Outcome of Surgery and Radiotherapy as Treatment of Early Laryngeal Cancer

Background: Carcinoma of the larynx is the most common cancer affecting the head and neck region. Among the different stages of this disease, early cancer (T1T2N0M0) has greater possibility of cure. Its modalities of treatment are surgery and radiotherapy. Methods: The study was done to compare between outcome of surgery and radiotherapy in early carcinoma larynx T1N0 catagory only. 60 cases of early carcinoma larynx were selected purposive sampling technique from all the patients of carcinoma larynx admitted into Otolaryngology and Head-Neck Surgery Department of Bangabandhu Sheikh Mujib Medical University,Dhaka; Dhaka Medical College Hospital, Dhaka; Shaheed Suhrawardy Medical College Hospital, Dhaka; Taqwah Specialized Hospital, Dhaka from January 2010 to June 2011. Results. Study showed 16.67% of the radiotherapy group had a primary site recurrence compared with 20.0% in the surgery group at 12 months (p = 0.59) and 6.67% of those who were treated with irradiation had a recurrence in the neck. 16.67% of patients in the surgery group had a recurrence in the neck (p < 0.05). There was no significant difference in primary site recurrence rates for the two treatment modalities, but regional recurrence was higher in the surgery group. Regarding speech and voice quality, radiotherapy was far superior to surgery. All patients in the radiotherapy group but only 3 of 10 in the surgery group had good or normal voice (p = .0017). Conclusions: Both surgery and irradiation are equally effective in treating early laryngeal carcinoma but Speech and voice quality were significantly better in patients treated by radiotherapy than those treated by surgery.

radiotherapy tending to be the treatment of choice in northern Europe, whereas patients are more likely to be treated with surgery in the United States and southern Europe. Organ preservation strategy favoring primary radical radiotherapy followed, if necessary, by salvage surgery. This strategy evolved over the years is based on the premise that treatment goals should include cure with acceptable side effects, minimal complications, and laryngeal preservation. Radiation failure can usually be salvaged by total or partial laryngectomy.
During the last two decades, radiotherapy gradually superseded surgery as the treatment of choice, and thus we are able to compare the results of surgery with radiotherapy for the treatment of early laryngeal cancer. The aim of this article is therefore to compare the results of the two treatment modalities in terms of recurrence at the site of the primary tumor, in the neck. Associations between variables were also studied. A small, intercalated study investigates speech and voice quality in patients from each treatment modality. [5][6][7][8] For early-stage laryngeal cancer, both surgery and radiotherapy are effective treatment modalities, offering a high rate of local control and cure for a selective group of patients. The probability of obtaining local control for early glottic cancer is similar when comparing the results of radiation therapy, cordectomy, and hemilaryngectomy. [7][8][9][10] Radiation therapy has been the treatment of choice for all previously untreated T1 and T2 vocal cord cancers at our institution. We currently treat most patients with irradiation and consider transoral laser excision for the small subset of patients with well-defined T1 tumors that are limited to the mid-third of the cord. In this area, excision will not significantly diminish voice quality. [11][12][13] Stage I and stage II supraglottic cancers may be treated with either radiation therapy alone or with a supraglottic laryngectomy with bilateral selective neck dissections (levels II-IV). In experienced hands, transoral laser excision also is an acceptable alternative for selected lesions. Overall, approximately 80% of patients at many institutions are treated initially by irradiation. 14

Objectives:
To compare the outcome of surgery and radiotherapy in the treatment of early (T1N0M0) carcinoma of the larynx Study Population : All consecutive cases of early stage carcinoma (T1N0) admitted in the above hospitals during the study period.

Methods of sampling:
Patients of carcinoma of the larynx are evaluated properly by detailed history taking, clinical examination and relevant investigation.
Technique of treatment: Two groups of patients were dealt separately.
Post operative follow up: All the patients were followed up after 2 weeks, 1 month and then three monthly for one year Operational definition: Major morbidity-which significantly hampered the patients quality of life like haematoma, seroma, flapnecrosis, stomal recurrence, stenosis of the tracheostomy, recurrent chest infections, distal metastasis, pharyngeal stenosis in partial laryngectomy patients. Severe radiation reaction necrosis of skin, respiratory distress following radiation and perichondritis of the larynx in radiotherapy.
Minor morbidity-Unavoidable minor complications like wound infection, nausea, vomiting, skin rashes, alopecia, mucositis or painful erythematous reaction in larynx and pharynx, dryness of mouth and throat, loss of taste, subcutaneous fibrosis in radiotherapy.

Study on Voice Quality:
We compare the voice quality of patients from the two treatment groups. Randomly 10 patients from each treatment group ware selected. The patients in the radiotherapy group were older (mean age, 56 years) than those in the surgery group (mean age, 52 years). There were no other significant differences between the two groups. Voice and speech quality was assessed by a simple scoring system Voice Handicap Index (VHI score) validated in standard questionnaires* The scoring method was a simple 4-point score.
1. Normal voice and speech (score 0-10). 2. Good voice and speech (score 11-30). 3. Moderate voice and speech (score 31-50). 4. Poor voice and speech (score >50). Table shows The age of the patient ranged from 30 to 79 year. The mean ± SD age was (54±10.94) most of the patients were above 40 years of age. The mean age of the radiotherapy group was 56 years, and the mean age for the surgical group was 52 years.

Results:
The table shows that supgraglottic carcinoma was found in 60% of radiotherapy group and 66.67% in surgery group, glottic carcinoma was 40% & 33%,respectively in radiotherapy and surgery group. No case found with subglottic carcinoma. There was no significant diffirence in these two groups regarding site of carcinoma.     Table shows that ten patients from each treatment group were recruited randomly. In the radiotherapy group, eight were scored as normal and two as good. For the surgery group, three patients had good voice and speech, four had moderate voice and speech, and three had poor voice and speech. This difference was ststistically significant (p=.001).    Table shows that there was a significant difference in the pattern of recurrence in the neck between the two treatment groups. Only 6.67% of those who were treated with irradiation had a recurrence in the neck. 16.67% of patients in the surgery group had a recurrence in the neck; this difference was statistically significant (p < 0.05).

Discussion:
The mean age of the radiotherapy group was 63 years, and the mean age for the surgical group was 61 years. There was no significant difference in male-female ratio for the two groups.
Among the aeteological factors, smoking, chewing betel nuts and betel leaves and alcohol are the most important factors contributing to the carcinoma larynx. Out of 30 cases 96.67% were smokers in radiotherapy group and 93.33% were in surgery group, 93.33% cases were habituated with chewing betel nut and tobacoo and only 50.0% and 43.33% cases were both chewing and smoker in Radiotherapy and Surgery groups respectively.
The findings of direct laryngoscopy showed supgraglottic carcinoma was found 60% in radiotherapy group and 66.67% were in surgery group and glottic carcinoma was (40% & 33%) only. No case was found with subglottic carcinoma. The nature of lesion was exophytic in (66.67% & 63.33%) and ulcerative (33.33% & 36.67%). There was no significant diffirence between the two Regarding histopathological examination 95% were squamous variety, similarity was seen by anather study16 There was no significant diffirence in these two groups-Majority of the subject. [15][16] In this study, out of 30 cases in surgery group, 6 patients had major complications and most of them were pharyngeal stenosis 2(6.67%) and 1 patien had minor complications. In radiotherapy group 3 patients had major complications and 27 patients hand minor complications most of them were dryness of mouth and throat. This study showed that regarding speech and voice 10 patients from each treatment group were recruited randomly by using computer. In the radiotherapy group, 8 were scored as normal and 2 as good. For the surgery group, three patients had good voice and speech, 4 had moderate voice and speech, and 3 had poor voice and speech. This result consistent with work of Thomas JV et al. 20 In this study, no significant difference was found when recurrence at the primary site for those patients treated by surgery or by irradiation was studied. 16.67% of the irradiation group had a primary site recurrence compared with 20.0% in the surgery group at 12 th months (p = 0.59). This result coincides by another study 20 , primary site recurrence were 20% in radiotherapy group and 22% in surgery group.
This study shows that there was a significant difference in the pattern of recurrence in the neck between the two treatment groups. Only 6.67% of those who were treated with irradiation had a recurrence in the neck. 16.67% of patients in the surgery group had a recurrence in the neck. This result coincide by another study 9.0% of radiotherapy group at primary site recurrence and 25.0% in surgery group. 20

Conclusion:
Both surgery and irradiation are equally effective at treating early laryngeal carcinoma but Speech and voice quality were significantly better in patients treated by irradiation than those treated by surgery.