Current opinion in diagnosis and treatment of laryngeal carcinoma

doi:10.1016/j.ctrv.2006.07.002

Cancer Treatment Reviews

Volume 32, Issue 7, November 2006, Pages 504-515

https://doi.org/10.1016/j.ctrv.2006.07.002 Get rights and content

Summary

Laryngeal carcinoma is the 11th commonest form of cancer in men world-wide, with 121,000 new cases in 1985. More than 95% of all laryngeal malignancies are squamous cell carcinomas.

Treatment indications in cancer of the larynx are often controversial, since there are few comparative studies of different available therapeutic approaches. Surgery and radiotherapy are both widely used, and the choice between these two procedures is the most common therapeutic decision which has to be taken. Laryngeal function preservation has gained more and more weight in the last decades and chemotherapy is also a significant component of several curative approaches. In the last decades, several organ-preserving surgical techniques have become available and consequently total laryngectomy results less applied.

Regardless of the treatment modality, Tis, T1, T2 laryngeal carcinomas have an 80–90% probability of cure, whereas for more advanced tumours this is approximately 60%.

The most effective approach to laryngeal cancer remains prevention and early diagnosis when this cancer is curable with function preserving treatments.

Section snippets

Anatomy

For clinical and staging purposes, the larynx is currently divided in supraglottic, glottic and subglottic regions.¹ Essential laryngeal anatomy is synthesised by Table 1.

Considering the significant metastatic potential of laryngeal carcinoma to the cervical lymph nodes, concise notes of clinical anatomy of cervical lymphatics are mandatory. A widely accepted level-based system can be synthesized as follows:

Level I: submental (IA) and submandibular (IB) lymph nodes;
Levels II (IIA enterior to

Epidemiology

Laryngeal carcinoma is the 11th commonest form of cancer in men world-wide, with 121,000 new cases in 1985.³ It is one of the most common malignancies in Europe, with about 52,000 new cases per year;⁴ approximately 9500–11,000 new cases of laryngeal cancer are estimated to occur yearly in the United States.5, 6 The yearly incidence rate for men in southern and northern Europe is between 18 per 100,000 and 6 per 100,000, respectively. For women, incidence rate is not higher than 1.5 per 100,000

Signs and symptoms

The most important functions of the larynx are to provide airway patency, protect the tracheo-bronchial tree from aspiration, and allow phonation. Tumours that involve the larynx may impair these function in a variable degree depending on location, size and depth of invasion. The presence of hoarseness, sore throat, shortness of breath, dysphagia or “lump in throat” sensation are all symptoms observed in early or moderately advanced stages of laryngeal cancers. Since lymph node metastases are

Histology

More than 95% of all laryngeal malignancies are squamous cell carcinomas.10, 11 Less common phenotypic expressions of this malignancy can occur. Verrucous squamous cell carcinoma is a locally aggressive but usually non-metastasizing highly differentiated variant.

Table 2 summarizes the histologic typing of primary laryngeal malignancies.

Distant metastases to the larynx are extremely uncommon occurrences (⩽0.2%).¹² Cutaneous melanomas are the preponderant primaries metastasizing to the larynx,

Risk factors

Tobacco is the predominant risk factor in laryngeal carcinogenesis. Alcohol is generally regarded as the second major risk factor. In most series, >95% of patients with squamous cell carcinoma of the larynx have a background of tobacco and/or alcohol consumption prior to tumour diagnosis. The appearance of laryngeal cancer has been related to other factors, such as environmental exposure (evidence does not support asbestos exposure itself as increasing the relative risk of laryngeal cancer),

Primary laryngeal squamous cell carcinoma development

Pre-invasive lesions (dysplasia and carcinoma in situ) are characterized by atypical or malignant cytologic features encompassed within the laryngeal squamous epithelium. Dysplasia shows cells which have features of malignancy, but which do not breach the basement membrane to reach into the adjacent lamina propria. In the natural history of laryngeal cancer, both dysplasia and carcinoma in situ of the laryngeal mucosa may subsequently evolve into an invasive neoplasm. It is also a fact that

Clinical assessment

The staging for laryngeal cancers is based on laryngeal sub-sites invasion, vocal cord mobility, and neck involvement. An outpatient setting examination with flexible and rigid laryngoscopes with or without local anaesthesia should assess the lesion extension and vocal cord mobility. The flexible fibro-rhinolaryngoscope has increased the reliability of endoscopy in patients whose larynx was previously difficult to visualize.

Direct laryngoscopy under general anaesthesia may be useful to allow

Treatment of laryngeal primary carcinoma

Regardless of the treatment modality, Tis, T1, T2 laryngeal carcinomas have an 80–90% probability of cure, whereas for more advanced tumours this is approximately 60%. Treatment indications in cancer of the larynx are often controversial, since there are few comparative studies of the different available therapeutic approaches.⁷ Surgery and radiotherapy are both widely used, and the choice between these two procedures is the most common therapeutic decision which has to be taken. Function

Recurrent laryngeal cancer

Small superficial recurrent cancers without laryngeal fixation or lymph node involvement are successfully treated by radiation therapy or surgery alone, including endoscopic laser excision surgery.⁶⁶

On the other hand more than 80% of the recurrent tumours are staged as rT3 or rT4. Total laryngectomy is considered the treatment of choice in the majority of these cases of laryngeal carcinoma relapse after partial laryngeal surgery or radiotherapy. Selected recurrent laryngeal cancers may be

Treatment of cervical lymph node metastases

Concise notes regarding surgical classification of neck dissection types are synthesized in Table 6.

Conclusions

Although in the management of laryngeal cancer significant clinical improvements have been allowed by new surgical procedures that have extended the indications to partial laryngectomies and by combination therapies (induction chemotherapy, concurrent administration of chemotherapy and radiotherapy, and adjuvant chemotherapy administered after the patient has been rendered free of disease), the most effective approach to laryngeal cancer remains prevention and early diagnosis when this cancer

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Demographic differences in early vs. late-stage laryngeal squamous cell carcinoma
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This study aims to evaluate how various demographic factors impact the stage at diagnosis and, therefore, prognosis of laryngeal cancer.
Using the National Cancer Database, 96,409 patients were diagnosed with laryngeal squamous cell carcinoma between 2004 and 2020. Early (stage 0 or I) vs. late-stage (stage IV) cancers were compared based on demographic variables utilizing Chi-square and multivariate analysis with a significance of p < 0.05.
Female, Black, and generally older patients were more likely to have late-stage cancer than their counterparts. When compared with a community cancer program, patients treated at other facility types were more likely to be diagnosed late. Patients with private insurance, Medicare, or other government insurance were all less likely to have late-stage cancer compared to patients without insurance. Compared to patients in the lowest median household income quartile, patients in the third quartile and fourth quartile were diagnosed earlier. Patients living in an area with the lowest level of high school degree attainment were most likely to be diagnosed late. Living in a more populous area was associated with a lower chance of being diagnosed late. Increasing Charlson-Deyo Score was associated with a stronger likelihood of being diagnosed at a later stage.
Patients who are female, Black, uninsured, have a low household income, live in less populated and less educated areas, are treated at non-community cancer programs, and have more comorbid conditions have later stage diagnoses. This data contributes to understanding inequities in healthcare.
Spectro-acoustic voice parameters in transoral laser microsurgery vs exclusive radiotherapy for early-stage glottic carcinoma: A systematic review and meta-analysis
2024, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
In early glottic squamous cell carcinoma, similar results have been described in terms of disease control between transoral laser microsurgery (TLM) and radiation therapy (RT). During the past two decades, several studies compared subjective vocal outcomes of exclusive RT with those of TLM, showing a trend towards improving results for TLM over time. However, the objective differences in terms of spectro-acoustic voice parameters between exclusive RT and TLM have been less frequently investigated.
The aim of this systematic review with meta-analysis was to evaluate voice quality after TLM and RT treatment for early glottic carcinoma, based on acoustic analysis parameters including jitter, shimmer, noise to harmonic ratio, fundamental frequency and maximum phonation time.
A search of the English published literature was conducted on the Pubmed, Scopus and Cochrane databases following PRISMA guidelines.
A total of 441 titles were retrieved from the search. After full-text screening and application of inclusion/exclusion criteria, 12 articles were included. We found no significant differences between TLM and RT treatment in the considered acoustic analysis parameters, except for Shimmer, with more favorable values reported in the RT group.
Considering the spread of the disease and expecting an improvement in long-term survival over time, well-designed and multicentric studies involving larger populations with a long-term follow up are mandatory to better assess objective voice outcomes in terms of spectro-acoustic voice parameters.
Complete response of glottic cancer to intra-arterial infusion chemotherapy combined with radiotherapy: A report of 4 cases
2023, Radiology Case Reports
Surgical resection is recommended for advanced-stage, resectable glottic cancer. However, total laryngectomy results in the loss of vocal function and reduces patients’ quality of life. At our institution, patients with cT3N0M0 stage III resectable glottic cancer who wish to preserve their larynx are treated with super-selective cisplatin infusion with concomitant radiotherapy (RADPLAT) to improve local control over systemic chemotherapy. Herein, we present 4 patients with glottic cancer who underwent biweekly intra-arterial infusion chemotherapy combined with radiation therapy 3 times. For intra-arterial infusion chemotherapy, 100 mg cis-diaminodichloroplatinum was infused into the superior thyroid artery, including the superior laryngeal artery branch. Thereafter, intensity-modulated radiation therapy was administered at doses of 70 Gy in 35 fractions for 3 patients and 66 Gy in 33 fractions for 1 patient. These patients showed complete response after chemoradiotherapy with no recurrence or metastases during the follow-up period to date (mean follow-up period: 56 months, range: 39-76 months).
Prognosis
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Non-squamous Laryngeal Cancer
2023, Otolaryngologic Clinics of North America
The Effectiveness of White Light Endoscopy Combined With Narrow Band Imaging Technique Using Ni Classification in Detecting Early Laryngeal Carcinoma in 114 Patients: Our Clinical Experience
2023, Journal of Voice
By displaying tumor-specific neoangiogenesis, narrow band imaging (NBI), a novel imaging approach, enhances the diagnosis of head and neck cancers and makes it more accurate
To determine the effect of NBI in combination with white light endoscopy (WLE) for diagnosis of preneoplastic or neoplastic laryngeal cancers according to Ni classification and to conclude if higher Ni classification and tumor stage are related.
We enrolled 114 patients with various laryngeal cancer between December 2018 and June 2021. Patients were examined with WLE and NBI. Squamous cell carcinoma (SCC) accounted for 46 cases, benign lesions 30 cases, and nondysplastic, low-grade, and severe dysplasias for 38 cases. Based on characteristics of the intraepithelial papillary capillary loop (IPCL), endoscopic NBI results were divided into five categories (I, II, III, IV, and V). Type I–IV are regarded to be benign, while type V is considered to be cancerous. An incisional biopsy was conducted to assess histopathology, and the histopathology was compared to the NBI results. We assessed the negative predictive value (NPV), positive predictive value (PPV), specificity, and sensitivity for WLE alone and WLE combined with NBI. Analyses were conducted using SPSS software version 26.
The WLE combined with NBI showed excellent sensitivity (96%) compared to WLE (86.4%). Specificity was higher in the WLE combined with NBI (96.4%) than WLE alone (91.7%). WLE combined with NBI saw a NPV of 89% as compared with WLE with 88%. WLE and WLE in combination with NBI, recorded a PPV of 90% and 98%, respectively.
The accuracy of detecting laryngeal cancer increases when WLE and NBI are combined. Combined NBI with WLE remains highly sensitive to early glottis cancer. Accuracy of preoperative NBI was high. In the diagnosis of laryngeal cancer, a higher Ni classification closely correlates with the late stages of the glottis tumor.

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^c: G.M. and R.M.R. contributed equally to the preparation of this manuscript.

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Anti-tumour treatmentCurrent opinion in diagnosis and treatment of laryngeal carcinoma

Summary

Section snippets

Anatomy

Epidemiology

Signs and symptoms

Histology

Risk factors

Primary laryngeal squamous cell carcinoma development

Clinical assessment

Treatment of laryngeal primary carcinoma

Recurrent laryngeal cancer

Treatment of cervical lymph node metastases

Conclusions

Am J Otolaryngol

Crit Rev Oncol/Hematol

Radiother Oncol

Eur J Cancer

Int J Pediatr Otorhinolaryngol

Am J Otolaryngol

Otolaryngol Clin North Am

Eur J Radiol

Lancet Oncol

Am J Otolaryngol

Am J Otolaryngol

Int J Radiat Oncol Biol Phys

Am J Surg

Oral Oncol

Ann Oncol

Ann Oncol

Cancer Radiother

Am J Surg

TNM classification of malignant tumours

American Head and Neck Society; American Academy of Otolaryngology – Head and Neck Surgery. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology – Head and Neck Surgery

Arch Otolaryngol Head Neck Surg

Estimates of the worldwide incidency of eighteen major cancers in 1985

Int J Cancer

Cancer incidence, mortality and prevalence worldwide, version 1.0. IARC Cancer Base No. 5

Cancer statistics, 1996

CA Cancer J Clin

The history, aetiology and epidemiology of laryngeal carcinoma

Clin Otolaryngol

EUROCIM (European Cancer Incidence and Mortality)

Metastatic neoplasms of the larynx: report of three cases

Laryngoscope

Laryngeal dysplasia and other epithelial changes on endoscopic biopsy: what does it all mean to the individual patient?

ORL J Otorhinolaryngol Relat Spec

Cancer of the larynx

Nodal disease in purely glottic carcinoma: is elective neck treatment worthwhile?

Laryngoscope

Carcinoma of the larynx: selective approach to the management of cervical lymphatics

Ear Nose Throat J

Distant metastases from laryngeal and hypopharyngeal cancer

ORL J Otorhinolaryngol Relat Spec

Distant muscular (gluteus maximus muscle) metastasis of laryngeal squamous cell carcinoma

Acta Otolaryngol

Controversies in the management of advanced laryngeal squamous cell carcinoma

Cancer

Correlation of local outcome after partial laryngectomy with cartilage abnormalities on CT

AJNR

Positron emission tomography in the evaluation of laryngeal carcinoma

Ann Otol Rhinol Laryngol

Ultrasonography-guided fine-needle aspiration for the assessment of cervical metastases

Arch Otolaryngol Head Neck Surg

Malignant cervical adenopathy

Anti-tumour treatment
Current opinion in diagnosis and treatment of laryngeal carcinoma