Laryngeal Cancer

The larynx (voice box) is located at the top of the trachea (windpipe). The larynx contains the vocal cords. Vocal cords vibrate and allow us talk and sing.

The opening to the larynx is covered by a large muscular flap called the epiglottis. The epiglottis covers the windpipe when we swallow, to prevent food from entering the trachea. The muscles of the larynx also help close the opening to the airway. This closing function is so important that seven of the eight muscles in the larynx are used for closure.

The remaining muscle (the cricoarytenoideus dorsalis) opens the airway. If the muscle stops functioning properly, the airway cannot remain open for breathing. This can cause roaring or gasping episodes, which may become life-threatening.

In cancer of the larynx (laryngeal cancer) malignant cells develop in the tissue of the larynx. Most laryngeal cancers form in the flat cells (squamous cell) that line the inside of the larynx.

Symptoms

About 11,000 new cases of laryngeal cancer are diagnosed each year.

Symptoms include:

  • A persistent sore throat or cough
  • Pain or problems swallowing
  • Ear pain
  • A lump in the neck or throat
  • A hoarse voice or other voice changes
  • Blood tinged sputum when coughing


Causes and Risk Factors

  • More common in people over age 50
  • Men are four times more likely than women to develop laryngeal cancer
  • Tobacco use is the most important risk factor (95 percent of people who develop laryngeal cancer are smokers)
  • Heavy alcohol drinkers have an increased risk. People who smoke and drink may have 100 times the risk, according to the American Cancer Society.
  • Other less common risk factors include acid reflux, exposure to the human papilloma virus (HPV), weakened immune system, and intense exposure to wood dust or certain chemicals

Diagnosis

To make a diagnosis, your doctor will ask questions about your symptoms and medical history. A physical exam of the throat and neck also is needed. Your doctor will feel for swollen lymph nodes in the neck, and look down your throat with a small, long-handled mirror to check for abnormal areas.

Other tests may be used for diagnosis:

  • Laryngoscopy - The doctor examines the larynx with a laryngoscope (a thin, lighted tube).
  • Endoscopy - A procedure to look at the organs and tissues inside the body and to check for abnormal areas. An endoscope (a thin, lighted tube) is inserted through an incision in the skin or an opening in the body, such as the mouth. The surgeon will remove tissue samples and lymph nodes for a biopsy if needed.
  • Computed tomography scan (CT or CAT scan) - A special type of X-ray that makes a series of detailed pictures of the inside the body. A computer is linked to the X-ray machine. Dye may be injected into a vein or swallowed in a pill to help the organs or tissues show up on the X-ray. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • Magnetic resonance imaging (MRI) - An imaging machine that uses a magnet, radio waves, and a computer to make detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • Biopsy - A biopsy is the removal of cells or tissues, which are viewed under a microscope, to check for signs of cancer.
  • Barium swallow - A barium swallow test consists of a series of x-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and stomach, and x-rays are taken. This procedure is also called an upper GI series.
  • Fine Needle Aspiration Biopsy (FNA) - A thin needle is placed into a lump in the neck. The cells are aspirated, and then examined under a microscope to determine if the lump is cancerous.
  • PET scan - PET scan helps determine if a tumor has spread to other areas in the body. During a positron emission tomography scan (PET), a small amount of radioactive sugar (glucose) is injected into a vein. The scanner makes computerized pictures of the areas inside the body. Cancer cells absorb more radioactive glucose than normal cells, so the tumor is highlighted on the pictures.

Treatments

There are three methods of cancer treatment:

Most treatments use two or more of these methods. If a cure is not possible, the goal may be to prevent the tumor from growing or spreading for as long as possible (palliative treatment). Palliative treatment also helps to relieve symptoms.

Cancer Staging

Staging the cancer helps doctors decide the prognosis and the best treatments to prescribe. Cancer stages are determined by the size and the exact location of the tumor.


Radiation Therapy (Radiotherapy)

People who are diagnosed with an early stage laryngeal cancer can often be cured with radiotherapy only. This treatment preserves the voice.

Radiation alone (without surgery) is successful in treating 80-90 percent of people with stage I laryngeal cancer, and 70-80 percent with stage II cancer. Stage III and IV usually require a combination of radiation and chemotherapy.

Radiotherapy may also be given as an additional therapy (adjuvant therapy). Adjuvant therapy is used after surgery:

  • If some cancer cells might still remain in the body
  • If the tumor was difficult to remove completely
  • When the tumor has penetrated the wall of the larynx
  • If the pathologist finds cancer cells in the lymph nodes
  • If the tumor is pressing against the windpipe it can cause pain and difficultly breathing or swallowing. Radiotherapy can relieve the symptoms by shrinking the size of the tumor. Only a short course of treatments is needed to control symptoms (palliation).
  • If the radiotherapy is not able to destroy all the cancer, surgery might be needed to remove the cancer that remains (called salvage surgery).


Chemotherapy

Chemotherapy alone cannot cure this type of cancer. It is prescribed for different reasons:

  • Together with radiotherapy as an alternative to surgery (called chemoradiation)
  • After surgery to decrease the risk of the cancer returning
  • To slow the growth of a tumor and control symptoms when the cancer cannot be cured (palliative treatment)


Surgery

Endoscopic laser surgery on the larynx is very effective. In stages I and II, surgery has better or equal cure rates when compared to radiation therapy.

Endoscopic Resection
Endoscopic resection can remove very early cancers of the larynx. General anesthesia is used. The surgeon inserts an endoscope (a tube with a camera and a light on the inside of the tube) into the throat to locate the cancer. Then the surgeon uses a scalpel or a laser to remove the cancerous tissue. A laser is a thin hot beam of light. It cuts tissue and controls bleeding at the same time.

Surgery is often the best and only option for large cancers, or cancer that does not respond to radiation treatments.

Partial Laryngectomy
Partial laryngectomy is used to treat small laryngeal cancer, or for cancer that has returned after radiation (recurrent cancer). During partial laryngectomy, only part of the larynx is removed. At least one part of one vocal cord is not removed. After a partial laryngectomy patients can still speak, but the voice might be hoarse or weak. There are different types of partial laryngectomies. Your doctor might use these names:

  • A cordectomy is the removal of one vocal cord.
  • A frontolateral laryngectomy is the removal of the front of both vocal cords and most of the cancerous cord.
  • An anterior frontal laryngectomy is the removal of the front of both vocal cords.
  • A hemilaryngectomy is the removal of one side of the voice box.

During the procedure, the surgeon will make an opening in the neck to the windpipe. This will create a temporary tracheostomy (a hole in the neck for breathing). The tracheostomy allows the larynx to heal after surgery. After healing, the patients usually speak and eat differently.

Supraglottic Laryngectomy
A supraglottic laryngectomy is used when the tumor is only in the area above the vocal cords. The surgeon will use either the laser or the open technique to remove the voice box structures above the vocal cords (the false vocal cords and the epiglottis).

During the procedure, the surgeon will make an opening in the neck to the windpipe. This will create a temporary tracheostomy (a hole in the neck for breathing). The tracheostomy allows the larynx to heal after surgery. After healing, patients usually speak and eat effectively.


Total Laryngectomy

The surgeon may need to remove the entire voice box to cure the cancer. This is called a total laryngectomy.

The larynx connects the mouth to the lungs. After the larynx is removed, there is no connection for air to enter the lungs. During the procedure, the surgeon will make an opening in the neck for breathing. The opening is called a tracheotomy or a stoma. The stoma is permanent after a total laryngectomy.

Without vocal cords, patients cannot speak in the normal way. One method to help patients speak is the creations of a fistula (a small opening in the tissues for passage of air). The fistula is made during the laryngectomy. A speech therapist can teach different ways to make sounds and help patients learn to speak again

Two weeks after surgery, the patient can eat without difficulty.


Neck Dissection

If cancer has affected the lymph nodes in the neck, a neck dissection (removal of the lymph nodes) might be needed during any type of head and neck cancer surgery.