Head & Neck

Laryngeal Cancer

The larynx, or voice box, is in the lower part of the throat, above the opening of the trachea (windpipe). It contains the vocal cords and helps keep food and fluids from entering the trachea. The top part of the larynx is called the supraglottis, the middle part is called the glottis, and the bottom part is the subglottis (see figure below). The vocal cords are in the glottis. Cancer that starts in the larynx is called laryngeal cancer and is treated differently depending on which of the three sections it starts in.

Most cancers of the larynx form in thin, flat cells called squamous cells, which line the inside of the larynx. These cancers are known as squamous cell carcinomas or squamous cell cancers.

Diagnosing laryngeal cancer

Laryngeal cancer is often found because of symptoms such as hoarseness or other voice changes, a sore throat that lasts a long time, constant coughing or pain when swallowing, coughing up blood and/or trouble breathing. If your doctor suspects laryngeal cancer, one or more of the following tests may be ordered:

  • Laryngoscopy is a procedure in which the doctor checks the larynx with a mirror or with a laryngoscope. A laryngoscope is a thin, tube-like instrument with a light and a lens for viewing. You may have numbing medicine sprayed at the back of your throat to make you more comfortable during the procedure.
  • Panendoscopy combines laryngoscopy with endoscopic procedures to examine other areas, such as the throat, esophagus and possibly the trachea. A general anesthetic is usually given before panendoscopy.
  • Biopsy is the removal of a sample of tissue for examination under a microscope. A biopsy is the only way to definitively diagnose laryngeal cancer. Biopsies of the larynx are done after giving a general anesthestic.

Imaging tests allow your doctor to see the inside of the body. They are not used to diagnose laryngeal cancers but can be used to look for a tumor or cancer spread, which helps your doctor stage your cancer. Imaging tests may include the following:

  • Computed tomography (CT) involves a scanner that rotates around you that makes a series of detailed cross-sectional images of areas inside the body, taken from different angles. These images are made by a computer linked to an X-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly.
  • Magnetic resonance imaging (MRI) is a procedure that uses radio waves and a powerful magnet linked to a computer to create images, usually in 3D, of the tissues and organs inside your body.
  • Barium swallow is a test often given to people who are having problems swallowing. You drink a chalky liquid, which coats your throat and esophagus, and X-rays are taken as you swallow. The liquid can show abnormal areas of the throat.
  • Chest X-ray may be taken to see whether cancer has spread to the lungs.
  • Positron emission tomography (PET) involves injecting sugar with a very low level of radioactivity into the bloodstream through a vein in the arm. Cancer cells absorb large amounts of the sugar, so the radioactive sugar will gather in cancer cells. The PET scanner will produce images with bright spots that correspond to areas where there is a high concentration of radioactive sugar.

Staging

After diagnosing your laryngeal cancer, your doctor will stage it, or determine the extent of its spread. Knowing the stage of your cancer will help your health care team recommend the best treatment option for you.

The TNM staging system, developed by the American Joint Committee on Cancer (AJCC), is typically used to stage head and neck cancers. This system classifies the cancer by tumor (T), node (N) and metastasis (M). The T category describes the size and location of the primary tumor. The N category describes lymph node involvement, indicating whether the lymph nodes show evidence of cancer cells. The location of these lymph nodes is important because it shows how far the disease has spread. The pathologic N category (sometimes denoted as pN) describes how many lymph nodes are involved and the amount of tumor cells found in the nodes. The M category describes distant metastasis (spread of cancer to another part of the body), if any. Staging for the M category is mainly clinical; however, a new M subcategory may be given based on the presence of tumor cells that can only be detected using a microscope or molecular testing.

Once the cancer has been classified, an overall stage is assigned. The main stages are Stage 0 (or I) through Stage IV, where Stage 0 (also known as “in situ”) is a precursor of an invasive cancer. Stages I and II are confined to the local area where the cancer is found; Stage III has often spread to the regional lymph nodes or lymphatic channels; and Stage IV has spread to distant sites (such as the lung or bone). Even these basic stages are sometimes further divided into subgroups of tumors that have a similar prognosis (Stage IB, Stage IIIC, etc). This grouping allows doctors to more accurately predict survival outcome according to stage and to adjust the treatment to the stage or substage of the cancer. For certain cancers, the AJCC also recommends tumor genetic testing, which can help determine which treatments are likely to be most effective.

Laryngeal cancer is staged differently depending on whether it started in the supraglottis, glottis or subglottis. The TNM values vary depending on where the cancer started, but the stages of laryngeal cancer determined by the TNM values are the same. Laryngeal cancer is staged from Stage 0, carcinoma in situ (in which the cancer cells are growing only in the inner lining layer of the larynx), to Stage IVC, in which the cancer has metastasized to distant organs (see Staging Tables below). Laryngeal cancer that spreads most often goes to the lungs, but it may also go to the bones, liver or other organs.

Although the original stage at diagnosis does not change, a doctor may reassess an individual’s cancer after treatment or if it has recurred, in a process known as restaging. This is rarely done but will likely involve the same diagnostic tests used for the original diagnosis. If a new stage is assigned, it’s often preceded by an “r” to denote that it’s a restage and different from the original stage given at diagnosis.

TNM classification for laryngeal cancer

Classification Definition
Tumor (T)
Tx Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
Tis Carcinoma in situ (cancer cells are present only in the surface layer of the throat but have not invaded into deeper layers).
Supraglottis
T1 Tumor limited to one subsite of supraglottis, with normal vocal cord movement.
T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.
T3 Tumor limited to larynx with vocal cord paralysis and/or invades nearby tissues.
T4a Moderately advanced local disease. Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).
T4b Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
Glottis
T1
  T1a
  T1b
Tumor limited to the vocal cord(s) with normal vocal cord mobility.
Tumor limited to one vocal cord.
Tumor involves both vocal cords.
T2 Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord movement.
T3 Tumor limited to the larynx with vocal cord paralysis and/or invasion of paraglottic space, and/or inner cortex of the thyroid cartilage.
T4a Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx.
T4b Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
Subglottis
T1 Tumor limited to the subglottis.
T2 Tumor extends to one or both vocal cords with normal or impaired movement.
T3 Tumor limited to larynx with vocal cord paralysis.
T4a Moderately advanced local disease. Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx.
T4b Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
Node (N)
Nx Regional lymph nodes cannot be assessed.
N0 Tumor cells have not spread (metastasized) to nearby lymph nodes.
N1 Metastasis in a single lymph node on same side as tumor, 3 centimeters (cm) (a little more than 1 inch) or less in diameter.
N2

 
  N2a
 
  N2b
  N2c
Metastasis in a single lymph node on same side as tumor, more than 3 cm but not more than 6 cm in diameter, or in multiple lymph nodes on same side as tumor, none more than 6 cm in diameter, or in lymph nodes on opposite side or both sides, none more than 6 cm in diameter.
Metastasis in a single lymph node on same side as tumor, more than 3 cm but not more than 6 cm in diameter.
Metastasis in multiple lymph nodes on same side as tumor, none more than 6 cm in diameter.
Metastasis in lymph nodes on opposite side or both sides, none more than 6 cm in diameter.
N3 Metastasis in a lymph node, more than 6 cm in diameter.
Metastasis (M)
M0 No distant metastasis, not spread to distant organs.
M1 Distant metastasis, spread to distant organs.

 

Stages of laryngeal cancer

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3
T1
T2
T3
N0
N1
N1
N1
M0
M0
M0
M0
IVA T4a
T4a
T1
T2
T3
T4a
N0
N1
N2
N2
N2
N2
M0
M0
M0
M0
M0
M0
IVB T4b
Any T
Any N
N3
M0
M0
IVC Any T Any N M1

Treatment options

Treatment for laryngeal cancer may include surgery, radiation therapy, chemotherapy, immunotherapy and targeted therapy.

Surgery

Surgery is often used to treat laryngeal cancer by removing the affected tissue. Your doctor will consider the location and stage of your cancer to choose the appropriate surgery for you.

Vocal cord stripping is the removal of the superficial layers of tissue on the vocal cords. This technique can be done to take a biopsy sample and to treat carcinoma in situ of the vocal cords. Most people can speak normally after they recover from surgery.

Cordectomy is the removal of all or part of a vocal cord. It can be used to treat very small cancers in the glottis. Removing part of a vocal cord can cause hoarseness.

Laryngectomy is the removal of all or part of the larynx. In a partial laryngectomy, only part of the larynx is removed. Some specific types of laryngectomies are discussed below. Your ability to speak normally after the surgery depends on how much of the larynx is removed.

With a supraglottic laryngectomy, only the part of your larynx above the vocal cords is removed. Supraglottic laryngectomy can be used to treat some supraglottic cancers. You can speak normally after this surgery.

In a hemilaryngectomy, your surgeon removes only one vocal cord and leaves the other. This procedure can be used to treat some small cancers of the vocal cords. It will change how you speak but allows some speech to remain.

In a total laryngectomy, the entire larynx is removed. The windpipe is brought up through the skin of the front of the neck and leaves a hole that you can breathe through. This is called a tracheostomy (also called a tracheostoma). After a laryngectomy, you will not be able to speak normally, but people who have this procedure can learn new ways to speak. A total laryngectomy should not affect your ability to swallow.

If you have a laryngectomy or tracheostomy, you may also have reconstructive surgery. To learn more about reconstructive surgery, click here.

Radiation therapy

Radiation therapy involves the use of high-energy particles such as X-rays to kill cancer cells. It can be used to treat some early laryngeal cancers. It is also used after surgery to try to kill any remaining cancer cells to lower the risk of recurrence. When it is used this way, it is called adjuvant therapy. Radiation therapy is often given with chemotherapy in a combination called chemoradiation therapy. Radiation therapy may also be used to manage pain caused by advanced laryngeal cancer. Radiation therapy is administered in two main ways: external and internal.

External-beam radiation therapy (EBRT) is the most common type of radiation therapy for laryngeal cancer. In this therapy, radiation is delivered to specific parts of the body from a machine. The therapy is similar to getting an X-ray, but the radiation is much stronger.

Before you begin radiation therapy, your health care team will take precise measurements to determine the best position for you to be in when radiation is given. The procedure itself is painless and does not last long, but getting you into place for treatment may take longer. Radiation therapy for laryngeal cancer is usually given once a day five days a week for about seven weeks. Smoking during radiation therapy is associated with worse outcomes. If you smoke, stop before radiation therapy begins.

Three-dimensional conformal radiation therapy (3D-CRT) is a newer EBRT technique. It involves the use of the results of imaging tests and special computers to pinpoint the location of the tumor. Multiple radiation beams are shaped and aimed at the tumor from different directions. The single beams are somewhat weak, making them less likely to damage normal tissues, but all the beams come together at the tumor to deliver a higher dose of radiation to it. Intensity-modulated radiation therapy (IMRT) is a form of 3D-CRT in which the patient is moved as radiation is delivered. IMRT is a common way to deliver EBRT for laryngeal cancer.

Internal radiation therapy is rarely used for laryngeal cancer. It involves the placement of radioactive material in or near the cancer. It may be used alone or in combination with EBRT.

Chemotherapy

Chemotherapy drugs, also called cytotoxic drugs, kill cells that divide quickly, such as cancer cells. Chemotherapy is considered a systemic treatment because the chemotherapy drugs travel throughout the body in the bloodstream. Chemotherapy is given in cycles, and treatment may involve the use of a single drug or multiple drugs in combination.

Immunotherapy

Immunotherapy uses the body’s own immune system to slow and kill cancer cells. With this treatment approach, substances — made either by the body or in a laboratory — are used to identify cancer cells as a threat and target them for destruction.

Targeted therapy

Targeted therapy drugs work by targeting specific proteins and genes that help cancer cells grow. Some of these drugs target the epidermal growth factor receptor (EGFR), a protein on the surface of cancer cells that helps them grow and divide. The drugs block EGFR and stop it from working, which can help slow or stop cancer growth.

Additional Resources

 

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