Toxicities	Grade	EOT		1st month F/U		3rd month F/U		6th month F/U
		Study	Control	Study	Control	Study	Control	Study	Control
Skin Reaction	0	0	0	15	13	25	25	25	25
	1	13	11	10	11	0	0	0	0
	2	12	14	0	1	0	0	0	0
Mucositis	0	0	0	15	14	25	25	25	25
	1	10	8	8	10	0	0	0	0
	2	15	17	2	1	0	0	0	0
Dysphagia	0	18	13	24	22	25	25	25	25
	1	6	10	1	3	0	0	0	0
	2	1	2	0	0	0	0	0	0

Glottic cancer is the most common laryngeal cancer and the intent of treatment is cure. In the present study, all 50 (100%) patients were histologically proven to have squamous cell carcinoma (SCC). Review shows that squamous cell carcinoma is the most common histology [1]. Review of literature on symptomatology highlights hoarseness as the most common presenting symptom while dysphagia, odynophagia, ear ache does not generally occur. The main complain at presentation given by 92% of patients in this study was hoarseness and 8% complained of hoarseness and dysphagia.

In this study, 21 (42%) of the patients had anterior commissure involvement. Studies have shown how anterior commissure involvement is poor predictor of local control and an indicator or recurrence [7,8]. LeQt et al. [9] stated that the five – year local control was 80% for patients with AC involvement and 88% for those without.

About 84% of patients had associated lifestyle habits of tobacco consumption either in the form of smoking or chewing, with 26% of them having mixed habits. Browman et al. [10] in their study concluded that patients with head and neck cancer who continued to smoke during treatment had reduced response to radiation. At the Christie and royal Marsden Hospital [11], in their study of 200 patients with T1 glottic cancer using hypo-fractionated regime, they found that severe late radiation complication was seen in only one patient who continued to smoke heavily after treatment.

In treating early glottic cancer, options include open partial laryngectomy, transoral laser excision, and radiotherapy. Favorable outcomes could be achieved by any of these modalities, and the local control rates at 5 years ranged from 85% to 95% in T1, and from 60% to 80% in T2 stages. The choice of treatment modality usually depends on T-stage, anterior commissure involvement, preference of patient and physician, general status of patient [9]. Among these therapies, radiotherapy may be preferred to surgery if the tumor size becomes bigger, considering the post-therapy voice quality,while open partial laryngectomy is usually considered for treating local recurrence following other modalities [12]. Less restrictive patient selection criteria also favor radiotherapy to surgery for patients who may not be fit for surgery [13].

Patients in the study arm completed their treatment in a range of 27-30 days while those in the control arm completed theirs in a range of 47 – 51 days. All 50 patients in this study completed their treatment. Literature reports that overall treatment time affects local control [9,14].

In this study none of the patients, within the follow up period of 6 months, in either arm had recurrences at local site. Literature states that recurrences occur within 5 years of treatment. Recurrence is more common in patients with anterior commissure involvement [14]. In a study by Ernis et al [15], five year regional control, CSS and OS rates were 95.4, 95.7% and 78.8% respectively. Arif et al [13] in their study reported, local control rate (LCR) at 5 years was 91% and 5yr overall survival (OS) was 86%. Patients with T1a and T1b had 95% and 88% LCR respectively.

Arunsingh et al [16], in 59 patients of histologically proven early glottis squamous cell carcinoma treated at Tata Memorial Hospital Kolkata during September 2011 to July 2014 that were analyzed, they found that hypo-fractionated radiotherapy is safe with acceptable toxicity rates and good overall control. In a study by Laskar et al [17], the local control and overall survival at 10 years were 84 and 86.1%, respectively, for TI glottic carcinoma. They concluded that radical radiotherapy schedules incorporating a higher dose per fraction yield acceptable local control rates and late toxicity. At the Christie and royal Marsden Hospital11, once daily radiotherapy over 3 weeks gives excellent local control in patients with T1 glottic squamous-cell carcinoma and has a low rate of severe complications. Results of our study are in concordance with those of many trials done on hypo-fractionated regime. The study group was small and the follow up period was short as compared to other trials which had larger study groups and longer follow up periods.

In our study, toxicities occurred in to the form of skin reactions, mucositis and dysphagia. At the end of one month, Grade 2 reactions were 48% vs 56% respectively in study and control arm (X2 = 0.762, p value 0.383). Grade 2 mucositis was 60% vs 68% in study vs control arm (X2 = 0.000, p value 0.01). Grade 2 dysphagia was seen in 4% vs 8% patients (X2 = 3.125, p value 0.210). Ernis et al. [13], reported RTOG grade 3 skin toxicity occurred in 9 (6.8%) of patients. RTOG grade 3 mucositis requiring enteral nutrition, occurred in 13 (9.8%) patients. Arunsigh et al. [16], reported in their study 7 (12.3%) patients had grade II skin reactions while 15 (26.8%) had grade II or more dysphagia. Yamakazi et al. [18], observed diffuse coating and/or edema of the vocal cords was recognized in 10 patients (11%) in study arm and 9 (10%) in control arm. Tai Gyu Kim et al.[19], stated that a vast majority of the patient experienced radiation mucositis and dermatitis presenting from 2 weeks of radiotherapy start, and complained of throat pain on swallowing and voice change.

In terms of voice quality, 80% vs 76% patients had normal voice by the 6th month of follow up and patients continued to report improvement in voice quality in subsequent follow ups. Verdonck-de Leeuw at al. [20] reported that voice characteristics improved after radiotherapy.

In conclusion, Hypo-fractionated radiotherapy is a safe modality of treatment with high local control rates, acceptable long term toxicities, favorable voice outcomes and symptomatic relief with added advantage of shorter treatment time which offers better patient compliance.

Good local control and acceptable toxicities have favored hypo-fractionated regime as the established treatment for early glottis cancer. Such favorable outcomes and advantage of shorter treatment time warrant for trials and studies of hypo-fractionated regimes in advanced stage glottic cancer and other malignancies too. In busy set ups where there is heavy patient load in the outpatient department and machines, hypo-fractionated radiotherapy is recommended in other malignancies.