When a client has a superficial tumor involving only 1 vocal cord which surgery?

Content Contributor: Ryan P. Smith, MD and Christine Hill-Kayser, MD

Last Reviewed: April 5, 2022

What is staging for cancer?

Staging is the process of learning how much cancer is in your body and where it is. For laryngeal cancer, tests like laryngoscopy, endoscopy, fine needle aspiration, barium swallow (if you are having trouble swallowing), CT, MRI, and/or PET scans may be done to help stage your cancer. Your providers need to know about your cancer and your health so that they can plan the best treatment for you. 

Staging looks at the size of the tumor and where it is, and if it has spread to other organs. The staging system for laryngeal cancer is called the “TNM system,” as described by the American Joint Committee on Cancer. It has three parts:

• T-describes the size/location/extent of the "primary" tumor in the larynx.
• N-describes if the cancer has spread to the lymph nodes.
• M-describes if the cancer has spread to other organs (metastases). 

Your healthcare provider will use the results of the tests you had to determine your TNM result and combine these to get a stage from 0 to IV. 

How is laryngeal cancer staged?

Laryngeal cancer impacts the voice box and the epiglottis. The staging of laryngeal cancer is based on where in the larynx the cancer starts. There are three parts of the larynx:

• Supraglottis: the area above the vocal cords.
• Glottis: the area that includes the vocal cords.
• Subglottis: this is the area below the vocal cords.    

Staging for laryngeal cancer is based on:

• The location and size of the tumor.
• If the tumor has spread to lymph nodes.
• If the tumor has spread to other organs. This is called metastasis.

Staging is important because it helps to guide your treatment options. The staging system is very complex. Below is a summary staging system. Talk to your provider about the stage of your cancer.

• Stage 0: The tumor is only on the surface of the cells in the larynx and has not spread to any lymph nodes or other parts of the body.
• Stage I: 
  • Supraglottis laryngeal cancer: The tumor is on one part of the larynx called the supraglottis and your vocal cords are not affected by the tumor. It has not spread to any lymph nodes of other parts of the body. It has not spread to any lymph nodes of other parts of the body.
  • Glottis laryngeal cancer: The tumor is located on the vocal cords and has not changed the ability of the vocal cords to move (this produces sound/speech). The number of vocal cords involved is also important in staging. It has not spread to any lymph nodes of other parts of the body.
  • Subglottis: The tumor is only affecting the subglottis. It has not spread to any lymph nodes of other parts of the body
• Stage II:
  • Supraglottis laryngeal cancer: The tumor is in more than one part of the supraglottis or glottis OR is outside of supraglottis near the base of your tongue or the wall of the sinus and is not attached to the larynx. It has not spread to any lymph nodes of other parts of the body.
  • Glottis laryngeal cancer: The tumor is in the glottis and has grown to the supraglottis and/or subglotis. The ability of your vocal cords to move (and produce sound/speech) is also affected.
  • Subglottis: The tumor is in the subglottis and has also grown to the vocal cords. The ability of your vocal cords to move may or may not be affected.
• Stage III
  • All types: The tumor is located within the larynx and the vocal cords cannot move OR the tumor has grown to other locations within the larynx or thyroid cartilage. The tumor may have also spread to one or more lymph nodes on the same side of the neck of the tumor and is not larger than 3 cm.
• Stage IV
  • All types: The tumor is moderately or very advanced. It has grown to other parts of the next beyond the larynx like the trachea, tongue, thyroid, or esophagus. In some cases, the tumor may also impact the carotid artery or other organs in the chests. The cancer has also spread to the lymph node(s). In the most advanced laryngeal cancers, called stage IVC, the cancer has spread to other organs.

How is laryngeal cancer treated?

Treatment for laryngeal cancer depends on the location of your cancer and if it has spread. Your treatment may include some or all of the following:

• Surgery
• Chemotherapy
• Radiation
• Clinical Trials

Surgery

The goal of surgery is to remove all of or as much of the cancer as possible while and not damage other tissue or organs near the tumor. There are a number of surgical options to treat cancer of the larynx. Possible surgical treatments for laryngeal cancer include:

• Vocal Cord Stripping: The top layers of tissue on the vocal cords are stripped away using a long surgical instrument. This is used to biopsy or treat stage 0 cancer. After recovery, the normal speaking voice is usually maintained.
• Cordectomy: Either part or all of your vocal cords are removed. How much this effects your ability to talk depends on how much of the vocal cord is removed. If only part of the vocal cord is removed, you may have hoarseness. If both cords are removed, you will not be able to speak normally.
• Laryngectomy: There are a number of different types of laryngectomies. 
  • Partial Laryngectomy: This procedure is used in smaller cancers where only part of the larynx is removed. There are two types: 
    • Supraglottic laryngectomy: The part of the larynx above the vocal cords, known as the supraglottis, is removed. You will be able to speak normally after surgery. 
    • Hemilaryngectomy: Used in smaller tumors of the vocal cords, involves the removal of one side of the larynx (and one vocal cord). Because some vocal cord remains, you will still be able to talk after, but your voice may change.
  • Total Laryngectomy: Used in advanced cancers, the entire larynx is removed. The windpipe (trachea) will be brought up through the skin on the front of the neck creating a hole (stoma) that you will now breathe through, rather than through your nose or mouth. This is known as a tracheostomy. You will not be able to speak normally. After recovery from the surgery, you should be able to swallow normally.
• Laser Surgery: In laser surgery, an endoscope is placed into your mouth and down into your throat to find the tumor and then vaporize or cut out (excise) the tumor using the laser that is on the tip of the endoscope. If this technique is used to remove part of the vocal cord, it can result in a hoarse voice.
• Lymph Node Dissection: If your providers thinks that the cancer has spread to the lymph nodes, they may choose to do a lymph node dissection or removal. There are several types of dissections, which can range from the removal of one or a few lymph nodes to the removal of nodes, nerves, and muscle. Your surgeon will determine the extent of dissection needed based on the size and location of the original tumor and if the nodes were enlarged on previous imaging tests. 

If the cancer has grown into your throat, you may have a partial or full pharyngectomy, which is the removal of the throat. If the cancer has affected your thyroid, you may need a thyroidectomy. (will link to these)

After any surgery for laryngeal cancer you may require more treatment to help you recover. This includes:

• Speech and swallow therapy: If your voice or swallowing is affected by the surgery, you will be referred to work with a speech therapist. A speech therapist will be able to teach you techniques and give you tools to improve your speech and swallowing.
• Nutrition support: If you are unable to swallow safely and well enough to maintain proper nutrition after surgery, you may have a gastrostomy tube (G-tube) placed. This is a tube that is placed directly through the skin and into the stomach with a port to give you liquid nutrition. This will likely be temporary until your swallowing improves enough to maintain proper nutrition. 
• Reconstructive surgery: You may also need reconstructive surgery depending upon how much normal tissue was removed. Skin may need to be taken from one part of your body to replace skin and tissues removed during surgery.

Radiation Therapy

You may need radiation therapy. Radiation therapy uses high-energy x-rays to kill cancer cells. Radiation may be used as the only treatment or in combination with surgery and/or chemotherapy. Early-stage laryngeal cancer may be treated with radiation alone. This can preserve better voice quality for some patients. When radiation is used with surgery it is called adjuvant therapy. Radiation may be used after surgery to kill any remaining cancer cells and to lower the chance of recurrence (your cancer coming back). Radiation may also be used for patients who cannot have surgery or whose cancer is so advanced that the goal is to manage symptoms, such as pain and bleeding. It can result in side effects such as skin irritation and it can affect nearby glands and tissues.

Chemotherapy

Chemotherapy is the use of anti-cancer medicines that go through your whole body. These medicines may be given through a vein (IV, intravenously) or by mouth. 

Chemotherapy is used to treat laryngeal cancer if it has spread (metastasized) or if the cancer was not completely removed during surgery. The chemotherapy medications commonly used to treat laryngeal cancer include cisplatin, carboplatin, fluorouracil, docetaxel, paclitaxel, methotrexate, capecitabine and epirubicin. 

Cetuximab, a targeted therapy, can be used in combination with chemotherapy or radiation to treat laryngeal cancer. Immunotherapy is the use of a person's own immune system to kill cancer cells. Pembrolizumab and nivolumab are both immunotherapy medications that target and block PD-1. PD-1 is a protein and when it is blocked the body starts an immune response against the cancer cells, which shrinks or slows tumor growth. These medications may be used for the recurrence of the cancer. In some cases, pembrolizumab is the first type of treatment used. 

Chemotherapy and radiation can be used together. This is called chemoradiation. Medications used in chemoradiation include carboplatin, cisplatin, docetaxel and/or cetuximab.

Your oncology team will go over the options and chose the best chemotherapy plan with you.

Clinical Trials

You may be offered a clinical trial as part of your treatment plan. To find out more about current clinical trials, visit the OncoLink Clinical Trials Matching Service.

Making Treatment Decisions

Your care team will make sure you are included in choosing your treatment plan. This can be overwhelming as you may be given a few options to choose from. It feels like an emergency, but you can take a few weeks to meet with different providers and think about your options and what is best for you. This is a personal decision. Friends and family can help you talk through the options and the pros and cons of each, but they cannot make the decision for you. You need to be comfortable with your decision – this will help you move on to the next steps. If you ever have any questions or concerns, be sure to call your team.

You can learn more about laryngeal cancer at Oncolink.org

References

American Cancer Society: Laryngeal and Hypopharyngeal Cancer. 2017. Found at: http://www.cancer.org/cancer/laryngealandhypopharyngealcancer

American Joint Committee on Cancer (AJCC) TNM Staging System for the Larynx (8th ed.)

Connor et al. Treatment, comorbidity and survival in stage III laryngeal cancer. Head and Neck. 2015:37(5)698-706.

Misono S. et al. Treatment and Survival in 10,429 patients with localized laryngeal cancer: a population-based analysis. Cancer. 2014:1810-1817.

National Cancer Institute Surveillance, Epidemiology, and End Results Program. SEER Stat Fact Sheets: Larynx Cancer. Found at: http://seer.cancer.gov/statfacts/html/laryn.html

National Institute of Health. National Cancer Institute: Laryngeal Cancer Treatment (PDQ®) Updated May 19, 2019. Found at: https://www.cancer.gov/types/head-and-neck/patient/adult/laryngeal-treatment-pdq

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