The Role of Hemilaryngectomy in the Management of T1 Vocal Cord Cancer

Abstract

To the Editor.\p=m-\Rothfieldet al1 recently published a report on a series of 54 patients with T1 squamous cell carcinoma of the true vocal cord treated with hemilaryngectomy; 43 of 54 patients were operated on for de novo lesions. The authors are to be commended for their excellent treatment results. However, they make several observations with which I take issue:1. The authors categorically state that hemilaryngectomy offers better cure rates than external-beam irradiation. They reported local control with hemilaryngectomy in 42 (98%) of 43 patients with de novo lesions; included were 3 patients who died of intercurrent disease. In a study of a series of patients with T1 vocal cord cancers recently published by the University of Florida (Gainesville), local control with irradiation was achieved in 144 (93%) of 155 patients suitable for a conservative laryngeal procedure.2 Eleven patients who died of intercurrent disease with the primary site continuously disease-free within 2 years of treatment were not included in the local control analysis, biasing the comparison against the radiother¬ apy series. Rothfield et al considered patients who developed local recur¬ rence more than 5 years from treat¬ ment to have developed second malig¬ nancies; these patients were coded as having a local recurrence in our study. This further biases the comparison against the radiotherapy series. The significance level between the treat¬ ment groups is = .22 (42 of 43 vs 144 of 155). The overall rate of local control with voice preservation for the entire radiotherapy series (no exclusions) was 157 (95%) of 166. I submit that these results are essentially the same as those presented by Rothfield et al, and that hemilaryngectomy and irra-diation offer equivalent local control rates. The likelihood of local control with irradiation is related to total dose, dose per fraction, and overall treatment time, so that local control with an optimal treatment schedule is better than the overall rate of 93%.3 2. The authors observe that hemi¬ laryngectomy provides more accurate staging than does management with irradiation. However, because the like¬ lihood of local control with hemilaryn¬ gectomy is the same as with irradia¬ tion, this additional information is useless.3. The authors note that follow-up is more straightforward and that multi¬ ple endoscopies with biopsy are avoided after hemilaryngectomy. In fact, there is far less anatomic distor¬ tion of the larynx following irradiation compared with hemilaryngectomy, so that irradiated patients are easier to observe. Additionally, we do not per¬ form endoscopy and/or biopsy on a patient following radiotherapy unless there is clinical evidence of recurrent disease; the indications for repeat fol¬ low-up endoscopy are the same no matter what the initial treatment.4. The authors state that the risk of a radiation-induced malignancy is avoided by using hemilaryngectomy. Multiple studies have shown no in¬ creased risk of second epithelial ma¬ lignancy in patients with head and neck cancer who ...