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Surgical Approach to Organ Preservation in the Treatment of Cancer of the Larynx

Surgical Approach to Organ Preservation in the Treatment of Cancer of the Larynx

The article by Dr. Weinstein is a discussion of the newer surgical options available for the treatment of patients with laryngeal cancer. Several aspects of the article deserve mention.

One positive aspect is that it reviews alternative treatments for laryngeal cancer. However, several misconceptions are presented that warrant discussion. The first misconception is the title of the article, "Surgical Approach to Organ Preservation in the Treatment of Cancer of the Larynx." A more accurate title would refer to limited resection or function-preserving surgery in the treatment of patients with laryngeal cancer. Is removal of "both true and false cords as well as the entire epiglottis and thyroid cartilage," as performed in a supracricoid partial laryngectomy with cricohyoidopexy, truly organ/function preservation?

The belief that the larynx is a "tone generator" can lead to a potential misinterpretation of quality-of-life studies. The author states, "Studies of voice quality after supracricoid partial laryngectomy with cricohyoidepiglottopexy have shown that, at 6 months, the phrase grouping and number or words per minute are similar to that of normal speakers, while the fundamental frequency is lower and wider than normal, suggesting voice instability."[1] The significance of the voice instability is unclear.

Furthermore, the author states that the quality of speech after this procedure is superior to that of total laryngectomy patients. This is not a fair comparison—the comparison should be to nonsurgical organ-preserving procedures. The question once again arises, if the true function of the organ is not being preserved, is this truly an organ-preserving procedure?

Other Quality-of-Life Issues

Although the author mentions that "it is the stoma and not the posttreatment voice quality that is the major determinant of quality of life,"[2] there are other determining factors derived from surveys and questionnaires. Patients treated with surgery tend to have a lower quality of life, compared to patients treated with radiation with or without chemotherapy. For example, long-term follow-up from the Veterans Affairs (VA) Laryngeal Cancer Study Group demonstrated a better quality of life in patients randomized to chemotherapy plus radiation vs surgery plus radiation.[3] In another quality-of-life study of head and neck cancers, laryngectomy patients had lower quality-of-life scores than patients treated with radiation alone.[4]

Although there are limited data on the quality of life of patients with early-stage lesions, voice quality appears to be better among patients treated nonsurgically. In a study by Vordonck-de Leeuw, voice quality following radiation therapy became comparable to the vocal performance of control speakers in 50% of patients. Also, voice quality was worse for patients who underwent vocal cord stripping for initial diagnosis instead of biopsies.[5] There is also evidence that voice quality for early laryngeal lesions is better with radiation therapy than with laser excision.[6,7] In other studies, however, as mentioned in the article, voice quality is equivalent. Thus, although there are alternative options for the treatment of early-stage lesions, there is ample evidence to show that radiation alone produces excellent results in early-stage cancers of the larynx, with minimal side effects.

Misrepresentation of Issues

Another deficiency in this article is a lack of balance and accurate reporting of results. Throughout the article, the author reports selected results on selected patients. For example, in the section entitled "Supracricoid Partial Laryngectomy With Cricohyoidepiglottopexy," the author states, "Among 67 patients with T2 lesions… the 5-year local control rate was 95.5%,"[8] and "[i]n 20 patients with T3 glottic carcinoma with vocal cord fixation, the 5-year actuarial local control rate was 90%."[9] However, the author fails to mention that both of these trials used induction chemotherapy. This is an important omission since we know that the use of induction chemotherapy changes the outcome of the disease, as seen in the VA laryngeal cancer study.[10]

The authors also fail to mention the use of radiation therapy in many of the trials. In the section "Supraglottic Partial Laryngectomy," the authors cite five references regarding the outcome of this procedure. However, three of these five series use radiation therapy in a significant number of their patients. In Lee et al, 83% of patients received postoperative radiation therapy[11]; in Spaulding et al, all patients received either pre- or postoperative radiation therapy[12]; and in Herranz-Gonzalez et al, postoperative radiation therapy was administered to node-positive patients.[13]

This important information was not presented in an article on organ preservation, although we know that the addition of radiation to surgery will compromise organ function.[14] Therefore, the question that remains unanswered is: What is the true local control rate for these procedures as a single modality?

Surgical Expertise

One of the difficulties with the surgeries mentioned in this article is that they require a high degree of surgical skill. These procedures are complex and demand significant expertise and experience. The author states, "A resident or fellow in surgical training might have been exposed to few, if any, extended vertical partial laryngectomies and extended supraglottic partial laryngectomies in training, making it difficult to use these procedures in practice." By the same reasoning, physicians-in-training will have little opportunity to master the techniques mentioned in this article, making these procedures impractical and not widely applicable. The fact that most of the references are from single institutions raises similar concerns.

Thus, except for select medical centers with select surgeons, these surgeries will have limited use. Furthermore, only select patients are suitable for these procedures. A majority of patients mentioned in the referenced studies were node negative,[8,9,15-18] and all patients need to be carefully selected for the appropriate procedure.

Lack of Outcome Data

Another criticism of the article is the occasional lack of outcome data. In the section on endoscopic approaches for organ-preserving surgery of carcinomas arising at the glottic level, the author provides minimal data on outcome. He states, "A reasonable approach is to recommend endoscopic excision when the surgeon predicts that the voice outcome will be comparable with radiation therapy." But he does not cite a single reference regarding local control or outcome associated with the use of endoscopic excision.

Thomas reported a 23% (24/106) retreatment rate for local recurrences or new primary lesions for early T1 glottic cancers treated with endoscopic procedures,[19] and Moreau had no local failures in 160 patients treated with endoscopic cordectomies.[20] This suggests that there is a high degree of technique variation and patient selection in these procedures.

Unequivalent Comparisons

A final aspect that deserves comment is that the article compares modern surgical approaches with older nonsurgical approaches. For example, there is evidence that hyperfractioned radiation therapy produces a better outcome than standard fractionation. In a randomized study by the Radiation Therapy Oncology Group (RTOG), hyperfractionation and accelerated fractionation radiation therapy with a concomitant boost were more effective than standard fractionation for locally advanced head and neck cancer.[21] Also, although the main comparison of surgery vs nonsurgical approaches is based on the VA laryngeal cancer study (which used sequential chemotherapy and radiotherapy), recent evidence suggests that concomitant chemotherapy and radiotherapy may be more effective in organ preservation.

Several phase II studies have demonstrated excellent results for advanced head and neck cancer with concomitant chemotherapy and radiation therapy.[22-25] There is also a phase III study that demonstrated improved 3-year disease-free and overall survival with concomitant chemotherapy and radiation therapy vs radiation therapy alone in advanced-stage oropharyngeal cancers.[26] Furthermore, the addition of hyperfractionated radiation with concomitant radiation therapy is associated with improved 5-year locoregional control and relapse-free survival rates, compared to hyperfractionated radiation therapy alone in advanced head and neck cancers.[27] Therefore, the optimal nonsurgical organ-preservation technique is yet to be determined.

Only a randomized trial in specific subsets of head and neck cancer—ie, early laryngeal or advanced T3 laryngeal cancer—will provide evidence as to which treatments are superior for organ preservation, function, and survival.

References

1. Crevier-Buchman L, Laccourreye O, Weinstein G, et al: Evolution of speech and voice following supracricoid partial laryngectomy. J Laryngol Otol 109:410-413, 1995.

2. DeSanto L, Olson K, Perry W: Quality of life after surgical treatment of cancer of the larynx. Ann Otol Rhinol Laryngol 104:763-769, 1995.

3. Terrell JE, Fisher SG, Wolf GT: Long-term quality of life after treatment of laryngeal cancer. The Veterans Affairs Laryngeal Cancer Study Group. Arch Otolaryngol Head Neck Surg 124(9):964-971, 1998.

4. Campbell BH, Marbella A, Layde PM: Quality of life and recurrence concern in survivor of head and neck cancer. Laryngoscope 110(6):895-906, 2000.

5. Vordonck-de Leeuw IM, Keuss RB, Hilgers FJ, et al: Consequences of voice impairment in daily life following radiotherapy for early glottic cancer: Voice quality, vocal function, and vocal performance. Int J Radiat Oncol Biol Phys 44(5):1071-1078, 1999.

6. Rydell R, Schalen L, Fey S, et al: Voice evaluation before and after laser excision vs radiotherapy of T1A glottic carcinoma. Acta Otolaryngol 115(4):560-565, 1995.

7. Epstein BE, Lee DJ, Kashima H, et al: Stage T1 glottic carcinoma: results of radiation therapy or laser excision. Radiology 175(2):567-570, 1990.

8. Laccourreye O, Weinstein G, Brasnu D, et al: A clinical trial of continuous cisplatin-fluorouracil induction chemotherapy and supracricoid partial laryngectomy for glottic carcinoma classified as T2 [see comments]. Cancer 74:2781-2790, 1994.

9. Laccourreye O, Salzer SJ, Brasnu, et al: Glottic carcinoma with a fixed true vocal cord: Outcomes after neoadjuvant chemotherapy and supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Otolaryngol Head Neck Surg 114:400-406, 1996.

10. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med 324:1685-1690, 1991.

11. Lee NK, Goepfert H, Wendt CD: Supraglottic laryngectomy for intermediate-stage cancer: U. T. M .D. Anderson Cancer Center experience with combined therapy. Laryngoscope 100:831-836, 1990.

12. Spaulding CA, Constable WC, Levine PA, et al: Partial laryngectomy and radiotherapy for supraglottic cancer: A conservative approach. Ann Otol Rhinol Laryngol 98:125-129, 1989.

13. Herranz-Gonzalez J, Gavilan J, Martinez-Vidal J, et al: Supraglottic laryngectomy: Functional and oncological results. Ann Otol Rhinol Laryngol 105:18-22, 1996.

14. Spriano G, Antognoni P, Sanguineti G, et al: Laryngeal long-term morbidity after supraglottic laryngectomy and postoperative radiation therapy. Am J Otolaryngol 21(1):14-21, 2000

15. Laccourreye H, Laccourreye O, Weinstein G, et al: Supracricoid laryngectomy with cricohyoidopexy: A partial laryngeal procedure for selected supraglottic and transglottic carcinomas. Laryngoscope 100:735-741, 1990.

16. Laccourreye H, Laccourreye O, Weinstein G, et al: Supracricoid laryngectomy with cricohyoidoepiglottopexy: A partial laryngeal procedure of glottic carcinoma. Ann Otol Rhinol Laryngol 99:421-426, 1990.

17. Bron L, Brossard E, Monnier P, et al: Supracricoid partial laryngectomy with cricohyoidoepiglottopexy and cricohyoidopexy for glottic and supraglottic carcinomas. Laryngoscope 110:627-634, 2000.

18. de Vincentiis M, Minni A, Gallo A, et al: Supracricoid partial laryngectomies: Oncologic and functional results. Head Neck 20:504-509, 1998.

19. Thomas JV, Olsen KD, Neel HB, et al: Recurrences after endoscopic management of early (T1) glottic carcinoma. Laryngoscope 104(9):1099-1104, 1994.

20. Moreau PR: Treatment of laryngeal carcinomas after endoscopic microsurgery. Laryngoscope 110(6):1000-1006, 2000.

21. Fu KK, Pajak TF, Trotti A, et al: A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated fractionation radiotherapy for head and neck squamous cell carcinomas: First report of RTOG 9003 [see comments]. Int J Radiat Oncol Biol Phys 48(1):7-16, 2000.

22. Vokes EE, Kies MS, Haraf DJ, et al: Concomitant chemoradiotherapy as primary therapy for locoregionally advanced head and neck cancer. J Clin Oncol 18 (8):1652-1661, 2000.

23. Vokes EE, Haraf DJ, Brockstein BE, et al: Paclitaxel, 5-fluorouracil, hydroxyurea, and concomitant radiation therapy for poor-prognosis head and neck cancer. Semin Radiat Oncol 9(2 suppl 1):70-76, 1999.

24. Haraf DJ, Kies M, Rademaker AW, et al: Radiation therapy with concomitant hydroxurea and fluorouracil in stage II and III head and neck cancer. J Clin Oncol 17(2):638-644, 1999.

25. Bensadoun RJ, Etienne MC, Dassonville O, et al: Concomitant b.i.d. radiotherapy and chemotherapy with cisplatin and 5-fluorouracil in unresectable squamous-cell carcinoma of the pharynx. Int J Radiat Oncol Biol Phys 42(2):237-245, 1998.

26. Calais G, Alfonsi M, Bardet E, et al: Randomized trial of radiation therapy vs concomitant chemotherapy and radiation therapy for advanced-stage oropharynx carcinoma [see comments]. J Natl Cancer Inst 91(24):2081-2086, 1999.

27. Brizel DM, Albers ME, Fisher SR, et al: Hyperfractionated irradiation with or without concurrent chemotherapy for locally advanced head and neck cancer [see comments]. N Engl J Med 338(25):1798-1804, 1998.

 
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