Laryngeal cancers are mostly squamous-cell carcinomas, reflecting their origin from the epithelium of the larynx.

Cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...

can develop in any part of the

larynx The larynx (), commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about ...

. The prognosis is affected by the location of the tumour. For the purposes of staging, the larynx is divided into three anatomical regions: the

glottis The glottis is the opening between the vocal folds (the rima glottidis). The glottis is crucial in producing vowels and voiced consonants. Etymology From Ancient Greek ''γλωττίς'' (glōttís), derived from ''γλῶττα'' (glôtta), v ...

(true vocal cords, anterior and posterior commissures); the supraglottis (

epiglottis The epiglottis is a leaf-shaped flap in the throat that prevents food and water from entering the trachea and the lungs. It stays open during breathing, allowing air into the larynx. During swallowing, it closes to prevent aspiration of food in ...

, arytenoids and

aryepiglottic folds The aryepiglottic folds are triangular folds of mucous membrane of the larynx. They enclose ligamentous and muscular fibres. They extend from the lateral borders of the epiglottis to the arytenoid cartilages, hence the name 'aryepiglottic'. They ...

, and false cords); and the subglottis. Most laryngeal cancers originate in the

, with supraglottic and subglottic tumours being less frequent. Laryngeal cancer may spread by: direct extension to adjacent structures,

metastasis Metastasis is a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body; the term is typically used when referring to metastasis by a cancerous tumor. The newly pathological sites, the ...

to regional cervical lymph nodes, or via the blood stream. The most common site of distant

metastases Metastasis is a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body; the term is typically used when referring to metastasis by a cancerous tumor. The newly pathological sites, the ...

is the

lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of ...

. Laryngeal cancer occurred in 177,000 people in 2018, and resulted in 94,800 deaths (an increase from 76,000 deaths in 1990). Five-year survival rates in the United States are 60.3%.

Signs and symptoms

The symptoms of laryngeal cancer depend on the size and location of the tumour. Symptoms may include the following: * Hoarseness or other voice changes * A lump in the neck * A

sore throat Sore throat, also known as throat pain, is pain or irritation of the throat. Usually, causes of sore throat include * viral infections * group A streptococcal infection (GAS) bacterial infection * pharyngitis (inflammation of the throat) * to ...

or feeling that something is stuck in the throat * Persistent cough *

Stridor Stridor (Latin for "creaking or grating noise") is a high-pitched extra-thoracic breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. It is different from a stertor which is a noise originating in the pha ...

- a high-pitched wheezing sound indicative of a narrowed or obstructed airway * Bad breath * Earache (due to referred pain) * Difficulty swallowing Adverse effects of treatment can include changes in appearance, difficulty eating, dry mouth, or loss of voice that may require learning alternate methods of speaking.

Risk factors

The most important risk factor for laryngeal cancer is

tobacco smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is beli ...

. Death from laryngeal cancer is 20 times more likely for the heaviest smokers than for their non-smoking peers. Heavy chronic consumption of alcohol, particularly alcoholic spirits, is also a significant risk factor. When present in combination, the usages of alcohol and tobacco appear to have a synergistic effect. Other reported risk factors include being of low socioeconomic status, male sex, or age greater than 55 years. Occupational exposure to environmental factors such as wood dust, paint fumes, and certain chemicals used in the metalworking, petroleum, plastics, and textile industries is also believed to be a risk factor for laryngeal cancers. Infections by some strains of Papillomaviridae carry some risk of laryngeal carcinoma. People with a history of head and neck cancer are known to be at higher risk (about 25%) of developing a second, separate cancer of the head, neck, or lung. This is likely due to chronic exposure to the carcinogenic effects of alcohol and

tobacco Tobacco is the common name of several plants in the genus '' Nicotiana'' of the family Solanaceae, and the general term for any product prepared from the cured leaves of these plants. More than 70 species of tobacco are known, but the ...

. In this situation, a field change effect may occur, where the epithelial tissues start to become diffusely dysplastic with a reduced threshold for malignant change. This risk may be reduced by quitting alcohol and tobacco.

Diagnosis

Diagnosis is made by the doctor on the basis of a

medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...

physical examination In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the pati ...

, and special investigations which may include a

chest x-ray A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in me ...

, CT or MRI scans, and tissue biopsy. The examination of the larynx requires some expertise, which may require specialist referral. The physical exam includes a systematic examination of the whole patient to assess general health and to look for signs of associated conditions and metastatic disease. The neck and

supraclavicular fossa The Supraclavicular fossa is an indentation (fossa) immediately above the clavicle. In terminologia anatomica, it is divided into ''fossa supraclavicularis major'' and ''fossa supraclavicularis minor'' Fullness in the supraclavicular fossa can be ...

are palpated to feel for cervical

adenopathy Lymphadenopathy or adenopathy is a disease of the lymph nodes, in which they are abnormal in size or consistency. Lymphadenopathy of an inflammatory type (the most common type) is lymphadenitis, producing swollen or enlarged lymph nodes. In cl ...

, other masses, and laryngeal crepitus. The oral cavity and oropharynx are examined under direct vision. The larynx may be examined by indirect laryngoscopy using a small angled mirror with a long handle (akin to a dentist's mirror) and a strong light. Indirect laryngoscopy can be highly effective, but requires skill and practice for consistent results. For this reason, many specialist clinics now use fibre-optic nasal endoscopy where a thin and flexible endoscope, inserted through the nostril, is used to clearly visualise the entire

pharynx The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its st ...

and larynx. Nasal endoscopy is a quick and easy procedure performed in clinic.

Local anaesthetic A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general a ...

spray may be used. If there is a suspicion of cancer,

biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a dise ...

is performed, usually under general anaesthetic. This provides histological proof of cancer type and grade. If the

lesion A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals. Types There is no designated classif ...

appears to be small and well localised, the surgeon may undertake excision biopsy, where an attempt is made to completely remove the tumour at the time of first biopsy. In this situation, the

pathologist Pathology is the study of the causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in th ...

will not only be able to confirm the diagnosis, but can also comment on the completeness of excision, i.e., whether the tumour has been completely removed. A full endoscopic examination of the larynx,

trachea The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air- breathing animals with lungs. The trachea extends from t ...

, and

esophagus The esophagus (American English) or oesophagus (British English; both ), non-technically known also as the food pipe or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to t ...

is often performed at the time of biopsy. For small glottic tumours further imaging may be unnecessary. In most cases, tumour staging is completed by scanning the head and neck region to assess the local extent of the tumour and any pathologically enlarged cervical lymph nodes. The final management plan will depend on the site, stage (tumour size, nodal spread, distant

), and histological type. The overall health and wishes of the patient must also be taken into account. A prognostic multigene classifier has been shown to be potentially useful for the distinction of laryngeal cancer of low or high risk of recurrence and might influence the treatment choice in future.

Staging

Laryngeal tumours are classified according to the guidelines set by academic organisations such as the

National Comprehensive Cancer Network National Comprehensive Cancer Network (NCCN) is an alliance of 32 cancer centers in the United States, most of which are designated by the National Cancer Institute (one of the U.S. National Institutes of Health) as comprehensive cancer centers. ...

(NCCN) . Overall classification, also known as " staging", can help predict treatment options for patients. Staging consists of three separate evaluations. The first is of the tumour/cancer itself ("T"). The second is the extent to which adjacent lymph nodes are involved in the tumour/cancer's spread ("N"). The third is the presence or absence of any distant

("M). The specific “staging” criteria for laryngeal cancer, as utilised in the NCCN’s 2019 Guidelines for Head and Neck Cancers, are:

T

TX: Unable to assess Tis: '' Carcinoma in situ''

Supraglottis

T1: Tumour present in only one subsite of the supraglottis.

Vocal cords In humans, vocal cords, also known as vocal folds or voice reeds, are folds of throat tissues that are key in creating sounds through vocalization. The size of vocal cords affects the pitch of voice. Open when breathing and vibrating for speec ...

have normal mobility. T2: Tumour invades mucosa. There is no fixation of the

. T3: Tumour causes fixation of the vocal cords, with or without invasion of neighbouring areas. T4: * T4A – Tumour invades at least one of the following: the outer cortex of the

thyroid cartilage The thyroid cartilage is the largest of the nine cartilages that make up the ''laryngeal skeleton'', the cartilage structure in and around the trachea that contains the larynx. It does not completely encircle the larynx (only the cricoid cartilage ...

, extra-laryngeal tissue * T4B – Tumour invades at least one of the following: the pre-vertebral space, any structures of the

mediastinum The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esopha ...

, the

carotid sheath The carotid sheath is an anatomical term for the fibrous connective tissue that surrounds the vascular compartment of the neck. It is part of the deep cervical fascia of the neck, below the superficial cervical fascia meaning the subcutaneous adi ...

, or the structures within the

Glottis

T1: Tumour only involves the

vocal cords In humans, vocal cords, also known as vocal folds or voice reeds, are folds of throat tissues that are key in creating sounds through vocalization. The size of vocal cords affects the pitch of voice. Open when breathing and vibrating for speec ...

. Vocal cords have normal mobility. * T1A – One vocal cord * T1B – Both vocal cords T2: Tumour meets at least one of the following criteria: * extends to supra- or sub-glottis * impairs vocal cord mobility T3: Tumour meets at least one of the following criteria: * causes fixation of the vocal cords * invades the paraglottic space * involves the

’s inner cortex T4: Same as “Supraglottis”

Subglottis

T1: Tumour is only in the subglottis T2: Tumour involves both subglottis and vocal cords (regardless of cord mobility) T3: Same as “

Glottis The glottis is the opening between the vocal folds (the rima glottidis). The glottis is crucial in producing vowels and voiced consonants. Etymology From Ancient Greek ''γλωττίς'' (glōttís), derived from ''γλῶττα'' (glôtta), v ...

” T4: Same as “ Supraglottis”

N

If Using Clinical (Non-Pathological) Diagnosis NX: Unable to assess N0: No involvement of neighbouring lymph nodes N1: Tumour meets ALL of the following criteria: * involves single lymph node * involved lymph node on the same side of the body as tumour * involved lymph node less than 3 cm in “greatest dimension” * lacks extension beyond the lymph node N2: Tumour meets ANY of the following criteria * N2A – Same as N1, except size can be between 3–6 cm * N2B – Same as N2A, except lymph nodes can be multiple, and there is no minimum size * N2C – Same as N2B, except lymph nodes can be on any side of the body N3: Tumour meets ANY of the following criteria: * N3A – Same as N1, except size is greater than 6 cm * N3B – Tumour obviously extends beyond the lymph node border (regardless of number, size, or location of lymph nodes) If Using Pathological Diagnosis NX: Same as “Clinical Diagnosis – NX” N0: Same as “Clinical Diagnosis – N0” N1: Same as “Clinical Diagnosis – N1” N2: Tumour meets ANY of the following criteria * N2A – Same as “Clinical Diagnosis – N2A”, except tumour can extend beyond the involved lymph node * N2B – Same as “Clinical Diagnosis – N2B” * N2C – Same as “Clinical Diagnosis – N2C” N3: Tumour meets ANY of the following criteria: * N3A – Same as “Clinical Diagnosis – N3A” * N3B – Any provable presence of tumour extension beyond the lymph node

M

M0: No evidence of distant metastasis M1: Evidence of distant metastasis

Treatment

Specific treatment depends on the location, type, and stage of the tumour.National Comprehensive Cancer Network, "Evidence Blocks for Head and Neck Cancers," 2019. Treatment may involve

surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pa ...

radiotherapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Rad ...

, or

chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents or alkylating agents) as part of a standardized chemotherapy regimen. Chemother ...

, alone or in combination. Surgical Treatment Surgical treatment may involve partial or full removal of the tumour. Neighbouring tissues and structures may or may not be removed, depending on their involvement in the tumour’s structure and spread. Full removal of the larynx may be necessary in some cases. Adjunct Treatment Adjunct treatment, most commonly the administration of

, may be necessary. Chemotherapy or radiotherapy may be necessary singly, in combination with each other, or in combination with surgery. Adjunct treatment may be necessary prior to surgical treatment, alongside surgical treatment, or after surgical treatment. Clinical decision-making can be difficult in circumstances where the patient is unable to access necessary adjunct treatment. Multi-Disciplinary Treatment Often, successful treatment of and recovery from laryngeal cancer will involve expertise outside of the realms of

oncology Oncology is a branch of medicine that deals with the study, treatment, diagnosis and prevention of cancer. A medical professional who practices oncology is an ''oncologist''. The name's etymological origin is the Greek word ὄγκος (''ó ...

. Physical therapists, occupational therapists, speech therapists,

psychiatrist A psychiatrist is a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders. Psychiatrists are physicians and evaluate patients to determine whether their sy ...

psychologist A psychologist is a professional who practices psychology and studies mental states, perceptual Perception () is the organization, identification, and interpretation of sensory information in order to represent and understand the pre ...

s, oral/maxillofacial surgeons,

dentist A dentist, also known as a dental surgeon, is a health care professional who specializes in dentistry (the diagnosis, prevention, management, and treatment of diseases and conditions of the oral cavity and other aspects of the craniofacial c ...

s, neurologists, neurosurgeons, and endocrinologists may all become involved in the care of patients with laryngeal cancer.

Epidemiology

Incidence is five in 100,000 (12,500 new cases per year) in the US. The American Cancer Society estimated that 9,510 men and women (7,700 men and 1,810 women) would be diagnosed with and 3,740 men and women would die of laryngeal cancer in 2006. According to the GLOBOCAN 2018 estimates of cancer incidence and mortality produced by the

International Agency for Research on Cancer The International Agency for Research on Cancer (IARC; french: Centre International de Recherche sur le Cancer, CIRC) is an intergovernmental agency forming part of the World Health Organization of the United Nations. Its role is to conduct and ...

, there were 177,422 new cases of laryngeal cancer worldwide in 2018 (1.0% of the global total.) Among worldwide cancer deaths, 94,771 (1.0%) were due to laryngeal cancer. In 2019, it is estimated that there will be 12,410 new laryngeal cancer cases in the

United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country Continental United States, primarily located in North America. It consists of 50 U.S. state, states, a Washington, D.C., ...

, (3.0 per 100,000). The number of new cases decreases every year at a rate of 2.4%, and this is believed to be related to decreased cigarette smoking in the general population. Laryngeal cancer is listed as a "rare disease" by the Office of Rare Diseases (ORD) of the

National Institutes of Health The National Institutes of Health, commonly referred to as NIH (with each letter pronounced individually), is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the lat ...

(NIH). This means that laryngeal cancer affects fewer than 200,000 people in the US.

References

External links

Staging cancer of the larynx

Cancer Management Handbook: Head and Neck Cancers
* Clinically reviewe
laryngeal cancer information
for patients, from Cancer Research UK * U
laryngeal cancer statistics
from Cancer Research UK {{Authority control Head and neck cancer of respiratory tract