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 II cancer is only in the larynx and has not spread to lymph nodes in the area or to distant sites.
Supraglottis: The cancer is in more than one area of the supraglottis, but the vocal cords can move normally.
Glottis: The cancer has spread to the supraglottis or the subglottis or both and the vocal cords may or may not be able to move normally.
Subglottis: The cancer has spread to the vocal cords, which may or may not be able to move normally.
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 II 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 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 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 be better for voice preservation; 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.
Surgery for Supraglottic Cancer: Researchers from Spain have reported a five-year local control rate of 80 percent for patients with stage II supraglottic cancer treated with surgery, with a larynx preservation rate of 87 percent.2
Laser Surgery for Supraglottic Cancer: Laser surgery involves use of a directed laser beam, rather than a scalpel, to perform the operation. Reports indicate better functional outcome with laser surgery than with open surgical procedures, with shorter hospital duration, fewer adverse health effects, and equivalent survival rates.
Researchers from Italy treated 61 patients with stage II supraglottic laryngeal cancer with laser surgery.3 Local control was achieved in 63 percent of patients with stage II disease and the ultimate laryngeal preservation rate was 94 percent.
Radiation Therapy for Supraglottic Cancer: In one study, treatment with radiation therapy alone (followed by surgery if radiation failed) produced local control in 81 percent of patients with stage II supraglottic cancer. Overall regional lymph node control was 88 percent and five-year survival was 78 percent. Serious health problems requiring surgery were seen in two percent of cases. These results confirm that radiation therapy is effective treatment for stage II cancer of the larynx in the supraglottic region. This treatment enables preservation of the larynx in most cases, with acceptable regional control and no loss of survival compared to adjuvant (post-surgery) radiation to the neck.
The best therapy for treatment of stage II glottic cancer is controversial. This stage of disease can be treated with surgery, laser surgery or radiation therapy.
Surgery for Glottic Cancer: Researchers from the Washington University have reported a local control rate of 85 percent for patients receiving either surgery or high-dose radiation therapy for stage II glottic cancer.4
Laser Surgeryfor Glottic Cancer: According to the results of a study involving 45 patients with stage II glottic cancer, the recurrence rate after laser surgery was 29 percent.5 Half of the patients who relapsed required a total laryngectomy and the other half were able to be treated by repeat laser therapy or radiotherapy.
In another study, 140 patients underwent laser surgery for previously untreated stage 0-II glottic cancer.6 When laser surgery failed, patients were treated with several different procedures, including repeat laser surgery, partial or total laryngectomy and/or radiation therapy. The larynx was preserved in 96 percent of patients. By the end of the study, 14 patients had died, but only two of them had died of laryngeal cancer. Five-year survival was 93 percent.
In a third study, laser surgery was used to treat 285 patients with stage 0-II glottic cancers.7 Over five years, less than two percent of study participants died of laryngeal cancer. Initial treatment resulted in local control in 86 percent of study subjects. The rate of larynx preservation was 94 percent.
Radiation Therapy for Glottic Cancer: A large study from Denmark reported that radiation therapy for stage II glottic cancer resulted in locoregional control in 67 percent of patients; 18 percent of patients eventually had a laryngectomy performed.8 In another study, the 10-year locoregional control rate for stage II glottic cancer treated with radiation therapy was 89 percent.9 This study was of interest in that 22 percent of patients developed a second primary cancer (a new cancer that was not a recurrence of the original cancer).
Although radiation preserves speech better than surgery there can still be significant speech problems, with reduced voice quality and greater than normal effort in voice production. Voice therapy during and after radiation therapy may result in better voice quality.
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 limited to a few patients in each study. Stage II 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 8 of 12 patients with stage II subglottic cancer with successful additional treatment with surgery in the case of radiation failures.10
Cancers of the supraglottis frequently spread into the lymph nodes of the neck. Cancer may be present in the lymph nodes even if the nodes feel normal during an exam. Spread of glottic and subglottic cancers is less frequent. Prophylactic (preventive) treatment of lymph node areas in the neck is usually recommended for stage II supraglottic cancers. In many centers it is common to surgically remove lymph nodes or to administer radiation therapy to the neck. A review of data from one medical center suggested that surgical removal of lymph nodes from both sides of the neck (bilateral lymph node dissection) decreased the risk of neck recurrences from 20 percent to 8 percent in patients with stage II-IV supraglottic laryngeal cancer.11 These authors also reported that bilateral neck dissection improved five-year survival from 72 percent to 83 percent. However, researchers from Spain reported similar results with unilateral (one-sided) and bilateral neck dissection.12 This suggests that removal of lymph nodes on only one side of the neck may be sufficient to prevent lymph node recurrences.
Radiation therapy can also be administered to the lymph nodes of the neck to prevent recurrences. A study of 32 patients with stage II supraglottic cancer reported a local neck recurrence rate of only 3.3% following prophylactic radiation therapy to the neck.13 These authors suggested that radiation therapy was as effective as surgery with fewer adverse health effects.
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 and doctor and patient 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 II laryngeal cancer.
Chemoradiotherapy: Researchers from Japan have reported that administering chemotherapy and radiation therapy at the same time may improve local control of patients with stage II glottic cancer.14 In this study of 20 patients the three-year survival with preservation of the larynx was 100%.
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.15
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 five 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.
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.
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 Laudadio P, Presutti L, Dall’Olio D, et al. Supraglottic laryngectomies: Long-term oncological and functional results. Acta Otolaryngol. 2006;126:640-649.
3 Motta G, Esposito E, Testa D, et al. CO2 laser treatment of supraglottic cancer. Head Neck 2004;26:442-446.
4 Specter JG, Sessions DG, Chan KS. Management of stage II (T2NOMO) glottic carcinoma by radiotherapy and conservative surgery. Head Neck 1999;21:116-123.
5 Konig O, Bockmuhl U, Haake K, et al. Glottic laryngeal carcinoma. Tis, T1 and T2-long term results. HNO 2006;54:93-98.
6 Pretti G, Nicolai P, Redaelli de Zinis LO, et al. Endoscopic CO2 laser excision for tis, T1, and T2 glottic carcinomas: cure rate and prognostic factors.Otolaryngol Head Neck Surg2000;123:124-31.
7 Eckel HE, Thumfart W, Jungehulsing M, et al. Transoral laser surgery for early glottic carcinoma. European Arch Oto 2000;257:221-226.
8 Jorgensen K, Godbaile C, Hansen O, et al. Cancer of the larynx-treatment results after primary radiotherapy with salvage surgery in a series of 1005 patients. Acta Oncol 2002;41:69-76.
9 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.
10 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.
11 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.
12 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.
13 Alpert TE, Marbidini-Gaffney S, Chung CT, et al. Radiotherapy for the clinically negative neck in supraglottic laryngeal cancer. Cancer Journal 2004;10:335-338
14 Concurrent chemoradiotherapy with carboplatin and uracil-ftegafur in patients with stage two (T2 N0 M0) squamous cell carcinoma of the glottic larynx. Journal of Laryngeal Otol 2006;120:478-481.
15 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.