Laryngeal cancer is a type of throat cancer that affects the larynx, also known as voice box cancer. It is a disease in which cancerous cells form in the tissues of the larynx. It is a type of cancer that affects the neck and head. Most laryngeal cancers would form in the thin flat cells inside the larynx.
Though it is formed on the larynx the cancer can spread to the thyroid, trachea, or oesophagus. It can also spread to the lymph nodes in the neck, the carotid artery, the upper part of the spinal column, the chest and other parts of the body.
The larynx is the air passageway between the pharynx and trachea. The term, glottis, is also used interchangeably with the word – larynx. It has a role in ensuring that functions that enable human beings to voice out are not compromised with breathing functions. It is divided into three: – The top including epiglottis is known as supralarynx. The middle including the vocal cords are known as the larynx and the bottom part is known as sublarynx.
The following image from the US National Cancer Institute depicts where the larynx is located and where laryngeal cancer can form and spread.
Credit: US National Cancer Institute
The survival rate of laryngeal cancer patients differs based on which part of the larynx the cancer started. The cancer could have started in the supralarynx, larynx or the sublarynx. It is also determined by the extent that the cancer had spread. The cancer is classified into three different categories based on how severely it has spread.
- Localised: The cancer has not spread outside of the larynx or hypopharynx.
- Regional: The cancer has spread outside the larynx or hypopharynx to nearby structures or lymph nodes.
- Distant: The cancer has spread extensively to distant parts of the body, such as the lungs.
The surveillance, epidemiology, and end results (SEER) database has predicted survival rates based on the spread and the location of the cancer as shown in the following table.
In the UK, survival is determined by the cancer stages. The higher the cancer stage is, the lower the survival rate becomes. At Stage 1, about 90% survives for 5 years or more after diagnosis. The laryngeal cancer is part of the larynx and the vocal cords are still able to move. At Stage 2, 70% would survive. In this stage, the cancer begins to spread. Up to 60% would survive a Stage 3 laryngeal cancer. At this stage, the cancer has grown throughout the larynx. It may also spread to a nearby lymph node located 3cm away from the larynx. The survival rate at Stage 4 is 30% and the cancer would have spread out into tissue outside the larynx such as the thyroid and spread to other parts of the body.
Laryngeal Cancer Staging
The process of determining the spread of cancer by doctors is known as staging. The process is also known as laryngeal carcinoma staging. The earliest is stage 0, otherwise known as carcinoma in situ (CIS). There are 4 main stages – I, II, III and IV. The 4 stages are split further by alphabets. The American Joint Committee on Cancer (AJCC) developed a TNM system to determine the stages. TNM basically refers to 3 key pieces of information:-
- The extent of the main tumour (T): Tumor location. Its growth into the larynx and nearby structures. Has it affected vocal cord movement?
- The spread to nearby lymph nodes (N): The extent the cancer spread to nearby lymph nodes in the neck. How many are affected? Are they on the same side (left or right) as to where the cancer started, and how large are they?
- The spread of metastasis (M) to distant parts of the body, such as the lungs, liver, or bones.
The stages of laryngeal cancer would differ a little based on the part of the larynx where the cancer began.
Stages for supraglottic laryngeal cancer
The tumor cells can grow from 3cm to 6cm in size. At Stage 0, it will fill up the larynx. At Stage 1, the tumour deepens at one part of the supraglottis. Stage 2 happens when it spreads into nearby lymph nodes. Between stages 0-2, vocal cords are not affected. At stage 3, the tumour may prevent the vocal cords from moving. It may have grown to nearby areas, tissues and glands. It is also possible for the cancer not to spread yet at this stage. Stage 4 or T4 is divided into three –
T4A is the moderately advanced level where the cancer is growing beyond the larynx. If it spreads into a single lymph node it is classified as N1 and if it doesn’t it is N0. When it advances into structures, it becomes cancer and is classified as N2.
T4B is a very advanced level where the cancer would have grown into the area in front of the spine of the neck. It is possible for it to be more than 6cm in size. At T4C, the cancer may have grown into structures, lymph nodes and affected the vocal cords.
Glottic laryngeal cancer stages
At Stage 0, the tumour is on the surface of cells inside the larynx. At Stage 1 it grows deeper in the vocal cords but does not affect the cords. At Stage 2, it spreads into the supraglottis. Vocal cords are affected at this stage. At Stage 3, the tumour would have stopped the cords from moving and may have grown into structures outside the larynx. At T4A – the moderately advanced level, it would have spread into tissues beyond the larynx, nodes and structures. At T4B and C, it is similar to supraglottic laryngeal cancer stages.
Subglottic laryngeal cancer stages
Stages 0 and 1 are similar to the supraglottic and glottic stages. The tumour spreads into the vocal cords and affects its movement at Stage 2. Stage 3 is where the vocal cords stop moving. Stage 4 is similar to the supraglottic and glottic laryngeal stages.
At an early stage, there are no clear symptoms that link to laryngeal cancer. Growths in the vocal cords may lead to hoarseness and coughing. Laryngeal cancer on the supraglottis may cause pain that worsens when swallowing. The pain may feel like ear pain.
Hoarseness is the most common symptom and it is an early sign that cancer is affecting your vocal cords. If you experience hoarseness for 3 to 4 weeks, please get yourself checked in to the hospital for further tests.
A lump in the throat or neck and discomfort or pain when chewing or swallowing are early symptoms of supraglottic cancer of the larynx. Breathlessness and persistent cough are symptoms of cancer in the subglottis.
Other symptoms include a sore throat, frequently choking on food, difficult or noisy breathing, persistent ear pain or an unusual sensation in and around the skin of the ear, unplanned and significant weight loss and persistent bad breath.
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The most significant risk factor that leads one to laryngeal cancer is smoking. Mortality among those with laryngeal cancer is more profound among smokers than non-smokers. Secondary smoke is also a risk factor. Moderate to heavy consumption of alcohol too raises the risk of getting laryngeal cancer. Gender and age group are risk factors too. It has been found that men are four times more likely to get laryngeal cancer than women. In terms of age, people above the age of 40 are more likely to have this cancer.
Human papillomavirus (HPV) is also a risk factor that increases the chances of one contracting laryngeal cancer. It is a group of over 150 related viruses that causes the growth of papilloma or warts. It is a form of sexually transmitted disease. While it has contributed to raising the risk of cancers of the throat (oropharynx), it is a rare risk factor for cancers of the larynx.
Poor nutrition that is deficient in vitamins A and E also can raise a person’s risk of laryngeal cancer. Foods that are rich in these vitamins may help prevent the disease, including eating fresh fruits and vegetables, although more research is needed.
Occupational hazard with exposure to asbestos also exposes one to the risk for decades. It is a weak carcinogenic factor for glottic cancer. There are also reported heightened risks due to mustard gas, hair dye, sulfuric acid, nickel, paint, wood dust, rubber products, diesel and gasoline fumes. There is also a significant risk to individuals who are exposed to diesel fumes. People in specific jobs such as brewers, metal workers, bartenders, machinists, farmers, textile processors, maintenance workers, mechanics, drivers and construction workers.
Those having Plummer-Vinson syndrome are also at risk of having laryngeal cancer. Plummer Vinson syndrome is made up of dysphagia, iron-deficiency anaemia and oesophagal webs. It increased the risk of squamous cell carcinoma of the pharynx and the oesophagus.
Researchers have not been able to pinpoint the exact cause of laryngeal cancer. However, the HPV that is known to raise the risk factor can also cause it.
Diagnosing the Cancer
Diagnosing laryngeal cancer is done mainly through laryngoscopy – a procedure in which a thin, lighted tube called an endoscope is used to examine the larynx. A biopsy test allows doctors to remove a small piece of any abnormal tissue in the larynx to examine under a microscope. There are also three types of scanning that are used for diagnosis. Computed tomography (CT) scan examines structures inside the body. A positron emission tomography (PET) scan use a radioactive tracer to show how an organ is functioning in real-time. It can detect cellular changes in organs and tissues earlier than CT and Magnetic Resonance Imaging scans. The difference between CT, PET and MRI is that the latter uses radio waves and magnets for imaging whereas the former uses X-rays. Hybrid PET/MRI scans are primarily used for diagnosing and monitoring cancers of the soft tissues (brain, head and neck, liver and pelvis).
Treatment and Prevention
Stage I and II are ideally treated with radiation or endoscopic or open surgery that preserve laryngeal function. For carcinoma in situ (stage 0) invasive glottic or supraglottic cancer, endoscopic surgical excision or radiation therapy are the best options with similar functional outcomes.
Advanced-stage laryngeal carcinomas (stage III-IV) were historically treated using total laryngectomy, reconstruction, and adjuvant postoperative chemoradiation therapy. While total laryngectomy is still required in cases of aggressive or extensive tumours, chemotherapy and radiation therapy protocols have now become the standard of care for many advanced laryngeal cancers.
The treatment options for locally advanced laryngeal cancer are concurrent radiation therapy and cisplatin 100mg/m2 on days 1, 22, and 43. Radiation therapy solely can be considered for patients who are medically unfit to undergo chemotherapy.
The best way of preventing laryngeal cancer is by adopting a healthy lifestyle. Avoid tobacco products, cut down on alcohol intake and opt for a Mediterranean diet – a diet made up of plenty of fresh fruits and vegetables, particularly tomatoes, citrus fruit (such as oranges, grapefruits and lemons), olive oil and fish oil.
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- Adeel, M. et al. (2018) “An overview of laryngeal cancer treatment at a tertiary care oncological center in a developing country,” Cureus, 10(6), p. e2730.
- Throat Cancer Survival Rate (no date) Cancer.org. Available at: https://www.cancer.org/cancer/laryngeal-and-hypopharyngeal-cancer/detection-diagnosis-staging/survival-rates.html (Accessed: July 17, 2021).
- Malignant Tumors of the Larynx Treatment & Management (2021) Medscape.com. Available at: https://emedicine.medscape.com/article/848592-treatment (Accessed: July 17, 2021).
- Stanford Health Care (2017) Stanfordhealthcare.org. Available at: https://stanfordhealthcare.org/medical-conditions/cancer/laryngeal-cancer/laryngeal-cancer-risk-factors.html (Accessed: July 17, 2021).
- Symptoms of larynx cancer (no date) Org.uk. Available at: https://www.nhs.uk/conditions/laryngeal-cancer/ (Accessed: July 30, 2021).