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 when you eat. The top part of the larynx is known as the supraglottis, the middle part is 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. When laryngeal cancer is suspected, tests are done to confirm the diagnosis.

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.

Treatment Options

Your doctor will consider many factors when exploring treatment options, including the stage of disease, the location and size of the tumor and your overall health status. Your doctor will also focus on preserving (as much as possible) the ability to talk, eat and breathe normally. Treatment options also depend on whether the laryngeal cancer is primary or recurrent. Standard treatment options for laryngeal cancer include surgery, radiation therapy and chemotherapy. Advances in cancer research have led to new options, such as immunotherapy and targeted therapy. You should talk to your health care team about the goal of treatment — whether the goal is to cure the cancer or to keep the cancer under control and relieve symptoms. Understanding the goal, as well as the benefits and risks of each option, will help you become better informed for making shared treatment decisions with your doctor.

Surgery

Surgery is done to remove the cancerous tissue. As with overall treatment decisions, your doctor will consider the location and stage of your cancer in choosing 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 and early cancers of the vocal cords. Most people can speak normally after they recover from this operation.

If the laryngeal cancer is confined to the surface of the vocal cords, your doctor may perform the surgery through endoscopy. With this procedure, the surgeon passes special surgical instruments through an endoscope (a hollow tube) that is placed down your throat into your voice box.

Transoral Laser Microsurgery (TLM) is an option that avoids the need for incisions in the neck. This approach is an option for laryngeal cancers that are superficial or limited in extent.

Cordectomy is the removal of all or part of a vocal cord. It can be used to treat 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, as described here. Your ability to speak normally after the surgery depends on how much of the larynx is removed.

  • Supraglottic laryngectomy. Only the part of your larynx above the vocal cords is removed. This procedure is done to remove some cancers that are confined to the supraglottis. Speech therapy is necessary after surgery to allow you to eat safely, and the effect on speech may vary.
  • Supracricoid laryngectomy. With this procedure, a larger part of the larynx is removed, including both vocal cords. Your ability to speak is preserved, although it will change how you speak.
  • Vertical hemilaryngectomy. With this procedure, only one vocal cord is removed. The other is kept intact. This procedure can be used to treat some small cancers of the vocal cords. It will change how you speak but allows some ability for speech to remain.
  • Total laryngectomy. With this procedure, the entire larynx is removed. The windpipe is brought up through the skin of the front of the neck, leaving a hole that you can breathe through. This is called a stoma. 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. This treatment is an option for more advanced disease and is usually done with removal of lymph nodes in the neck, or lymph node dissection.

If your doctor performs a laryngectomy, you may also have reconstructive surgery. To learn more, see Reconstructive Surgery.

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 delivered in two main ways: externally and internally. 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. Internal radiation therapy, which is rarely used for laryngeal cancer, involves the placement of radioactive material in or near the cancer. It may be used alone or in combination with EBRT.

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.

Chemotherapy

Chemotherapy drugs kill cells that divide quickly, such as cancer cells. Chemotherapy is considered a systemic treatment because the 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. When chemoradiation therapy is used, the chemotherapy drug helps make the cancer cells more sensitive to the radiation. Sometimes, chemoradiation is used as the primary treatment and, if the tumor goes away completely, surgery does not need to be done. It may also be given after surgery to decrease the likelihood that the cancer will recur (return).

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. Immunotherapy for head and neck cancers involves the use of drugs known as immune checkpoint inhibitors. These inhibitors are usually given intravenously (through a vein) every two weeks and may be given with or without chemotherapy. Immunotherapy may be an option for recurrent or metastatic laryngeal cancer.

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. Targeted therapy may be given alone or in combination with chemotherapy.

Other types of immunotherapy and targeted therapy are being evaluated in clinical trials. Ask your doctor or other member of your health care team if a clinical trial is an option for you.

 

TNM classification for laryngeal cancer

Classification Definition
Tumor (T)
TX Primary tumor cannot be assessed.
Tis Carcinoma in situ.
Supraglottis
T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility.
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 fixation and/or invades any of the following: postcricoid area, preepiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage.
T4 Moderately advanced or very advanced.
  T4a Moderately advanced local disease. Tumor invades through the outer cortex of 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 Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility.
  T1a Tumor limited to one vocal cord.
  T1b Tumor involves both vocal cords.
T2 Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.
T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.
T4 Moderately advanced or very advanced.
  T4a Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, cricoid cartilage, 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.
Subglottis
T1 Tumor limited to the subglottis.
T2 Tumor extends to vocal cord(s) with normal or impaired mobility.
T3 Tumor limited to larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.
T4 Moderately advanced or very advanced.
  T4a Moderately advanced local disease. Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus).
  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 No regional lymph node metastasis.
N1 Metastasis in a single ipsilateral (on the same side) lymph node, 3 cm or smaller in greatest dimension and ENE*(-).
N2 Metastasis in a single ipsilateral (on the same side) lymph node, 3 cm or smaller in greatest dimension and ENE*(+);
or larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-);
or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-);
or in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension and ENE(-).
  N2a Metastasis in single ipsilateral (on the same side) node, 3 cm or smaller in greatest dimension and ENE*(+);
or a single ipsilateral node, larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-).
  N2b Metastasis in multiple ipsilateral (on the same side) nodes, none larger than 6 cm in greatest dimension and ENE*(-).
  N2c Metastases in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension and ENE*(-).
N3 Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE*(-);
or metastasis in a single ipsilateral (on the same side) node, larger than 3 cm in greatest dimension and ENE(+);
or multiple ipsilateral, contralateral (on the opposite side), or bilateral (on both sides) lymph nodes, any with ENE(+);
or a single contralateral node of any size and ENE(+).
  N3a Metastasis in a lymph node, larger than 6 cm in greatest dimension and ENE*(-).
  N3b Metastasis in a single ipsilateral (on the same side) node larger than 3 cm in greatest dimension and ENE*(+);
or multiple ipsilateral, contralateral (on the opposite side), or bilateral (on both sides) nodes, any with ENE(+);
or a single contralateral node of any size and ENE(+).
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.
*Extranodal extension (ENE) refers to cancer cells that have spread beyond the lymph node into surrounding tissues.

Staging 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
M0
M0
IVA T4a
T1, T2, T3, T4a
N0, N1
N2
M0
M0
IVB Any T
T4b
N3
Any N
M0
M0
IVC Any T Any N M1

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer Science+Business Media.

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