Laryngeal Neoplasms

Author Credentials 

Erik T. Interval, MD
Fellow, Creighton University and Nebraska Methodist / Head & Neck Surgical Oncology

William Lydiatt, MD
Chair, Department of Surgery Nebraska Methodist Hospital and
Clinical Professor of Surgery, Creighton University
Creighton University and Nebraska Methodist Hospital
Head and Neck Surgery
8303 Dodge St
Omaha, NE 68154

Module Learning Objectives 
  1. Recognize the risk factors for development of laryngeal carcinoma.
  2. Describe the differential diagnosis of benign and malignant neoplasms of the larynx.
  3. Explain staging of laryngeal carcinoma.
  4. Review the diagnostic techniques for determining extension of disease and their utility in laryngeal cancer.
  5. List the treatment options for laryngeal carcinoma.
  6. Cite the rehabilitation options for patients with laryngeal carcinoma.
  7. Explain long-term follow-up and survivorship for patients with a history of laryngeal carcinoma.

Embryology

Learning Objectives 
  1. Understand the embryological tissue planes and derivation of structures in the larynx.
References 
  1. de Bakker BS, et al. The Development of the Human Hyoid-Larynx Complex Revisited. Laryngoscope. 2017;Dec, epub ahead of print.
  2. Patel PK et al. Head and Neck Embryology. Online. https://emedicine.medscape.com/article/1289057-overview. 2016.
  3. Tewfik TL et al. Congenital malformations of the larynx: Embryology. Online. https://emedicine.medscape.com/article/837630-overview. 2017.
  4. Soerdjbalie-Maikoe V, van Rijn R. Embryology, normal anatomy, and imaging techniques of the hyoid and larynx with respect to forensic purposes: a review article. Forensic Science, Medicine, and Pathology. 2008;4(2):132-139.

Anatomy

Learning Objectives 

Understand the anatomic relationships that define the larynx:

  1. Basic anatomy
    1. Cartilages
    2. Muscles
    3. Vessels
    4. Nerves
    5. Ligaments
  2. Anatomic sites
    1. Supraglottis
      1. Subsites
    2. Glottis
      1. Layers of the vocal cord
    3. Subglottis
References 
  1. Shah JP, Patel SG, Singh B. Chapter 10: Larynx and Trachea, in Shah JP, Patel SSG, Singh B, editors. Head and Neck: Surgery and Oncology, 4th ed. Philadelphia PA, Elsevier, 2007:356-425
  2. Barnes S, Jones O. The Larynx. www.teachmeanatomy.info. Accessed March 19, 2018. 
  3. Vashishta R et al. Larynx Anatomy. https://emedicine.medscape.com/article/1949369-overview. Accessed March 19, 2018.
  4. Silver CE. Surgical Anatomy, in Silver CE, Ferlito A, editors. Surgery for Cancer of the Larynx and Related Structures, 2nd ed. Philadelphia, W.B. Saunders, 1996:13-26.

 

 

Pathogenesis

Learning Objectives 
  1. Know the types of benign and malignant lesions that arise in the larynx.
  2. Understand the risk factors for development of squamous cell carcinoma of the larynx.
  3. Understand the concept of and molecular basis for field cancerization.
References 
  1. Winn DM, Lee Y-CA, Hashibe M, Boffetta P. The INHANCE consortium: toward a better understanding of the causes and mechanisms of head and neck cancer. Oral Dis. 2015 Sep;21(6):685-93.
  2. Kadakia SK, Badhey A, Milam M, Lee T, Ducid Y. Topical Oral Cavity Chemoprophylaxis Using Isotretinoin Rinse: A 15-Year Experience. Laryngoscope. 2017 Jul;127(7):1595-1599. 
  3. Hong WK, Lippman SM, Itri LM, et al. Prevention of second primary tumors with isotretinoin in squamous-cell carcinoma of the head and neck. N Engl J Med. 1990 Sep 20;323(12):795-801.
  4. Davidson, BJ. Epidemiology and etiology. In: Shah, J, editor. Atlas of Clinical Oncology; Cancer of the Head and Neck. Hamilton, Ontario: B.C. Decker. 2001:1-18.
  5. Braakhuis BJ et al.  Second primary tumors and field cancerization in oral and oropharyngeal cancer: molecular techniques provide new insights and definitions. Head Neck. 2002 Feb;24(2):198-206.
  6. Slaughter DP, Southwick HW, Smejkal W. Field cancerization in oral stratified squamous epithelium: Clinical implications of multicentric origin. Cancer. 1953 Sep;6(5):963-8.

Basic Science

Learning Objectives 

Understand the pattern of local spread of supraglottic, glottic, and subglottic laryngeal tumors based on clinical anatomy.

References 
  1. Mendenhall, WM. Laryngeal Cancer: General Principles and Management. In: Harrison, LB, editor. Head and Neck Cancer: A Multidisciplinary Approach, 4th ed. Philadelphia PA, 2014:441-458.
  2. Ferlito A, Silver CE. Squamous Cell Carcinoma and its Precursors, in Silver CE, Ferlito A, editors. Surgery for Cancer of the Larynx and Related Structures, 2nd ed. Philadelphia, W.B. Saunders, 1996:27-42.

Incidence

Learning Objectives 
  1. Know the incidence of squamous cell carcinoma of the head and neck at various sites.
  2. Know the incidence and pattern of nodal metastasis in laryngeal carcinoma.
References 
  1. Rivière D, et al. Lymph-node metastasis following total laryngectomy and total pharyngolaryngectomy for laryngeal and hypopharyngeal squamous cell carcinoma: Frequency, distribution, and risk factors. Eur Ann Otorhinolaryngol Head Neck Dis. 2017 Dec 22. pii: S1879-7296(17)30184-9.
  2. Candela FC, Shah J, Jacques DP, et al. The patterns of cervical lymph node metastases from squamous cell carcinoma of the larynx. Arch Otolaryngol Head Neck Surg. 1990 Apr;116(4):432-5.
  3. Lindberg R. Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer. 1972;29(6):1446-9.
  4. Siegel R, Miller K, Jemal A. Cancer Statistics 2018. CA Cancer J Clin. 2018;68:7-30. 

Patient Evaluation

Learning Objectives 

Know the proper use and importance of history, physical examination, radiographic evaluation, dental evaluation, laboratory evaluation, and examination under anesthesia.

References 
  1. Mendenhall, WM. Laryngeal Cancer: General Principles and Management. In: Harrison, LB, editor. Head and Neck Cancer: A Multidisciplinary Approach, 4th ed. Philadelphia PA; 2014:441-458.
  2. Lydiatt WM, Lydiatt DD. Chapter 9. In: Shah, J, editor. Atlas of Clinical Oncology; Cancer of the Head and Neck. Hamilton, Ontario: B.C. Decker; 2001:169-84.
  3. Shah JP, Patel SG, Singh B. Chapter 10: Larynx and Trachea, in Shah JP, Patel SSG, Singh B, editors. Head and Neck: Surgery and Oncology, 4th ed. Philadelphia PA, Elsevier; 2007:356-425.

Measurement of Functional Status

Learning Objectives 
  1. Be aware of the importance of assessing the entire patient including their general medical and nutritional state with specific attention to their ability to tolerate therapy.
    1. This should be an important aspect to the decision-making process regarding treatment selection.
  2. Know that functional status should also include an assessment of potential psychological morbidity. The clinician must prepare the patient as much as possible for the ravages of treatment.
References 
  1. American Head and Neck Society
  2. Wachal B, et al. Association of Modified Frailty Index Score with Perioperative Risk Factors for Patients Undergoing Total Laryngectomy. JAMA Otolaryngol Head Neck Surg. 2017 Aug 1; 143(8):818-823.doi: 10.1001/jamaoto.2017.0412
  3. de Leeuw JRJ, de Graeff A, Ros WJG, et al. Prediction of depressive symptomatology after treatment of head and neck cancer: the influence of pretreatment physical and depressive symptoms, coping, and social support. Head and Neck. 2000 Dec;22(8):799-807.
  4. Panwar A, Cheung VW, Lydiatt W. Supportive Care and Survivorship Strategies in Management of Squamous Cell Carcinoma of the Head and Neck. Hematol Oncol Clin N Am. 2015 Dec;29(6):1159-1168.
  5. Lydiatt WM, et al. Prevention of depression with escitalopram in patients undergoing treatment for head and neck cancer: double-blind, placebo-controlled clinical trial. JAMA Otolaryngol Head Neck Surg. 2013 Jul;139(7):678-86. Doi: 10.1001/jamaoto.2013.3371.
  6. Piccirillo JF. Inclusion of comorbidity in a staging system for head and neck cancer. Oncology. 1995 Sept;9:831.
  7. Support for People with Oral and Head and Neck Cancer.

Imaging

Learning Objectives 
  1. Understand when and when not to utilize diagnostic imaging. Imaging should be determined on an individual basis.
  2. Know that it is vital to evaluate for evidence of cartilage destruction and pre-epiglottic extension to determine staging.
  3. Understand that cervical nodes may be evaluated at the same time. However, understand that imaging alone is not sufficient to rule out lymphatic metastases.
  4. Understand the role of imaging in clinical follow-up, and that PET / CT after initial post-treatment scan is not necessarily routinely indicated.
References 
  1. Hermans, R. Laryngeal Neoplasms. In: Hermans R, editor. Head and Neck Cancer Imaging. Heidelberg, Germany; 2008:43-80.
  2. Bennett, JA. Laryngeal Cancer: Radiologic Imaging Concerns. In: Harrison, LB, editor. Head and Neck Cancer: A Multidisciplinary Approach, 4th ed. Philadelphia PA; 2014:459-467.

Pathology

Learning Objectives 
  1. Understand the various subtypes of squamous cell carcinoma of the larynx.
  2. Recognize the various non-squamous malignancies of the larynx.
References 
  1. Lewis JS. Not Your Usual Cancer Case: Variants of Laryngeal Squamous Cell Carcinoma. Head and Neck Pathol. 2011 Mar;5(1):23-30. 
  2.  Ferlito A. The World Health Organization’s Revised Classification of Tumours of the Larynx, Hypopharynx, and Trachea. Ann Otol Rhinol Laryngol. 1993 Sep;102:666-669. 
  3. Lin HW, Bhattacharyya N. Staging and Survival Analysis for Nonsquamous Cell Carcinomas of the Larynx. Laryngoscope. 2008 Jun;118:1003-1013.
  4. Ferlito A. Unusual Laryngeal Neoplasms, in Silver CE, Ferlito A, editors. Surgery for Cancer of the Larynx and Related Structures, 2nd ed. Philadelphia, W.B. Saunders; 1996:43-64.

Treatment

Learning Objectives 
  1. Understand that benign laryngeal neoplasms are typically treated with surgery using both endoscopic and open means depending on the lesion.
  2. Know that malignant lesions may also be treated with surgery.
    1. Early laryngeal cancer can be treated using single-modality treatment: radiation or surgery.
    2. Functional results, quality of life, and specific factors regarding the tumor and experience of the treating physicians tend to dictate the approach.
    3. Advanced cancer is treated with combined modality therapy, whether primary surgery with adjuvant treatment or primary chemoradiation.
  3. Understand the role of the addition of chemotherapy in high-risk patients in the postoperative setting.
References 
  1. Shah JP, Patel SG, Singh B. Chapter 10: Larynx and Trachea, in Shah JP, Patel SSG, Singh B, editors. Head and Neck: Surgery and Oncology, 4th ed. Philadelphia PA, Elsevier; 2007:356-425.
  2. Holsinger FC and McWhorter AJ. Laryngeal Cancer: Surgical Decision Making and Technique. In: Harrison, LB, editor. Head and Neck Cancer; A Multidisciplinary Approach, 4th ed. Philadelphia PA; 2014:473-481.
  3. Mendenhall, WM. Laryngeal Cancer: Radiation Therapy Technique. In: Harrison, LB, editor. Head and Neck Cancer: A Multidisciplinary Approach, 4th ed. Philadelphia PA; 2014:468-472.
  4. Davis LW, Williams WH. Controversy in the management of laryngeal tumors: Radiation therapy perspective. In Thawley, SE, Panje, WR, Batsakis, et al., editors. Comprehensive Management of Head and Neck Tumors, vol. 1. 2nd ed. Philadelphia: W.B. Saunders; 1999:1081-89.
  5. Mendenhall WM, Amdur RJ, Morris CG, Hinerman RW. T1-T2N0 Squamous cell carcinoma of the glottis larynx treated with radiation therapy. J Clin Oncol. 2001 Oct 15;19(20):4029-4036. 
  6. Smee RI, Williams JR, Broadley K, Bridger GP. Early glottic carcinoma treated by radiotherapy: defining a population for surgical salvage. Laryngoscope. 2013 Jan;123(1):171-176.
  7. Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med. 1991 Jun 13;324(24):1685-90.
  8. Forrastiere AA, Zhang Q, Weber R, et al. Long-term results of RTOG 91-11: A comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol. 2013 Mar 1;31(7):845-52.
  9. Bernier J, Cooper J, Pajak T, van Glabbeke M, et al. Defining risk levels in locally advanced head and neck cancers: a comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (#9501). Head & Neck. 2005 Oct;27(10):843-50.

Surgical Therapies

Learning Objectives 
  1. Understand the surgical procedures related to laryngeal cancer.
References 
  1. Holsinger FC and Laccourreye O. Exam Under Anesthesia for the Patient with Cancer: Direct Laryngopharyngoscopy and Mucosal Tatouage, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier; 2011:327-334.
  2. Spriano G, Ruscito P, Pellini R. Horizontal Supraglottic Laryngectomy, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier; 2011:335-345.
  3. Holsinger FC et al. Supracricoid partial laryngectomy with cricohyoidopexy or cricohyoidoepiglottopexy, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier; 2011:346-358.
  4. Holsinger FC, Bhayani MK. Total laryngectomy, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier; 2011:359-372.
  5. Reece G. Stomaplasty for Hands-Free Voice with Tracheoesophageal Puncture, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier; 2011:373-382.
  6. Bhayani MK, Holsinger FC. Tracheoesophageal Puncture in the clinic via transnasal esophagoscopy, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier; 2011:383-388.
  7. Holsinger FC. Transoral laser microsurgery: Supraglottic, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier; 2011:389-396.
  8. Christopoulos A, Holsinger FC, Ferris RL. Transoral laser resection of glottic tumors, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier; 2011:397-408.

Staging

Learning Objectives 

Know how to stage laryngeal carcinoma both clinically and pathologically.

References 
  1. Patel SG, Lydiatt WM, Glastonbury CM. Larynx, in: Amin MB, editor. AJCC Cancer Staging Manual, Eight Edition. New York: Springer, 2017:149-161.

Complications

Learning Objectives 
  1. Be aware of the complications of therapy and how to manage them.
  2. Complications of surgical and nonsurgical therapy are substantial.
    1. Surgical complications following chemotherapy and radiation are significant and can be prolonged.
References 
  1. Wachal B, et al. Association of Modified Frailty Index Score with Perioperative Risk Factors for Patients Undergoing Total Laryngectomy. JAMA Otolaryngol Head Neck Surg. 2017 Aug 1; 143(8):818-823.doi: 10.1001/jamaoto.2017.0412.
  2. Forrastiere AA, Zhang Q, Weber R, et al. Long-term results of RTOG 91-11: A comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol. 2013 Mar 1;31(7):845-852.
  3. Terrell JE, Fischer SG, Wolf GT. Long-term quality of life after treatment of laryngeal cancer. The Veterans Affairs Laryngeal Cancer Study Group. Arch Otolaryngol Head Neck Surg. 1998 Sep;124(9):964-71.

Review

Review Questions 
  1. List the major risk factors for squamous cell carcinoma of the larynx.
  2. Describe the presenting signs and symptoms of laryngeal tumors.
  3. Understand staging of laryngeal tumors.
  4. Understand the definition of and difference in treatment between early and advanced laryngeal tumors.
  5. Describe the geographic differences in cancer incidence across the world.
Resources 

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  1. Annual Meeting Webcast (AMW):