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Original Article |

Local Control After Supracricoid Partial Laryngectomy for "Advanced" Endolaryngeal Squamous Cell Carcinoma Classified as T3 FREE

Xavier Dufour, MD; Stéphane Hans, MD; Erwan De Mones, MD; Daniel Brasnu, MD; Madeleine Ménard, MD; Ollivier Laccourreye, MD
[+] Author Affiliations

From the Department of Otorhinolaryngology–Head and Neck Surgery, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris, University of Paris V, Paris, France. Dr Dufour is now with the Department of Otorhinolaryngology–Head and Neck Surgery, Centre Hospitalo-universitaire, Poitiers, France. The authors have no relevant financial interest in this article.


Arch Otolaryngol Head Neck Surg. 2004;130(9):1092-1099. doi:10.1001/archotol.130.9.1092.
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Objectives  To determine the incidence of local control in patients with "advanced" moderately to well-differentiated endolaryngeal invasive squamous cell carcinoma classified as T3, treated with a supracricoid partial laryngectomy; to identify any statistical relationship; and to analyze the consequences of local recurrence.

Design  Retrospective nonrandomized case series.

Setting  A tertiary referral care center and university teaching hospital.

Patients  An inception cohort of 118 patients. Tumor stage was T3 N0 M0 in 90 patients, T3 N1 M0 in 21 patients, T3 N2 M0 in 5 patients, and T3 N3 M0 in 2 patients.

Interventions  All patients underwent supracricoid partial laryngectomy. A platin-based induction chemotherapy regimen was used in 100 patients. Postoperative radiotherapy was used for 24 patients.

Main Outcome Measures  Local recurrence, nodal recurrence, distant metastasis, and survival; univariate and multivariate analysis of local recurrence.

Results  Nine patients developed a local recurrence. The 1-, 3-, and 5-year actuarial local control estimates were 97.3%, 93.5%, and 91.4%, respectively. In a stepwise regression model, the presence of positive margins of resection was the only variable that statistically increased the risk of local recurrence (P = .008). Local recurrence resulted in a significant increase in nodal recurrence (P<.001) and distant metastasis (P<.001) and a significant decrease in survival (P = .03). An overall 89.8% laryngeal preservation rate and 98.3% local control rate were achieved.

Conclusion  Supracricoid partial laryngectomies should be considered when an organ preservation strategy is discussed in patients with advanced endolaryngeal squamous cell carcinoma classified as T3.

Figures in this Article

Since their introduction in the North American otolaryngology literature in the early 1990s,1,2 the supracricoid partial laryngectomies (SCPLs) have had a widespread diffusion. By October 2003, a MEDLINE analysis noted that more than 80 articles devoted to technical modifications, complications, and oncologic and functional results after SCPLs have been published in the English-language medical literature. Furthermore, review of the reported literature noted that this technique is now being used and advocated in numerous countries such as Australia, Belgium, Brazil, China, France, Greece, Germany, Italy, India, Japan, Korea, Mexico, Poland, Spain, Switzerland, Turkey, and the United States (MEDLINE analysis). Recently, Weinstein et al3 also demonstrated that the quality of life after SCPLs was superior to that after total laryngectomy with tracheoesophageal puncture, and that a histologic assessment of whole-organ sections of total laryngectomy specimens indicated that many patients who had been subjected to total laryngectomy may have been candidates for SCPLs. However, although 2 reports4,5 from our department in the early 1990s documented the initial results achieved with SCPLs in patients with advanced glottic, supraglottic, and transglottic cancer, we were not able to find a single report in the medical literature specifically designed to analyze the role as well as the limits of SCPLs in a large series of patients with advanced endolaryngeal carcinoma classified as T3 and long-term follow-up. This lack of data, together with the simultaneous advent, in the past 10 years, of induction chemotherapy–radiotherapy and chemoradiation protocols6,7 in patients with advanced endolaryngeal squamous cell carcinoma, was the initial impetus for the current series. More specifically, our series, based on 118 patients with moderately to well-differentiated advanced invasive squamous cell carcinoma of the endolarynx classified as T3 consecutively treated with SCPLs at a single institution, was designed to analyze local control, to search for potential variables that influenced local control, to study the oncologic consequences of local recurrence, to confirm (or not) the results previously reported from our department,4,5 and to compare our results with the reported data when an induction chemotherapy–radiotherapy or a chemoradiation protocol was used.6,7

The present retrospective studies were based on the analysis of the medical files, operative charts, and pathological reports of 118 patients with a previously untreated, moderately to well-differentiated, "advanced" endolaryngeal invasive squamous cell carcinoma classified as T3, according to the 2002 International Union Against Cancer staging classification system.8 All patients were consecutively treated in our department between January 1, 1972, and December 31, 1997, with an SCPL. Table 1 documents the sex, age, tobacco intake, alcohol intake, and comorbidity according to the Charlson et al9 comorbidity index–weighted score.

Table Graphic Jump LocationTable 1. Characteristics of 118 Patients

The tumor originated from the glottis and the supraglottis in 43 and 66 patients, respectively. The tumor was considered to be transglottic in origin in the remaining 9 patients. None of the tumors in our series was considered to originate from the epilarynx. The tumor was classified as T3 because of fixation of the true vocal cord (67 patients), fixation of the arytenoid cartilage (18 patients), preepiglottic space invasion (78 patients), and/or suspected minimal thyroid cartilage invasion (15 patients). The true vocal cord and the arytenoid cartilage on the tumor-bearing side were fixed in 67 and 18 patients, respectively. In this series, the infraglottic extent of the tumor never reached the upper border of the cricoid cartilage, the posterior commissure was free of tumor, and extralaryngeal spread of tumor was not encountered, as all of these are considered in our department to be major contraindications to the completion of SCPL.1,2 Nodal staging, according to the 2002 International Union Against Cancer staging classification system,8 was as follows: N0, 90 patients (76.3%); N1, 21 patients (17.8%); N2, 5 patients (4.2%); and N3, 2 patients (1.7%). Therefore, in our series, 111 patients were considered to have stage III disease and 7 patients were considered to have stage IV.

Preoperatively, 100 patients had an induction chemotherapy regimen. Our current regimen was based on cisplatin (25 mg/m2 per day) and fluorouracil (1 g/m2 per day) delivered as daily continuous intravenous dosages. Cisplatin and fluorouracil were delivered by means of a portable chemotherapy delivery system that provided a continuous infusion of the drugs during a period of 24 hours. Antiemetics and oral hyperhydration (2 L/d) were used routinely during the treatment course. The course duration was 4 days. Induction chemotherapy was administered with a 15- to 21-day hiatus between courses, with the ultimate interval being determined by toxicity. The dosages were adjusted to tolerance. Clinical examination, blood cell counts, and chemistry studies performed 15 days after each course allowed for analysis of the cumulative toxicity according to the Eastern Cooperative Oncology Group criteria.10 In the early years, 5 to 6 courses were used before SCPL completion. At the present time, 2 to 3 courses are used before SCPL. A workup with a complete head and neck examination, direct laryngoscopy, and laryngeal computed tomography (since the late 1980s) performed by the last course allowed analysis of the clinical response to neoadjuvant chemotherapy. The clinical response at the tumor site after the induction chemotherapy regimen was measured as a complete response, a partial response greater than 90%, a partial response greater than 50% but less than or equal to 90%, and no change in 16, 5, 52, and 27 patients, respectively. The clinical response to the induction chemotherapy regimen led to a modification in the definitive treatment option in 18 patients (18%) who were considered initially not to be amenable to SCPL because of fixation of the arytenoid cartilage and the true vocal cord on the tumor-bearing side. This remobilization of the arytenoid cartilage after the induction chemotherapy regimen led to modification of the surgical approach with the use of SCPL in lieu of the initially planned total laryngectomy.

The surgical procedure performed was SCPL with cricohyoidopexy in 81 patients and SCPL with cricohyoidoepiglottopexy in 37 patients. The arytenoid cartilage on the tumor-bearing side was completely resected in 56 patients (47.5%) and partially resected in 45 patients (38.1%). In the remaining 17 patients (14.4%), both arytenoid cartilages were spared. Ninety-nine patients (83.9%) had an associated neck dissection at the time of surgery. A bilateral selective neck dissection of level II through IV nodes (sparing the internal jugular vein, cranial nerve XI, and the sternomastoid muscle)11 was performed in 75 patients. Fourteen patients had an associated unilateral selective neck dissection of level II through IV nodes (sparing the internal jugular vein, cranial nerve XI, and the sternomastoid muscle).11 Seven patients had an ipsilateral radical neck dissection together with a contralateral selective neck dissection. Three patients had an ipsilateral radical neck dissection.11 No jugulocarotid lymph node dissection was performed in the remaining 19 patients. An ipsilateral paratracheal lymph node dissection was performed in 8 patients.

The margins of resection were positive in 3 patients (2.5%), close in 3 patients (2.5%), and negative in 112 patients (94.9%). Pathological analysis of the specimen showed no residual tumor (complete histologic regression) in 18 patients (18%) and thyroid cartilage invasion in 15 patients (12.7%). Pathological analysis of the resected lymph nodes in 99 patients noted at least 1 positive jugulocarotid lymph node in 21 patients (21.2%), extracapsular spread in 10 patients (10.1%), fibrosis within the node in 2 patients (2.0%), and no disease in 66 patients (66.7%). Among the 90 patients classified as N0, 72 had a selective neck dissection and, of these, 12 (16.7%) had a positive jugulocarotid lymph node. Among the 8 patients who had a paratracheal lymph node dissection, none had a positive paratracheal lymph node.

Postoperative radiotherapy (PRT), used in 24 patients (20.3%) in our series, was performed at various centers outside our institution. Indications for PRT varied over time. The use of PRT to the larynx was based on close margins of resection in 1 patient, thyroid cartilage invasion in 3 patients, nodal metastasis in 8 patients, and presence of nodal metastasis with extracapsular spread of tumor in 8 patients. In the remaining 4 patients, PRT was performed while the margins of resection were free of tumor and no positive node was noted. The mean dose delivered to the remaining larynx was 45 Gy (range, 26-60 Gy). The mean dose delivered to the neck was 50 Gy (range, 26-65 Gy).

Follow-up data were collected at periodic visits to our department. All patients were followed up for a minimum of 5 years or until death. A personal computer with StatView (SAS Institute Inc, Cary, NC) software was used for storing and calculating statistical data. Our report was specifically designed (1) to determine the precise incidence of local control; (2) to search for a potential statistical relationship with the following variables: sex, tobacco intake, alcohol intake, site of origin of the tumor (glottic, supraglottic, or transglottic), fixation of the true vocal cord, fixation of the arytenoid cartilage, clinical response to induction chemotherapy, arytenoid cartilage resection on the tumor-bearing side (none, partial, or complete), pathological preepiglottic space invasion, pathological thyroid cartilage invasion, margins of resection, and PRT to the remaining larynx (yes vs no and, if yes, dose delivered); and (3) to determine the consequences of local control in terms of salvage total laryngectomy, nodal control, distant metastasis, survival, causes of death, overall local control rate, and overall laryngeal preservation rate. Perineural invasion and angiolymphatic invasion were not tested for potential statistical relationship with local control, as these variables were not looked for by our pathologists. To avoid bias linked to potential confounding variables, we also used a stepwise regression model. All significant or nearly significant variables (P<.1) related to local recurrence in univariate analysis were included in the stepwise regression model. Survival, local control, nodal control, and distant metastasis estimate were calculated by the Kaplan-Meier12 actuarial life-table method with the log-rank test method for statistical comparison. The nonparametric Mann-Whitney test and the χ2 test were used for quantitative and qualitative variables analysis, respectively. Statistical significance was set at the P = .05 level.

INCIDENCE OF LOCAL CONTROL AND VARIABLES INFLUENCING LOCAL RECURRENCE

The 1-, 3-, and 5-year actuarial local control estimate was 97.3%, 93.5%, and 91.4%, respectively (Figure 1). Overall, 9 patients developed local recurrences. Local recurrence was not encountered after the 60th postoperative month (Figure 1). In univariate analysis (Table 2), the only variables that statistically increased the incidence of local recurrence were positive margins of resection (P<.001) and the nonresection of the arytenoid cartilage on the tumor-bearing side (P = .02). When the Kaplan-Meier product-limit method was used, the 1-, 3-, and 5-year actuarial local control was 97.1%, 94.1%, and 93.0%, respectively, in patients with negative margins of resection, and 100%, 80.0%, and 60.0%, respectively, in patients with positive margins of resection (Figure 2; P = .01). Similarly, as depicted in Figure 3, the 1-, 3-, and 5-year actuarial local control estimate was 99.0%, 95.7%, and 94.6%, respectively, when the arytenoid cartilage was resected on the tumor-bearing side, compared with 85.7%, 77.9%, and 68.2%, respectively, when the arytenoid cartilage was not resected on the tumor-bearing side (P = .002). In a stepwise regression model, the only variable that statistically influenced local recurrence was positive margins of resection (P = .008).

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Figure 1.

Actuarial local control among 118 patients (Kaplan-Meier12 actuarial life-table method).

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Table Graphic Jump LocationTable 2. Univariate Analysis of Local Recurrence
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Figure 2.

Statistical comparison of local control in patients with negative margins of resection (solid line) and positive margins of resection (dashed line) (Kaplan-Meier12 actuarial life-table method).

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Figure 3.

Statistical comparison of local control in patients with arytenoid cartilage resected (solid line) and not resected (dashed line) on the tumor-bearing side (Kaplan-Meier12 actuarial life-table method).

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CONSEQUENCES OF LOCAL RECURRENCE

Overall, 63 patients died in our series. The percentage of patients who died of metachronous second primary tumor and intercurrent disease (30.1% and 27.0%, respectively) was much higher than the percentage of patients who died of distant metastasis, nodal recurrence, complication related to treatments, or local recurrence (11.1%, 9.5%, 4.7%, and 3.1%, respectively). The 1-, 3-, and 5-year actuarial survival estimate was 93.6%, 84.4%, and 74.0%, respectively, in patients without local recurrence, compared with 100%, 66.7%, and 41.7%, respectively, in patients with local recurrence (Figure 4). Survival was statistically more likely to occur in patients with local control than in patients who had a local recurrence (P = .03).

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Figure 4.

Statistical comparison of survival in patients without (solid line) and with (dashed line) local recurrence (Kaplan-Meier12 actuarial life-table method).

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In our series, salvage treatment for local recurrence was always a total laryngectomy. Three patients had PRT after salvage total laryngectomy. In patients who underwent salvage total laryngectomy, perioperative or postoperative death and postoperative pharyngocutaneous fistula were not encountered. The ultimate course of these patients was as follows: 7 patients died (local recurrence, 2 cases; nodal recurrence, 1; distant metastasis, 3; suicide, 1) and 2 patients were alive without evidence of disease at last follow-up. Because 3 patients in our series also had a completion total laryngectomy due to severe aspiration, the overall laryngeal preservation rate and local control rate were 89.8% (106/118) and 98.3% (116/118), respectively.

The 1-, 3-, and 5-year actuarial nodal control estimate was 97.1%, 95.1%, and 95.1%, respectively, in patients without local recurrence, compared with 77.8%, 66.7%, and 53.3% in patients with local recurrence (Figure 5). Nodal recurrence was statistically more likely to occur in patients with local recurrence than in patients who achieved local control (P<.001).

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Figure 5.

Statistical comparison of nodal control in patients without (solid line) and with (dashed line) local recurrence (Kaplan-Meier12 actuarial life-table method).

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The 1-, 3-, and 5-year distant metastasis estimate was 99.0%, 98.0%, and 95.8%, respectively, in patients without local recurrence, compared with 100%, 71.4%, and 71.4%, respectively, in patients with local recurrence (Figure 6). Distant metastasis was statistically more likely to occur in patients with local recurrence than in patients who achieved local control (P<.001).

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Figure 6.

Statistical comparison of freedom from distant metastasis in patients without (solid line) and with (dashed line) local recurrence (Kaplan-Meier12 actuarial life-table method).

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In the past 15 years, various reports from outside our institution documented successful outcome when SCPLs were used in patients with selected endolaryngeal invasive squamous cell carcinomas.1320 However, none of these reports was strictly limited to patients with endolaryngeal invasive squamous cell carcinoma classified as T3, based on a large series of patients with a long-term follow-up, and/or used an actuarial method to document the local control achieved. Therefore, currently it is difficult from the literature analysis to affirm that SCPLs provided a truly significant advance in the management of endolaryngeal cancer classified as T3, more commonly treated worldwide with total laryngectomy or radiotherapy with salvage surgery as rescue for local failure.

In the current retrospective series, 118 patients with selected endolaryngeal invasive squamous cell carcinoma classified as T3 (considered not to be amenable to a conventional partial vertical or supraglottic laryngectomy for cure) were included, all patients were followed up for a minimum of 5 years or until death, and the Kaplan-Meier12 actuarial life table was used to document local control. Under such conditions and as depicted in Figure 1, the 1-, 3-, and 5-year actuarial local control estimate was 97.3%, 93.5%, and 91.4%, respectively. Furthermore, an overall 89.8% laryngeal preservation rate and 98.3% local control rate was achieved after salvage treatment. The reported results in the current series are in line with previous reports from our department3,4 and are clearly better than the results achieved when radiotherapy alone is used; Mendenhall,21 in a 1998 article reviewing the results of radiotherapy alone for T3 or T4 squamous cell carcinoma of the larynx, stated that "local control after radiotherapy is approximately 65% for patients with T3 glottic and supraglottic carcinoma." The figures achieved in our series in terms of local control and laryngeal preservation are also superior to the 64% laryngeal preservation rate noted in the Department of Veterans Affairs study6 using radiotherapy in patients with more than a 50% decrease in the volume of the tumor after a platin-based induction chemotherapy regimen, as well as the 84% laryngeal preservation rate at 2 years recently reported by Forastiere et al7 after the use of concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer.

These high rates of initial local control and ultimate laryngeal preservation achieved in our series when SCPL was performed in patients with endolaryngeal invasive squamous cell carcinoma classified as T3 might be explained by various factors. The first one is the strict respect of the oncologic contraindications for these procedures. As previously stated,1,2 SCPL should not be performed if the cricoid cartilage is invaded, if the tumor reaches the upper border of the cricoid cartilage, if the posterior commissure is involved, if the arytenoid cartilage is fixed, or if there is extralaryngeal spread of tumor. Second, from a surgical point of view and in contrast to the other partial laryngectomies sometimes advocated in patients with endolaryngeal invasive squamous cell carcinoma classified T3, SCPL (1) avoids any blind entry to the larynx through the thyroid cartilage, (2) allows a wide en bloc resection of the muscles and mucosa to be performed, and (3) offers the surgeon an extremely wide exposure that allows for resection, under direct vision, of spaces (paraglottic and preepiglottic), endolaryngeal muscles, and mucosa where the cancer might be present.

Overall in our series, 9 patients had a local recurrence. Local recurrence was not encountered after the 60th postoperative month (Figure 1). As expected, and unfortunately, local recurrence in our series was strongly associated with nodal recurrence, distant metastasis, and reduced survival. As depicted in Figure 4, Figure 5, and Figure 6, nodal control, control of distant metastasis, and survival were significantly reduced in patients in whom local treatment failed when compared with patients in whom the completion of SCPL achieved local control. In univariate analysis (Table 2, Figure 2, and Figure 3), the only variables that statistically increased the risk of local recurrence were the margins of resection and the surgical approach toward the arytenoid cartilage on the tumor-bearing side. Local recurrence was statistically more likely to occur if the margins of resection were positive (P<.001) and if the arytenoid cartilage on the tumor-bearing side was not resected (P = .02). Although not significant in the stepwise regression model, in univariate analysis, the preservation of the arytenoid cartilage on the tumor-bearing side statistically increased the risk of local recurrence. In our opinion, this finding emphasizes the importance of comprehensive resection of the paraglottic space posteriorly. In the stepwise regression model, the only variable that statistically increased the risk of local recurrence in our series was positive margins of resection (P = .008). The presence of positive margins of resection is a well-known negative factor for local control and survival in patients with T3 laryngeal carcinoma.19 However, of the 6 patients who had positive margins of resection in our series, only 2 patients had local recurrences. In our opinion, all of these figures underscore (1) the still-existing difficulty of evaluating precisely the infraglottic extent of tumor in patients with endolaryngeal invasive squamous cell carcinoma classified as T3 and (2) the still-existing difficulties for the pathologist to assess precisely the limit of the tumor on the resected specimen. Interesting also is the notion that in the current series no significant statistical relationship was noted between local recurrence and the various causes for the T3 classification of the tumors (preepiglottic space invasion, thyroid cartilage invasion, and fixation of the true vocal cord). In our opinion, this notion, together with the 91.4% 5-year actuarial estimate for local control, clearly confirms the validity of SCPL in patients with moderately to well-differentiated, advanced, invasive, endolaryngeal squamous cell carcinoma classified as T3 when the major contraindications (fixation of the arytenoid cartilage on the tumor-bearing side, invasion of the posterior commissure, infraglottic extent of tumor reaching the upper border of the cricoid cartilage, invasion of the cricoid cartilage, and extralaryngeal spread of tumor) are respected, as suggested in our previous reports.3,4

When our data are analyzed, 2 other interesting points come into view. First, most patients (100 of 118) had an induction chemotherapy regimen before SCPL. In univariate analysis (Table 2), neither the clinical response nor the histologic response to the induction chemotherapy regimen appeared to influence significantly the risk for local control. Therefore, at first glance, it might be tempting to conclude that induction chemotherapy in the current series was an overtreatment. However, 21 (21%) of the 100 patients had a complete clinical response or a 90% or greater reduction of the tumor volume after the induction chemotherapy regimen, and 52 patients (52%) had more than a 50% reduction in the tumor volume after the induction chemotherapy regimen. The clinical response to the induction chemotherapy regimen led to a modification in the definitive treatment option in 18 patients (18%). These patients were considered initially not to be amenable to SCPL because of fixation of the arytenoid cartilage and the true vocal cord on the tumor-bearing side. After induction chemotherapy, the remobilization of the arytenoid cartilage permitted the use of SCPL in lieu of an initially planned total laryngectomy. Finally, pathological analysis of the specimen showed no residual tumor (complete histologic regression) in 18 patients (18%), and when compared with the literature815 that documents the use of SCPL without an induction chemotherapy regimen, our results in terms of local control and laryngeal preservation rate appeared to be better. It appears, therefore, that the use of induction chemotherapy in our series was not useless.

From a conceptual point of view, one might also consider that the use of induction chemotherapy could allow selection of the good and very good responders in an attempt to offer them a less surgically aggressive option from a functional point of view (namely, an endoscopic laser resection, radiotherapy alone, a chemoradiation protocol such as the one advocated in the Veterans Affairs Laryngeal Group study,6 a concurrent chemotherapy-radiotherapy protocol such as the one recently reported by Forastiere et al,7 or an intra-arterial chemoradiation protocol such as the one initiated by Robbins et al22) as the ultimate treatment modality. Overall and schematically, such an approach tends to provide radiation in the best cases (the very good responders) and uses conservation surgery in poor responders or nonresponders. This management policy also offers other advantages: (1) it gives team members (surgeon, radiation therapist, and medical oncologist) time to discuss in depth the advantages and disadvantages of the various treatment options available, (2) it gives the patient time to understand all the aspects of the treatments available as well as their consequences, (3) it reduces the stress inherent in the simultaneous diagnosis of an advanced cancer and the choice of the definitive treatment modality, (4) it allows the physicians to adapt their treatment preferences to the tumor response, (5) it avoids radiotherapy for the management of a metachronous second primary tumor of the head and neck in a large group of patients, (6) it avoids the classic selection of the treatment option according to the specialist's training (the radiotherapist wishes to radiate, the surgeon wishes to operate), and (7) from a human point of view, it allows a strong patient-physician relationship to be built before definitive treatment is performed. As suggested in the recent report by Forastiere et al7 documenting the use of induction chemotherapy and concurrent chemotherapy and radiotherapy vs radiotherapy alone in patients with advanced laryngeal squamous cell carcinoma, we believe that the use of an induction chemotherapy regimen also allows for a reduction in the rate of distant metastasis.

Furthermore, one must note that our main results, namely, a 91.4% 5-year actuarial local control estimate and an 89.8% overall laryngeal preservation rate, compare favorably with the overall 64% laryngeal preservation rate reported when induction chemotherapy and radiotherapy were used6 and the 84% overall laryngeal preservation rate recently reported when a concurrent chemotherapy and radiotherapy protocol was used7 in patients with advanced-stage squamous cell carcinoma of the larynx. From this perspective and from the results achieved in the current series, it appears clear to us and others2224 that (1) the response to induction chemotherapy regimen should be used for modification of the therapeutic strategy for pharyngolaryngeal carcinomas and (2) SCPL should be now completely integrated in the organ preservation strategies used worldwide in patients with advanced endolaryngeal invasive squamous cell carcinoma classified as T3.

The last point in our series that deserves further attention is the relatively rare use of PRT together with the low dose delivered. Postoperative radiotherapy was used in 24 patients (20.3%) in our series. The mean dose delivered to the remaining larynx was 45 Gy (range, 26-60 Gy). The mean dose delivered to the neck was 50 Gy (range, 26-65 Gy). From a statistical point of view (Table 2), neither the use of PRT nor the dose delivered influenced significantly the risk of local recurrence. In our opinion, our results strongly suggest that PRT to the remaining larynx is an overtreatment when the margins of resection are free of tumor, because of the extremely high rate of local control and laryngeal preservation (91.4% and 89.8%, respectively), as well as the low rate of positive margins of resection (2.5%). On the other hand, we believe that PRT should be used in selected cases, mainly in patients with multiple positive nodes in the neck and/or extracapsular spread after associated jugulocarotid lymph node dissection. We also believe that by limiting radiotherapy, we were better prepared to treat the expected metachronous second primary tumors. Such an approach resulted in an actuarial survival estimate of 93.6%, 84.4%, and 74.0% at 1, 3, and 5 years in this report. Such an approach allowed us to save the use of radiotherapy for the management of various metachronous second primary tumors and is, in our opinion, one of reasons for the 93.6%, 84.4%, and 74.0% actuarial survival estimate achieved at 1, 3, and 5 years, respectively, in our series.

As with any retrospective study, numerous biases might be discussed in the present report. However, we found no prospective studies in the literature reporting long-term results in terms of local control and laryngeal preservation in endolaryngeal invasive squamous cell carcinoma classified as T3. The experience gained in our department with this inception cohort of 118 patients followed up until death and/or for more than 5 years noted that the use of SCPL in selected tumors classified as T3 allowed for a very important increase in terms of local control and laryngeal preservation when compared with radiotherapy alone. Furthermore, the use of induction chemotherapy in most patients did not appear to be detrimental, and radiotherapy was avoided in more than 80% of cases to manage future metachronous second primary tumors. Altogether such results (1) demonstrate that SCPL provided a significant advance in the management of selected laryngeal cancer classified as T3, more commonly treated worldwide with total laryngectomy or radiotherapy alone with salvage surgery as rescue for local failure; (2) challenge the systematic use of PRT in laryngeal malignancies; and (3) suggest that SCPLs with or without an induction chemotherapy regimen should now be considered when an organ preservation strategy is discussed with patients.

Correspondence: Ollivier Laccourreye, MD, Department of Otorhinolaryngology–Head and Neck Surgery, Hôpital Européen Georges Pompidou, 20-40 Rue Leblanc, 75015 Paris, France.

Accepted for publication March 2, 2003; final revision received January 13, 2004; accepted March 2, 2004.

This study was supported by the Progrès 2000 traveling fellowship from the Association Progrès 2000, Paris, France (Dr Dufour). We also thank Therval Co, Neuilly-sur-Seine, France, and Daniel Molle and Frederic Sesini for their financial support regarding the Progrès 2000 traveling fellowship.

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PubMed
Kaplan  EMeier  P Nonparametric estimation from incomplete observations. J Am Stat Assoc.1958;53:457-481.
Schroder  UJungehulsing  MKlussmann  JPEckel  HE Cricohyoidopexy (CHP) and cricohyoidoepiglottopexy: indication, complications, functional and oncological results. HNO.2003;51:38-45.
PubMed
Lima  RAFreitas  EQKligerman  J  et al Supracricoid laryngectomy with CHEP: functional results and outcome. Otolaryngol Head Neck Surg.2001;124:258-260.
PubMed
Schwaab  GKolb  FJulieron  M  et al Subtotal laryngectomy with cricohyoidopexy as first treatment procedure for supraglottic carcinoma: Institut Gustave Roussy experience (146 cases,1974-1997). Eur Arch Otorhinolaryngol.2001;258:246-249.
PubMed
Adamopoulos  GYiotakis  JStavroulaki  PManolopoulos  L Modified supracricoid partial laryngectomy with cricohyoidopexy: series report and analysis of results. Otolaryngol Head Neck Surg.2000;123:283-293.
PubMed
Bron  LBrossard  EMonnier  PPasche  P Supracricoid partial laryngectomy with cricohyoidoepiglottopexy and cricohyoidopexy for glottic and supraglottic carcinomas. Laryngoscope.2000;110:627-634.
PubMed
de Vincentiis  MMinni  AGallo  ADi Nardo  A Supracricoid partial laryngectomies: oncologic and functional results. Head Neck.1998;20:504-509.
PubMed
Coman  WBGrigg  RGTomkinson  AGallagher  RM Supracricoid laryngectomy: a significant advance in the management of laryngeal cancer. Aust N Z J Surg.1998;68:630-634.
PubMed
Chevalier  DPiquet  JJ Subtotal laryngectomy with cricohyoidopexy for supraglottic carcinoma: review of 61 cases. Am J Surg.1994;168:472-473.
PubMed
Mendenhall  WM T3-4 squamous cell carcinoma of the larynx treated with radiation therapy alone. Semin Radiat Oncol.1998;8:262-269.
PubMed
Robbins  KTKumar  PWong  FS  et al Targeted chemoradiation for advanced head and neck cancer: analysis of 213 patients. Head Neck.2000;22:687-693.
PubMed
Lecanu  JBMonceaux  GPerie  SAngelard  BSt Guily  JL Conservative surgery in T3-T4 pharyngolaryngeal squamous cell carcinoma: an alternative to radiation therapy and to total laryngectomy for good responders to induction chemotherapy. Laryngoscope.2000;110:412-416.
PubMed
Lefebvre  JL Larynx preservation: the discussion is not closed. Otolaryngol Head Neck Surg.1998;118:389-393.
PubMed

Figures

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Figure 1.

Actuarial local control among 118 patients (Kaplan-Meier12 actuarial life-table method).

Graphic Jump Location
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Figure 2.

Statistical comparison of local control in patients with negative margins of resection (solid line) and positive margins of resection (dashed line) (Kaplan-Meier12 actuarial life-table method).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Statistical comparison of local control in patients with arytenoid cartilage resected (solid line) and not resected (dashed line) on the tumor-bearing side (Kaplan-Meier12 actuarial life-table method).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Statistical comparison of survival in patients without (solid line) and with (dashed line) local recurrence (Kaplan-Meier12 actuarial life-table method).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Statistical comparison of nodal control in patients without (solid line) and with (dashed line) local recurrence (Kaplan-Meier12 actuarial life-table method).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Statistical comparison of freedom from distant metastasis in patients without (solid line) and with (dashed line) local recurrence (Kaplan-Meier12 actuarial life-table method).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Characteristics of 118 Patients
Table Graphic Jump LocationTable 2. Univariate Analysis of Local Recurrence

References

Laccourreye  HLaccourreye  OWeinstein  GMenard  MBrasnu  D Supracricoid laryngectomy with cricohyoidopexy: a partial laryngeal procedure for selected supraglottic and transglottic carcinomas. Laryngoscope.1990;100:735-741.
PubMed
Laccourreye  HLaccourreye  OWeinstein  GMenard  MBrasnu  D Supracricoid laryngectomy with cricohyoidoepiglottopexy: a partial laryngeal procedure for glottic carcinoma. Ann Otol Rhinol Laryngol.1990;99:421-426.
PubMed
Weinstein  GSEl-Sawy  MMRuiz  C  et al Laryngeal preservation with supracricoid partial laryngectomy results in improved quality of life when compared with total laryngectomy. Laryngoscope.2001;111:191-199.
PubMed
Laccourreye  OSalzer  SJBrasnu  DShen  WLaccourreye  HWeinstein  GS Glottic carcinoma with a fixed true vocal cord: outcomes after neoadjuvant chemotherapy and supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Otolaryngol Head Neck Surg.1996;114:400-406.
PubMed
Laccourreye  OBrasnu  DBiacabe  BHans  SSeckin  SWeinstein  G Neo-adjuvant chemotherapy and supracricoid partial laryngectomy with cricohyoidopexy for advanced endolaryngeal carcinoma classified as T3-T4: 5-year oncologic results. Head Neck.1998;20:595-599.
PubMed
Department of Veterans Affairs Laryngeal Cancer Study Group Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med.1991;324:1685-1690.
PubMed
Forastiere  AAGoepfert  HMaor  M  et al Concurrent chemotherapy and radiotherapy for organ preservation in advanced larynegal cancer. N Engl J Med.2003;349:2091-2098.
PubMed
Sobin  LWittekind  C TNM Classification of Malignant Tumors. 6th ed. New York, NY: Wiley-Liss Inc; 2002.
Charlson  MEPompei  PAles  KLMacKenzie  CR A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis.1987;40:373-383.
PubMed
Oken  MMCreech  RHTormey  DC  et al Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol.1982;5:649-655.
PubMed
Robbins  KTMedina  JEWolfe  GTLevine  PASessions  RBPruet  CW Standardizing neck dissection terminology: official report of the Academy of Head and Neck Surgery and Oncology. Arch Otolaryngol Head Neck Surg.1991;117:601-605.
PubMed
Kaplan  EMeier  P Nonparametric estimation from incomplete observations. J Am Stat Assoc.1958;53:457-481.
Schroder  UJungehulsing  MKlussmann  JPEckel  HE Cricohyoidopexy (CHP) and cricohyoidoepiglottopexy: indication, complications, functional and oncological results. HNO.2003;51:38-45.
PubMed
Lima  RAFreitas  EQKligerman  J  et al Supracricoid laryngectomy with CHEP: functional results and outcome. Otolaryngol Head Neck Surg.2001;124:258-260.
PubMed
Schwaab  GKolb  FJulieron  M  et al Subtotal laryngectomy with cricohyoidopexy as first treatment procedure for supraglottic carcinoma: Institut Gustave Roussy experience (146 cases,1974-1997). Eur Arch Otorhinolaryngol.2001;258:246-249.
PubMed
Adamopoulos  GYiotakis  JStavroulaki  PManolopoulos  L Modified supracricoid partial laryngectomy with cricohyoidopexy: series report and analysis of results. Otolaryngol Head Neck Surg.2000;123:283-293.
PubMed
Bron  LBrossard  EMonnier  PPasche  P Supracricoid partial laryngectomy with cricohyoidoepiglottopexy and cricohyoidopexy for glottic and supraglottic carcinomas. Laryngoscope.2000;110:627-634.
PubMed
de Vincentiis  MMinni  AGallo  ADi Nardo  A Supracricoid partial laryngectomies: oncologic and functional results. Head Neck.1998;20:504-509.
PubMed
Coman  WBGrigg  RGTomkinson  AGallagher  RM Supracricoid laryngectomy: a significant advance in the management of laryngeal cancer. Aust N Z J Surg.1998;68:630-634.
PubMed
Chevalier  DPiquet  JJ Subtotal laryngectomy with cricohyoidopexy for supraglottic carcinoma: review of 61 cases. Am J Surg.1994;168:472-473.
PubMed
Mendenhall  WM T3-4 squamous cell carcinoma of the larynx treated with radiation therapy alone. Semin Radiat Oncol.1998;8:262-269.
PubMed
Robbins  KTKumar  PWong  FS  et al Targeted chemoradiation for advanced head and neck cancer: analysis of 213 patients. Head Neck.2000;22:687-693.
PubMed
Lecanu  JBMonceaux  GPerie  SAngelard  BSt Guily  JL Conservative surgery in T3-T4 pharyngolaryngeal squamous cell carcinoma: an alternative to radiation therapy and to total laryngectomy for good responders to induction chemotherapy. Laryngoscope.2000;110:412-416.
PubMed
Lefebvre  JL Larynx preservation: the discussion is not closed. Otolaryngol Head Neck Surg.1998;118:389-393.
PubMed

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