Laryngology seminar
2005-6-9
Laryngeal cancer with anterior commissure involvement
R3 林志峰
一.Introduction :
-anterior vocal commissure (AC) of the larynx : “X space” , “plane 0”
-laryngeal cancer involve AC (AC(+)):
poor local control and outcome, poor R/T response
-AC : mucosa, intermediate lamina of the thyroid cartilage , Broyles’
tendon (anterior commissure tendon) and its correlated structures
-AC(+) classification , (Rucci et al, 2003)
AC1: involve the AC subsite without crossing the midline
AC2: involve the AC subsite and cross the midline only in part of
longitudinal extension
AC3: whole AC subsite
progressively worse prognosis from AC1~3 ; not widely accepted
-Tumors from vocal folds, ventricular bands, laryngeal surface of the
epiglottis , or AC itself may have AC (+)
二. Diagnosis of laryngeal cancer with anterior commissure involvement
-
eT : 40.38% correct according to pT(Barbosa, 2005) : understage
iT (routine CT ,thicker than 1.0 mm):75 % correct
CT + 70-degree telescope (Eryilmaz, 2003) : 70-100%,
esp. subglottic region
CT with 1.0 mm thick + GRACI sign : 96% (Barbosa, 2005)
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-GRACI sign : Gross Radiologic Anterior Commissure Involvement
-helicoidal axial CT scan , 1.0 mm thick, from the thyroid tip to the inferior
border of the cricoid cartilage ,GRACI(+), if :
-AVC thickening >1mm , at least 2 continuous CT slices (horizontal plane)
-tumor growing (vertical plane)
superiorly : preepiglottic space
anteriorly : thyroid cartilage
inferiorly : cricoid cartilage
among 52, only iT1x1 and iT2x1 with GRACI(-) were pT3
No false-positive
GRACI sign enhance iT to 96.15% accuracy (Barbosa, 2005)
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三.Literature review and prognostic factors
1.AVC (+) :
poor prognosis (Rucci ,1996)
lower R/T effectiveness , because of understage(Reddy,1998)
poor response to R/T, because of understage, CT not performed, R/T
technical factor : underdosage (Maheshwar ,2001)
apparent in initial stages, but already deeply extended
2. Maheshwar et al ,2001
3.for T1 glottic cancer, AC (+) or(-) ; CGMH ,Chen et al ,2003
Local control
Disease-specific survival
4.Differences in disease free survival (R/T v.s.OP) Rucci et al ,2003
T1-2 glottic cancer ,AC (+)
T2, AC(+)
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5.negative prognostic factors for early glottic cancer Tx with R/T
: AC (+) , arytenoids protection, total R/T dose < 66Gy ,male gender
(Abderrahim et al ,2004)
6.oppositely, Gowda et al, 2003; Frachin et al, 2003; Stoeckli et al ,
2003 : AC(+) not a negative prognostic factor.
四. Treatment : Correct stage is important for choices of Tx
1.R/T ,reserving surgical salvage for failures
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-for T1 glottic cancer; CGMH ,Chen et al ,2003
AC(+)
AC(-)
Explanation : fraction size > 200cGy overcomes the tendency to
underdose at the air-tissue interface
-Hyperfractionation with acceleration may be beneficial (twice daily,
1.2Gy/fraction ; total dose of 74-80Gy) (M.D.Anderson Cancer
center for T2N0 glottic cancers)
-acute toxicity reaction ; comparable serious late complications
-R/T : better voice quality subjectively ; acoustic analysis and speech
aerodynamic studies: not return to normal , asymmetry & loss of
elasticity
2. OP : subjective change of voice quality
-horizontal glottectomy (Calearo and Teatini’s ,Majer-Piquet’s
crico-hyoido-epiglottopexy, and Labayle’s cricohyoidopexy)
-vertical laryngectomies :(Tucker’s frontoanterior and
Leroux-Robert’s frontolateral)
-endoscopic cold steel instruments (2-5mm margins) , microdebrider,
or laser surgery
-endoscopic vertical partial laryngectomy
3.Photodynamic therapy :T1-2, no scarring, excellent voice
preservation, repeatability, minimal side effects, single outpatient
procedure.
4.C/T : play a small role
combine Tx modalities.
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Reference
1.The larynx : early stage disease . Cancer of the head and neck .
P169-182. Jatin P.Shah
2. Anterior vocal commissure invasion in laryngeal carcinoma
diagnosis.Laryngoscope. 2005 Apr;115(4):724-30. Barbosa MM, Araujo
VJ Jr, Boasquevisque E, Carvalho R, Romano S, Lima RA, Dias FL,
Salviano SK.
3. Radiotherapy for T1 glottic carcinoma: impact of anterior commissure
involvement , Journal of Laryngology & Otology, 1 April 2001, vol. 115,
no. 4, pp. 298-301(4)Maheshwar A. A.; Gaffney C. C
4.RISK FACTORS AND PROGNOSIS OF ANTERIOR COMMISSURE
VERSUS POSTERIOR COMMISSURE T1-T2 GLOTTIC CANCER
Ann Otol Rhinol Laryngol 112:2003 p223-229 Lucio Rucci et al
5. RADIOTHERAPY OF EARLY-STAGE GLOTTIC CANCER:
ANALYSIS OF FACTORS AFFECTING PROGNOSISAnn Otol Rhinol
Laryngol 112:2003 , Joseph et al
6. Decreased local control following radiation therapy alone in
early-stage glottic carcinoma with anterior commissure
extension.Strahlenther Onkol. 2004 Feb;180(2):84-90. Zouhair A, Azria
D, Coucke P, Matzinger O, Bron L, Moeckli R, Do HP, Mirimanoff RO,
Ozsahin M.
7. The management of early laryngeal cancer: options for patients and
therapists. Current Opinion in Otolaryngology & Head and Neck
Surgery 2005,13: 85-91
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