Laryngeal Cancer
Laryngeal cancer is the second most common head and neck cancer. The most common type is squamous cell carcinoma (SCC)
It peaks between 40 and 70 years of age. The 5-year survival rate is 65%.
Regions of the larynx
| Site | Anatomical boundaries | Histology |
|---|---|---|
| Supraglottic Site | From the epiglottis to the junction of the ventricle and the true vocal cord | Respiratory epithelium |
| Glottic Site | From the superior surface of the true vocal fold to 1 cm below the true vocal folds | Stratified squamous epithelium |
| Subglottic Site | From 1cm below the true vocal folds to the inferior cricoid cartilage | Respiratory epithelium |
Histological subtypes of laryngeal cancer
| Histology | Description |
|---|---|
| Squamous Cell Carcinoma | >95% of Laryngeal Cancer. Basaloid SCC is the most aggressive high-grade variant. |
| Verrucous Carcinoma (Ackerman’s Tumor) | Slow-growing and locally destructive. Appears exophytic (warty), fungating, and grey-white in color. It rarely metastasizes and has an excellent prognosis. |
| Adenocarcinoma | 1% of laryngeal cancer. Primarily in the supraglottic and subglottic regions. More aggressive than SCC. |
| Adenoid Cystic Carcinoma | Perineural spread, an indolent course, and may present with distant metastasis years after primary treatment |
| Spindle Cell Carcinoma | Poorly differentiated variant of SCC with spindle cell stroma component |
| Neuroendocrine Tumors | Paragangliomas, Carcinoid tumors, Small cell carcinoma |
| Sarcomas | Fibrosarcoma, chondrosarcoma, malignant fibrous histiocytoma, rhabdomyosarcoma |
| Metastatic | Rare. Primaries from the kidney, prostate, breast, stomach, and lung. |
Premalignant glottic lesions
| Histology | Description |
|---|---|
| Hyperplasia and Hyperkeratosis | An increase in the number of cells and keratin production |
| Mild Dysplasia | Mild atypia |
| Moderate Dysplasia | Moderate atypia |
| Severe Dysplasia (Carcinoma in Situ) | Full-thickness features of malignancy without invasion of the basement membrane |
| Microinvasive Carcinoma | Discrete foci invade beyond the basement membrane |
| Invasive Carcinoma | Invasion through the basement membrane |
Subsites of laryngeal cancer
| Feature | Supraglottic | Glottic | Subglottic |
|---|---|---|---|
| Frequency | ~40% | ~60% (most common) | Rare |
| Prognosis | Poor (early spread, late detection) | Best (early symptoms) | Poor |
| Lymphatic Spread | Rich → early, bilateral nodal spread (II–IV) | Poor → late, ipsilateral spread | To paratracheal nodes (Level VI) |
| Tumor Spread Pattern | Superior → base of tongue | Limited initially (ligament barriers) | Inferior → cricoid, trachea |
| Special Feature | The fusion plate limits the spread between regions | Barriers (vocal ligament, conus elasticus) | Silent progression |
| Key Early Symptom | Sore throat, dysphagia | Hoarseness | Stridor |
| Other Symptoms | Hemoptysis, aspiration, odynophagia, otalgia, weight loss | Stridor (late), dysphagia, weight loss | Late hoarseness, hemoptysis, dysphagia |
| Unique Entity | Marginal tumor (aggressive, basaloid SCC) | — | — |
- Risk factors
- Smoking and alcohol use
- The highest risk is in current smokers
- Risk increases with the number of cigarettes
- Risk reduces to the level of an individual who has never smoked approximately 20 years after cessation
- History of Recurrent Respiratory Papillomatosis (HPV)
- Previous head and neck Radiation
- Plummer-Vinson Syndrome
- Premalignant lesions
- Leukoplakia
- Hyperkeratosis with atypia
- Carcinoma in Situ
- Genetic mutations in p53, p16, and cyclin D1
- Occupational toxins
- Asbestos
- Wood dust
- Coal dust
- Cement dust
- Polycyclic aromatic hydrocarbons
- Fanconi’s anemia
- Congenital dyskeratosis
- Low socioeconomic status
- Smoking and alcohol use
- Signs and symptoms
- Hoarseness
- Persistent
- Stridor (Airway obstruction)
- Dysphagia
- Odynophagia
- Throat pain
- Haemoptysis
- Referred Otalgia
- Globus sensation
- Weight loss
- Hoarseness
- Differentials
- Fungal laryngitis
- Sarcoidosis
- Tuberculosis
- Wegener’s granulomatosis
- Benign vocal cord tumors
- Polyps
- Cysts
- Hemangioma
- Papilloma
- Investigations
- Indirect laryngoscopy
- Flexible nasolaryngoscopy to visualize cord mobility
- Rigid endoscopy of the larynx
- Direct laryngoscopy under general anaesthesia and biopsy
- Chest X-ray for chest metastasis, mediastinal nodes, and co-existing lung disease
- CT scan of the base of the skull to the thoracic inlet
- PET scan for follow-up and detection of distant metastases
- Pulmonary function tests
- Liver function tests
- Urea and Creatinine
- Electrolytes
- Full Hemogram
- Treatment of Carcinoma in Situ and Micro-Invasive Carcinoma
- Treatment of Laryngeal Carcinoma
- Primary radiation to the primary site
- CO2 laser
- Conservative Laryngeal Surgery
- Total Laryngectomy and neck dissection
- Organ Preservation
- Induction chemotherapy, then Chemoradiation
- Chemoradiation only
- Palliation
- Tracheostomy
- Gastrotomy
- Post-operative complications
- Fistula
- Tracheotomy Complications:
- Pneumothorax
- Haemorrhage
- Subcutaneous emphysema
- Speech alterations
- Swallowing problems
- Persistent aspiration
- Bronchopneumonia
- Esophageal or pharyngeal stenosis
- Perichondritis and shondritis
- Stomal stenosis
- Post-operative voice management
- Writing
- Artificial larynx (electrolarynx)
- Esophageal speech
- Tracheoesophageal Puncture
AJCC T Staging comparison
| Stage | Supraglottic | Glottic | Subglottic |
|---|---|---|---|
| T1 | Limited to 1 subsite, normal cords | Limited to the vocal folds | Limited to the subglottis |
| T2 | >1 subsite or adjacent spread, no fixation | Extends the supra/subglottis or ↓ mobility | Extends to the vocal cords |
| T3 | Cord fixation or invasion (pre-epiglottic/paraglottic space, thyroid cartilage) | Cord fixation or paraglottic invasion | Cord fixation or paraglottic invasion |
| T4 | Invades beyond the larynx / major structures | Advanced invasion | Advanced invasion |