Precise radiation, better airway preservation: vocal cord-only image-guided intensity-modulated radiation therapy for early-stage glottic cancer

Purpose Radiotherapy (RT) achieves excellent local control (LC) in early-stage glottic cancer (ESGC); however, treatment-related edema or necrosis may necessitate tracheostomy and adversely affect quality of life. We compared tracheostomy rates and oncologic outcomes between whole-larynx radiotherapy (WLRT) and vocal cord–only radiotherapy (VC-RT) in patients with ESGC. Methods We retrospectively analyzed 247 patients with Tis–T2 glottic cancer treated with definitive RT (2007–2023) at two Middle Eastern centers. Patients received WLRT (n = 166) or VC-RT (n = 81). The primary endpoint was a tracheostomy rate (TR) ≥6 months after RT for non-recurrent airway compromise. Secondary endpoints included 3-year local failure (LF) and overall survival (OS). TR and LF rates were analyzed using cumulative incidence with death as a competing risk, whereas OS was estimated using the Kaplan–Meier method. Results The median age was 59 years; 97.6% of patients were men and 78.9% were smokers. The median follow-up among surviving patients was 38.2 months (range 1.6–194 months). The median potential follow-up for the entire cohort, estimated by the reverse Kaplan–Meier method, was 45.3 months. VC-RT patients more frequently had cT2 disease (22.2% vs. 5.4%, p < 0.001) and received accelerated fractionation (19.8% vs. 7.2%, p = 0.0069). Overall, 20 of 247 patients (8%) required tracheostomy without recurrence. Edema-related tracheostomy occurred exclusively in WLRT patients (14.2% vs. 0% with VC-RT; p < 0.001). Tracheostomy was reversed in 8/20 patients (40%) after a median of 13.4 months. The 3-year LF rates were 7.6% with VC-RT and 11.6% with WLRT (p = 0.18), and OS was 93.3% and 89.5% (p = 0.16), respectively. Conclusions VC-RT reduces the risk of tracheostomy without compromising oncologic outcomes.