Optimal Treatment for Early Glottic Carcinoma

Abstract The management of early glottic cancer has evolved significantly over the past two decades, with transoral laser microsurgery and radiotherapy emerging as the two favored modalities of treatment. Although the role of Open partial conservative surgery has reduced but there are still some specific indications. The preference of one modality over another has generated lot of debate and continues to be controversial. As the survival outcomes are similar in all the modalities, we need to consider factors like professional needs, quality of life, vocal function and cost-effectiveness as regards the modality to be preferred. This manuscript aims at comprehensive overview of the contemporary literature comparing all the treatment modalities. Optimal Treatment for Early Glottic Carcinoma Open conservative laryngeal surgery (CLS), transoral laser microsurgery (TOLMS) and radiation therapy are valid and effective options for treating Tis, T1, and T2 glottic lesions. Although the evidence favoring any of the single modality to another is globally low level, but there is considerable shift towards trans-oral laser microsurgery. Subjective selection bias and opinion affect the decision making. The opportunity for CLS and TOLMS depend on the experience and expertise of the surgical oncology specialists. Three important tumor factors have significant influence on decision making in early glottic cancer: T-stage, true vocal cord mobility and involvement of anterior commissure (AC). Main treatment goal in early laryngeal cancer is to optimize local control, while optimizing preservation of function and hence quality of life. For achieving this goal, a careful initial clinical evaluation is very important. The clinical examination is most often performed using fiberoptic or rigid endoscopy to assess the extent of lesion and laryngeal mobility, which is the main issue in treatment of early glottic cancer. Laryngeal mobility was the only predictor of minor thyroid cartilage invasion treated with conservation laryngeal surgery and for early-stage to mid stage tumors involving the AC [1,2]. AC must be thoroughly evaluated clinically, as the approach and outcomes differ with the disease extension to this critical site. Subglottic extension and proximity of the tumor to the cricoid cartilage must be ascertained in view of organ-preservation surgery, in which a stable cricoid is essentially preserved. Evaluation under general anesthesia with 30 degree angled rigid endoscope helps in assessing AC and subglottic extension. Initial workup should include CT and/or MRI of the larynx especially if there is AC or subglottic extension on laryngoscopy. Guidelines are not generally useful and do not provide detail for selection of optimal treatment modality for particular patient. To optimize patient outcome, current evidence must be combined with experience of the multidisciplinary team managing these patients. Emphasis should be on an honest and open discussion regarding all of the aspects of different treatment options.