Management of T3N0M0 glottic carcinoma: therapeutic outcomes

Abstract

Background: The best therapeutic approach for the treatment of T3N0M0 (stage III) glottic carcinoma is controversial.

Method: A retrospective study of Tumor Research Project data were performed using patients with T3N0M0 glottic squamous cell carcinoma treated with curative intent by seven different treatment modalities from January 1950 to December 1996 at Washington University School of Medicine/Barnes-Jewish Hospital.

Results: Two hundred patients with T3N0M0 glottic carcinoma were treated using seven modalities: total laryngectomy (TL, n = 30), TL with neck dissection (TL/ND, n = 40), conservation surgery alone (CS, n = 22), radiation therapy alone (RT, n = 29), TL combined with RT (TL/RT, n = 31), TL and ND combined with RT (TL/ND/RT, n = 36), and CS combined with RT (CS/RT, n = 12). The overall 5-year observed survival rate (OS) was 54% and the 5-year disease-specific survival rate (DSS) was 67%. The 5-year DSS for the individual treatment modalities included TL, 65.4%; TL/ND, 76.5%; CS, 71.4%; RT, 56.5%, TL/RT, 51.9%; TL/ND/RT, 71.4%; and CS/RT, 80%. There was no significant difference in DSS for any individual treatment modality (P =.375). The overall local and regional control rate was 74% (148 of 200). The overall recurrence rate was 37.5% with recurrence at the primary site and in the neck of 19.5% and 11%, respectively. Recurrence was not related to treatment modality. The 5-year DSS after treatment of recurrent cancer (salvage rate) was 35.8%. The incidence of distant metastasis was 11% and for second primary cancers it was 19.5%. There was no statistically significant difference in survival between necks initially treated (72%, 5-y DSS) versus necks observed and later treated if necessary (70%, 5-y DSS) (P =.797).

Conclusions: The seven treatment modalities had statistically similar recurrence, complication, and survival rates. Patients with clear surgical margins have a significant survival advantage compared with patients with close and involved margins. Because postoperative radiation therapy in patients with positive margins did not improve survival, formal re-resection of the site of the positive margin should be considered. In patients whose N0 neck was not treated electively, close follow-up observation with meticulous examinations combined with appropriate treatment for subsequent neck disease resulted in a similar survival rate compared with those patients whose N0 necks were treated initially. Six-year minimum follow-up is recommended for early identification of primary and neck recurrence and for discovering expected second primary cancers. Patients treated with RT and CS had statistically similar rates of survival, maintenance of voice, and acquired permanent tracheal stoma. CS is a valid alternative to RT in treating highly selected patients with T3N0 glottic carcinoma.