 64. In 23 patients, the tumor was primarily supraglottic and in 16 it was primarily glottic. No cases of subglottic tumor producing complete fixation were noted. Direct laryngoscopy and biopsy were routinely performed, and the histologie diagnosis was squamous cell carcinoma in all cases. Direct microlaryngoscopy was used in approxi¬ mately one fourth of these patients. Ten patients had clinically palpable

cervical nodes, seven were unilateral, and two were bilateral. There was no evidence of distant metastasis in this series. Employing the 1962 Joint Commit¬ tee classification (Table 1), six lesions were classified as T2, 21 lesions as T„ and 12 lesions as T4. Twenty-nine patients were at stage II, five at stage III, and five at stage IV. When reclassified according to the 1972 Joint Committee classification, 25 cases were classified as T:l, and 14 were classified as T,. All 29 previously stage II lesions became stage III by virtue of the fixed vocal cord, but four previously stage IV lesions became stage III. The totals with the 1972 classification were 38 stage III, and one stage IV lesion. The overall treat¬ ment results for this group of 39 patients gave a determinate five-year survival of 41% and an absolute figure of 23%. The patients were next analyzed by mode of therapy (Table 2). The largest group, 20 patients, were treated surgi¬ cally. Eleven of these patients had primarily supraglottic lesions; nine had glottic lesions. Eighteen patients had wide field laryngectomy with neck dissection; two had laryngec¬ tomy alone. Of the 18 patients undergoing radical neck dissection,

Table 2.—Survival Rate in 39 Patients Mode of Therapy _A_

Sur¬ vival

Length Determi¬ nate, %

Absolute, %

Surgery (20 Pa-

Combination (9 Pa-

tients)

tients)

5 yr

3 yr

62 41

42 33

Radiotherapy (10 Pa¬

tients) 20

mo

four patients had clinically palpable cervical nodes preoperatively; how¬ ever, only two were found to have metastatic disease in the pathologic specimen. Two patients without clini¬ cally palpable nodes preoperatively were found to have positive lymph nodes in the surgical specimen. The five-year survival figure for the group treated surgically was 62% by the determinate and 41% by the absolute method. Nine patients were treated with a combination of preoperative radio¬ therapy, ranging from 5,000 to 6,500 rads, and wide field laryngectomy with neck dissection. Of the nine, six had primarily supraglottic tumors and three had glottic tumors. One of the nine required a staged bilateral neck

dissection. In all nine cases, histologie study of the primary lesion showed persistence of tumor. Three patients had clinically palpable cervical nodes preoperative¬ ly, but metastasis was confirmed

histologically There

in

were two

ever, who had

only

one

patient.

other patients, how¬ no

palpable

nodes

preoperatively, but were found to have positive lymph nodes on histo¬ logie study of the specimen from the

neck. At 40 months, six of the nine patients who received combined ther¬ apy had died of disease, two had died

of other causes, and one was unavail¬ able for follow-up. For these reasons, five-year survival figures are not available. The calculated three-year survival figures, however, were 42% by the determinate and 33% by the absolute method. Ten of the 39 patients were treated with radiotherapy alone, ranging from 4,700 to 7,000 rads. Six patients in this group had primarily supra¬ glottic tumors and four had glottic tumors. Three of the ten had clinically palpable cervical nodes. At 20 months, seven of the ten had died of disease, two had died of other causes, and one was unavailable for follow-up. Five-year survival figures were also calculated for the supraglottic and glottic groups. A total of 23 patients had primarily supraglottic lesions, and the rates were 34% determinate and 22% absolute. The 16 patients with glottic tumors had survival figures of 55% determinate and 25% absolute. Using the 1972 classification, 22 patients with T2, N,„ (no regional lymphnode metastasis) M„, (no distant metastasis) stage III lesions from the fixed cord group were compared with 32 T2, N,„ M,„ stage II laryngeal lesions without cord fixation. The five-year survival rates for the stage III group were 41% determinate and 22% absolute, whereas the stage II lesion group had figures of 65% and 46%, respectively, indicating a poorer prognosis with cord fixation. Prior to the 1972 classification revision, all of these lesions would have been stage II. COMMENT

The therapeutic results in our group of 39 patients with fixed vocal cords support the contention that vocal cord fixation substantially worsens the prognosis, and agree with others who believe that the treatment of choice in this type of lesion is primarily surgi¬ cal. In 1969, Lenz et al" reported a five-year survival rate of 20% for fixed vocal cords that were treated with radiotherapy alone. In 1965, Shaw" reviewed 141 glottic carcinomas treated surgically, and reported a crude survival rate of 63.8%; in those cases with vocal cord fixation, the crude survival rate was reduced to

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45%. Martensson et al1" reviewed 578 of laryngeal carcinoma treated during the years 1940 to 1959. All were classified according to the 1962 TNM classification. He also noted a substantially poorer prognosis in those cases with impaired vocal cord mobility and recommended that in poorly differentiated T2 and in all T3 lesions, cord mobility should be used as the criterion for therapy. Surgical therapy was recommended for cases with impaired mobility. In 1970, Vermund" reviewed a total of 162 patients with vocal cord fixa¬ tion and found a five-year survival rate of 42% with primary radiothera¬ py and 61% with surgery. He believed, however, that partial fixation was not nearly as prognostically unfavorable as complete fixation, noting that with cases

complete fixation, radiotherapy re¬ sulted in a five-year survival of only 29%, and radiotherapy with surgery resulted in

a

survival of 55%. With

partial fixation, the radiotherapy group had a five-year survival of 47%; the surgical group had a 74% survival rate.

Although the total number

of

patients in our series treated with radiotherapy alone or the combination of radiotherapy and surgery are small, the results in both groups were disap¬ pointing. Residual tumor was noted in all patients receiving preoperative radiotherapy, suggesting that this form of therapy fails to penetrate and completely eradicate invasive lesions. The delay of two months or more in carrying out the definitive surgical procedure in those patients receiving preoperative radiotherapy may also be a factor in accounting for the substantially poorer results in the

combination group. Most patients in this series had very large lesions, five requiring tracheos¬ tomy prior to definitive therapy. Small lesions causing complete fixa¬ tion were a rare finding, and it seems that most lesions that penetrate deeply to cause fixation also spread superficially. When a small tumor develops with complete fixation, the possibility that neurogenic cord paral¬ ysis may have preceded the develop¬ ment of the lesion should be consid¬ ered. We have recently documented a case in which a T,A carcinoma of the

was found four after complete paralysis of the years same cord was diagnosed. Conservation surgical techniques were not used in our series when complete vocal cord fixation was pres¬ ent. However, others812 have advo¬ cated these techniques in selected

right

true vocal cord

cases.

In the initial evaluation of the cord mobility must be assessed, and any loss of mobility should be recorded in degree of partial

patient, vocal

complete fixation. Indirect mirror laryngoscopy, using topical anesthesia, is most helpful in assessing cord mobility. Direct laryn¬ goscopy under topical anesthesia is also helpful. However, the possibility of laryngospasm requiring emergency tracheostomy in these large lesions should be considered.,:1 Direct microlaryngoscopy under general anesthe¬ sia provides excellent visualization of the extent of the lesions, and, during recovery, cord mobility can be evalu¬ ated. Laryngography and laryngeal tomography provide additional assist¬ ance in determining the extent of the

or

tumor.

References 1. Meurman Y: Extended cordectomy for intrinsic laryngeal cancer: Application and results of plastic covering of excision surface, in

Proceedings of Fifth International Congress of Otology, Rhinology and Laryngology. Assen, Netherlands, Van Gorcum & Co, 1955, pp 513\x=req-\

521. 2. Clinical Classification and Staging of the Larynx, Chicago Joint Committee on Cancer Staging and End Results Reporting. Chicago, American College of Surgeons, 1962. 3. Holinger PH, Lederer FL, Soboroff BJ: The TNM classification of cancer of the larynx and pharynx. Otolaryngol Clin North Am 489-495, 1969. 4. Clinical Staging System for Carcinoma of the Larynx, American Joint Committee for

Staging and End Results Reporting. Chicago, American College of Surgeons, 1972. 5. Kirchner JA: One-hundred laryngeal cancers studied by serial section. Ann Otol Rhinol Laryngol 78:689-709, 1969. 6. Kirchner JA, Som ML: Clinical significance of fixed vocal cord. Laryngoscope 81:1029-1044, Cancer

1971. 7. Norris CM, Tucker GF, Kuo BF, et al: A correlation of clinical staging, pathological findings and five-year end results in surgically treated cancer of the larynx. Ann Otol Rhinol Laryngol 79:1033-1045, 1970. 8. Lenz M, Okranietz C, Berne AS: Radiotherapy of cancer of the larynx, in Pack GT, Ariel IM (eds): Treatment of Cancer and Allied Diseases. New York, Paul B. Hoeber, Inc, 1959, pp

528-550. 9. Shaw HJ: Glottic cancer of the larynx. J Laryngol Otol 79:1-14, 1965. 10. Martensson D, Fluur E, Jacobsson F: Aspects on treatment of cancer of the larynx. Ann Otol Rhinol Laryngol 76:313-329, 1967. 11. Vermund H: Role of radiotherapy in cancer of the larynx as related to the TNM system of staging. Cancer 25:485-502, 1970. 12. Blaugrund S: Cordal carcinoma of the larynx with posterior extension: Surgical treatment. Bull NY Acad Med 49:908-914, 1973. 13. Bonneau RA, Lehman RH: Stomal recurrence following laryngectomy. Arch Otolaryngol 101:408-412, 1975.

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Vocal cord fixation in laryngeal carcinoma.

The 1962 TNM classification (T, tumor and extent; N, regional lymph node metastasis, M, distant metastasis) did not emphasize vocal cord fixation in s...
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