Laryngeal and Hypopharyngeal Cancer

What Are Laryngeal and Hypopharyngeal Cancers?

Laryngeal cancer affects the larynx (lair-inks) which is often called the "voice box" or the "Adam's apple." As shown in the picture below, the larynx has 3 main sections:

• the glottis (vocal cords)
• the supraglottis (area above the vocal cords, including the epiglottis, which closes off when you swallow food)
• the subglottis (the area below the vocal cords)

Cancers that start in different parts of the larynx are treated differently.

The larynx and vocal cords sit above the trachea and are the entrance to the lungs. The larynx makes sound for speaking and protects the airway during swallowing. The vocal cords change the sound and pitch of the vice. They close tightly when a person swallows and open to allow breathing.

Cancer can also affect the hypopharynx which surrounds the larynx. It part of the esophagus or food pipe. Food enters the esophagus here as it passes through the neck and chest into the stomach.

Cancers of the larynx and hypopharynx are both covered here because they are so close to each other. Several types of cancer form in these 2 areas.

Almost all of these cancers start from the thin, flat cells (squamous cells) that line the larynx and hypopharynx. Squamous cell cancer does not form suddenly. It starts when the cells begin to change. Smoking and heavy alcohol drinking usually cause the changes. The cells become pre-cancers. Most pre-cancers will not become cancers. If the causes (like smoking) stop, these pre-cancers usually go away.

But some pre-cancers do grow into cancers. The earliest form of cancer is called carcinoma in situ (in si-too) or CIS. This is where only the cells of the lining layer are affected. In situ is a Latin term that means "in place." CIS has not yet spread into lower layers of cells or spread to other parts of the body. Some of these very early cancers go away on their own. Most can be cured by stripping or cutting away the lining layer of cells, or by destroying them with a laser beam. If CIS is not treated it can develop into cancer that can spread into nearby tissue and to other parts of the body.

While other kinds of cancer can start in the glands and tissue of the larynx and hypopharynx, they are very rare. The information here refers only to squamous cell cancer.

What Causes Laryngeal and Hypopharyngeal Cancers?

A risk factor is anything that affects your chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, such as smoking, can be controlled. Others, like a person's age or race, can't be changed. But having a risk factor, or even several, does not mean that you will get the disease. And many people who do get the disease did not have any known risk factors.

Risk Factors for These Cancers

Tobacco Use

Most people who get these cancers are smokers. The risk is many times greater in smokers than in those who don't smoke. The more a person smokes, the greater the risk. Even chewing tobacco has been reported to raise the risk of these cancers.

Alcohol Abuse

Heavy drinkers have a much greater risk of cancer of the larynx. Using both tobacco and alcohol greatly increases the risk.

Diet

Poor eating habits often go along with alcohol abuse. This may be why alcohol abuse raises the risk of these cancers. A lack of foods with B vitamins and vitamin A may also play a role.

HPV

HPV stands for human papilloma virus. Most of these viruses cause warts on the hands, feet, and other places. Some also cause cancers of the sex organs. HPV may be a factor in some cases of cancer of the larynx and hypopharynx as well.

Weak Immune System

These cancers are more common in people who have a weak immune system. This can be caused by diseases present at birth, by AIDS, or by certain drugs that people who have had organ transplants need to take.

Work Hazards

Long and intense exposure to wood dust, paint fumes, and to certain chemicals can increase the risk of these cancers. Working with asbestos, used in the past as insulation, may also increase laryngeal cancer risk.

Gender

These cancers are between 4 and 5 times more common in men than in women. In the past, men were more likely to smoke and drink. But now this is changing and women's risks are increasing.

Age

Because these cancers take a long time to grow, they are not common in young people. Most people are over 65 when these cancers are first found.

Race

These cancers are more common among African Americans than among whites.

Heartburn

This disease, called GERD (gastroesophageal reflux disease) by doctors, might be a risk factor for these cancers.

How Are Laryngeal and Hypopharyngeal Cancers Found?

Many cancers of the larynx and some of the hypopharynx can be found early. Cancer that forms on the vocal cords are often found at an early stage because they cause hoarseness. Cancers that start above or below the vocal cords are often found at later stages. Talk to your doctor if you have any of these symptoms:

• sore throat that doesn't go away
• constant coughing
• trouble swallowing or pain with swallowing
• ear pain that doesn't go away
• trouble breathing
• weight loss
• hoarseness that lasts more than 2 weeks
• lump or mass in the neck

Tests to Find Out if You Have Laryngeal or Hypopharyngeal Cancer

History and Physical Exam

If there is any reason to suspect cancer, the first step is for the doctor to gather facts about your symptoms, risk factors, family history and medical conditions. You will have a physical exam and your doctor will ask you questions about your health. Your doctor will probably refer you to a doctor with special training in these cancers (an otolaryngologist). You will also need to have some tests. These might include any of the following:

Blood tests

Blood tests won't tell if you have these cancers, but they will provide information about your overall health.

Complete Head and Neck Exam

If there is reason to suspect a cancer, you will be sent to a head and neck surgeon. The larynx and hypopharynx are deep inside the neck and not easy to check. This doctor will give you an exam with a mirrors and special fiber-optic scope. This flexible, lighted tube will be put through the mouth or nose. The scope helps the doctor to "see" these areas. The mouth, neck, and nose will be carefully checked, too.

Panendoscopy (Pan-en-dos-kuh-pee)

If the doctor suspects you have cancer in the head and neck he or she will do a complete exam of this area. This exam is done in the operating room while the patient is asleep (under general anesthesia.) The surgeon looks at the entire area through a scope and may take a sample of tissue (biopsy) to be looked at under a microscope. Biopsy is discussed below.

Once a tumor has been found, imaging studies may be useful in finding out how far it has spread.

Imaging Tests

CT or CAT Scan (Computed Tomography)

These scans use x-rays to take a series of pictures of the body from many angles. A computer combines the pictures to form a detailed image. This test can help your doctor learn the size of the tumor and whether it has spread to the lymph nodes or nearby tissue. CT scans take longer than standard x-rays. You will need to lie still on a table while they are being done. You may also have an IV (intravenous) line through which a contrast "dye" is injected.

MRI (Magnetic Resonance Imaging)

Like a CT scan, an MRI displays a cross-sectional picture of the body. But the MRI uses radio waves and strong magnets instead of x-rays. MRI scans take longer than CT scans--often up to an hour. Also, you are placed in a narrow tube which can upset some people. Newer, "open" MRI machines can help with this if needed. A contrast dye might be injected just as with CT scans.

Barium Swallow

This is a series of x-rays taken while you swallow a liquid with barium in it. Barium coats the inside surface of the throat and helps create a good picture.

Chest X-ray

This is routine for people with head and neck cancers. It is done to check for lung cancer and emphysema.

PET Scan

PET scans use a form of sugar that contains a radioactive atom. Most cancer cells in the body absorb large amounts of this sugar. A special camera can find where the sugar has collected. Your doctor can use this test to see if the cancer has spread to lymph nodes or other places. Newer machines combine CT and PET scans to even better pinpoint the tumor.

Biopsy

A biopsy is a test that involves taking a sample of tissue to see if it contains cancer cells. It is the only sure way to know that a growth is cancer. There are many different types of biopsies that might be done to check for cancer cells. Some are done in the operating room with the patient asleep. Others can be done with a thin (fine) needle in the doctor's office.

How Are Laryngeal and Hypopharyngeal Cancer Treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

There is a lot for you to think about when choosing the best way to treat or manage your cancer. Often there is more than one treatment to choose from. Take time to think about all of the choices. Two things to consider are the type of cancer and the stage (extent) of the cancer. But your age, your overall health, and your own preferences are also important.

It's often a good idea to get a second opinion, perhaps from a doctor who has treated this type of cancer. A second opinion can give you more information and help you feel better about the treatment plan you choose.

The Main Types of Cancer Treatment

The 3 main types of treatments for these cancers are:

• surgery
• radiation
• chemotherapy

Sometimes 2 or more of these treatments are used together. If it doesn't look like the cancer can be cured, the goal of treatment might be to remove or destroy as much of the cancer as possible to delay the spread or return of the cancer. Sometimes treatment is aimed at relieving symptoms. This is called palliative treatment.

If at all possible, the doctor will try to save your larynx and voice. Most experts do not recommend removing the larynx unless there are no other options. People who lose their voice can suffer from feeling depressed and lonely.

Surgery

There are several kinds of surgery for these cancers. Some may remove the cancer. Others help restore the look and function of the head and neck.

Vocal Cord Stripping

This method involves using a long tool to strip away the cancer in the top layers of tissue of the vocal cords. Very early (stage 0) cancers are sometimes treated this way.

Cordectomy

This method involves removing all or part of the vocal cords..

Laser Surgery

Lasers can be used to treat some early cancers. An endoscope is used to find the tumor which is then "zapped� or cut out with a laser.

Partial Laryngectomy (lair-in-jek-tuh-me)

Smaller cancers of the larynx can often be removed without taking out the entire voice box. The goal is to leave as much of the voice box as possible while removing the cancer. Sometimes it is even possible to preserve some speech.

Total Laryngectomy

This surgery involves taking out the entire voice box. The windpipe must be brought up to the front of the neck as a hole (stoma). The person then breathes through this stoma.

Possible complications after this surgery include bleeding, development of a fistula (an abnormal opening), development of a stricture (narrowing), and having food or liquid enter the lungs (aspiration). Aspiration can lead to pneumonia.

Illustrations by permission of the Mayo Foundation. From "Looking Forward...A Guidebook for the Laryngectomee" by R.L. Keith, et al, New York, Thieme-Stratton, Inc. and copyrighted by the Mayo Foundation, 1984.

Total or Partial Pharyngectomy (fair-in-jek-tuh-me)

This operation is done for cancers of the hypopharynx. All or part of the hypopharynx is removed. Surgery may also be done to rebuild the throat. This will help the patient to swallow after the operation. Most often, the larynx will also be removed.

Flap Methods

Sometimes a muscle and area of skin may be moved from an area close to your throat, such as the chest, to rebuild the throat after surgery. Tissues from other parts of your body such as a piece of intestine or a piece of arm muscle may also be used to replace parts of your throat.

Neck Dissection

Because these cancers often spread to the lymph nodes in the neck, it may be necessary to remove these lymph nodes. This is called a "neck dissection." The amount of tissue to be removed depends on the size of the cancer and how much it has spread.

Tracheotomy

If a tumor is too large to remove or is blocking the windpipe, an opening may be made in the neck. This will bypass the tumor and help with breathing.

Gastrostomy Tube (G-tube or feeding tube)

Surgery may also be done to improve nutrition. A patient who cannot swallow enough food may need a feeding tube placed through the skin in the belly (abdomen) directly into the stomach.

Effect of Surgery on Speech

This can vary. If the surgery does not damage the vocal cords, then speech may be normal. With any more extensive surgery, there will usually be hoarseness. Any larger operation, especially laryngectomy, will eliminate normal speech altogether. (See the section "Restoring Speech After Total Laryngectomy.")

Radiation Therapy

Radiation therapy is treatment with high energy rays (such as x-rays) to kill or shrink cancer cells. The radiation may come from outside the body (external radiation) or from radioactive materials placed directly in the tumor. External radiation is often the main treatment for laryngeal and hypopharyngeal cancer. It may be used instead of surgery for small cancers that can be destroyed without surgery. It is also used for patients whose health does not permit them to have surgery. Often chemotherapy is also given.

Treatment is usually given daily, 5 days per week, for about 7 weeks. Other schedules for treatment are being studied.

Radiation can also be used after surgery to kill cancer cells that could not be seen during surgery. Radiation can be used to ease symptoms such as pain, bleeding, and problems with swallowing, too. It can be used to ease problems caused by cancer that has spread to bones. Side effects from radiation could include the following:

• mild skin problems
• dry mouth (which can lead to problems with tooth decay)
• sore throat
• hoarseness
• trouble swallowing
• decreased sense of taste
• problems with breathing from swelling of the larynx
• tiredness

Most of these side effects go away after a short while. Talk to your doctor or nurse if you are having trouble with any side effects. There are often ways to help.

Chemotherapy

Chemotherapy or chemo refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout the body.

Chemo is useful in treating cancer that has spread to organs beyond the head and neck. It has also been used to ease symptoms of tumors that are too large to be completely removed and that radiation treatment has not been able to control. Many doctors now recommend chemo along with radiation as the main treatment for large larynx cancer instead of laryngectomy (see below).

Chemo can have some side effects. These side effects will depend on the type of drugs given, the amount taken, and how long treatment lasts. Side effects could include the following:

• nausea and vomiting
• loss of appetite
• hair loss
• mouth sores
• a higher chance of infection (from a shortage of white blood cells)
• bleeding or bruising after minor cuts or injuries (caused by a shortage of blood platelets)
• shortness of breath
• tiredness (from low red blood cell counts)

Most side effects go away after treatment ends. Anyone who has problems with side effects should talk with their doctor or nurse, as there are often ways to help.

Chemo with Radiation Therapy (Chemoradiotherapy)

Chemo given at the same time as radiation can shrink tumors better than either treatment alone. Studies are going on to find out whether this combination can control advanced disease that is confined to the head and neck area. This treatment may help people avoid large operations that cause loss of natural speech.

Survival Rates by Stage for These Cancers

Below are listed the 5-year relative survival rates for cancers from each of the sites. The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is found. Keep in mind that many of these patients live much longer than 5 years after diagnosis.

While these numbers give an overall picture, every person is different. Statistics can't predict what will happen in your case. Talk with your cancer care team if you have questions about your own chances of a cure, or how long you might survive your cancer. They know your situation best.

Supraglottis

Stage	5-year relative survival
I	83%
II	70%
III	57%
IV	43%

Glottis

Stage	5-year relative survival
I	65%
II	62%
III	55%
IV	37%

Subglottis (These numbers are less accurate because of the small number of patients.)

Stage	5-year relative survival
I	54%
II	68%
III	53%
IV	36%

Hypopharynx

Stage	5-year relative survival
I	41%
II	36%
III	36%
IV	20%