General Information
The larynx is divided into 3 anatomical regions. The supraglottic larynx
includes the epiglottis, false vocal cords, ventricles, aryepiglottic folds,
and arytenoids. The glottis includes the true vocal cords and the anterior and
posterior commissures. The subglottic region begins about 1 centimeter below
the true vocal cords and extends to the lower border of the cricoid cartilage
or the first tracheal ring.
The supraglottic area is rich in lymphatic drainage. After penetrating the
pre-epiglottic space and thyrohyoid membrane, lymphatic drainage is initially
to the jugulodigastric and midjugular nodes. About 25% to 50% of patients
present with involved lymph nodes. The precise figure depends on T stage. The
true vocal cords are devoid of lymphatics. As a result, vocal cord cancer
confined to the true cords rarely, if ever, presents with involved lymph nodes.
Extension above or below the cords may, however, lead to lymph node
involvement. Primary subglottic cancers, which are quite rare, drain through
the cricothyroid and cricotracheal membranes to the pretracheal, paratracheal,
and inferior jugular nodes, and occasionally to mediastinal nodes.[1]
A clear association has been made between smoking, excess alcohol ingestion,
and the development of squamous cell cancers of the upper aerodigestive
tract.[2] If a patient with a single cancer continues to smoke and drink
alcoholic beverages, the likelihood of a cure for the initial cancer (by any
modality) is diminished, and the risk of second tumor is enhanced. Second
primary tumors, often in the aerodigestive tract, have been reported in up to
25% of patients whose initial lesion is controlled. A study has shown that
daily treatment of these patients with moderate doses of isotretinoin
(13-cis-retinoic acid) for 1 year can significantly reduce the incidence of
second tumors.[3] No survival advantage has yet been demonstrated, however, in
part because of recurrence and death from the primary malignancy. Additional
trials are ongoing.
Supraglottic cancers typically present with sore throat, painful swallowing,
referred ear pain, change in voice quality, or enlarged neck nodes. Early
vocal cord cancers are usually detected because of hoarseness. By the time
they are detected, cancers arising in the subglottic area commonly involve the
vocal cords; thus symptoms usually relate to contiguous spread.
The most important adverse prognostic factors for laryngeal cancers include
increasing T stage and N stage. Other prognostic factors may include sex, age,
performance status, and a variety of pathologic features of the tumor,
including grade and depth of invasion.[4]
Prognosis for small laryngeal cancers that have not spread to lymph nodes is
very good, with cure rates of 75% to 95% depending on the site, tumor bulk,[5]
and degree of infiltration. Although most early lesions can be cured by either
radiation therapy or surgery, radiation therapy may be reasonable to preserve
the voice, leaving surgery for salvage. Patients with a preradiation
hemoglobin level greater than 13 grams per deciliter have higher local control
and survival rates than patients who are anemic.[6] This observation is being
evaluated in a randomized clinical trial.
Locally advanced lesions, especially those with large clinically involved lymph
nodes, are poorly controlled with surgery, radiation therapy, or combined
modality treatment. Distant metastases are also common even if the primary
tumor is controlled.
Intermediate lesions have intermediate prognoses, depending on site, T stage,
N stage, and performance status. Therapy recommendations for patients with
these lesions are based on a variety of complex anatomic, clinical, and social
factors, which should be individualized and discussed in multidisciplinary
consultation (surgery, radiation therapy, and dental and oral surgery) prior to
prescribing therapy.
Patients treated for laryngeal cancers are at highest risk of recurrence in the
first 2 to 3 years. Recurrences after 5 years are rare and usually represent
new primary malignancies. Close, regular follow-up is crucial to maximize the
chance for salvage. Careful clinical examination and repetition of any
abnormal staging study are included in follow-up, along with attention to any
treatment-related toxic effect or complication.
References
- Spaulding CA, Hahn SS, Constable WC: The effectiveness of treatment of lymph nodes in cancers of the pyriform sinus and supraglottis. Int J Radiat Oncol Biol Phys 13 (7): 963-8, 1987.
[PUBMED Abstract]
- Spitz MR: Epidemiology and risk factors for head and neck cancer. Semin Oncol 21 (3): 281-8, 1994.
[PUBMED Abstract]
- Hong WK, Lippman SM, Itri LM, et al.: Prevention of second primary tumors with isotretinoin in squamous-cell carcinoma of the head and neck. N Engl J Med 323 (12): 795-801, 1990.
[PUBMED Abstract]
- Yilmaz T, Hoşal S, Gedikoglu G, et al.: Prognostic significance of depth of invasion in cancer of the larynx. Laryngoscope 108 (5): 764-8, 1998.
[PUBMED Abstract]
- Reddy SP, Mohideen N, Marra S, et al.: Effect of tumor bulk on local control and survival of patients with T1 glottic cancer. Radiother Oncol 47 (2): 161-6, 1998.
[PUBMED Abstract]
- Fein DA, Lee WR, Hanlon AL, et al.: Pretreatment hemoglobin level influences local control and survival of T1-T2 squamous cell carcinomas of the glottic larynx. J Clin Oncol 13 (8): 2077-83, 1995.
[PUBMED Abstract]
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