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Symptoms and signs of laryngeal cancer differ based on the involved portion of the larynx. Hoarseness is common early in glottic cancers but is a late symptom for supraglottic and subglottic cancers. Patients with subglottic cancer often present with airway obstruction, and hoarseness is a common late symptom. Patients with supraglottic cancer often present with dysphagia; other common symptoms include airway obstruction, otalgia, development of a neck mass, or a "hot potato" voice. Patients with these symptoms should be referred for direct laryngoscopy without delay.

• Laryngoscopy

• Operative endoscopy and biopsy

• Imaging tests for staging

All patients who have hoarseness for > 2 to 3 weeks should have their larynx examined by a head and neck specialist. Some practitioners use a mirror to evaluate the larynx, but most prefer a flexible fiberoptic examination. Any lesions discovered require further evaluation, usually with operative endoscopy and biopsy, with concomitant evaluation of the upper airway and gastrointestinal tract for coexisting cancers. The incidence of a synchronous second primary tumor may be as high as 10%.

Early Laryngeal Cancer

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Patients with confirmed carcinoma typically have neck CT with contrast and a chest x-ray or chest CT. Most clinicians also do PET of the neck and chest at the time of diagnosis.

For purposes of clinical stage classification, the larynx is divided into 3 regions: supraglottis, glottis, and subglottis (1). Laryngeal cancer is staged according to size and site of the primary tumor (T), number and size of metastases to the cervical lymph nodes (N), and evidence of distant metastases (M). There are separate N categories for HPV-related and HPV-unrelated cancers. Staging usually requires imaging with CT, MRI, or both, and often PET.

Clinical staging (cTNM) is based on the results of the physical examination and tests done before surgery. Pathologic staging (pTNM) is based on the pathologic characteristics of the primary tumor and the number of positive nodes found during surgery.

Extranodal extension is incorporated into the "N" category for metastatic cancer to neck nodes. Clinical diagnosis of extranodal extension is based on finding evidence of gross extranodal extension during the physical examination together with imaging tests confirming the finding. Pathologic extranodal extension is defined as histologic evidence of tumor in a lymph node extending through the lymph node capsule into the surrounding connective tissue, with or without associated stromal reaction.

The overall relative 5-year survival rate for patients with laryngeal cancer is 61%. Early-stage glottic carcinoma has an 85 to 95% 5-year survival rate (1). Patients who present with regional nodal disease have a 46% relative 5-year survival rate, and those who present with distant metastases have a 34% relative 5-year survival rate (see National Cancer Institute: Cancer Stat Facts: Laryngeal Cancer).

• Early-stage (T1 and T2): Surgery or radiation therapy

• Moderately advanced (T3): Radiation therapy and sometimes chemotherapy

• Advanced (T4): Surgery (often followed by radiation therapy and sometimes chemotherapy) or sometimes chemotherapy and radiation therapy

Early-stage glottic carcinoma is treated with laser excision, radiation therapy, or occasionally open laryngeal surgery. Endoscopic laser resection and radiation therapy usually preserve a normal voice and post-treatment function and have similar cure rates. Whether surgery or radiation is used to treat early-stage glottic cancer usually depends on the location of the lesion in the glottis, the preferences of the treating institution, and the patient.

For moderately advanced glottic carcinoma, defined by a lack of vocal cord mobility or extension into the tongue, most patients are treated with both chemotherapy and radiation therapy. If the patient presents with extension outside of the larynx or with cartilage invasion, a laryngectomy provides the best oncologic results; the laryngectomy is commonly total, but endoscopic laser resection or open partial laryngectomy can be used in select appropriate cases. A total laryngectomy is also commonly used for salvage situations; however, endoscopic resection or open partial laryngectomy may sometimes be used in these situations.

Early supraglottic carcinoma can be effectively treated with radiation therapy or partial laryngectomy. Laser resection has shown considerable success on early-stage supraglottic squamous cell carcinomas and minimizes functional changes after surgery. If the carcinoma is more advanced but does not affect the true vocal cords, a supraglottic partial laryngectomy can be done to preserve the voice and glottic sphincter. If the true vocal cords also are affected, a supracricoid laryngectomy or a total laryngectomy is required if surgery is chosen.

As with glottic carcinoma, most advanced-stage supraglottic cancers initially are treated with chemotherapy and radiation therapy. The supraglottis has a rich lymphatic network, so in all patients with supraglottic cancer, the neck must be treated with surgery, radiation, or both.

Early subglottic carcinoma is rarely treatable with endoscopic resection so radiation is the mainstay of treatment. For more advanced subglottic lesions or lesions with metastasis, chemoradiation is the standard of care unless there is extension outside of the larynx or extensive cartilage invasion in which case total laryngectomy provides the best outcome.

(See also the National Cancer Institute’s summary Laryngeal Cancer Treatment.)

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

1. National Cancer Institute’s Summary: Laryngeal Cancer Treatment