The Farber Center: For Radiation Oncology

Larynx cancer may also be called cancer of the larynx or laryngeal carcinoma. The larynx contains the vocal cords, which vibrate and make sound when air is directed against them. There are three main parts of the larynx: the glottis (the middle part of the larynx where the vocal cords are located); the supraglottis (the tissue above the glottis); and the subglottis (the tissue below the glottis). The subglottis connects to the trachea, which takes air to the lungs.

Cancer of the larynx is a disease in which cancerous (malignant) cells are found in the tissues of the larynx.

• Enlarged neck lymph nodes
• Sore throat
• Ear pain
• Difficulty swallowing
• Hoarseness
• Cough
• Pain

Risk Factors

• Age: Cancer of the larynx occurs most often in people over the age of 55.
• Gender: Men are four times more likely than women to get cancer of the larynx.
• Race: African Americans are more likely than whites to be diagnosed with cancer of the larynx.
• Active smoking by patients with head and neck cancer is associated with significant increases in the annual rate of second primary tumor development compared to former smokers or nonsmokers. The use of unfiltered cigarettes or dark, air-cured tobacco is associated with further increases in risk.
• Alcohol is a less potent carcinogen than tobacco, alcohol consumption is a risk factor for laryngeal tumors. In individuals who use both tobacco and alcohol, these risk factors appear to be synergistic, and they result in a multiplicative increase in the risk of developing laryngeal cancer.
• A personal history of head and neck cancer. Almost one in four people who have had head and neck cancer will develop a second primary head and neck cancer.
• Occupation: Workers exposed to sulfuric acid mist or nickel have an increased risk of laryngeal cancer. Also, working with asbestos can increase the risk of this disease. Asbestos workers should follow work and safety rules to avoid inhaling asbestos fibers.

Physical exam: The doctor will feel your neck and check your thyroid, larynx, and lymph nodes for abnormal lumps or swelling. To see your throat, the doctor may press down on your tongue.

Indirect laryngoscopy: The doctor looks down your throat using a small, long-handled mirror to check for abnormal areas and to see if your vocal cords move as they should. This test does not hurt. The doctor may spray a local anesthesia in your throat to keep you from gagging. This exam is done in the doctor's office.

Direct laryngoscopy: The doctor inserts a thin, lighted tube called a laryngoscope through your nose or mouth. As the tube goes down your throat, the doctor can look at areas that cannot be seen with a mirror. A local anesthetic eases discomfort and prevents gagging. You may also receive a mild sedative to help you relax. Sometimes the doctor uses general anesthesia to put a person to sleep. This exam may be done in a doctor's office, an outpatient clinic, or a hospital.

CT scan An x-ray machine linked to a computer takes a series of detailed pictures of the neck area. You may receive an injection of a special dye so your larynx shows up clearly in the pictures. From the CT scan, the doctor may see tumors in your larynx or elsewhere in your neck.

Biopsy: If an exam shows an abnormal area, the doctor may remove a small sample of tissue. Removing tissue to look for cancer cells is called a biopsy. For a biopsy, you receive local or general anesthesia, and the doctor removes tissue samples through a laryngoscope. A pathologist then looks at the tissue under a microscope to check for cancer cells. A biopsy is the only sure way to know if a tumor is cancerous.

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

Barium swallow: A series of x-rays of the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and stomach, and x-rays are taken. This procedure is also called an upper GI series.

T stands for tumor (its size and how far it has spread within larynx and to nearby organs).

Tis: carcinoma (cancer) in situ. This is a very early cancer where cancer cells are found only in one layer of tissue. This stage applies to the glottic, supraglottic, and subglottic larynx

Glottic larynx

T1: tumor that is limited to the vocal folds, but it does not affect movement of the folds.

T1a: tumor in just the right or left vocal fold.

T1b: tumor in both vocal folds.

T2: tumor that has spread to the supraglottis and/or the subglottis. T2 also describes a tumor that affects the movement of the vocal fold, without paralyzing the fold.

T3: tumor that is limited to the larynx and paralyzes at least one of the vocal folds.

T4a: The tumor has spread to the thyroid cartilage and/or the tissue beyond the larynx.

T4b: The tumor has spread to the area in front of the spine (prevertebral space), chest area, or encases the arteries.

Supraglottic larynx

T1: tumor located in a single area above the vocal folds that doesn’t affect movement of the vocal folds.

T2: tumor that started in the supraglottis, but has spread to the mucus membranes that line other areas, such as the base of the tongue.

T3: tumor that is limited to the larynx with vocal fold involvement and/or has spread to surrounding tissue.

T4a: tumor has spread through the thyroid cartilage and/or the tissue beyond the larynx.

T4b: tumor has spread to the area in front of the spine (prevertebral space), chest area, or encases the arteries.

Subglottic larynx

T1: tumor that is limited to the subglottis.

T2: tumor that has spread to the vocal folds and may or may not affect movement of the folds.

T3: tumor that is limited to the larynx and affects the vocal folds.

T4a: tumor has spread to the cricoid or thyroid cartilage and/or the tissue beyond the larynx.

T4b: tumor has spread to the area in front of the spine (prevertebral space), chest area, or encases the arteries.

N stands for spread to nearby lymph nodes in the neck

N0: There is no evidence of cancer in the regional nodes.

N1: Cancer has spread to a single node on the same side as the primary tumor and the cancer found in the node is 3 cm or smaller.

N2: Describes any of the following conditions:

N2a: Cancer has spread to a single lymph node on the same side as the primary tumor, and is larger than 3 cm, but not larger than 6 cm.
N2b: Cancer has spread to more than one lymph node on the same side as the primary tumor, and none measure larger than 6 cm.
N2c: Cancer has spread to more than one lymph node on either side of the body, and none measure larger than 6 cm.
N3: Cancer found in the lymph nodes is larger than 6 cm.

M is for metastasis (spread to distant organs).

M0: The cancer has not spread to distant sites.

M1: The cancer has spread to distant sites.

Stage Grouping

Stage 0
Tis, N0, M0

Stage I
T1, N0, M0

Stage II
T2, N0, M0

Stage III
T3, N0, M0, OR T1 to T3, N1, M0

Stage IVA
T4a, N0 or N1, M0, OR T1 to T4a, N2, M0

Stage IVB
T4b, Any N, M0, OR Any T, N3, M0

Stage IVC:
Any T, Any N, M1

RADIATION THERAPY
uses high-energy rays to damage cancer cells and stop them from growing. The rays are aimed at the tumor and the surrounding area. Doctors may suggest this type of treatment for some cancers because it can destroy the tumor and you may not lose your voice. Radiation therapy may be combined with surgery to destroy microscopic cancer cells that may remain in the area after surgery. Radiation therapy also may be used for tumors that cannot be removed with surgery.

SURGERY
may be recommended as primary treatment for some tumors, thus avoiding radiation. Surgery followed by radiation is suggested for some patients with advanced cancers. Surgery is the usual treatment if a tumor does not respond to radiation therapy or grows back after radiation therapy. When patients need surgery, the type of operation depends mainly on the size and exact location of the tumor.

If a tumor on the vocal cord is very small, the surgeon may use a laser, a powerful beam of light, to remove the tumor. Surgery to remove part or the entire larynx is called a partial or total laryngectomy. The surgeon may perform a tracheostomy, creating an opening called a stoma in the front of the neck, which may be temporary or permanent. Air enters and leaves the trachea and lungs through this opening. A tracheostomy tube, sometimes called a "trach tube," keeps the new airway open.

A partial laryngectomy preserves the voice. The surgeon removes only part of the voice box --just one vocal cord, part of a cord or just the epiglottis, cartilage that projects upward behind the tongue. In these cases, the tracheostomy is temporary. After a brief recovery period, the trach tube is removed and the opening closes.

In a total laryngectomy, the whole voice box is removed and the stoma or opening is permanent. The patient breathes through the stoma and must learn to talk in a new way. If your doctor thinks the cancer may have spread, the lymph nodes in the neck and some of the tissue around them may be removed. These nodes are often the first place the laryngeal cancer spreads.

CHEMOTHERAPY
is the use of drugs to kill cancer cells. Your doctor may suggest one drug or a combination of drugs. In some cases, anticancer drugs are given during radiation therapy. Chemotherapy also may be used for cancers that have spread elsewhere in the body.

Possible Treatment Side Effects
Dr. Farber, Dr. Spierer, and their staff at The Farber Center for Radiation Oncology will discuss potential side effects with you before, during, and after treatment, and ensure that your experience is personalized.