Head & Neck

Laryngeal Cancer

The larynx (LAYR-inx) is often called the voice box because it is home to your vocal cords. This short, hollow organ in the lower part of your throat is a passageway involved in functions that help you talk, breathe and swallow. It enables you to speak and protects your vocal cords with cartilage walls that form your Adam’s apple. The larynx helps you breathe as part of the respiratory system. When you swallow, a tissue flap called the epiglottis (eh-pih-GLAH-tis) covers your trachea (windpipe) to keep food and liquid from entering your lungs.

Only 2 inches long, the larynx has three parts. The vocal cords are in the middle part called the glottis. Above is the supraglottis, and below is the subglottis, which ends at the top of your trachea.

Cancer of the larynx is also called laryngeal (layr-un-JEE-ul) cancer. It most often first develops in the organ’s moist lining in thin, flat squamous (SKWAY-mus) cells. Symptoms may include hoarseness or voice changes; persistent sore throat; constant cough; ear pain; lump in the throat; painful swallowing; trouble breathing; or coughing up blood.

Clinical guidelines for treatment recommend a comprehensive pre-treatment evaluation. This should include a baseline assessment of voice, breathing and swallowing functions. It should also include counseling to thoroughly discuss the benefits and risks of each treatment option and the impact potential side effects and late effects may have on your quality of life.

Common Treatments

A comprehensive pre-treatment evaluation, which includes a baseline assessment of voice, breathing and swallowing functions, is recommended for people with laryngeal cancer. Your doctor will also consider those results for treatment planning and for monitoring during and after treatment.

One or more of the following options, in addition to clinical trials, may be part of your treatment plan. (See Treatment Options for general descriptions of each treatment type.)

Surgery

Your medical team will focus on removing the tumor and preserving (as much as possible) your ability to speak, eat and breathe normally. Following are some surgical procedures, beginning with least invasive, that may be recommended.

Vocal cord stripping removes the superficial layers of tissue on the vocal cords. This technique can be done for a biopsy sample or to treat pre-cancers and early-stage cancers of the vocal cords. Most people can speak normally after recovery.

Endoscopic resection is performed through an endoscope and is used when cancer is confined to the vocal cords or is early stage.

Transoral Laser Microsurgery (TLM) avoids the need for neck incisions and may be used for laryngeal cancers that are superficial or limited in extent.

Cordectomy removes all or part of a vocal cord and may be used to treat small cancers of the glottis. Removing part of a vocal cord typically causes hoarseness.

Laryngectomy removes all or part of the larynx. Your ability to speak normally after recovering from surgery depends on how much of the larynx is removed.

  • Supraglottic laryngectomy removes the part of the larynx above the vocal cords and may be used when tumors are confined to the supraglottis. Speech therapy will be necessary after recovery, and the effect on speech varies.
  • Vertical hemilaryngectomy may be used to treat cancers of the vocal cords. The procedure involves removing one vocal cord, leaving the other intact. Your speech will change, but you may still have some ability to speak.
  • Supracricoid laryngectomy removes a large part of the larynx, including both vocal cords. Your ability to speak is preserved, although how you speak will change.
  • Total laryngectomy removes the entire larynx and vocal cords. This surgery permanently separates the trachea (windpipe) from the esophagus and then attaches the trachea to a hole created in the front of the neck called a stoma (see Living With a Stoma). The stoma is the new airway to breathe through instead of breathing through your mouth and nose. A total laryngectomy may be used to treat advanced or recurrent cancers when there are no other viable options. Lymph nodes in the neck may be removed at the same time (neck dissection). Following recovery, you must learn new ways to communicate because normal speech is no longer possible. Most of the time, you will be able to swallow after you heal from surgery. If your doctor performs a laryngectomy, you may also have reconstructive surgery (see Reconstructive Surgery).

Radiation Therapy

Some early laryngeal cancers are treated with radiation therapy. It may also be used after surgery (adjuvant therapy) in an effort to eliminate any remaining cancer cells to lower the risk of recurrence and as a way to ma-nage pain caused by advanced laryngeal cancer in patients who cannot undergo surgery. Chemotherapy often enhances the effectiveness of radiation therapy, so it is often given with chemotherapy in a combination called chemoradiation therapy.

External-beam radiation therapy (EBRT), the type of radiation therapy most commonly used to treat laryngeal cancer, is typically given once daily for a set amount of time. Forms of EBRT include three-dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiation therapy (IMRT). Another type, hyperfractionated radiation therapy, involves a daily total dose of radiation that is smaller than usual, given in two doses and treatments daily over the same period of time as a standard course of radiation therapy.

Chemotherapy

Chemotherapy, used alone or with radiation therapy, may be used to treat advanced or recurrent laryngeal cancer. In some cases, chemoradiation therapy is the primary treatment for laryngeal cancer, and if no traces of the tumor remain, surgery may not be ne-cessary. Chemoradiation therapy may also be used before or after surgery or radiation therapy as neoadjuvant therapy or after as adjuvant therapy to decrease the likelihood of cancer recurrence.

Immunotherapy

Immunotherapy, in the form of immune checkpoint inhibitors, may be used to treat recurrent or metastatic laryngeal cancer that has progressed during or after treatment with chemotherapy. Other immunotherapy options may be available in clinical trials.

Targeted Therapy

This may be an option to treat types of laryngeal cancer that contain specific genetic abnormalities, proteins or growth factors. Targeted therapy drugs may be given alone or in combination with chemotherapy or radiation therapy.

Clinical Trials

Investigators continue to evaluate targeted therapies and radiosensitizers (drugs that increase the effectiveness of radiation therapy by making tumor cells more vulnerable to it) for treating recurrent or metastatic laryngeal cancer. Ask your doctor if you should consider a clinical trial (See Clinical Trials).

Staging

Diagnosing your type of laryngeal cancer is an important step in creating the best treatment plan for you. Your doctor will perform a thorough exam, imaging studies, blood tests and a biopsy and use these test results to stage the cancer. Staging determines the extent of your cancer, where it is located and whether it has metastasized (spread) to nearby organs, tissues or lymph nodes, or to other parts of your body.

The TNM staging system, developed by the American Joint Committee on Cancer (AJCC), is typically used to classify and stage laryngeal cancer. 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 indicates whether the lymph nodes show evidence of cancer cells. The number and location of these lymph nodes are important because they show how far the disease has spread. The M category describes metastasis (spread of cancer to another part of the body), if any.

Staging Criteria

Once the cancer is classified, an overall stage is assigned. Laryngeal cancer may be Stage 0 through Stage IV. Also known as “in situ,” Stage 0 is a precursor of an invasive cancer. Stages I and II are generally confined to the local area where the cancer is found, and Stage III has spread to the regional lymph nodes in the neck. Stage IV is further divided into Stages IVA, IVB and IVC. Stages IVA and IVB are locally or regionally advanced disease, and Stage IVC has spread to distant sites, such as the liver, lungs or bone.

These basic stages are designed to group patients who have a similar prognosis (outlook). This grouping allows doctors to more accurately predict outcomes for patients depending on the type of treatment they receive. In certain cancers, the stage is also determined by other factors.

Sometimes your doctor may reassess your stage after treatment or if cancer recurs. This is known as restaging. It is rarely done but typically involves the same diagnostic tests used for the original staging. If a new stage is assigned, it’s often preceded by an “r” to denote that it’s been restaged and different from the original stage given at diagnosis.

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.

 

Key Takeaways

  • The larynx, or voice box, is involved in essential functions: speaking, breathing and swallowing.
  • After diagnosis, a comprehensive pre-treatment evaluation is recommended.

Additional Resources

 

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