Laryngeal and Hypopharyngeal Cancer

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What is Laryngeal and Hypopharyngeal Cancer?

About the larynx and hypopharynx

The larynx, commonly called the voice box, is a tube-shaped organ in the neck that is important for breathing, talking, and swallowing. It is located at the top of the windpipe or trachea. The front walls protrude from the neck to form what most people call the Adam’s apple. The larynx contains the vocal folds (vocal cords) that vibrate to make sound for speech production. During breathing, the larynx opens like a valve to allow air to pass into the lungs. During swallowing, the vocal folds come together and, with a flap of tissue called the epiglottis, protect the airway and prevent food from entering to the lungs.

There are three parts of the larynx:

Glottis. The middle section that holds the vocal fold.

Supraglottis. The area above the vocal folds.

Subglottis. The area below the vocal folds that connects the larynx to the windpipe.

The hypopharynx (also called the gullet) is the lower part of the throat and surrounds the larynx. The pharynx (throat) is a hollow tube about five inches long that starts behind the nose (nasopharynx) and ends at the level of the larynx (laryngopharynx). The pharynx leads into the esophagus (the tube that goes to the stomach).

About cancer in the larynx or hypopharynx

Cancer can begin in any part of the larynx or hypopharynx. Cancer occurs in the larynx or hypopharynx when normal cells change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).

About 95% of all cancers of the larynx and hypopharynx are categorized as squamous cell carcinomas, meaning they began in the flat, squamous cells that form the lining of these organs.

Laryngeal and hypopharyngeal cancers are two of the main types of cancer in the head and neck region, a grouping called head and neck cancer. This section covers both laryngeal cancer and hypopharyngeal cancer together since treatments are often similar; however, these are two separate types of cancer.

Symptoms and Signs

People with laryngeal or hypopharyngeal cancer may experience the following symptoms or signs. Sometimes, people with laryngeal or hypopharyngeal cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.

Hoarseness or other voice changes that do not go away within two weeks (often an early symptom)

An enlarged lymph node or a lump in the neck

Airway obstruction, difficulty breathing, and noisy breathing

Persistent sore throat or a feeling that something is caught in the throat

Difficulty swallowing that does not go away

Ear pain

Chronic bad breath

Choking

Unexplained weight loss

Fatigue

People who notice any of these symptoms or signs should talk with a doctor and/or dentist, especially if they don’t go away or get worse. Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often.

Because many of these symptoms can also be caused by other noncancerous health conditions, it is always important to receive regular health and dental screenings, especially for those who routinely drink alcohol or use tobacco products or have used them in the past.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms. When detected early, laryngeal and hypopharyngeal cancer can often be treated successfully while preserving the function of the larynx and/or hypopharynx.

Risk Factors and Prevention

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

These two factors greatly increase the risk of developing laryngeal or hypopharyngeal cancer, and using them together increases this risk even more:

Tobacco. Use of tobacco—including cigarettes, cigars, pipes, chewing tobacco, and snuff—is the single largest risk factor for head and neck cancer. Eighty-five percent (85%) of head and neck cancer is linked to tobacco use. Secondhand smoke may also increase a person’s risk.

Alcohol. Frequent and heavy consumption of alcohol increases the risk of both laryngeal and hypopharyngeal cancer.

Other factors that can raise a person’s risk of developing laryngeal or hypopharyngeal cancer include:

Gender. Men are four to five times more likely than women to develop laryngeal and hypopharyngeal cancer.

Age. People over 55 are at higher risk, although younger people may also develop the disease.

Race. Black people are more likely than white people to develop laryngeal and hypopharyngeal cancer.

Occupational inhalants. Exposure to asbestos, wood dust, paint fumes, and certain chemicals may increase a person’s risk of laryngeal and hypopharyngeal cancer.

Poor nutrition. A diet low in vitamins A and E can raise a person’s risk of laryngeal and hypopharyngeal cancer. Foods that are rich in these vitamins may help prevent the disease.

Gastroesophageal reflux disease (GERD). Chronic reflux of stomach acid into the larynx and pharynx may be associated with laryngeal and hypopharyngeal cancer. This may or may not be associated with the symptoms of heartburn.

Plummer-Vinson syndrome. This rare condition involves iron deficiency and causes difficulty swallowing. The presence of this disease increases the risk of hypopharyngeal cancer.

Prevention and Early Detection

Research continues to look into what factors cause laryngeal and hypopharyngeal cancer and what people can do to lower their personal risk. There is no proven way to completely prevent these diseases, but there may be steps you can take to lower your cancer risk.

Stopping the use of  tobacco products is the most important thing a person can do, even for people who have been smoking for many years. People who use alcohol and tobacco should receive a general screening examination at least once a year even if they are not experiencing any symptoms. This is a simple and quick procedure in which the doctor looks in the nose, mouth, and throat for abnormalities and feels for lumps in the neck. If anything unusual is found, the doctor will recommend a more extensive examination.

Talk with your doctor if you have concerns about your personal risk of developing laryngeal or hypopharyngeal cancer.

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. This list describes options for diagnosing these types of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Signs and symptoms

Previous test results

The following tests may be used to diagnose laryngeal or hypopharyngeal cancer:

Physical examination. The doctor will feel for any lumps in the neck, lip, gums, and cheek. The doctor will inspect the nose, mouth, throat, and tongue for abnormalities and often use a mirror for a clearer view of these structures. Although there is no specific blood test that detects laryngeal or hypopharyngeal cancer, several tests, including blood and urine tests, may be done to help determine the diagnosis and learn more about the disease.

Laryngoscopy. This test can be performed in three ways:

In an indirect laryngoscopy, the doctor sprays the throat with a local anesthetic (medication to block the awareness of pain) to numb the area and prevent gagging and then uses a small, long-handled mirror to see the vocal folds.

In a fiberoptic laryngoscopy, the doctor inserts a lighted tube through the person’s nose or mouth and down the throat to view the larynx and hypopharynx.

In a direct laryngoscopy, done in an operating room, the person receives a sedative or general anesthetic. The doctor then views the larynx and hypopharynx using an instrument called a laryngoscope. A sample of tissue for a biopsy (see below) is often taken during a direct laryngoscopy. Frequently, the doctor will recommend a triple endoscopy, a procedure done under general anesthesia to examine the ear, nose, and throat area, as well as the trachea and the bronchus, which are located next to the lung and the esophagus.

Videostroboscopy. This fiberoptic video technique is used so the doctor can see the larynx. It is performed in the same way as the indirect laryngoscopy. It is used to view the vocal folds and can detect motion abnormalities and other changes, including changes in vibration. Videostroboscopy helps to determine the location and size of a tumor, as well as how the tumor has affected the function of the larynx and hypopharynx.

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The type of biopsy performed will depend on the location of the cancer. For instance, during a fine needle aspiration biopsy, cells are withdrawn using a thin needle inserted directly into the tumor. The sample removed during the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).

Molecular testing of the tumor. Your doctor may recommend running laboratory tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumor. Results of these tests will help decide whether your treatment options include a type of treatment called targeted therapy .

The following imaging tests may be used to determine the extent of the cancer:

X-ray/barium swallow. An x-ray is a way to create a picture of the structures inside of your body, using a small amount of radiation. Sometimes, the patient will be asked to swallow barium, which coats the mouth and throat, to enhance the image on the x-ray (called a barium swallow). A barium swallow is used to identify abnormalities along the throat and esophagus. A special type of barium swallow, called a modified barium swallow, may be needed to evaluate difficulties with swallowing. A dentist may take extensive x-rays of the teeth, mandible (jawbone), and maxilla (upper jaw), including a panorex (panoramic view). If there are signs of cancer, the doctor may recommend a computed tomography scan (see below).

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can also be used to measure the tumor’s size. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein or given orally (by mouth) to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of soft tissue, such as the tonsils and the base of the tongue.

Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. This test can detect the spread of cancer to the liver or the cervical lymph nodes (lymph nodes in the neck).

Bone scan. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark. In head and neck cancer, a bone scan is recommended if there are signs that the cancer has spread to the bone.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

Stages and Grades

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to determine the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

One tool that doctors use to describe the stage is the TNM system. TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How large is the primary tumor and where is it located?(Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body?(Metastasis, M)

The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Here are more details on each part of the TNM system for both laryngeal cancer and hypopharyngeal cancer.

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below and has been divided into an outline of tumors of the larynx and tumors of the hypopharynx.

Tumors of the larynx

TX: The primary tumor cannot be evaluated.

T0: No evidence of a tumor is found.

Tis: This is a stage called carcinoma (cancer) in situ. It is a very early cancer where cancer cells are found only in one layer of tissue.

When describing T1 to T4 tumors, doctors divide the larynx into three regions: the glottis, the supraglottis, and the subglottis.

Glottis tumor of the larynx

T1: The tumor is limited to the vocal folds, but it does not affect the movement of the folds.

T1a: The tumor is only in the right or left vocal fold.

T1b: The tumor is in both vocal folds.

T2: The tumor has spread to the supraglottis and/or the subglottis. T2 also describes a tumor that affects the movement of the vocal fold, without paralyzing the fold.

T3: The tumor is limited to the larynx and paralyzes at least one of the vocal folds.

T4a: The tumor has spread to the thyroid cartilage and/or the tissue beyond the larynx.

T4b: The tumor has spread to the area in front of the spine (prevertebral space), chest area, or encases the arteries.

Supraglottis tumor of the larynx

T1: The tumor is located in a single area above the vocal folds that does not affect the movement of the vocal folds.

T2: The tumor started in the supraglottis but has spread to the mucous membranes that line other areas, such as the base of the tongue.

T3: The tumor is limited to the larynx with vocal fold involvement and/or has spread to surrounding tissue.

T4a: The tumor has spread through the thyroid cartilage and/or the tissue beyond the larynx.

T4b: The tumor has spread to the area in front of the spine (prevertebral space), chest area, or encases the arteries.

Subglottis tumor of the larynx

T1: The tumor is limited to the subglottis.

T2: The tumor has spread to the vocal folds and may or may not affect the movement of the folds.

T3: The tumor is limited to the larynx and affects the vocal folds.

T4a: The tumor has spread to the cricoids (ring-shaped cartilage near the bottom of the larynx) or thyroid cartilage and/or the tissue beyond the larynx.

T4b: The tumor has spread to the area in front of the spine (prevertebral space), chest area, or encases the arteries.

Tumors of the hypopharynx

T1: The tumor is small, no larger than 2 centimeters (cm), and is limited to a single site in the lower throat.

T2: The tumor involves more than one site in the lower throat, but does not touch the voice box, or the tumor measures between 2 cm and 4 cm.

T3: The tumor is larger than 4 cm or has spread to the larynx.

T4a: The tumor has spread into nearby structures, such as the thyroid, the arteries that carry blood to the brain, or the esophagus.

T4b: The tumor has spread to the prevertebral fascia (space in front of the spinal cord), encases the arteries, or involves mediastinal (chest-area) structures.

Node (for both larynx and hypopharynx). The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the head and neck are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. Since there are many nodes in the head and neck area, careful assessment of lymph nodes is an important part of staging.

NX: The regional lymph nodes cannot be evaluated.

N0: There is no evidence of cancer in the regional nodes.

N1: The cancer has spread to a single node on the same side as the primary tumor, and the cancer found in the node is 3 cm or smaller.

N2: Describes any of the following conditions:

N2a: The cancer has spread to a single lymph node on the same side as the primary tumor and is larger than 3 cm, but not larger than 6 cm.

N2b: The cancer has spread to more than one lymph node on the same side as the primary tumor, and none measure larger than 6 cm.

N2c: The cancer has spread to more than one lymph node on either side of the body, and none measure larger than 6 cm.

N3: The cancer found in the lymph nodes is larger than 6 cm.

Distant metastasis (for both larynx and hypopharynx). The "M" in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: Distant metastasis cannot be evaluated.

M0: The cancer has not spread to other parts of the body.

M1: The cancer has spread to other parts of the body.

Cancer stage grouping

Doctors assign the stage of the laryngeal or hypopharyngeal cancer by combining the T, N, and M classifications.

Stage 0: This stage describes a carcinoma in situ (Tis) with no spread to lymph nodes (N0) or distant metastasis (M0).

Stage I: This stage describes a small tumor (T1) with no spread to lymph nodes (N0) or distant metastasis (M0).

Stage II: This stage describes a tumor that has spread to some nearby areas (T2) but has not spread to lymph nodes (N0) or to distant parts of the body (M0).

Stage III: This stage describes any larger tumor (T3) with no spread to regional lymph nodes (N0) or metastasis (M0), or a smaller tumor (T1, T2) that has spread to regional lymph nodes (N1) but has no sign of distant metastasis (M0).

Stage IVA: This stage describes any invasive tumor (T4a) that either has no lymph node involvement (N0) or that only has spread to a single same-sided lymph node (N1), but without distant metastasis (M0). It is also used to describe any tumor (any T) with more significant spread to the lymph nodes (N2) but no distant metastasis (M0).

Stage IVB: This stage describes any cancer (any T) with extensive spread to lymph nodes (N3) but no distant metastasis (M0). For laryngeal cancer, it is also used for a very advanced localized tumor (T4b), with or without lymph node involvement (any N), but no distant metastasis (M0).

Stage IVC: This stage indicates there is evidence of distant spread (any T, any N, M1).

Grade

In addition to the TNM system, doctors also describe a primary tumor by its grade (G), which is determined by using a microscope to examine tissue from a tumor. Usually a pathologist compares the tumor tissue with normal tissue. Normal tissue contains many different types of cells grouped together, which is called differentiated. Tissue from a tumor usually has cells that look more alike, called poorly differentiated. Generally, the more differentiated the tissue (the lower the grade), the better the prognosis.

GX: The grade cannot be evaluated.

G1: The cells look more like normal tissue (well differentiated).

G2: The cells are only moderately differentiated.

G3: The cells don’t resemble normal tissue (poorly differentiated).

Recurrent: Recurrent cancer is cancer that has come back after treatment.  If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

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