International Journal of Radiation Oncology*Biology*Physics
Clinical Investigations331 cases of clinically node-negative supraglottic carcinoma of the larynx: a study of a modest size fixed field radiotherapy approach
Introduction
Even with the advent of voice sparing surgical techniques, radiotherapy with surgery in reserve is commonly used in the management of supraglottic carcinoma of the larynx. Local control figures from 70% to 100% for early disease (T1-2) and 50% to 70% for advanced disease (T3-4) 1, 2, 3 are comparable to the results of surgical series 4, 5, 6. However uncertainty exists over the treatment of the node-negative neck. The supraglottic larynx is abundantly supplied with lymphatics and occult regional lymph node metastases are common. In early-stage disease (T1 and T2), as many as one-third of clinically negative necks may contain occult nodal metastases at the time of diagnosis 7, 8. Marks and Ogura have highlighted the problem of bilateral neck node metastases 4, 9: elective bilateral neck dissection, if performed, can be associated with considerable morbidity (10). Despite advances in staging with cross-sectional imaging, ultrasound, and positron emission tomography (PET), selection of patients for therapeutic neck dissection remains difficult 1, 8, 11. Many radiotherapy techniques, however, adapt themselves readily to include all the neck node areas, and a number of retrospective series of node-negative supraglottic carcinoma of the larynx show low regional relapse rates 2, 3. Harwood et al.’s study (2) in particular is important, because their radiotherapy technique changed during the study period from a small field, free set-up to a whole neck, fixed set-up using an immobilization shell (Fig. 1a). As a consequence of this they claimed an improvement in regional neck node control from 75% to 95% with no loss of primary control. They were able to treat the whole neck in front of the cord with acceptable morbidity, using a dose of 50 Gy in 20 fractions over 4 weeks. This dose appears relatively low when compared to standard 2 Gy fractionation schedules. However, in support they provide an analysis of dose–response curves for supraglottic carcinomas of the larynx showing no significant gradient over the range of biologically effective doses (BED) employed.
The Christie Hospital, Manchester, has in contrast maintained a very consistent policy over many years of treating tumor plus margin only for the infrahyoid region, with a modest upward extension of the field for suprahyoid disease (Fig. 1b). Using modest field sizes a higher BED can be prescribed, with the expectation of maximizing primary tumor control in anticipation of a significant dose response effect. This requires regular monthly follow-up for the first 2 years and prompt referral for radical neck dissection if lymph node metastases are detected. A third approach involves the use of lateral opposed whole neck treatments up to cord tolerance, with shrinking fields to deliver a high BED to the primary (Fig. 1c).
We have examined retrospectively a series of patients with clinically node-negative carcinoma of the supraglottic larynx treated with modest sized, fixed field, definitive radiotherapy at the Christie Hospital. In particular, we have examined the influence of dose, fractionation, and field size on both local and regional control, as well as serious morbidity.
Section snippets
Methods and materials
In the 10-year period between 1982 and 1992 a total of 331 node-negative cases of supraglottic carcinoma of the larynx were treated with definitive radiotherapy at the Christie Hospital, Manchester. Information on staging, treatment, and follow-up was obtained retrospectively from patient case notes. The male:female ratio was 230:101, and the median age was 63 years (range 32–90). Every patient had histologically confirmed squamous cell carcinoma of the supraglottic larynx. Tumors were staged
Results
A total of 80 patients relapsed in the larynx. Seventeen patients were salvaged after laryngectomy, giving an actuarial 5-year local control of 79%. Local control was significantly better (p = 0.01) for early-stage disease (Fig. 2). Five-year actuarial local control figures by stage were 92%, 81%, 67%, and 73% for T1, T2, T3 and T4 disease respectively. Of those patients who were ultimately free from disease, 90% retained their larynx. There was no significant difference in local control by
Discussion
Radiotherapy is widely used to treat early supraglottic carcinoma of the larynx, but even for advanced tumors local control rates exceeding 60%, with preservation of the larynx in most cases, have been reported 1, 2, 3, 13, 14. This study confirms that radiotherapy with surgical salvage can achieve good long-term local control and survival for all stages of supraglottic carcinoma of the larynx. Our local control and survival figures are particularly good for T4 disease (73% and 61%
References (27)
- et al.
Supraglottic laryngeal carcinomaAn analysis of dose-time-volume factors in 410 patients
Int J Radiat Oncol Biol Phys
(1983) - et al.
The problem of neck relapse in early stage supraglottic cancer
Int J Radiat Oncol Biol Phys
(1987) - et al.
Value of contralateral supraomohyoid neck dissections
Am J Surg
(1983) - et al.
Radiation therapy for advanced (T3T4N0-N3M0) laryngeal carcinomaThe need for a change of strategy: A radiotherapeutic viewpoint
Int J Radiat Oncol Biol Phys
(1987) - et al.
Salvage surgery following radiation failure in squamous cell carcinoma of the supraglottic larynx
Int J Radiat Oncol Biol Phys
(1995) Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract
Am J Surg
(1990)Carcinoma of the supraglottis
- et al.
Influence on radiotherapy treatment time on control of laryngeal cancerComparisons between centres in Manchester, UK and Toronto, Canada
Radiother Oncol
(1994) - et al.
The influence of the number of fractions and of overall treatment time on local control and late complication rate in squamous cell carcinoma of the larynx
Int J Radiat Oncol Biol Phys
(1983) - et al.
Radical external beam radiotherapy for 333 squamous carcinomas of the oral cavity—evaluation of late morbidity and a watch policy for the clinically negative neck
Radiother Oncol
(1996)
Apparent rates of proliferation of acutely responding normal tissues during radiotherapy of head and neck cancer
Int J Radiat Oncol Biol Phys
Supraglottic larynx cancer, T1–4 N0, treated by radical radiation therapy
Acta Oncol
Radiotherapy for squamous cell carcinoma of the larynxAn alternative to surgery
Head Neck
Cited by (35)
Transoral robotic supraglottic laryngectomy: Long-term functional and oncologic outcomes
2024, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryHead and neck cancers volume reduction: should we reduce our prophylactic node radiation to spare the antitumor immune response?
2022, Cancer/RadiotherapieCitation Excerpt :In case of N0 tumors, exclusive irradiation of the GTV also seems feasible. In a cohort of 331 patients with supraglottic cancer, radiation doses of 50 to 55 Gy in 16 fractions, without prophylactic irradiation, resulted in a high rate of regional control (90%), without acute toxicity [21]. It should be noted that for other highly lymphophilic cancers which present a very high risk of microscopic dissemination, such as non-small cell lung cancer or lymphoma, it has been shown that prophylactic lymph node irradiation does not improve clinical outcomes.
Treatment/Comparative Therapeutics: Cancer of the Larynx and Hypopharynx
2015, Surgical Oncology Clinics of North AmericaCitation Excerpt :Compared with primary RT and open surgery, oncologic outcomes and laryngeal preservation rates may be higher with TLM (Fig. 4) for supraglottic cancers.85,86 Five-year local control has been reported as 98% to 100% for T1 and 89% to 100% for T2 disease with TLM,87,88 compared with lower rates with RT alone.28,89,90 Similar transoral techniques have been applied to select hypopharynx tumors with acceptable oncologic and functional results.
Early Treatment of the Larynx
2010, Early Diagnosis and Treatment of Cancer Series: Head and Neck CancersSupraglottic laryngectomy. Still on-going
2006, Acta Otorrinolaringologica Espanola