Laryngeal Carcinoma:

An Overview
Ryan Eric Neilan
MS IV
For the Dept of Otolaryngology
University of Texas Medical Branch
July 20, 2007

Overview
11,000

new cases of laryngeal

cancer per year in the U.S.
Accounts for 25% of head and neck
cancer and 1% of all cancers
One-third of these patients
eventually die of their disease
Most prevalent in the 6th and 7th
decades of life

Overview
4:1

male predilection
Downward shift from 15:1 post WWII
Due to increasing public acceptance
of female smoking
More prevalent among lower
socioeconomic class, in which it is
diagnosed at more advanced stages

Subtypes
Glottic

Cancer: 59%

Supraglottic
Subglottic
Most

Cancer: 40%

Cancer: 1%

subglottic masses are extension

from glottic carcinomas

History
The first laryngectomy for cancer of
the larynx was performed in 1883 by
Billroth
Patient was successfully fed by mouth
and fitted with an artificial larynx
In 1886 the Crown Prince Frederick of
Germany developed hoarseness as he
was due to ascend the throne.

Crown Prince Frederick of Germany

History
Was

evaluated by Sir Makenzie of

London, the inventor of the direct
laryngoscope
Fredericks lesion was biopsied and
thought to be cancer
He refused laryngectomy and later
died in 1888

History

Frederick was
succeeded by Kaiser
Wilhelm II, who along
with Otto von Bismark
militarized the
German Empire and
led them into WW I

Could an
Otolaryngologist have
prevented WW I?

Risk Factors

Risk Factors
Prolonged

use of tobacco and

excessive EtOH use primary risk
factors
The two substances together have a
synergistic effect on laryngeal tissues
90% of patients with laryngeal
cancer have a history of both

Risk Factors
Human

Papilloma Virus 16 &18

Chronic Gastric Reflux
Occupational exposures
Prior history of head and neck
irradiation

Histological Types
85-95%

of laryngeal tumors are

squamous cell carcinoma
Histologic type linked to tobacco and
alcohol abuse
Characterized by epithelial nests
surrounded by inflammatory stroma
Keratin Pearls are pathognomonic

Histological Types
Verrucous

Carcinoma
Fibrosarcoma
Chondrosarcoma
Minor salivary carcinoma
Adenocarcinoma
Oat cell carcinoma
Giant cell and Spindle cell carcinoma

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy

Natural History
Supraglottic

tumors more aggressive:

Direct extension into pre-epiglottic

space
Lymph node metastasis
Direct extension into lateral
hypopharnyx, glossoepiglottic fold, and
tongue base

Natural History
Glottic tumors grow slower and tend to
metastasize late owing to a paucity of
lymphatic drainage
They tend to metastasize after they
have invaded adjacent structures with
better drainage
Extend superiorly into ventricular walls
or inferiorly into subglottic space
Can cause vocal cord fixation

Natural History
True

subglottic tumors are uncommon

Glottic spread to the subglottic space is
a sign of poor prognosis
Increases chance of bilateral disease
and mediastinal extension
Invasion of the subglottic space
associated with high incidence of stomal
reoccurrence following total
laryngectomy (TL)

Presentation
Hoarseness

Most common symptom

Small irregularities in the vocal fold
result in voice changes
Changes of voice in patients with
chronic hoarseness from tobacco and
alcohol can be difficult to appreciate

Presentation
Patients

presenting with hoarseness

should undergo an indirect mirror exam
and/or flexible laryngoscope evaluation
Malignant lesions can appear as friable,
fungating, ulcerative masses or be as
subtle as changes in mucosal color
Videostrobe laryngoscopy may be needed
to follow up these subtler lesions

Presentation
Good

neck exam looking for cervical

lymphadenopathy and broadening of
the laryngeal prominence is required
The base of the tongue should be
palpated for masses as well
Restricted laryngeal crepitus may be
a sign of post cricoid or
retropharyngeal invasion

Presentation
Other

symptoms include:

Dysphagia
Hemoptysis
Throat pain
Ear pain
Airway compromise
Aspiration
Neck mass

Work up
Biopsy

is required for diagnosis

Performed in OR with patient under
anesthesia
Other benign possibilities for
laryngeal lesions include: Vocal cord
nodules or polyps, papillomatosis,
granulomas, granular cell neoplasms,
sarcoidosis, Wegners granulomatosis

Work up
Other

potential modalities:

Direct laryngoscopy
Bronchoscopy
Esophagoscopy
Chest X-ray
CT or MRI
Liver function tests with or without US
PET ?

Staging- Primary Tumor (T)

TX

Minimum requirements to assess

primary tumor cannot be met

T0

No evidence of primary tumor

Tis

Carcinoma in situ

Staging- Supraglottis
T1

Tumor limited to one subsite of supraglottis with normal vocal

cord mobility

T2

Tumor involves mucosa of more than one adjacent subsite of

supraglottis or glottis, or region outside the supraglottis (e.g.
mucosa of base of the tongue, vallecula, medial wall of piriform
sinus) without fixation

T3

Tumor limited to larynx with vocal cord fixation and or invades

any of the following: postcricoid area, preepiglottic tissue,
paraglottic space, and/or minor thyroid cartilage erosion (e.g.
inner cortex)

T4a Tumor invades through the thyroid cartilage and/or invades

tissue beyond the larynx (e.g. trachea, soft tissues of neck
including deep extrinsic muscles of the tongue, strap muscles,
thyroid, or esophagus)
T4
b

Tumor invades prevertebral space, encases carotid artery, or

invades mediastinal structures

Staging- Glottis
T1

Tumor limited to the vocal cord (s) (may involve anterior or

posterior commissure) with normal mobilty

T1a

Tumor limited to one vocal cord

T1b

Tumor involves both vocal cords

T2

Tumor extends to supraglottis and/or subglottis, and/or with

impaired vocal cord mobility

T3

Tumor limited to the larynx with vocal cord fixation and/or

invades paraglottic space, and/or minor thyroid cartilage
erosion (e.g. inner cortex)

T4a

Tumor invades through the thyroid cartilage, and/or invades

tissues beyond the larynx (e.g. trachea, soft tissues of the
neck including deep extrinsic muscles of the tongue, strap
muscles, thyroid, or esophagus

T4b

Tumor invades prevertebral space, encases carotid artery, or

invades mediastinal structures

Staging- Subglottis
T1

Tumor limited to the subglottis

T2

Tumor extends to vocal cord (s) with normal or

impaired mobility

T3

Tumor limited the larynx with vocal cord fixation

T4a

Tumor invades cricoid or thyroid cartilage and/or

invades tissues beyond larynx (e.g. trachea, soft
tissues of the neck including deep extrinsic muscles of
the tongue, strap muscles, thyroid, or esophagus)

T4b

Tumor invades prevertebral space, encases carotid

artery, or invades mediastinal structures

Staging- Nodes
N0

No cervical lymph nodes positive

N1

Single ipsilateral lymph node 3cm

N2a Single ipsilateral node > 3cm and

6cm
N2b Multiple ipsilateral lymph nodes, each
6cm
N2c Bilateral or contralateral lymph nodes,
each 6cm
N3
Single or multiple lymph nodes > 6cm

Staging- Metastasis
M0 No distant metastases
M1 Distant metastases present

Stage Groupings
0
I
II
III
IVA
IVB
IVC

Tis
T1
T2
T3
T1-3
T4a
T1-4a
T4b
Any T
Any T

N0
N0
N0
N0
N1
N0-2
N2
Any N
N3
Any N

M0
M0
M0
M0
M0
M0
M0
M0
M0
M1

Treatment
Premalignant

lesions or Carcinoma in
situ can be treated by surgical
stripping of the entire lesion
CO2 laser can be used to accomplish
this but makes accurate review of
margins difficult

Treatment
Early stage (T1 and T2) can be treated
with radiotherapy or surgery alone,
both offer the 85-95% cure rate.
Surgery has a shorter treatment
period, saves radiation for recurrence,
but may have worse voice outcomes
Radiotherapy is given for 6-7 weeks,
avoids surgical risks but has own
complications

Treatment
XRT

complications include:

Mucositis
Odynophagia
Laryngeal edema
Xerostomia
Stricture and fibrosis
Radionecrosis
Hypothyroidism

Treatment
Advanced

stage lesions often receive

surgery with adjuvant radiation
Most T3 and T4 lesions require a total
laryngectomy
Some small T3 and lesser sized
tumors can be treated with partial
larygectomy

Treatment

Adjuvant radiation is started within 6 weeks of

surgery and with once daily protocols lasts 6-7
weeks
Indications for post-op radiation include: T4
primary, bone/cartilage invasion, extension
into neck soft tissue, perineural invasion,
vascular invasion, multiple positive nodes,
nodal extracapsular extension, margins<5mm,
positive margins, CIS margins, subglottic
extension of primary tumor.

Treatment
Chemotherapy can be used in addition
to irradiation in advanced stage
cancers
Two agents used are Cisplatinum and
5-flourouracil
Cisplatin thought to sensitize cancer
cells to XRT enhancing its
effectiveness when used concurrently.

Treatment
Induction

chemotherapy with definitive

radiation therapy for advanced stage
cancer is another option
Studies have shown similar survival
rates as compared to total
laryngectomy with adjuvant radiation
but with voice preservation.
Role in treatment still under
investigation

Treatment

Modified or radical neck dissections are

indicated in the presence of nodal disease
Neck dissections may be performed in
patients with supra or subglottic T2 tumors
even in the absence of nodal disease
N0 necks can have a selective dissection
sparing the SCM, IJ, and XI
N1 necks usually have a modified
dissection of levels II-IV

Surgical Options

Hemilaryngectomy

No more than 1cm

subglottic extension
anteriorly or 5mm
posteriorly
Mobile affected cord
Minimal anterior
contralateral cord
involvement
No cartilage invasion
No neck soft tissue
invasion

Supraglottic laryngectomy

T1,2, or 3 if only by
preepiglottic space
invasion
Mobile cords
No anterior commissure
involvement
FEV1 >50%
No tongue base disease
past circumvallate
papillae
Apex of pyriform sinus
not invloved

Supracricoid Laryngectomy

Resection of true
vocal cords,
supraglottis, thyroid
cartilage
Leave arytenoids
and cricoid ring
intact
Half of patients
remain dependent
on tracheostomy

Total Larygectomy
Indications:

T3 or T4 unfit for partial

Extensive involvement of thyroid and
cricoid cartilages
Invasion of neck soft tissues
Tongue base involvement beyond
circumvallate papillae

Total Laryngectomy

Total Laryngectomy

Total Laryngectomy

Total Laryngectomy

Voice Rehabilitation
Tracheostomal

prosthesis

Electrolarynx
Pure

esophageal speech

Complications

Inaccurate staging
Infection
Voice alterations
Swallowing difficulties
Loss of taste and smell
Fistula
Tracheostomy dependence
Injury to cranial nerves: VII, IX, X, XI, XII
Stroke or carotid blowout
Hypothyroidism
Radiation induced fibrosis

Prognosis
5 year survival
Stage I
Stage II
Stage III
Stage IV

>95%
85-90%
70-80%
50-60%

After initial treatment patients are followed at 46 week intervals. After first year decreases to
every 2 months. Third and fourth year every
three months, with annual visits after that

Prognosis
Patients

considered cured after being

disease free for five years
Most laryngeal cancers reoccur in the
first two years
Despite advances in detection and
treatment options the five year
survival has not improved much over
the last thirty years

References

Malignant Tumors of the Larynx and Hypopharynx.

Hypopharynx. Cummings- Otolaryngology- Head and Neck
Surgery. 4th ed., Mosby, 2005.
Malignant Laryngeal Lesions. Lawani- Current Diagnosis and Treatment in Otolaryngology- Head and
Neck Surgery. McGraw-Hill and Lange, 2004.
Neck. Moore- Essential Clinical Anatomy. 2nd ed., Lippincott, 2002.
Head and Neck. Rohen- Color Atlas of Anatomy. 5th ed., Lippincott, 2002.
Surgery for Supraglottic Cancer.
Cancer. Myers- Operative Otolaryngology Head and Neck Surgery Vol. 1. 1st
ed., Saunders, 1997.
Surgery for Glottic Carcinoma.
Carcinoma. Myers- Operative Otolaryngology Head and Neck Surgery Vol. 1. 1st ed.,
Saunders, 1997.
The Larynx.
Larynx. Lore and Medina- An Atlas of Head and Neck Surgery. 4th ed., Elsevier, 2005.
Hinerman, R, Morris, C, et al. Surgery and Postoperative Radiotherapy for Squamous Cell Carcinoma of
the Larynx and Pharynx. Am J Clin Oncol. 2006; 29(6): 613-621.
Huang, D, Johnson, C, et al. Postoperative Radiotherapy in Head and Neck Carcinoma with
Extracapsular Lymph Node extension and/or Positive Resection Margins: a Comparative Study. Int J
Radiat Oncol Biol Phy. 1992; 23:737-742.
Bernier, J, Domenge, C, et al. Postoperative Irradiation with or without Concomitant Chemotherapy for
Locally Advanced Head and Neck Cancer. N Engl J Med. 2004; 350: 1945-1952.
Sessions, D, Lenox, J, et al. Supraglottic Laryngeal Cancer: Analysis of Treatment Results.
Laryngoscope. 2005; 115: 1402-1410.
Wolf, GT. The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction Chemotherapy
Plus Radiation Compared with Surgery Plus Radiation in Patients with Advanced Laryngeal Cancer. New
England Journal of Medicine. 1991; 324: 1685-90.
Lefebre J, Chevalier D, Luboinski B, Kirkpatrick A, Collette L, Sahmoud T. Larynx Preservation in
Pyriform Sinus Cancer: Preliminary Results of a European Organization for Research and Treatment of
Cancer Phase III Trial. Journal of the National Cancer Institute. Jul 1996. 88(13): 890-899.
Grants Atlas 10th ed. CD-ROM