health.am

General Prevention

• Indirect laryngoscopy for patients with persistent hoarseness lasting beyond 1-2 weeks
• Cessation of smoking and/or alcohol abuse

Epidemiology

• Predominant age:
  1. Median age of occurrence in the sixth and seventh decades
  2. Less than 1% of laryngeal cancers arise in patients younger than 30 years of age.
  3. Very rare in young patients, in general
• Predominant sex: Male > female (5:1), however, increasing incidence in women who smoke

Incidence

5 in 100,000 (12,500 new cases per year)

Etiology

• Smoking
• Alcohol abuse

Associated conditions

>10% of patients may have a synchronous squamous cell carcinoma in the lower or upper aerodigestive tract, most notably in the esophagus or lungs.

Diagnosis

Signs and Symptoms

• Persistent hoarseness in an elderly or middle-aged cigarette smoker
• Dyspnea and stridor
• Ipsilateral otalgia
• Dysphagia
• Odynophagia
• Chronic cough
• Hemoptysis
• Weight loss owing to poor nutrition
• Halitosis owing to tumor necrosis
• Mass in the neck from metastatic lymph node
• Laryngeal tenderness owing to tumor necrosis or suppuration
• Lump in the neck
• Broadening of the larynx on palpation with loss of crepitation
• Tenderness of the larynx
• Fullness of the cricothyroid membrane

Tests

Lab
Liver function studies to rule out metastatic disease Imaging

• Computed tomography (CT) or magnetic resonance imaging if chest and liver or brain metastasis suspected
• Bone scan if bone metastasis suspected
• Screening chest radiograph to rule out metastatic disease

Diagnostic Procedures/Surgery

• Laryngoscopy: Fungating, friable tumor with heaped-up edges and granular appearance, with multiple areas of central necrosis and exudate surrounding areas of hyperemia
• Indirect and/or direct laryngoscopy and biopsy to determine stage of disease as well as histologic confirmation

Differential Diagnosis

• Acute or chronic laryngitis
• Benign vocal cord lesions such as polyps, nodules, and papillomas
• Tuberculosis or fungal infection of the larynx

Clinical Findings

The initial presenting symptoms of cancer of the larynx depend upon the site involved. Supraglottic cancers tend to present late with symptoms of dysphagia, odynophagia, hemoptysis, or referred otalgia. Stridor and hoarseness are late findings. Palpable cervical lymphadenopathy is a common presenting sign. Glottic cancers often present early with hoarseness, and palpable lymphadenopathy is uncommon. Late symptoms include dysphagia, odynophagia, stridor, or cough. Subglottic cancer presents with dyspnea, stridor, or palpable cervical lymphadenopathy.

T STAGE: LARYNGEAL CANCER
Supraglottis T1 Tumor limited to one subsite of the supraglottis with normal vocal cord mobility T2 Tumor invades more than one subsite of the supraglottis or glottis, with normal vocal cord mobility T3 Tumor limited to the larynx with vocal cord fixation and/or invades the postcricoid area, medial wall of the piriform sinus, or pre-epiglottic tissues T4 Tumor invades through the thyroid cartilage and/or extends to other tissues beyond the larynx (eg, to the oropharynx or soft tissues of the neck) Glottis T1 Tumor limited to the vocal cord(s) (may involve anterior or posterior commissures) with normal mobility T1a: Tumor limited to one vocal cord T1b:Tumor involves both vocal cords T2 Tumor extends to the supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3 Tumor limited to the larynx with vocal cord fixation T4 Tumor invades through the thyroid cartilage and/or extends to other tissues beyond the larynx (eg, to the oropharynx or soft tissues of the neck) Subglottis T1 Tumor limited to the subglottis T2 Tumor extends to the vocal cord(s) with normal or impaired vocal cord mobility T3 Tumor limited to the larynx with vocal cord fixation T4 Tumor invades through the thyroid cartilage and/or extends to other tissues beyond the larynx (eg, to the oropharynx or soft tissues of the neck)

Treatment

T1 and T2 cancers of the supraglottic and glottic larynx respond well to radiation therapy. Survival rates are similar to those achieved with surgery, including laser excision, but without the attendant morbidity. Elective radiation therapy to the neck is given to patients with supraglottic carcinomas. T3 and T4 cancers of the supraglottic and glottic larynx are treated with a combination of cisplatin-based chemotherapy and radiation therapy in an effort to avoid the morbidity associated with total laryngectomy. Patients are reevaluated following initial chemotherapy and radiation therapy. If there is complete disappearance of the cancer and biopsies are negative, surgery is avoided. In this way, nearly two-thirds of patients can be spared laryngectomy. Survival rates for patients receiving initial chemotherapy and radiation therapy are the same as those for patients receiving total laryngectomy.

Surgical options for supraglottic and glottic cancer include partial laryngectomy or total laryngectomy. Partial laryngectomy is appropriate for patients with T1 and T2 cancers. Vertical partial laryngectomy removes the ipsilateral vocal cord and overlying laryngeal cartilage. The procedure can be extended superiorly to include the ipsilateral false cord or posteriorly to include the ipsilateral arytenoid cartilage. It is an appropriate procedure for patients with reduced cord mobility due to cancer bulk but not for patients with reduced cord mobility due to invasion of the intrinsic musculature. Horizontal partial laryngectomy is indicated for patients with cancers arising above the level of the true cords. All patients will have some degree of aspiration following this procedure, but careful patient selection can minimize the long-term consequences. Total laryngectomy is appropriate therapy for some patients with T3 laryngeal cancers and for most patients with T4 cancers. In this situation, wide field laryngectomy includes removal of the bilateral level II, III, and IV cervical lymph nodes. Ipsilateral thyroid lobectomy is performed to facilitate paratracheal lymph node dissection.

The presence of cervical lymph node metastases is an indication for radical or modified neck dissection. Elective neck dissection or radiation therapy is not indicated for T1 and T2 glottic cancers but is indicated for all supraglottic cancers and for T3 and T4 glottic cancers. If the primary cancer is treated by surgery, an elective neck dissection is appropriate unless adjuvant radiation therapy to the primary cancer site is planned. In that case, elective neck radiation therapy can be given and the neck dissection deferred. If the primary cancer is treated with radiation therapy, elective neck radiation therapy is appropriate and operative dissection can be deferred.

Diet

• Nasogastric or gastrostomy feeding may be necessary if tumor involves esophageal inlet.
• No special diet otherwise

Activity

Patient may remain fully active unless he or she is debilitated from more advanced disease and/or greater degree of surgery.

Medication (Drugs)

• Narcotics may be necessary for pain control during treatment for mucositis secondary to radiation therapy.
• Nystatin mouth rinses for oral thrush

Surgery

• Tracheotomy may be necessary if tumor is large enough to cause upper airway obstruction
• Early disease may be treatable by either radiation therapy or laser cordectomy on an outpatient basis. Ninety percent cure rates are the rule.
• More advanced disease needs inpatient care necessitating partial or total laryngectomy and postoperative radiation therapy 4-5 weeks after surgery, depending on the stage of disease.

Complications

• Temporary odynophagia or dysphagia secondary to mucositis and/or thrush during radiation therapy
• Persistent hoarseness despite adequate treatment, necessitating further adjunctive procedures and/or speech therapy
• Tracheostomal stenosis requiring stenting with laryngectomy tubes or further surgery
• Dysphagia secondary to upper esophageal stricture after total laryngectomy, necessitating dilatation
• Aspiration after partial laryngectomy, necessitating complete laryngectomy or tracheotomy
• Inability to decannulate after partial laryngectomy because of laryngeal stenosis and/or aspiration
• Radiation-induced chondronecrosis, which mimics tumor recurrence
• Radiation edema, necessitating emergent tracheotomy

Prognosis

Five-year survival rates for supraglottic cancer with appropriate treatment are as follows: stage I, 90-95%; stage II, 75-80%; stage III, 50%; stage IV, 20-40%.

Five-year survival rates for glottic cancer with appropriate treatment are as follows: stage I, 80-95%; stage II, 70-80%; stage III, 50-70%; stage IV, 20-50%.

References

• Forastiere AA et al: Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349:2091. Pubmed: 14645636
• Hinerman RW et al: Carcinoma of the supraglottic larynx: treatment results with radiotherapy alone or with planned neck dissection. Head Neck 2002;24:456. Pubmed: 12001076
• Hinerman RW et al: Early laryngeal cancer. Curr Treat Options Oncol 2002;3:3. Pubmed: 12057082
• Mendenhall WM et al: Management of T1-T2 glottic carcinomas. Cancer 2004;100:1786. Pubmed: 15112257
• Ariyan S. Cancer of the Head and Neck. St. Louis, MO: Mosby; 1987.
• Cummings CW, et al., eds. Otolaryngology Head and Neck Surgery. Vol 3. 3rd ed. New York, NY: Mosby; 1998.
• Suen JY, Myers EN. Cancer of the Head and Neck. 3rd ed. Philadelphia, PA: WB Saunders; 1996.