Laryngeal cancer

Laryngeal cancer

OVERVIEW:

Most common cancer representing less than 1% of all malignant lesions. Squamous cell carcinomas comprise 5-98% of all malignant neoplasms of the larynx.
• Less than 2% of all carcinomas
• At the time of diagnosis, 62% will have local disease, 26% regional disease and 8% distant disease in the lungs, liver and/or bone
• No racial predilection

System(s) affected: Pulmonary
Genetics: Unknown
Incidence/Prevalence in USA: 5/100,00 (12,500 new cases per year)
Predominant age:
• Median age of occurrence in the 6th and 7th decades
• Less than 1% of laryngeal cancers arise in patients under 30 years of age
Predominant sex: Male > Female (5:1). However, increasing incidence in women who smoke.

SIGNS AND SYMPTOMS:

• Persistent hoarseness in an elderly or middle aged cigarette smoker
• Dyspnea and stridor
• Ipsilateral otalgia
• Dysphagia
• Odynophagia
• Chronic cough
• Hemoptysis
• Weight loss due to poor nutrition
• Halitosis due to tumor necrosis
• Mass in the neck from metastatic lymph node
• Laryngeal tenderness due to tumor necrosis or suppuration
• Lump in the neck
• Broadening of the larynx on palpation with loss of crepitation
• Tenderness of the larynx
• Fullness of the cricothyroid membrane

CAUSES:

• Smoking
• Alcohol abuse

RISK FACTORS:

Included in Causes

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS:

• Acute or chronic laryngitis
• Benign vocal cord lesions such as polyps, nodules, and papillomas
• Tuberculosis or fungal infection of the larynx

LABORATORY:

Liver function studies to rule out metastatic disease

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS:

N/A

SPECIAL TESTS:

• Laryngoscopy - fungating, friable tumor with heaped up edges and granular appearance with multiple areas of central necrosis and exudate surrounding areas of hyperemia
• CT or MRI if chest and liver or brain metastasis suspected

IMAGING:

• Bone scan if bone metastasis suspected
• Screening chest x-ray to rule out metastatic disease

DIAGNOSTIC PROCEDURES:

Indirect and/or direct laryngoscopy and biopsy to determine stage of disease as well as histologic confirmation

TREATMENT

APPROPRIATE HEALTH CARE:

Outpatient primarily

GENERAL MEASURES:

Tracheotomy care, when applicable

SURGICAL MEASURES:

• Tracheotomy may be necessary if tumor is large enough to cause upper airway obstruction
• Early disease may be treatable by either radiation therapy or laser cordectomy on an outpatient basis. 90% cure rates are the rule.
• More advanced disease needs inpatient care necessitating partial or total laryngectomy, and postoperative radiation therapy 4-5 weeks after surgery depending on the stage of disease

ACTIVITY:

Fully active unless the patient is debilitated from more advanced disease and/or greater degree of surgery

DIET:

• Nasogastric or gastrostomy feeding may be necessary if tumor involves esophageal inlet
• No special diet otherwise

PATIENT EDUCATION:

Material is available from local cancer society

MEDICATIONS

DRUG(S) OF CHOICE:

• Narcotics may be necessary for pain control during treatment for mucositis secondary to radiation therapy
• Nystatin mouth rinses for oral thrush

Contraindications: N/A
Precautions: N/A
Significant possible interactions: N/A

ALTERNATIVE DRUGS:

N/A

FOLLOW UP

PATIENT MONITORING:

• Repeat indirect laryngoscopy and complete head and neck examinations for at least five years after treatment to detect early recurrence or second primary
• Yearly chest x-ray and liver function tests
• Patients with dysphagia should undergo barium swallow and/or esophageal endoscopy to rule out second tumor in the esophagus
• Patients with unexplained pain should have appropriate radiological or nuclear medicine, bone scans
• Mental status change indicates CT scan of the brain to rule out brain metastases

PREVENTION/AVOIDANCE:

• Indirect laryngoscopy for patients with persistent hoarseness lasting beyond one to two weeks
• Cessation of smoking and/or alcohol abuse

POSSIBLE COMPLICATIONS:

• Temporary odynophagia or dysphagia secondary to mucositis and/or thrush during radiation therapy
• Persistent hoarseness despite adequate treatment necessitating further adjunctive procedures and/or speech therapy
• Tracheostomal stenosis requiring stenting with laryngectomy tubes or further surgery
• Dysphagia, secondary to upper esophageal stricture after total laryngectomy necessitating dilatation
• Aspiration, after partial laryngectomy necessitating completion laryngectomy or tracheotomy
• Inability to decannulate after partial laryngectomy due to laryngeal stenosis and/or aspiration
• Radiation induced chondronecrosis which mimics tumor recurrence
• Radiation edema necessitating emergent tracheotomy

EXPECTED COURSE AND PROGNOSIS:

• Early disease is expected to have greater than 90% cure

MISCELLANEOUS

ASSOCIATED CONDITIONS:

• Less than 10% of patients may have a synchronous squamous cell carcinoma in the lower or upper aero-digestive tract; most notably in the esophagus or lungs

AGE-RELATED FACTORS:

Pediatric: N/A
Geriatric: N/A
Others: N/A

PREGNANCY:

• Very rare in young patients in general
• Natural history of disease and treatment side effects have to be weighed against the possibilities of continuing on to delivery

SYNONYMS:

Cancer of larynx

ICD-9-CM:

161.0 Malignant neoplasm of larynx

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Medical Diagnosis » L » Laryngeal cancer