Regarding:

> 57 in generally good health who was diagnosed with carcinoma of the R true
> cord 13 years ago. Treated with vocal cord stripping followed by radiation
> therapy. Now presents with carcinoma of right cord with immobile cord.

A few comments.

1. Theorem: All cells exposed to a carcinogen, given enough time, become
cancerous. This is the basic concept of field cancerization, and my experience
suggests that it is so (1). Thus, it is most probable that this patient has a
further expression (a second cancer) of his sick mucosa, not a recurrence some
13 years after XRT. So what? Either way,
he's got cancer and needs treatment.
2. Well, it demonstrates one of the problems with XRT. XRT does not change the
process of carcinogenisis, and this patient's course is not uncommon. Given
enough time, second, third, fourth, etc. cancers occur in sick mucosa, despite
smoking cessation, despite xrt, and despite surgery, too (2). There is no known
cure. And patients should understand
this so they accept life-time follow up, and so that they seek help with onset
of any symptom. Surely this patient for some time ignored voice change.
3. Another problem with XRT is that it makes sick mucosa sicker, an effect that
is permanent and progressive, and it harms healthy tissue too, diminishing
blood supply and causing fibrosis.
4. We were not informed as to the present status of this patient's neck and
laryngeal tissues, but I would guess that 13 years post XRT they are such that
they would not survive even modest surgical trauma and bacterial exposure.
Under these circumstances total laryngectomy is less likely to lead to tissue
loss and fistula than is any partial
procedure. And if there is serious concern regarding tissue survival, a control
fistula is preferred to allowing nature to take its course.
5. The exception to this is that proposed by Dr Mohr. A transoral attempt at
excision by CO2 laser may allow total removal (3). If not, no harm has been
done. Instead, there is a more accurate evaluation of the extent of the cancer,
allowing better informed choice of therapy, which can be carried out
immediately if so desired.
6. Lastly, my comments of a few days ago regarding treatment choice also are
appropriate here.

1. Vaughan  CW, Incze  JS, Lui  P, Kulapaditharon  B: Premalignant Changes in
Normal Appearing Epithelium in Patients with SCC of the Upper Aerodigestive
Tract. American Journal of Surgery,  l44:40l-05, l982.
2. Gillis  TM, Incze  J , Strong  MS,  Vaughan  CW, and Simpson  GT:  Natural
History and Management of Keratosis, Atypia, Carcinoma in Situ and
Microinvasive Cancer of the Larynx.  American Journal of Surgery,  5l2-l6,
l983.
3. Vaughan CW,  Strong  MS,  and Jako  GJ: Laryngeal carcinoma: Transoral
treatment utilizing the CO2 laser.   American Journal of Surgery,  l36:490-93,
1978.

Charles W Vaughan MD
Boston University