Alternate Names To Larynx Cancer?
Larynx cancer sometimes may be referred to as throat cancer, cancer of the voicebox, cancer of the supraglottis, glottic cancer, and subglottic cancer.
What Is Larynx Cancer?
Larynx of the cancer refers to cancer in any of the subsites that define the area of the larynx. The larynx, also known as the voice box, is responsible for speaking, breathing, and protection of the lungs. It has three different subsites: supraglottis, glottis, and subglottis. The supraglottis is the region immediately above the vocal cords. The glottis is the region that includes the vocal cords. The subglottis is the region immediately below the vocal cords.
Types Of Larynx Cancer
The vast majority of cancers of the larynx are squamous cell carcinoma. However, there are other cancers that also occur in this region that are on the differential diagnosis that must be considered.
- Squamous Cell Carcinoma (SCC). The vast majority of larynx cancers are squamous cell carcinoma. These cancers involve the malignant transformation of the mucosal lining within the larynx.
- Salivary Gland Tumors. The larynx houses small (minor) salivary glands that can be subject to malignant transformation. These cancers have a distinct behavior different from that of cancer involving the epithelial lining. They involve glandular tissue, with different treatment principles (see Salivary Gland Cancer).
- Lymphoma. Lymphoma may present as a lesion in the larynx due to the diffuse distribution of lymphoid tissue.
- Mucosal Melanoma. Melanoma, similar to the type of melanoma found in the skin, may also manifest in the laryx.
- Soft Tissue Cancers. Soft tissue cancers may present in the larynx, although rare. These involve sarcomas that may arise from muscle, fat, or joint spaces.
- Nerve Tumors. Nerve tumors (e.g. neurofibroma) may also arise within the larynx.
What Are The Causes Of Larynx Cancer?
Like all other head and neck cancers, chronic exposure to irritants such as alcohol and tobacco pose a significant risk to the development of laryngeal cancer. Plummer-Vinson syndrome, characterized by iron deficiency anemia as well as swallowing problems, is also a risk factor for the development of laryngeal cancer cancer. Other risk factors include asbestos exposure, radiation exposure, marijuana use, or history of HPV papillomatous infections in childhood.
What Are The Signs And Symptoms Of Larynx Cancer?
Laryngeal cancers often present with signs and symptoms related to the close proximity of the vocal cords and the esophagus.
- Lump in the Neck. Laryngeal cancers may present as enlarged neck masses.
- Pain. Frequently patients may present with throat soreness, that is non-specific in quality and nature. Conversely, patients may present with increasing pain with swallowing.
- Bleeding. Bleeding from a site within the larynx may be a presenting sign. Any bleeding without full visualization or characterization of the involved site warrants further workup.
- Hoarseness. Frequently, patients will present with a hoarse voice or changes in voice quality. Any voice changes that do not resolve beyond three months of conservative management should be evaluated by a specialist.
- Breathing Difficulties. Patients may report breathing difficulties or noisy breathing, particularly when lesions increase in size and encroach on the airway.
- Swallowing Difficulties. Masses near or around the esophagus or vocal cords may cause intolerance to solid food that may progress to intolerance to liquid. Patients may also have a sensation of food being stuck in their throat that does not resolve with throat clearing (globus).
How Is Larynx Cancer Diagnosed?
In addition to routine history and physical examination, the physician may perform ancillary tests and procedures in order to confirm the presence and type of laryngeal cancer, as well as to determine the presence of second primary cancers (SPC) or the spread of malignant disease elsewhere.
Biopsy. Oftentimes the first step in the diagnosis of laryngeal cancer is to perform a biopsy. Taking a biopsy will confirm the presence of abnormal cells under the microscopic view, and is imperative in making the diagnosis of laryngeal cancer.
- Operative Biopsy: Laryngeal biopsies are performed in the operating room under general anesthesia. This allows for more complete visualization and mapping of the tumor and tissue sampling, and is known as “direct laryngoscopy with biopsy”.
- Lymph Node Biopsy. If a patient presents with a neck mass, particularly in the setting of no identifiable lesion, the physician may sample tissue from lymph node. There are several types of lymph node biopsy.
- Fine Needle Biopsy (FNB). If the mass can be felt by the clinician, then a small needle can be introduced with an attempt at extracting cells for microscopic assessment. The appearance of abnormal cells will help support the diagnosis of cancer. Sometimes, not enough cells are extracted, and repeat biopsies may need to be performed. This may also be performed with the help of ultrasound or computed tomography (CT) guidance
- Core Biopsy (CB). Similar to the Fine Needle Biopsy, a core biopsy is performed by introducing a larger caliber needle, with extraction of tissue as opposed to cells. This core biopsy allows for extraction of more tissue and can be more useful, but often times not necessary, as an FNB is sufficient. This can also be done with or without ultrasound or CT-guided assistance
- Operative Biopsy. If the location of the node is too deep, or not readily felt by a clinician, the surgeon may elect to perform biopsy under general anesthesia in an operating room.
Blood Work. The physician may elect to perform routine blood analysis to assist in determining the presence of oropharyngeal cancer or other present diseases. Blood work may not be necessary, and the decision to obtain blood work is individualized to every patient.
- Liver Function Tests (LFTs): Can be utilized to determine the presence of concurrent liver disease that may be associated with risk factors for the development of oropharyngeal cancer (alcohol consumption, hepatitis). Furthermore, abnormal values may indicate the presence of metastatic liver disease.
- Complete Blood Count (CBC): This will identify the presence of any anemia that can sometimes be associated with poor nutrition, or chronic illness.
- Nutritional Blood Work: If a patient seems nutritionally depleted, particularly in advanced cases, the clinician may elect to obtain laboratory work up to measure nutrition markers in the blood work. This may assist in determining if a patient requires supplemental nutrition.
Imaging. Oftentimes a physician may elect to obtain imaging that will help in better understanding the presence of cancer and any other underlying issues. Imaging may be performed of the primary site, or of the general region to better define disease extent. The physician may elect to obtain further imaging in situations in which they are concerned for local invasion (e.g. into bone, muscle, adjacent sites), or regional invasion (to the neck).
- Chest X-rays: Chest radiography may be obtained in order to define the presence of disease in the lungs. Often times patients with larygneal cancer, have a longstanding history of smoking may have associated lesions in their lungs that should be identified.
- Computed Tomography (CT): CT-Scans usually provide a more detailed image of the head and neck region, identifying parts of the tumor that is not readily seen on exam, as well as the presence of regional disease not readily detected (e.g. in the neck). CT-Scans can be obtained with or without contrast. Given the complexity of the region, usually CT scans are obtained with scans, to help in identify the vascular architecture within the neck. However, this is not always necessary, and CT scans may be obtained without contrast in circumstances that preclude patient receiving contrast (iodine allergies, kidney disease).
- Magnetic Resonanice Imaging (MRI): MRI can also be utilized with or without contrast in order to provide superior visualization of soft tissue as well as the brain. Often times an MRI may be needed if there is indeterminate findings on other imaging modalities, with a need for more accurate mapping.
- 18-Fluorodeoxyglucose Positron Emission Tomography (18-FDG PET): FDG-PET scans may be performed with CT or MRI imaging modalities and are utilized for the identification of regional or distant metastases.
- Ultrasound (US): Ultrasound may be utilized to better characterize neck masses, or used in conjunction with biopsy techniques. US can indicate suspicious characters of lesions that would direct a physician to more aggressive workup (biopsy, excision).
- Barium Swallow: Swallow studies may be performed in order to determine the degree of obstruction, and presence of any other lesions within the esophagus.
What Are The Possible Treatments For Larynx Cancer?
Depending on the site of disease, the clinical staging, and patient factors (co-morbid health conditions, patient preferences) a patient-specific treatment plan should be outlined. Broadly speaking there are 3 types of treatment that can be used in combination or separately depending on the type and stage of cancer. The decision to embark on a particular treatment plan should be made involving a multidisciplinary team of physicians (surgeons, radiation oncologists, and medical oncologists) and the patient. Patient-specific goals and outcomes should be defined, with a thorough discussion of the risks, benefits, and alternatives of all the separate treatment types. Broadly state, nasopharyngeal cancer is usually treated with radiation with or without chemotherapy.
Surgery. Surgery is commonly performed in the treatment of laryngeal cancer. The extent and type of surgery is heavily influenced on the site of the lesion, as well as the patient’s general health status.
- Transoral Surgery: Transoral surgery for laryngeal cancer can be performed with endoscopes and lasers. These minimally invasive procedures are used in specific circumstances whereby the tumor is confined and can be fully visualized with a transoral approach..
- Conservation Laryngeal Surgery: This type of open surgery involves the surgical removal of part of the larynx and the voice box. It is used in early staged lesions.
- Total Laryngectomy: In advanced lesions with involvement of the voice box and surrounding structures, surgery may involve removal of the entire voice box in order to fully remove all present disease.
Radiation. Radiation is another option for the treatment of laryngeal cancer.
- Definitive Radiation (with or without chemotherapy). This type of radiation treatment involves using radiation as the primary mode to treat the tumor. The goals of definitive radiation therapy is complete removal of all tumor with external sources of radiation.
- Adjuvant Radiation (with or without chemotherapy). This refers to the use of radiation in combination with surgery. The goal of adjuvant radiation is to treat any remaining disease after surgical removal (e.g in circumstances with positive margins).
- Neoadjuvant Radiation (with or without chemotherapy). Radiation given prior to surgery is referred to as neoadjuvant radiation. This is not routinely performed in the treatment of hypopharyngeal cancers and is used in academic centers as part of larger studies.
Chemotherapy. The use of systemic medications is used adjunctively with either surgery or radiation, and is used to target disease distant from the local site. It is not used as a primary treatment modality as it does not facilitate eradication at the primary site. Chemotherapy is often used in circumstances of advanced disease (Stage III or IV), or when certain risk factors for distant disease are present. Such risk factors include lymph nodes with disease that have extended out of their capsule (not contained), positive surgical margins, or involvement of nerves and blood vessels.
- Induction Chemotherapy. This refers to chemotherapy performed prior to surgery or radiation. This may be used to determine the biological response of the tumor to chemotherapy, as well as “shrink” tumors to a manageable size that can be better removed with surgery or radiation.
- Adjuvant Chemotherapy. This refers to chemotherapy given after definitive treatment with another modality was performed (either surgery or radiation).
- Concurrent Chemotherapy. This refers to the decision to administer chemotherapy and radiation concurrently after surgery. This may be the case in situations of predictors of aggressive disease on pathology.
Other Considerations. Specific attention should be given to the presence or absence of neck disease in the patient.
- Therapeutic Neck Interventions. If there is any presence of disease within the neck it should be addressed with some type of therapeutic intervention. Positive neck disease is usually treated through surgical resection or radiation of the actual positive nodes, and all intervening nodes in the neck. This is to ensure accurate pathological characterization of the nodes in the neck and prevent recurrence in the neck (from missed disease).
- Elective Neck Interventions. In the absence of any clinical evidence of disease, an elective neck intervention may be performed. This means treating the neck (with radiation or surgery) due to the potential for “occult” or hidden disease that is not clinically apparent.
Are There Preventative Steps Or Measures To Avoid Larynx Cancer?
The best steps to prevent throat cancer is to avoid offending agents, specifically alcohol and tobacco.
What Are The Risks If Larynx Cancer Is Left Untreated?
Larynx cancer that is not treated will continue to progress and cause significant detriment to a patient’s health. As the tumor grows patients will experience progressive worsening of their ability to swallow, speak, and breathe. Ultimately this can cause severe nutritional problems, breathing problems, and ultimately result in the untimely death of a patient.
- Symptoms related to swallowing, speaking, or breathing that do not resolve or progress over the course of weeks to months should be evaluated by a specialist.
- Smoking cessation is an important part in the prevention and treatment of throat cancer.
- Multiple options exist in the treatment of throat cancer. It is important to speak with a specialist that can discuss all surgical and non-surgical options available.
What Makes You The Right Doctor For Larynx Cancer?
Dr. Mourad is a Head and Neck Surgeon with advanced training in reconstructive surgery. He performs all aspects of head and neck cancer surgery including minimally invasive and reconstructive procedures. He is also a leader in his field with two published books, numerous book chapters, and more than 40 peer reviewed publications, book chapters, and presentations. He frequently speaks at national and international conferences to help in advancing this field. Most importantly, Dr. Mourad is empathetic to the needs of his patients. He views the ability to treat his patients to be nothing short of an honor and a privilege.