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Laryngeal Cancer

by Bradley A. Schiff, MD

Ninety percent of laryngeal cancer is squamous cell carcinoma. Smoking, alcohol abuse, lower socioeconomic status, and being male and > 60 yr increase risk. Early diagnosis is common with vocal cord tumors because hoarseness develops early. However, supraglottic tumors (above the vocal cords) and subglottic tumors (below the vocal cords) often manifest at an advanced stage because they can remain asymptomatic for a longer time frame. Diagnosis is based on laryngoscopy and biopsy. Treatment of early-stage tumors is with surgery or radiation. Advanced-stage tumors are often treated with chemotherapy and radiation therapy. Surgery is reserved for salvage treatment or lesions with extralaryngeal extension or cartilage destruction. Reestablishment of speaking ability is needed if a total laryngectomy is done.

Squamous cell carcinoma is the most common cancer of the larynx. In the US, it is 4 times more common among men and is more common among people of lower socioeconomic status. Over 95% of patients are smokers; 15 pack-years of smoking increase the risk 30-fold. The incidence of laryngeal cancer is decreasing, particularly among men, most likely due to changes in smoking habits.

Sixty percent of patients present with localized disease alone; 25% present with local disease and regional nodal metastatic disease; and 15% present with advanced disease, distant metastases, or both. Lymph node metastasis are more common in supraglottic and subglottic tumors than with glottic cancers due to the minimal lymphatic drainage of the glottis. Distant metastases occur most frequently in the lungs and liver.

Common sites of origin are the true vocal cords (glottis) and the supraglottic larynx. The least common site is the subglottic larynx, where only 1% of primary laryngeal cancers originate. Verrucous carcinoma, a rare variant of squamous cell carcinoma, usually arises in the glottic area and has a better survival rate than standard squamous cell carcinoma.

Symptoms and Signs

Symptoms and signs differ based on the involved portion of the larynx. Hoarseness is common early in glottic cancers but is a late symptom for supraglottic and subglottic cancers. Patients with subglottic cancer often present with airway obstruction, and hoarseness is a common late symptom. Patients with supraglottic cancer often present with dysphagia; other common symptoms include airway obstruction, otalgia, development of a neck mass, or a "hot potato" voice. Patients with these symptoms should be referred for direct laryngoscopy without delay.

Diagnosis

  • Laryngoscopy

  • Operative endoscopy and biopsy

  • Imaging tests for staging

All patients who have hoarseness for > 2 to 3 wk should have their larynx examined by a head and neck specialist. Some practitioners use a mirror to evaluate the larynx, but most prefer a flexible fiberoptic examination. Any lesions discovered require further evaluation, usually with operative endoscopy and biopsy, with concomitant evaluation of the upper airway and GI tract for coexisting cancers. The incidence of a synchronous second primary tumor may be as high as 10%.

Patients with confirmed carcinoma typically have neck CT with contrast and a chest x-ray or chest CT. Most clinicians also do PET of the neck and chest at the time of diagnosis.

Treatment

  • Early-stage (T1 and T2): Surgery or radiation therapy

  • Moderately advanced (T3): Radiation therapy and sometimes chemotherapy

  • Advanced (T4): Radiation therapy and sometimes chemotherapy

For early-stage glottic carcinoma (see Staging of Head and Neck Cancer), laser excision, radiation therapy, or occasionally open laryngeal surgery results in a 5-yr survival rate of 85 to 95%. Endoscopic laser resection and radiation therapy usually preserve a normal voice and post-treatment function and have similar cure rates. Whether surgery or radiation is used to treat early-stage glottic cancer usually depends on the preferences of the treating institution and the patient.

For advanced glottic carcinoma, defined by a lack of vocal cord mobility or extension into the tongue, most patients are treated with chemotherapy and radiation therapy. If the patient presents with extension outside of the larynx or with cartilage invasion, a laryngectomy provides the best oncologic results; the laryngectomy is commonly total, but endoscopic laser resection or open partial laryngectomy can be used in select appropriate cases. A total laryngectomy is also commonly used for salvage situations; however, endoscopic resection or open partial laryngectomy may sometimes be used in these situations.

Early supraglottic carcinoma can be effectively treated with radiation therapy or partial laryngectomy. Laser resection has shown considerable success on early-stage supraglottic squamous cell carcinomas and minimizes functional changes after surgery. If the carcinoma is more advanced but does not affect the true vocal cords, a supraglottic partial laryngectomy can be done to preserve the voice and glottic sphincter. If the true vocal cords also are affected, a supracricoid laryngectomy or a total laryngectomy is required if surgery is chosen. As with glottic carcinoma, most advanced-stage supraglottic cancers initially are treated with chemotherapy and radiation therapy. The supraglottis has a rich lymphatic network, so the neck must be addressed in all patients with supraglottic cancer.

Treatment of hypopharyngeal carcinomas is similar to that of laryngeal cancer. Early-stage lesions usually are treated with radiation alone, although endoscopic resection is an option. However, the majority of patients with hypopharyngeal cancer have advanced-stage disease because of the silent nature of the disease and frequent regional lymphatic spread; such patients are treated with chemotherapy and radiation therapy primarily, with surgical salvage.

Rehabilitation

Rehabilitation may be required after either surgical or nonsurgical treatment. Significant swallowing problems are common after chemotherapy and radiation therapy and may require esophageal dilation, swallowing therapy, or, in severe cases, surgical replacement of the pharynx or gastrostomy tube feedings. Swallowing also is affected by surgery and may require swallowing therapy or dilation as well.

Speech, on the other hand, is more significantly affected by surgery. After total laryngectomy, the patient requires creation of a new voice by way of

  • Esophageal speech

  • A tracheoesophageal puncture

  • An electrolarynx

In all 3 techniques, sound is articulated into speech by the pharynx, palate, tongue, teeth, and lips.

Esophageal speech involves taking air into the esophagus during inspiration and gradually eructating the air through the pharyngoesophageal junction to produce a sound.

A tracheoesophageal puncture involves placement of a one-way valve between the trachea and esophagus to facilitate phonation. This valve forces air into the esophagus during expiration to produce a sound. Patients receive physical rehabilitation, speech therapy, and appropriate training in the maintenance and use of this valve and must be cautioned against the possible aspiration of food, fluids, and secretions.

An electrolarynx is a battery-powered sound source that is held against the neck to produce sound. Although it carries a great deal of social stigma for many patients, it has the advantage of being functional immediately with little or no training.

Key Points

  • Hoarseness is common early in glottic cancers but is a late symptom for supraglottic and subglottic cancers.

  • All patients who have hoarseness for > 2 to 3 wk should have their larynx examined by a head and neck specialist.

  • Patients with confirmed carcinoma typically have neck CT with contrast and often PET/CT for advanced stages.

  • Treat early-stage (T1 and T2) cancer with surgery or radiation therapy.

  • Treat moderately advanced (T3) cancer with radiation therapy and sometimes chemotherapy.

  • Treat advanced cancer (T4) that extends outside of the larynx with surgery and then postoperative chemotherapy and radiation therapy.

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