SQUAMOUS-CELL CARCINOMA OF THE PYRIFORM SINUS - A NONRANDOMIZED COMPARISON OF THERAPEUTIC MODALITIES AND LONG-TERM RESULTS

From January 1964 through December 1991, 408 patients with squamous ce ll carcinomas involving the pyriform sinus were treated at Washington University Medical Center. Their ages ranged from 29 to 83 years (mean , 62.3; median 59) and the male to female ratio was 5:1. The mean dura tion of symptoms prior to diagnosis was 3.9 months (range 1 to 32 mont hs) and 89% had a smoking or ethanol history. Sixty-seven percent had T3 or T4 lesions and 87% were stage III or IV at presentation. Sixty-n ine percent had neck metastases. The treatment strategy varied with re spect to radiation and reconstruction. Prior to 1978, preoperative rad iation (3.5 to 5000 cGy) was used. Postoperative radiation was given t hereafter (600+ Gy). Since 1982, flap reconstruction (usually pectoral is major myocutaneous) has been used to close the partial laryngophary ngectomy (PLP) defect. Almost all NO necks were treated by radiation o r surgery and all N1-N3 lesions were treated by combined therapy. Pyri form tumors were subdivided into three groups: 1. one-wall lesions (n = 48), 2. medial-wall lesions which involved the aryepiglottic fold or supraglottis (N = 267), and 3. two- or three-wall lesions which exten ded to the pyriform apex or post-cricoid region (N = 93). Ninety-five patients had single-modality therapy and 302 had combined treatment. T wo hundred seven patients had conservation surgery (PLP) and 157 had t otal laryngopharyngectomy alone or in combination with radiation, Thir ty-three patients were treated by radiation alone. Eleven patients wer e excluded from the study because of distant metastases (TxNxM1) at pr esentation. The cumulative survival (NED) at 5, 10, 15, and 20 years w as 56%, 35%, 31%, and 20%, respectively. The cumulative locoregional c ontrol rate was 71%. At 5 years (NED), the cure rates for one-wall les ions (73%) were better than for medial-wall lesions (63%) or 2- and 3- wall lesions (49%). One-wall lesions were smaller, medial-wall lesions behaved similar to supraglottic tumors, and two- or three-wall tumors behaved as hypopharyngeal tumors. The cure rates were related to T st age with T1 + T2 > T3 + T4 (28%). Neck metastases reduced the cure rat e by 26% and N1 > N2-N3 by an additional 12%. Other factors contributi ng to therapeutic failure were distant metastases (17.7%), second prim ary tumors (6.2%; oropharynx and lung were most common), and intercurr ent disease fatalities (9.5%). The secondary therapeutic salvage rate was 44% for surgery and 32% for radiation therapy. The therapeutic com plication rate was 19% with 3.6% leading to fatality. On a selected ba sis, radiation combined with conservation surgery (71%) was more curat ive than with total laryngectomy (53%) or radiation alone (27%). There was no statistical difference between preoperative or postoperative r adiation in either the conservation surgery or total laryngopharyngect omy groups. Postoperative radiation with flap reconstruction decreased the incidence of all complications, especially perioperative or delay ed fatal complications (from 20% to 5.7%) in conservation surgery pati ents.