Laryngeal Cancer

Clinical evaluation

• Evaluation begins with a thorough medical history, including a review of risk factors (smoking history, alcohol use, occupational exposures), and a physical examination of the head, neck, and oral cavity. The neck is palpated for lymphadenopathy.

Laryngoscopy

• Laryngoscopy is the essential first examination for any patient with suspected laryngeal pathology. It allows direct visualization of the vocal cords and the full extent of the larynx. Two approaches are used:
  
  
  • Indirect laryngoscopy: A rigid endoscope is introduced through the mouth while the patient vocalizes, allowing the physician to observe vocal cord motion and identify mucosal abnormalities.
  • Flexible fiber-optic nasopharyngoscopy: A thin, flexible endoscope is passed through the nose, providing a clear, magnified view of the entire pharynx and larynx. This is the standard outpatient examination and can be performed with topical anesthesia.
    
    

When laryngoscopy reveals a suspicious lesion, direct laryngoscopy under general anesthesia is performed to obtain tissue for biopsy and to accurately map the extent of disease.

Biopsy

• Tissue biopsy under general anesthesia is required for definitive diagnosis. A histopathological specimen confirms the presence, type, and grade of malignancy. If the lesion appears small and well-localized, the surgeon may attempt complete excision at the time of initial biopsy.

Imaging studies

• Following histological confirmation, imaging is used to determine the extent of local disease and assess for regional and distant spread:
  • CT (Computed Tomography): The primary imaging modality for staging laryngeal cancer. Evaluates tumor extent, cartilage invasion, and lymph node involvement.
  • MRI (Magnetic Resonance Imaging): Provides superior detail for soft tissue involvement and perineural spread.
  • PET-CT (Positron Emission Tomography - CT): Identifies regional lymph node metastasis and distant spread.

Laryngeal cancer is staged using the TNM system, separately for each anatomical subsite (glottis, supraglottis, and subglottis). The following provides a simplified overview of the general staging framework:

Stage I

• Small tumor confined to the site of origin; normal vocal cord mobility; no lymph node involvement

Stage II

• Tumor extends to adjacent laryngeal subsite(s) or region; may affect vocal cord mobility; no lymph node involvement

Stage III

• Tumor fixes the vocal cord; or there is involvement of one ipsilateral lymph node ≤ 3 cm; no distant metastasis

Stage IVA

• Tumor invades through cartilage or extends into soft tissue outside the larynx; or regional lymph node involvement

Stage IVB

• Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures; or lymph node > 6 cm

Stage IVC

• Distant metastasis present

Stage at diagnosis is the most important prognostic factor. Glottic cancers detected at early stages (Stage I–II) have particularly favorable outcomes because vocal cord fixation has not yet occurred.

Treatment is determined based on the stage, subsite, tumor grade, and the patient's overall health and functional goals – particularly the preservation of voice and swallowing. The guiding principle of modern laryngeal cancer treatment is to achieve adequate oncological control using the minimum extent of resection necessary to maximize quality of life.

Surgery

• Surgery is one of the primary treatment modalities, particularly for early-stage and resectable disease. The goal is complete tumor removal while preserving laryngeal function wherever oncologically feasible. Surgical approaches include:
  
  
  • Transoral laser microsurgery (endoscopic laser resection): A minimally invasive approach performed entirely through the mouth using a laser under microscopic guidance. Suitable for early glottic and selected supraglottic cancers. Preserves voice and avoids external incision.
    
    
  • Vertical partial laryngectomy: An open surgical approach that removes part of the larynx, preserving phonation and swallowing in appropriately selected patients.
    
    
  • Supraglottic laryngectomy: Removes the supraglottis while preserving the vocal cords. Indicated for selected supraglottic cancers; swallowing rehabilitation is required postoperatively.
    
    
  • Supracricoid partial laryngectomy: Removes the majority of the larynx but preserves the cricoid cartilage and at least one arytenoid, maintaining breathing without a permanent tracheostomy and allowing for voice restoration.
    
    
  • Total laryngectomy: Complete removal of the larynx, required for advanced tumors where organ-preserving surgery is not oncologically adequate. It results in permanent separation of the airway (tracheostomy) from the digestive tract. Voice rehabilitation is essential following this procedure.
    
    
  • Neck dissection: Performed when regional lymph node metastasis is present or suspected.

Radiation therapy

• Radiation therapy is an effective primary treatment modality for early-stage laryngeal cancer – particularly early glottic cancer – as it may achieve cure rates comparable to surgery while preserving vocal quality. It is also used as:
  
  • Post-operative adjuvant therapy after surgery in high-risk cases (positive or close surgical margins, multiple lymph node involvement, perineural invasion).
  • Concurrent chemoradiation for organ-preservation in advanced but resectable laryngeal cancers where total laryngectomy would otherwise be required.

Chemotherapy

• Chemotherapy is used primarily in the following settings:
  
  • Concurrent chemoradiation: Combining chemotherapy (typically cisplatin-based) with radiation therapy as an organ-preservation strategy for advanced laryngeal cancers, aiming to avoid total laryngectomy.
  • Induction chemotherapy: Administered prior to radiation or chemoradiation in selected advanced cases to reduce tumor volume.
  • Palliative chemotherapy: For recurrent or metastatic disease not amenable to surgery or radiation.

Smoking cessation before and during treatment is strongly recommended, as continued tobacco use reduces treatment effectiveness and increases the risk of recurrence.