Laryngeal cancer

Malignant tumors that grow on, above or below the vocal folds are known as laryngeal cancer. These cancers mostly originate from the mucosa that lines the larynx from within. Experts also refer to laryngeal cancer as laryngeal carcinoma.

The larynx is located about halfway up the anterior region of the neck, and forms the passageway from the pharynx to the trachea. On the one hand, it ensures that no food or drink gets into the windpipe – thus providing protection from choking. On the other, its vocal folds make it possible to produce sounds and thus to speak.  

Experts divide laryngeal tumors into three groups, depending on where they grow: 

• on the vocal folds
• above the vocal folds
• below the vocal folds 

Laryngeal cancer pertains to head and neck tumors, along with oral cancer and pharyngeal cancer. It is a rather rare tumor, with about 3,200 people in Germany developing it every year. Men are affected by laryngeal cancer far more frequently than women. 

The symptoms caused by laryngeal cancer depend on whereabouts in the larynx the cancer develops. If laryngeal tumors grow on the vocal folds, they usually cause hoarseness early on. If tumors grow above or below the vocal folds, symptoms often appear later. In particular, they include difficulty swallowing and breathing problems. 

The following warning signs may indicate a tumor in the larynx: 

• hoarseness 
• a constant foreign body sensation, especially on one side 
• pain that spreads into the ear 
• difficulty swallowing 
• pain when swallowing 
• neck swelling 
• speaking difficulties 
• breathing difficulties 
• coughing up blood  
• mouth odor 

Do these symptoms last longer than four weeks? It is advisable to see a doctor no later than then. A family doctor can start narrowing down what could be causing the symptoms and, if necessary, refer the patient for further diagnostic testing by specialists. 

Like nearly every cancer, laryngeal cancer is based on genetic mutations. These cause normal body cells to change into malignant cancer cells and begin growing in an uncontrolled manner. Most of these genetic mutations develop by chance in the course of a lifetime. But there are risk factors that promote laryngeal cancer.   

Known risk factors include: 

• regular smoking 
• excessive alcohol consumption 
• asbestos dust exposure 
• exposure to harmful substances like ionizing radiation (e.g. uranium), aerosols containing sulfuric acid, polycyclic aromatic hydrocarbons, coal or tar products 
• in a smaller portion of patients, infections with human papillomaviruses (HPVs), especially with the high-risk HPV 16 type 
• cancer precursors – certain whitish (leukoplakia or pachydermia) or reddish (erythroplakia) mutations of the laryngeal mucosa

Tobacco consumption and alcohol consumption are the main risk factors, and are particularly harmful in combination. There is moreover evidence that malnutrition or increased consumption of meat or fried food may raise the risk for laryngeal cancer.

Laryngeal cancer can develop from cancer precursors. These are tissue changes in which cells are altered compared to the original tissue. If these altered cells grow destructively deep into the tissue, this means that a malignant laryngeal tumor has developed. This tumor can then spread to other organs (metastasize).

Depending on the tumor’s point of origin, the further spread and progression of the laryngeal cancer are different:

• Laryngeal tumors that grow on the vocal folds only rarely develop lymph node metastases in the early stages of the disease. 
• Laryngeal tumors that grow above or below the vocal folds often spread into the cervical lymph nodes in the neck at an early stage.   

Laryngeal cancer spreads into the lungs in particular via the blood, while more rarely, metastases settle in bone and the liver. The main risk factors, tobacco and alcohol, can make it more likely that the patient will develop secondary cancer in the head and neck region, most commonly lung cancer, esophageal cancer, cancer of the oral cavity or pharynx. 

The most effective way of reducing the personal risk of developing laryngeal cancer is to stop consuming tobacco and alcohol. 

If laryngeal cancer is suspected, the doctor initially asks patients about their symptoms, possible existing risk factors and their general state of health. Examinations are conducted after the medical history has been taken.  

Physical examination and biopsy  

A detailed otolaryngological examination is performed. What if a malignant tumor of the larynx is suspected after this examination? In that case, the doctor takes tissue samples (biopsies) from suspected areas to have analyzed in the lab at a cellular level. The patient usually receives a general anesthetic for that. Doctors moreover examine the upper respiratory and digestive tracts. This should rule out possible secondary tumors.  

The tissue samples taken are examined in a laboratory under a microscope and with microbiological tests to determine their histological and biological properties. If analysis of the biopsy indicates that the cells are malignant, the patient has laryngeal cancer.

Scans 

Scans that generate images of the inside of the body help doctors assess the extent to which the tumor has spread. This enables them to determine whether the cancer has already formed metastases in the cervical lymph nodes in the neck or in tissues (organs and/or lymph nodes) further away, or whether there are any other tumors (secondary tumors). The following imaging techniques are used for this purpose:  

• magnetic resonance imaging (MRI)
• computed tomography (CT)
• positron emission tomography (PET)
• an ultrasound of the neck and, if necessary, the abdomen.  

What if it is not definitely possible to assess the lymph nodes in the neck using imaging techniques? Doctors can then carry out an additional fine needle biopsy (puncture). In this procedure, a thin cannula sucks in cells that are then examined. 

Do you want to learn more about how a biopsy is taken and what happens to the cell and tissue samples afterwards? The website of the Cancer Information Service of the German Cancer Research Center has detailed information about the biopsy procedure and the risks involved (in German). 

For many patients, a logopedic and dental examination or nutrition advice is useful before treatment begins.

There are various treatment options for laryngeal tumors. The main goal of therapy is optimal treatment of the tumor, but also to preserve the function of the larynx to the greatest extent possible. The treatment depends on:

• the general state of health
• the spread of the tumor
• potential therapy consequences
• the wishes of the patient

Treatment of a laryngeal tumor

At an early stage, laryngeal cancer can normally be cured by an operation or radiotherapy. Specialists generally only recommend complete removal of the larynx in cases where tumors are growing above the vocal folds. While these tumors are very rare, they grow the most aggressively in most cases.

Even when tumors are at an advanced stage, there are treatment options that aim to cure the disease: 

• Surgery aims to remove the tumor in its entirety. In most cases, this requires complete removal of the larynx. 
• Radiation is usually also applied to the surgical site. Patients at a higher risk of relapse also receive chemotherapy to reinforce the effects of radiotherapy. 
• What if surgery is not possible or is refused by the patient? Doctors will then consider applying radiotherapy to the tumor and neck, which is usually also combined with chemotherapy and, more rarely, with antibody therapy.  

Patients should discuss the advantages and disadvantages of every therapeutic option in detail with the doctors treating them. Patients can also discuss with the doctors whether and under which conditions the larynx can be preserved. 

Treatment of cervical lymph nodes 

As a precautionary measure, medical specialists generally recommend removal of the cervical lymph nodes or treatment with radiotherapy – even if no suspicious cervical lymph nodes have been detected. In many cases, hidden lymph node metastases are already present.  

The risk of hidden metastases is only low if the laryngeal cancer is growing on the vocal folds and is still in an early stage. In that case, such a treatment is not required.  

Have noticeable cervical lymph nodes already been detected during the examinations? If so, surgeons remove the cervical lymph nodes rather more extensively during the operation. If necessary, they also have to remove other tissue. If surgery is not possible or is refused by the patient, radiotherapy is used to treat the cervical lymph nodes, in combination with chemotherapy if necessary. 

Treatment for incurable laryngeal cancer 

In this situation, the most important therapy goal is to repress the tumor and slow the growth of the cancer in order to prolong the patient’s survival. At the same time, symptoms should be relieved to the best extent possible. An individual determination is made about what the therapy looks like. The following can be used: 

• chemotherapy
• targeted therapy
• immunotherapy
• radiation therapy 
• surgery

In general, early supportive therapy such as pain therapy, nutrition advice or monitoring by a psycho-oncologist is important. 

Would you like to know more about the treatment of laryngeal cancer? Which side effects are possible and how can debilitating symptoms be handled? Get free information about this from the Cancer Information Service of the German Cancer Research Center.
Particularly if you find speaking difficult, you can use the e-mail service. However, you can also obtain personalized information over the phone. 

Cancer treatment can be physically and mentally exhausting. Medical rehabilitation (rehab) after a cancer therapy should help patients to recuperate. It is also designed to help them cope with the consequences of the disease and its treatment as best as possible.  

A medical rehab program thus focuses on the personal medical history and individual limitations. Possible measures for those affected by laryngeal cancer are: 

• voice rehabilitation
• swallowing and speech therapy 
• nutritional therapy and/or 
• psycho-oncological care 

Aftercare   

The aftercare for laryngeal cancer has various aims. Above all, it is used to recognize a relapse, possible secondary carcinomas and long-term consequences of the treatment early and introduce appropriate measures. Once treatment has been completed, patients are therefore examined regularly, initially at short intervals, then at longer ones. However, patients can attend aftercare more frequently if experiencing symptoms.  

An aftercare appointment always includes: 

• precise questioning about the general state of health, symptoms and results of therapy (medical history) 
• a thorough otolaryngological examination
• palpation and ultrasound of the neck

Depending on the individual tumor, the risk of relapse and the therapy, doctors can regularly arrange for computed tomography (CT) or magnetic resonance imaging (MRI). If necessary, a positron emission tomography (PET/CT) can also be added.

Is the cancer incurable? Follow-ups and regular care help with recognizing debilitating symptoms early and alleviating them. The aim is to maintain the patient’s quality of life for as long as possible. 

During or after laryngeal cancer, it is not always easy for patients to get back into everyday life. Cancer and its treatment can involve radical changes. What can help someone cope better with the disease and potential therapy outcomes depends on the individual situation.  

Depending on the therapy, the following problems are just some that can occur:  

• dysphonia or aphonia (loss of voice) 
• difficulty swallowing 
• loss of the normal sense of smell 
• dry mouth 
• changes to the teeth and jaws 
• chewing problems 
• lymphedema in the face and neck area

For those whose larynx was surgically removed, new voice training techniques must be learned. They moreover have to learn to deal with an artificial connector to the trachea (tracheostoma).  

If you need support, talk with the doctors treating you about the options. Self-help groups and patient associations can also help. 

Doctors of various specialties work closely together in the treatment of laryngeal cancer. Hospitals with extensive experience in treating laryngeal cancer patients can have this confirmed with certification. The German Cancer Society (DKG) regularly checks their compliance with certain professional requirements.

You can find the addresses of the certified centers on the OncoMAP website.   

Do you have further questions about dealing with the condition in everyday life and additional support options? You will find information about this at the website of the Cancer Information Service of the German Cancer Research Center (in German).

For all questions about laryngeal cancer, you can also make direct contact with Cancer Information Service doctors by dialing the freephone number (0800) 420 30 40 or by sending an e-mail to krebsinformationsdienst@dkfz.de.