What are the treatment options for glottic laryngeal cancer?

Treatment of Glottic Laryngeal Cancer

For early-stage glottic cancer (T1-T2N0), either radiation therapy or larynx-preservation surgery achieves equivalent survival outcomes with 80-90% cure rates, making treatment selection dependent on tumor characteristics, anticipated functional outcomes, and patient preference rather than oncologic superiority. 1

Carcinoma In Situ

• Endoscopic removal (stripping or laser excision) is the preferred treatment over radiation therapy for carcinoma in situ. 1
• This approach reserves radiation for potential future malignancies in the upper aerodigestive tract. 1

Early-Stage Disease (T1-T2N0)

T1 Glottic Cancer

• Endoscopic laser resection is preferred for superficial tumors located in the middle third of the vocal cord, particularly on the free edge, where voice outcomes remain excellent. 1
• Radiation therapy (60-64 Gy) is preferred for indistinct lesions or those arising in widespread abnormal-appearing mucosa where surgical margins would be difficult to define. 1, 2
• Local control rates are 90-95% with either modality. 3
• Open organ-preservation surgery (partial laryngectomy) remains an alternative option. 1

T2 Glottic Cancer - Favorable

A favorable T2 lesion is superficial on imaging with preserved vocal cord mobility. 1

• Radiation therapy is preferred by most clinicians for favorable T2 lesions, achieving 70-80% local control with superior functional outcomes. 1, 3
• Open organ-preservation surgery (supracricoid partial laryngectomy with cricohyoidoepiglottopexy) provides higher local control rates but results in permanent hoarseness. 1
• This surgical option is reasonable for patients willing to sacrifice voice quality for improved local control, particularly given compromised survival after radiation failure in some T2 cases. 1

T2 Glottic Cancer - Unfavorable

Unfavorable features include impaired vocal cord mobility or deep invasion. 1

• Open organ-preservation surgery is recommended due to higher local control rates compared to radiation alone. 1
• For T2N+ disease, concurrent chemoradiation therapy with high-dose cisplatin (100 mg/m² on days 1,22,43) is an evidence-based organ-preservation option supported by randomized trials. 1

Critical Caveat for Early-Stage Disease

Single-modality treatment is mandatory—combining surgery with radiation in T1-T2N0 disease compromises functional outcomes without survival benefit. 4

Advanced-Stage Disease (T3-T4a)

Resectable T3-T4a with Laryngeal Preservation Desired

• Concurrent chemoradiation with high-dose cisplatin (100 mg/m² on days 1,22,43) is the preferred Category 1 recommendation for laryngeal preservation. 1
• This approach achieves the highest rate of larynx preservation compared to other radiation-based strategies, with equivalent overall survival when salvage total laryngectomy is incorporated. 1
• Cure rates for low-volume T3-T4a disease are 65-70% with concurrent chemoradiation. 3

Induction Chemotherapy Option

• Induction chemotherapy followed by response-based management is a Category 2A option for T3N2-3 disease when patients would otherwise require total laryngectomy. 1
• This approach is not recommended for T1-T2N0 disease outside clinical trials due to insufficient data. 1

Primary Surgery for Advanced Disease

• Total laryngectomy is indicated when laryngeal preservation is not desired or feasible, followed by adjuvant radiation therapy. 1
• Selected cases can be managed with conservation surgical techniques preserving vocal function. 1
• Pulmonary function tests should be obtained before surgery. 1

Patients Unsuitable for Laryngeal Preservation

• Patients with nonfunctional larynx or tumor penetration through cartilage into soft tissues are poor candidates for organ preservation and should undergo primary total laryngectomy. 4
• Patients with extensive or poorly functioning T4a disease should not be offered chemoradiotherapy with salvage surgery as backup, but rather upfront total laryngectomy with adjuvant (chemo)radiation. 5

Medically Unfit Patients

• Definitive radiation therapy without chemotherapy is an option for T3N0-1 patients who are medically unfit or refuse chemotherapy. 1

Adjuvant Treatment After Surgery

Standard Adjuvant Radiation

• Adjuvant treatment depends on pathologic risk features identified at surgery. 1
• For T2N0 disease with risk features or positive margins, adjuvant radiation alone is recommended (not chemoradiation), based on RTOG 95-01 showing no benefit from adding chemotherapy. 1

Adjuvant Chemoradiation

• Adjuvant concurrent chemoradiation is indicated for extracapsular spread and/or positive margins, based on unplanned subgroup analysis showing improved locoregional control and disease-free survival. 1

Salvage Surgery

• Surgery is reserved for persistent disease after chemoradiation/RT or locoregional recurrence. 1
• Ultimate disease control including surgical salvage reaches 100% for T1 and 82% for T2 lesions. 6

Essential Multidisciplinary Considerations

Mandatory Consultations

• Multidisciplinary consultation is critical before treatment due to potential loss of speech and swallowing dysfunction. 1
• Pre-treatment assessment of voice and swallowing function guides treatment selection between organ preservation versus total resection. 4

Patient Counseling

• Patients must understand that no larynx-preservation approach offers survival advantage over total laryngectomy with appropriate adjuvant treatment. 4
• Treatment selection depends on anticipated functional outcome, patient wishes, reliability of follow-up, and general medical condition. 1

Common Pitfalls to Avoid

• Planning surgery with anticipated positive margins requiring postoperative radiation is unacceptable, as this compromises both oncologic and functional outcomes. 4
• Failing to achieve initial local control in T2 disease can compromise survival, making treatment selection critical. 1
• Continued cigarette smoking worsens outcomes after therapy—patients must be enrolled in cessation programs. 4
• Avoiding unnecessary tri-modality treatment (surgery + radiation + chemotherapy) is essential. 5