Prostate Cancer Awareness Month

Stage I Larynx Cancer

There are three main parts of the larynx: the glottis (the middle part of the larynx where the vocal cords are), the supraglottis (the tissue above the glottis) and the subglottis (the tissue below the glottis). The subglottis connects to the trachea, which takes air to the lungs.

Stage I cancer of the larynx is limited to one area and has not spread to lymph nodes in the area or to distant sites.

Supraglottis: The cancer is only in one area of the supraglottis and the vocal cords are normal.

Glottis: The cancer is in the vocal cords and the vocal cords can move normally.

Subglottis: The cancer has not spread outside the subglottis.

A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.

The following is a general overview of the treatment of stage I cancer of the larynx. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.

Treatment Overview

Treatment depends on where the cancer is found in the larynx. American Society of Clinical Oncology guidelines state that all patients with stage I-II laryngeal cancer should be treated with the intent of preserving the larynx.[1] Treatment may involve partial laryngectomy (removal of part of the larynx), radiation therapy, or laser surgery (use of laser beams to remove areas of cancer). Partial laryngectomies lead to the highest local control rates (lowest risk of cancer recurrence in the area of the larynx) reported so far; radiation therapy is believed to preserve the voice the best; and laser surgery requires relatively little time and expense, produces few adverse health effects, and has been linked with good local control rates and excellent treatment options in case of local failure. All specialists dealing with the treatment of early laryngeal cancer should be able to offer these different treatment modalities to their patients and to deal specifically with each patient’s individual needs and preferences.

Cancer of the Supraglottis

Radiation Therapy: Stage I cancer of the supraglottis can be treated with surgery or radiation therapy. When radiation therapy is used, surgery is reserved for the treatment of cancer recurrence. Most studies suggest that radiation therapy is associated with better preservation of vocal function than surgery. In one study, radiation therapy (with surgery after recurrence) resulted in local cancer control in 92 percent of patients with stage I supraglottic cancer, and regional lymph node control in 91 percent.[2] Five-year survival was 83 percent. These results suggest that radiation therapy is effective treatment for stage I cancer of the larynx in the supraglottic region.

Surgery: Surgery (partial removal of the larynx) is effective primary treatment of cancer of the supraglottis with results comparable to radiation therapy.[3]

Cancer of the Glottis (Vocal Cords)

Radiation Therapy: Prior to the development of laser surgery, radiation therapy was the standard treatment for glottic cancer. Radiation therapy produces excellent results, but these results do not appear to be superior to laser surgery. The overall control rates for patients with stage I and II glottic cancer is approximately 90 percent following radiation therapy.[4]

Surgery: Surgical stripping was also a common treatment of stage I glottic cancer before the development of laser surgery, but this approach is generally no longer used. Surgical treatment was associated with a 95 percent preservation rate of the larynx, which is approximately the same as for laser surgery.[5]

Laser Surgery: Several studies suggest that laser surgery offers an effective approach to the treatment of stage I glottic cancer. In an Italian study involving 117 patients with T1a glottic cancer (cancer limited to one vocal cord) and 22 patients with T1b glottic cancer (cancer in both vocal cords), laser surgery resulted in a local control rate of 90 percent and no cancer deaths.[6] In another study, laser surgery for treatment of stage 0 and stage I larynx cancer was initially successful in 86 of 98 patients.[7] Eight of 12 recurrences were treated successfully with repeat laser surgery and 4 with laryngectomy.

Cancer of the Subglottis

Cancer of the subglottis represents less than two percent of all cases of laryngeal cancer and most of these patients have advanced disease. Thus, data on treatment is sparse and limited to a few patients in each study. Stage I cancer in the subglottis is typically treated with radiation therapy. In some cases, a hemilaryngectomy (removal of one side of the larynx) may be necessary when radiation therapy is not successful. In a study from Canada, radiation therapy controlled local disease in seven of 11 patients with stage I subglottic cancer with successful additional treatment with surgery in the case of radiation failures.[8]

Treatment of the Neck

Cancers of the larynx may spread into the lymph nodes of the neck. The question of whether to treat the lymph nodes of patients with stage I larynx cancer is controversial. If recurrence were inevitable, preventive treatment, consisting of surgical removal of the lymph nodes or radiation therapy, would be best approach. However, for stage I patients this would mean treating a large number of patients who would not relapse. This is an important decision since there are side effects of radiation therapy or surgical removal of lymph nodes. The current consensus of opinion is that preventive treatment of the neck may not be indicated for stage I cancer of the larynx, but may be appropriate for stage II and III cancer without clinical lymph node involvement. However, there may be specific locations of stage I cancer of the larynx where the potential for undetected spread to lymph nodes would be high and preventive treatment desirable.[9][10]

Strategies to Improve Treatment

The progress that has been made in the treatment of early cancer of the larynx has resulted from early diagnosis, improved surgical and radiation therapy techniques, as well as participation in clinical studies. Future progress in the treatment of early cancer of the larynx will result from patients and doctors continuing to participate in appropriate studies. Areas of active exploration to improve the treatment of cancer of the larynx include the following:

Improved Radiation Therapy Techniques: Three-dimensional conformal radiation therapy and intensity modulated radiotherapy (IMRT) are relatively new promising techniques which could increase the dose of radiation to cancers without increasing toxicity. There are relatively few reports of these new techniques for treatment of stage I laryngeal cancer. For more information, go to Radiation Therapy for Head & Neck Cancer.

Cryotherapy: Cryotherapy (freezing) is being evaluated for the treatment of a variety of cancers. Recently, researchers from the Cleveland Clinic have reported that laser surgery performed in conjunction with cryotherapy resulted in excellent primary site control with improved voice quality.[11]

Photodynamic Therapy: The concept behind photodynamic therapy is that light from a laser, enhanced by photosensitizing agents, can kill cancer cells without damage to normal cells. The basic technique is over 50 years old but the past 5 years have seen the development of reliable, portable lasers and better photosensitizing agents, making the technique quick, effective and relatively free from side-effects. For patients with head and neck cancer, functional outcomes with photodynamic therapy are probably better than surgery or radiation therapy but there is inadequate long-term survival data.In one study 10 patients with recurrent early-stage laryngeal cancer were treated with photodynamic therapy, with local control in eight. This therapy was successful in preserving the larynx.

An advantage to photodynamic therapy is that it can usually be given to outpatients under local anesthetic. Patients receive intravenous temoporfin (an agent that makes cells sensitive to light), followed four days later by brief laser illumination of the cancer site. Sensitivity to light takes two to three weeks to resolve, during which time patients must avoid bright light. About 10 percent of some 1000 patients treated worldwide had photosensitivity reactions, which generally involved mild redness. Post-treatment pain may require treatment with opiate pain medications.

Chemoprevention of Second Cancers

Second primary cancers occur in 10 to 30 percent of head and neck cancer patients. A primary cancer is a new cancer, rather than a recurrence of a previous cancer. Chemoprevention (the use of drugs, vitamins, or other agents to reduce the risk of cancer) offers an attractive approach to combat this threat.  In the last 10 to 15 years several chemoprevention studies with vitamin A, retinoids or agents working through other mechanisms (such as antioxidants) have been launched.  Large chemoprevention trials are being carried out in the US and in Europe but no definitive study has yet been published.  End-points of these studies are second tumors, local/regional recurrence, distant metastasis and long-term survival rates.

References:


[1] American Society of Clinical Oncology. American Society of Clinical Oncology clinical practice guideline for the use of larynx-preservation strategies in the treatment of laryngeal cancer. Journal of clinical Oncology 2006;24:3693-3704.

[2] Sykes AD, Sievin NJ, Gupta NK, et al. 331 cases of clinically node-negative supraglottic carcinoma of the larynx: a study of a modest size fixed field radiotherapy approach. International Journal of Radiation Oncology Biology Physics 2000;46:1109-1115.

[3] Jones AS, Fish B, Fenton JE, et al. The treatment of early laryngeal cancers (T1-T2 N0): surgery or irradiation? Head Neck 2004;26:127-135.

[4] Franchin G, Minatel E, Gobitti C et al. Radiotherapy for patients with early-stage glottic carcinoma: univariate and multivariate analyses in a group of consecutive, unselected patients. Cancer 2003;98:765-772.

[5] Smith JC, Johnson JT Myers EN. Management and outcome of early glottic carcinoma. Otolaryngology- Head and Neck 2002;126:356-364.

[6] Gallo A, de Vincentiis M, Manciocco V. CO2 laser cordectomy for early-stage glottic carcinoma: a long-term follow-up of 156 cases. Laryngoscope 2002;112:370-374.

[7] Konig O, Bockmuhl U, Haake K, et al. Glottic laryngeal carcinoma. Tis, T1 and T2-long term results. HNO 2006;54:93-98.

[8] Paisley S, Warde PR, O’Sullivan B, et al. Results of radiotherapy for primary subglottic squamous cell carcinoma. International Journal of Radiation Oncology Biology Physics 2002;52:1245-1250.

[9] Rodrego JP, Cabanillas R, Franco V, et al. Efficacy of routine bilateral neck dissection in the management of N0 neck in T1-T2 unilateral supraglottic cancer. Head Neck 2006;28:534-539.

[10] Chiu RJ, Myers EN, Johnson JT. Efficacy of routine bilateral neck dissection in the management of supraglottic cancer. Otolaryngol Head and Neck Surg 2004;131:485-488.

[11] Knott PD, Milstein CF, Hicks DM, et al. Vocal outcomes after laser resection of early-stage glottic cancer with adjuvant cryotherapy. Arch Otolaryngol Head Neck Surg 2006;132:1226-1230.

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