Carcinoma of the Anterior Commissure

■ REVIEW ARTICLE
Carcinoma of the Anterior Commissure
Jesús Herranza, Javier Gavilánb, and Juan C. Vázquez-Barrosa
a
Servicio de Otorrinolaringología. Hospital Universitario Juan Canalejo. A Coruña. Spain.
Servicio de Otorrinolaringología. Hospital Universitario La Paz. Madrid. Spain.
b
Treatment of glottic carcinoma with anterior commissure
involvement is under debate. Treatment spectrum includes
surgery, open or endoscopic, and radiotherapy. Since similar
results are reported in the literature, preferences depend on
experience and skill of the person responsible for treatment.
Our objective is the analysis of scientific data published in
Medline, CancerLit, Cochrane Register, and EMBASE,
between 1996 and 2007.
Twenty-five articles matched our selection criteria. None
was a controlled randomized, double-blind trial, clinical
guidelines, or a meta-analysis. Eleven were historical,
7 clinical trials, 6 review articles, and 1 was a Cochrane
review. There is no scientific data to support
recommendations for the most effective treatment in patients
with squamous cell carcinoma of the anterior commissure.
The available evidence is level 5, with a D recommendation
grade.
Key words: Carcinoma. Larynx. Anterior commissure.
Radiotherapy. Laser. Surgery.
Carcinoma de comisura anterior
El tratamiento de los tumores glóticos que afectan a la
comisura anterior admite una variedad de opciones
(cirugía abierta, cirugía endoscópica o radioterapia), con
similares resultados desde el punto de vista oncológico.
Las preferencias terapéuticas varían según los países y la
experiencia. El objetivo del presente estudio es analizar la
evidencia científica de las series publicadas entre 1996 y
2007 e incluidas en las bases de datos MEDLINE, CancerLit, EM-BASE y Cochrane Plus.
Se identificaron 25 artículos con los criterios de búsqueda,
ninguno de ellos controlado, aleatorizado, a doble ciego,
meta-análisis o guía de práctica clínica. Se encontraron
11 estudios descriptivos, 7 ensayos clínicos, 6 artículos de
revisión y una revisión Cochrane.
Actualmente no hay evidencia científica suficiente para
determinar cuál es el tratamiento más eficaz en los tumores de comisura anterior, pues la que hay es de nivel 5,
con un grado de recomendación D.
Palabras clave: Carcinoma. Laringe. Comisura anterior.
Radioterapia. Láser. Cirugía.
INTRODUCTION
The anterior commissure (AC) is a key area for the
assessment of laryngeal cancer, from both a therapeutic
standpoint and in terms of prognosis and functional sequelae.
Primary AC tumours are rare, but glottic tumours involving
the commissure are not infrequent and overshadow both
the possibilities of a cure and the functional sequelae. Its
anatomical characteristics make it a vulnerable point for the
The authors have not indicated any conflict of interest.
Correspondence: Dr. J. Herranz.
Courel, 6. 15179 Oleiros. A Coruña. Spain.
E-mail: jhg@canalejo.org
Received on May 23, 2007.
Accepted for publication on May 29, 2007.
dissemination of cancer, therefore its correct assessment,
difficult to achieve clinically, is important to understand the
true extension of the tumour1, as well as to evaluate the
prognosis2, as its involvement is related to a reduction in
local control of the illness2-4, despite the fact that the tumour
may be anatomically small. The clinical appearance of an
initial stage does not necessarily translate to an incipient
cancer5.
There is no unanimity on the treatment of tumours
affecting the AC, but several surgical options6-10, open or
endoscopic, and radiotherapy11 are available. The high ratio
of cures in the initial stages of laryngeal cancer, including
most of the tumours affecting the AC, implies an assessment
of results based on survival as well as the impact of functional
sequelae12-14.
The purpose of this article is to review the current status
of therapeutic options for laryngeal cancer involving the
AC, comparing open or endoscopic surgical treatments and
radiotherapy, analyzing the scientific evidence indices for
each15.
Acta Otorrinolaringol Esp. 2007;58(8):367-70
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Herranz J et al. Carcinoma of the Anterior Commissure
METHOD
DISCUSSION
The scientific literature published between 1995 and
2007 has been reviewed as collected in MEDLINE,
EMBASE, CancerLit, and the Cochrane Register of
Controlled Trials.
The search query was for randomized controlled studies
comparing surgery, both open and endoscopic, and
radiotherapy.
The study population was patients with a histologically
confirmed diagnosis of epidermoid carcinoma of the
larynx with involvement of the AC. Types of treatment:
open surgery, endoscopic surgery using laser and
radiotherapy.
The following variables were sought in the trials: survival,
relapses, morbidity, voice quality and quality of life.
The electronic search on MEDLINE used the following
categories: with abstract, between 1996 and 2007, in English,
Spanish, French, Italian or German, randomized controlled
study, clinical trial, double blind trial, meta-analysis, review
articles, clinical practice guidelines, and with the following
terms: anterior commissure, larynx neoplasm, cancer,
radiotherapy, surgery, laser, transoral, endolaryngeal,
hemilaryngectomy.
The AC of the larynx is the area connecting the 2 vocal
cords with the thyroid cartilage. If we were to attempt to
find in the literature a widely-accepted definition of this
anatomical structure, it would be a wasted effort despite
the term being used in the classification of the UICC and
the AJC18. Most of the studies aim to identify the weak points
through which tumours affecting the AC can extend into
other levels of the larynx (supraglottis, subglottis), cartilage
or extralaryngeal structures19-22, although not all of them
agree on the role of the AC as a weak spot or barrier in cancer
of the larynx. Where there is no doubt is that tumours
affecting the AC behave differently from other tumours in
the glottic region and require more exhaustive diagnostic
procedures. A specific classification for AC in glottic tumours
(AC0: no invasion; AC1: infiltration on one side only; AC2:
infiltration only partially crossing the midline; AC3:
infiltration of the entire AC on both sides of the midline)
correlates with the prognosis for patients in terms of local
control at 3 and 5 years2. However, over and above the need
to modify or increase the TNM classification, something
that may be more of a complication than a simplification23,24,
experience has shown that tumours affecting the commissure
are usually larger in extension than initially suspected on
clinical examination12,24.
Clinical evaluation of the lesion depending on whether
it has an infiltrating or non-infiltrating morphology implies
different behaviour1. Whereas in the latter case, the tumour
is usually limited to the glottic plane, in the first the tumour
is often deeply invasive, reaching other planes of the larynx
and behaving as a true anterior transglottic tumour1. Studies
with magnetic resonance do not improve the detection rate
of infiltrating lesions obtained with the use of computerized
tomography, which gives excellent anatomic detail of the
larynx and the adjacent structures. The slices are normally
axial, but coronal and sagittal slices are also possible with
magnetic resonance.
Cartilage has a low density in computerized tomography,
unless it is calcified, as usually occurs in elderly patients.
In magnetic resonance it gives a high signal because of the
fatty core. The mucosae of the subglottis and the AC must
be no thicker than >1 mm in magnetic resonance imaging.
The vocal cords give a low-level signal (ligament), whereas
the bands give an intense signal (they contain fat)25,26.
Early endoscopic treatment of glottic tumours by CO2
laser is today the procedure most commonly used in our
setting, although there is still some debate on the subject.
The driving force behind this technique, W. Steiner,
introduced the option of fragmented resection of the
tumour, with control of surgical margins, as an alternative
to open surgery. In his experience, the surgeon’s skill in
obtaining adequate exposure and orientation of the tumour
is the key to preventing relapse27. The use optional subjects
small calibre laryngoscopes and the external manipulation
of the laryngeal skeleton improve visibility, as does the
partial resection of the anterior area of the ventricular
bands. Resection of the anterior portion of the ventricular
bands must be done with caution in view of their
Description of the Studies Found
The above search criteria found 25 articles, none of which
met the criteria of randomized controlled trial, double blind
trial, meta-analysis or clinical practice guidelines. Those
found were 11 descriptive studies, 7 clinical trials, 6 review
articles and a Cochrane Review16.
According to the Cochrane review, which studied the
use of radiotherapy compared with open surgery or
endolaryngeal surgery (with or without laser) for the
treatment of early-stage carcinoma of the larynx (T1, T2),
there is still uncertainty about the comparative benefits
and the social costs of the different treatment modes. The
implementation of a randomized prospective study
comparing the various treatment modes is difficult, as
many professionals assume similar survival rates, 100%
at 5 years in T1 after surgery, and 91.7% after radiotherapy,
but the functional sequelae are more marked in surgery.
On the other hand, the only randomized prospective
study is impaired by methodological and analytical
flaws17.
According to this study, the use of endoscopic surgery
reduces the functional sequelae, as well as the morbidity
and the length of hospital stay, with the associated savings
in resources. The implementation of a randomized
prospective study measuring voice quality, quality of life,
costs, complications, and morbimortality may require an
international programme, due to the small number of cases
at each individual institution16.
As for the results of the Cochrane review, the
recommendations given in the articles published are only
based on their authors’ opinions and, therefore, have a level
5 for scientific evidence and a recommendation grade D,
according to the Oxford Centre for Evidence-Based Medicine
(CEBM).
368 Acta Otorrinolaringol Esp. 2007;58(8):367-70
Herranz J et al. Carcinoma of the Anterior Commissure
importance in the vocal rehabilitation phase. The tumour
must be resected with magnification and direct vision. The
insertion of the vocal cord in the thyroid cartilage is
completely resected together with the surrounding
perichondrium. If there is sub-glottic growth under the
AC, the resection must extend to the lower edge of the
thyroid cartilage to ensure inclusion of the full extension
of the tumour. The cricothyroid membrane, if necessary,
is also completely resected. In difficult cases, a biopsy must
be made after 6-8 weeks to ensure there is no relapse27.
Steiner et al.9 report local control at T1a with involvement
of the AC in 84% and 84% after 3 and 5 years, respectively,
with 7% of total laryngectomies. In T1b with involvement
of the AC, 81% and 73% after 3 and 5 years, respectively,
with 13% of total laryngectomies.
In the opinion of Pearson et al.8, open surgery, unlike
endoscopic surgery, approaches the tumour blind, as the
surgeon must, before entering the larynx, cut open the skin,
separate the prelaryngeal muscles and section the thyroid
cartilage following anatomical references, before then
resecting the tumour with worse magnification and in poorer
light. According to this author, open surgery is a meticulous
procedure that does not allow adaptation to the specific
situation of each patient. For Pearson, the functional outcome
is impaired when treatment is effected after a relapse
following radiotherapy, which occurred in over 50% of his
patients. Prior radiotherapy hinders histological diagnosis,
as well as the imaging assessment, at the same time as it
delays and hinders healing.
Partial or conservative surgery, where the goal is the
resection of the lesion without the need to have a permanent
tracheostome, is a safe and well-contrasted procedure. As
in the case of endoscopy, it requires an awareness of the
technique and some experience, something that is more and
more difficult to acquire due to the greater trend towards
endoscopic surgery and organ-sparing techniques as well
as the greater morbidity (speech and swallowing) related
with it28. Such an approach is indicated in those cases where,
due to experience, anatomical conditions or availability, the
patient is not a candidate for endoscopic treatment.
Most of the studies carried out in the last few years, on a
total of 1,785 patients, into the impact of AC involvement
in disease control for patients with T1 and T2 tumours treated
with radiotherapy coincide. With the exception of 2 studies
that did not find any relationship, the involvement of the
AC is one of the poorest prognostic factors in the
multivariable analyses26.
Voice quality has been extensively evaluated and the
studies coincide. Radiotherapy is the procedure that has the
least repercussion on voice quality5.
CONCLUSIONS
There is currently insufficient scientific evidence to
recommend any treatment as the most effective for AC
tumours. The treatment of a patient with a cancer involving
the AC must be individualized in the light of the size,
extension, age, general health and anatomical conditions of
the patient, as well as the expertise and abilities of the
therapeutic team in the various treatment options.
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