See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/13806328

In relation to the arytenoid edema in the radiotherapy of the early vocal cord
cancer: Arytenoid shielding and small size of the field

Article  in  Radiotherapy and Oncology · December 1997

DOI: 10.1016/S0167-8140(97)00128-X · Source: PubMed

CITATIONS READS

6 13

2 authors:

Angeles Rovirosa Albert Biete

Hospital Clínic de Barcelona Hospital Clínic. University of Barcelona
478 PUBLICATIONS   1,253 CITATIONS    381 PUBLICATIONS   1,945 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Intraoperative Radiotherapy View project

Postoperative brachytherapy in endometrial carcinoma, fractionation schedules and late complications View project

All content following this page was uploaded by Angeles Rovirosa on 12 June 2018.

The user has requested enhancement of the downloaded file.


ELSEVIER Radiotherapy and Oncology
Letters to the Editor
IN RELATION TO THE ARYTFNOID EDEMA IN
THE RADIOTHERAPY OF THE EARLY VOCAL
CORD CANCER: ARYTENOID SHIELDING AND
SMALL SIZE OF THE FIELD
To the Editor,
We read with interest the paper entitled ‘Effect of ary-
tenoid sparing during radiation therapy of early stage
glottic carcinoma’, published recently by Alla1 et al. [ 11.
The authors analyzed 70 patients with early vocal cord
carcinoma (Tis-Tl-T2, NO) treated with radiotherapy. In
40 of these patients the arytenoids sparing was done by a
block in the posterior aspect of treated volume after a
mean dose of 54 Gy (45-64). The local control, survival
and complications were similar between the patients with
the arytenoid sparing and those without the arytenoid
block.
We wish to offer some thoughts and data which we
think are relevant to this subject. Searching through the
literature reveals that the most important factor in ary-
tenoid edema is the size of the field. An increased inci-
dence of arytenoid edema after radiotherapy has been
reported when the size of the fields reaches 6x6 cm [2-
5,8,9]. Perhaps, the number of patients studied by Alla1 et
al. did not allow them to establish a relationship between
the size of the field and the arytenoid edema in the two
groups of patients. Nevertheless, the mean field treatment
size was similar in both groups, and they seemed bigger
than 6x6 cm in the majority of the cases (a 41.5*8 cm2
surface in the group without arytenoid shielding and a 38
~6.8 cm2 in the group with shielding). As the authors
mentioned, the influence of the arytenoid sparing has
been poorly studied in relation to the local control and
complications, and they argued that arytenoid shielding
was not useful in their case to avoid complications. How-
ever, we would like to report some published papers of-
fering different views to those of Alla1 et al.
Cellai et al. [3], in a retrospective study of 205 patients
with Tl-T2 glottic carcinoma, found an increased inci-
dence of larynx edema in the 85 cases with treatment
fields bigger than 6x6 cm. Teshima et al. [9] reported
12% arytenoid edema in .87 patients when the size of the
field was 6x6 cm, while there was a 2% incident rate
when the fields size were 5x5 cm. The survival rate was
similar in both groups. In the Alla1 et al. series, the grade
2-3 late laryngeal complications, the majority in the form
Elsevier Science Ireland Ltd.
EL
ADIOTHERAPY
& ONCOLOGY
PY*..LO(nllYmnU~I.~~lm
,“,..“UII..~~IOIOL..“.~~.
45 (1997) 209-211
of arytenoid edema, appeared in 16% of the group with-
out block and in 20% of the group with arytenoid sparing,
the difference between both not being significant. Ter-
haard et al. [8], Chatani et al. [4] and Fein et al. [5] also
considered that the size of the field is a prognostic factor
in the appearance of larynx complications. Probably, the
high and similar incidence of larynx complications in
both groups of the Alla1 et al. series is more related to the
size of the field than to the use of an arytenoid block.
According to Alla1 et al., a critical factor for optimal
treatment results in the glottic carcinoma is to obtain the
most exact possible knowledge of the tumor extension
and careful attention to the treatment technique. As a con-
sequence, the arytenoids sparing should be limited to
those cases without ambiguity in the tumor localization, if
the daily patient positioning could be assured and the
treatment could be individualized. In the 199Os, the im-
mobilization systems and the CT planning allow an indi-
vidualized treatment that permits the exclusion of ary-
tenoids whenever possible [2,6,7]. In the hypothetical
case that the arytenoids block will not offer any gain in
the local control and complications, we believe that
whenever possible, we should avoid the high dose irra-
diation of healthy tissue such as the arytenoids.
We would like to report that since January 1994 we
have been using the CT for the vocal cord localization,
determination of the size of the fields and the dosimetric
study [6,7]. In 29 patients with early vocal cord cancer
treated until November 1996, the median given dose was
66 Gy, 2 Gy/day, 5 fractions per week. The patients were
treated with 2 opposite or 2 oblique anterior fields by a 6
MV Linac. The mean follow-up in those patients was
24 months (an interval of 8-41 months). The median size
of the field was 5x5 cm, the treatment areas being less
than 35 cm2 in all the cases except one, whose area was
42 cm2. The arytenoid sparing after 46 Gy was done only
in 2 patients, with our knowing their placement by the CT
and taking into account the dosimetric study (because of
the location and extension of the tumor in the vocal
cords). The arytenoid edema after 6 months was present
only in 3 patients and was classified as grade I of the
RTOG. In 90% of the cases the anterior half of the ary-
tenoids received 66 Gy, and smaller doses in the rest of
the cases.
The actuarial survival free of disease at 2 and 3 years
was 93%. One patient had local relapse that was treated
by cordectomy. One patient had CT images suspicious of
 210 Letter to the Editor
relapse, but this did not have pathological confirmation
because the patient died of dementia; this last patient was
considered dead by relapse for the survival study. All the
patients that are alive have voice preservation and the
quality of voice was considered normal or practically
normal by the patients in 83% of the cases. Three patients
died of second neoplasms and one died of brain vascular
disease.
An immobilization system for the daily treatment setup
and a CT-based planning treatment will allow us the use
of small fields and the arytenoids sparing whenever pos-
sible in order to optimize the treatments and to avoid
complications.
References
111Allal, AS., Miralbell, R., Lehmann, W. and Kurtz, J.M. Effect of
arytenoid sparing during therapy of early stage glottic carcinoma.
Radiother. Oncol. 43: 6563.1997.
121 Amdur, R.J., Conine, F.E., Harris, R.D. and Leopold, K.A. Ary-
tenoid sparing during the irradiation of early vocal cord cancer.
Int. J. Radiat. Oncol. Biol. Phys. 32: 801-808, 1995.
[31 Cellai, E., Chiavacci, A. and Ohni, P. Causes of failure of curative
radiation therapy in 205 early glottic cancets. Int. J. Radiat. On-
col. Biol. Phys. 19: 1139-l 142, 1990.
[41 Chatani, M., Matayoshi, Y., Ha&i, N., Inoue, Ta., Teshima, T.
and Inoue, To. Radiation therapy for early glottic carcinoma: in-
dication for the wedge filter. Strahlenther. Oncol. 169: 655-659,
1993.
PI Fein, D.A., Lee, W.R., Hanlon, A.L., Ridge, J.A., Curran, W.J.
and Coia, L.R. Do overall treatment time, field, size, and tmat-
ment energy influence local control of Tl-T2 squamous cell car-
cinomas of the glottic larynx?. Int. J. Radiat. Oncol. Biol. Phys.
34: 823-831, 1996.
WI Rovirosa, A., Berenguer, J., Sanchez-Reyes, A., et al. Simulation
by a diagnostic CT for the early vocal cord carcinoma. Med. Do-
sim. 22: 13-16, 1997.
r71 Rovirosa, A., Bereguer, J., Sanchez-Reyes, A., et al. Considera-
tions after simulation by a diagnostic CT of 25 TlNO vocal cord
carcinomas. Quality assurance. Radiother. Oncol. 40: Sl48,19%.
PI Terhaard. C.H.J., Snippe, K., Ravasz, L.A., Tweel, V.D. and
Hordijk, G.J. Radiotherapy in Tl laryngeal cancer: prognostic
factors for the locoregional control and survival, uni- and multi-
variate analysis. Int. J. Radiat. Oncol. Biol. Phys. 21: 1179-l 186,
1991.
PI Theshima, T., Chatani, M. and Toshihiko, I. Radiation therapy for
early glottic cancer (TINOMO): II. Prospective randomized study
concerning radiation field. Int. J. Radiat. Oncol. Biol. Phys. 18:
119-123.1990.
Sincerely,
Angeles Rovirosa, Albert Biete (Received 10 June 1997;
accepted 30 June 1997)
Department of Radiation Oncology, Hospital Clinic i
Universitari of Barcleona, Willarroel No 170, 08036
Barcelona, Spain
0167-8140/97/.$17.00 Q 1997 Elsevier Science Ireland Ltd.
All rights reserved
PII SOl67-8140(97)00128-X
View publication stats
ABOUT ARYTENOID SHIELDING DURING
RADIATION THERAPY OF EARLY STAGE
GLOTI’IC CARCINOMA
To the Editor,
I appreciate Drs. Rovisora and Biete’s comments on
our article [l] and read with interest the results of their
study on arytenoid sparing during radiotherapy of early
glottic carcinoma. I would like to add a note of clarifica-
tion concerning the results, both our own and those re-
ported by others, upon which Rovirosa and Biete have
based their arguments. While acknowledging that the
weak points of our study (retrospective nature, small
number of patients and heterogeneity of the two groups)
might have infuenced the results, one should place our
data in their proper context. Indeed, the data pertain to
arytenoid shielding (at a median dose of 54 Gy) and not
arytenoid sparing (from the first treatment session). Thus,
these observations cannot be extrapolated to the other
techniques sparing the arytenoid during the full course of
radiotherapy, such as the use a small fields determined on
CT planning or oblique anterior fields.
Moreover, our data concern patients treated mostly
with @Co; in this setting papers reporting a relation be-
tween field size and arytenoid edema are rather contro-
versial, particularly if we consider only studies in which
investigators have tried to compare what is truly compa-
rable. Thus, in the study of Terhaard et al. [7], field size
was not considered as an independent factor in the multi-
variate analysis for mild late laryngeal complications. In
the study of Chatani et al. [2] minor complications ap-
peared to be linked also to the use of wedges, and for
large Tla tumors, 5-year relapse-free survival was sig-
nificantly lower in the group of patients treated with a
field size of 5x5 cm. Similar results underlying the im-
penance of the field size have been reported by Harwood
et al. [5] and Hintz et al. [6]. Concerning the study of Fein
et al. [4], no statistical evaluation was done to assess the
relation between late complications and field size, in con-
tradiction to what Rovirosa and Biete seem to state. By
mentioning the work of Cellai et al. [3], the authors make
me think that we are not addressing the same subject
since in this study the larger fields were too large to be
discussed in our setting (8x10 cm). Moreover, those pa-
tients were treated partially with electrons up to 20 MeV
and some of them with fractions of 3 Gy. In the random-
ized study of Teshima et al. [8], which is the most perti-
nent study, patients were treated with 4 MV photons, and
their results may not be reproducible by using 6oco
beams. Indeed I don’t think that 5-mm reduction of the
posterior limit of the field will influence significantly late
complications considering the large penumbra of the 6oco
bC3lXl.S.
Concerning the results reported by the authors in this
issue, it is interesting to note that in only 2 cases (7%)