Head & Neck

Laryngeal Cancer

The larynx is a small, hollow organ in your throat. Commonly called the voice box, the larynx is home to your vocal cords and is part of your respiratory system. Its cartilage walls form the Adam’s apple, which protects the vocal cords directly behind it. Your larynx enables you to speak, helps you breathe and swallow, and helps keep fluid and food from going into your trachea (windpipe) when you eat.

Cancer of the larynx, also called laryngeal cancer, most often first develops in the lining of the larynx in thin, flat cells called squamous cells. Though it’s only about two inches long, the larynx has three parts. The vocal cords are in the middle, or glottis, with the supraglottis above and the subglottis below.

Symptoms that may indicate laryngeal cancer include hoarseness or other voice changes, a persistent sore throat, constant coughing, ear pain, a lump in the throat, painful swallowing, coughing up blood or trouble breathing.

Once your test results confirm the diagnosis, your doctor will stage the cancer using the TNM (tumor, node, metastasis) system. Laryngeal cancer is staged from Stage 0 through Stage IVC, although each of the three parts of the larynx are staged differently (see staging tables below).

Recently updated clinical guidelines for laryngeal cancer treatment recommend all patients undergo a comprehensive pre-treatment evaluation that includes a baseline assessment of voice, breathing and swallowing function. It should also include counseling to thoroughly discuss the risks, benefits and potential impact each treatment option may have on quality of life.

Your doctor will recommend treatment based on the location, stage, size and extent of the cancer, whether it is primary or recurrent (has returned), findings from the pre-treatment assessments, your overall health and personal preferences, and other factors.

Common Treatments

Standard treatment options are surgery, radiation therapy, chemotherapy and immunotherapy. Clinical trials may also be recommended (see Treatment Options).

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 a number of surgical procedures, beginning with least invasive, that your medical team may consider.

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 as described below. Your ability to speak normally after recovering from surgery depends on how much of the larynx is removed.

  • Supraglottic laryngectomy removes only 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 removes one vocal cord, leaving the other intact. This procedure may be used to treat cancers of the vocal cords. It will change your speech but may still allow some ability to speak.
  • Supracricoid laryngectomy removes a larger 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. The stoma is the new airway to breathe through because you will be unable to breathe through your mouth and nose.
    A total laryngectomy is usually reserved for 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. 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 in patients who cannot undergo surgery.

Two types of external-beam radiation therapy (EBRT), three-dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiation therapy (IMRT), are often used to treat laryngeal cancer.

Chemotherapy

Chemotherapy used alone or with radiation therapy may be used as treatment options for 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 necessary. Chemoradiation therapy may also be used after surgery as adjuvant therapy to decrease the likelihood of cancer recurrence.

Immunotherapy

Immunotherapy may be used to treat recurrent or metastatic laryngeal cancer.

Other Treatments

Targeted therapy may be used in combination with radiation therapy. It may also be used with chemotherapy for metastatic cancer. Clinical trial 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.

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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