What is the Larynx?

The larynx is the upper portion of the windpipe ("trachea") which has a two main functions: conducting air down into the lungs, and producing speech in humans. The human larynx is composed of 3 areas: supraglottis, glottis, and subglottis. Theglottis is literally the "voicebox" and contains the paired vocal cords. The subglottis extends about 1/2" below the glottis, while the supraglottis extends about 2 inches above the vocal cords. The epiglottis, which is a flap of flesh that folds down over the trachea to protect the lungs during swallowing, is part of the supraglottis. The whole larynx is in front of the foodpipe ("esophagus") and is just behind the skin of the throat.

Placing a finger directly under the "Adams apple" (which is a movable bone in the neck called the hyoid) and humming allows you to feel the vocal cords vibrating right under your finger. Only a thin membrane and the skin of the neck separate the vocal cords from your finger at this point; doctors use it as a landmark to insert an emergency air tube ("cricothyrotomy") in situations where a patient's upper airway is blocked. The area of the vocal cords is the narrowest part of the airway and the easiest to block by tumor or an object swallowed "the wrong way". All the air we breath in and out all passes over the vocal cords, which come together to raise the pitch of our voice. A special muscle connects to the vocal cords to tighten them; cancers can invade this muscle and then limit the action ("mobility") of the vocal cords. An important nerve ("recurrent laryngeal") supplies this muscle that tightens the vocal cords; cancer invading the nerve can also paralyze the cords. When the cords don't move properly, it's crucial to know why.

The supraglottis and subglottis have an extensive network of draining glands ("lymph channels") which carry tissue fluids to bean sized lymph glands in the neck where they are filtered and purified before being returned to the bloodstream. Cancer cells can break off and travel through these the lymph channels, and into the bloodstream. The true vocal cords do not have any draining glands, so cancers starting on the vocal cords tend to spread more slowly than those originating above or below the vocal cords. Two plates of cartilage (thyroid and cricoid) protect the upper and lower larynx, but as mentioned don't extend over the front of the vocal cords. Cancers that spread locally can invade into cartilage. More rarely, they can invade into the esophagus lying behind the larynx. The larger the cancer, the more risk of distant spread.

What Is Larynx Cancer?

Larynx cancer simply means one that started in the larynx proper, as described above. The larynx is lined with cells which grow rapidly before birth and during childhood through puberty. In the adult, however, new cell production is under very tight control. New cells are produced by division of older ones to replace those lost due to old age and injury. The genetic material inside the cell (the "genes" made up of DNA) instructs the cell through the division process. Normally, if the genes are damaged, the cell won't divide at all. However, due to particular types of gene damage, the cell may start dividing out of control. Cancer starts in a single cell, when it starts dividing out of control. When cells divide rapidly, they form a clump of cells known as a tumor.

A tumor merely means a swelling, it can be caused by most any infection or irritation and is not necessarily cancer. A tumor which grows only in it's local area, and does not spread distantly, is called"benign" and is not cancer. An example of a benign tumor of the vocal cords are thepolyps (bumps) on the cords which may develop after repeated voice strain, and cause hoarseness. In contrast, a tumor which has the ability to spread to distant areas is called"malignant" andit is cancer. For a cancer, the process of local growth is called"invasion" and of distant travel"metastasis". Distant travel can mean through the lymph channels into the local lymph nodes of the neck ("lymphogenous metastasis") or toany organ of the body via the bloodstream ("hematogenous metastasis"). The most common organs for cancer to spread to in the bloodstream are the lungs, liver, bone and brain. It is important to catch and treat cancer early, for the longer and larger it grows, the more the chance of distant spread.

How Common is Larynx Cancer?

Each year in the United States there are12,500 new cases of larynx cancer which leads to about 800 deaths. Almost 90% of larynx cancer patients are males. The most common age to get larynx cancer is between 60 and 70 years old. Glottis cancer (the area of the true vocal cords) is by far the most common, making up 65% of cases. The second most common site is the supraglottis, at about 30% of cases. The remaining 5% of cases occur in the subglottis. Patients may develop a "transglottic" cancer, it means the disease crosses anatomic boundaries to invade more than one area of the larynx. It may even be impossible to say just where a transglottic cancer started.

Currently, about 2% of all cancer cases are larynx cancer. In general, the worldwide rate of larynx cancer has beenincreasing over 3 decades, but the cure rate has also been increasing.

What Causes or Increases the Frequency of Larynx Cancer?

As with any cancer, the reason why any one person gets larynx cancer and another does not isunknown. However, as with many cancers, certain factors ("risk factors") have been noted that make it more likely to get larynx cancer. These include:

Male Sex - as mentioned, nearly 90% of cases occur in males. This may be due to heredity and other risks males are more likely to take.
Older Age - larynx cancer is not usually a disease of the young: only 5% occur in patients less than 45 years old; it's vanishingly rare in children.
Tobacco Use - is the best identified risk factor which people can control. When smoke is inhaled, it irritates the larynx and causes changes in the thin and delicate lining (the "mucosa"). The lining cells may start quickly dividing to repair a perceived injury. In general, the more often cells divide, the more likely a cancerous cell is to arise.
Marijuana Use - heavy use in particular has been associated with larynx cancer. This is thought to be a major factor in younger patients getting it.
Alcohol Use - has been associated with various head and neck cancers, but less so for areas uncontacted by the alcohol such as the larynx.
Viruses - such as papillomavirus which causes polyps (bumps) on the vocal cords increases the risks for certain cancers, just as similar virus infection on the genitals may lead to cancers of the penis and vulva. Viruses actually get into and change the genes, leading to cancer.
Multiple Aero-Digestive Cancers - If a person has one cancer of the head, neck, lungs or digestive system, the risk is about 5% that they have another simultaneous cancer. The risk is about 25% that they will develop another cancer in this region over time, especially if they continue to use tobacco and alcohol.

What are the Symptoms of Larynx Cancer?

Early larynx cancer likely hasno symptoms. To be just 1 cm. (about 1/2 inch) big, a tumor needs to grow to contain 1 billion cells. This means about 9 doublings. This may take months to years to occur and go totally unnoticed. However, just a few more doublings will lead to a gigantic tumor which will definitely cause symptoms. Usually larynx cancer grows to a fairly large size locally before spreading to local lymph glands and to distant organs; especially if it started on the vocal cords. Common symptoms:

Hoarseness - This keeps getting worse and is caused by either the cancer interfering with the vocal cords themselves, or the nerves or muscles which cause the vocal cords to tense. Any worsening hoarseness must be evaluated - non-cancerous causes such as infection, post-nasal drip and polyps are much more likely than larynx cancer.
Throat Pain - Tends to occur as the cancer invades nerves. However, many larynx cancers become very large without causing much pain.
Swollen Glands - in the neck are worrisome for the cancer spreading to local lymph nodes. The swelling is most commonly on the groove at either side of the "Adams apple", along the length of the neck. These lymph glands are called the "cervical nodes" (here the word cervical means neck). Also, lymph glands in the very front of the throat may enlarge ("Delphian nodes") especially with cancers located near the midline of the throat. It is important to realize the neck swelling does not prove cancer - it may well be caused by a simple infection. However, lymph nodes involved with cancer will just continue to grow larger without treatment.
Breathing Difficulty - Recall that the larynx is the narrowest portion of the tube for breathing. If it gets clogged by tumor, it can cause difficulty breathing in ("stridor") or difficulty breathing out ("wheezing"). These may need emergency treatment to restore free breathing.
Swallowing Problems - Since the larynx lies directly in front of the esophagus a growing tumor can compress this foodpipe, or even invade into it. This can cause a sensation of a lump in the throat with swallowing trouble ("dysphagia") first with solids and eventually with liquids. Swallowing is painful ("odynophagia") when cancer invades nerves.
Signs of Distant Spread - A cancer can spread to anywhere in the body. Most commonly, bone pain, brain problems, lung problems and liver problems are seen from this "metastasis".

How is Larynx Cancer Diagnosed and Evaluated?

The only absolute way to diagnose any cancer is to get a piece of it ("biopsy" ) and have a pathologist ( physician specializing in making diagnoses of tissue samples) confirm cancer under a microscope. If a patient comes in with signs and symptoms suggestive of larynx cancer, the following are done:

Complete Physical Examination includes special attention to the head and neck area. Specifically, doctors carefully examine the mouth, tongue and throat for white patches ("leukoplakia") and red patches ("erythroplasia") which may be precancerous areas, as well as for any actual tumors. The neck is felt for any enlarged lymph glands which may represent spread of the cancer. If the glands are enlarged, the size, shape and texture of them is noted. The vocal cords are viewed with a special mirror ("indirect laryngoscopy") and the location, size and appearance of any tumor noted. The patient is asked to say "eeee" so the motion of the vocal cords can be assessed. If suspicion of cancer persists, then a special scope is used to evaluate the area behind the nose, the esophagus and larynx ("triple endoscopy"). The scope has a cutting tool so that any areas suspicious for cancer may be biopsied. Thus the larynx can be directly seen via the endoscope ("direct laryngoscopy") and the tumor described and sampled.

Routine Laboratory Tests include Complete Blood Count (CBC ) to look for anemia and infection, and a Chemistry Panel (SMA ) to check blood sodium, potassium, sugar, cholesterol, and liver and kidney function. A routine urinalysis (UA ) is gotten to look for blood, sugar, protein or infection of the urinary tract. If surgery is contemplated, blood tests for clotting (bleeding time, PT, PTT) will be needed by the surgeon. Unfortunately, there is no blood test ("tumor marker") for larynx cancer, but signs of spread to major organs and bone may be picked up by the routine tests listed above.

Radiology Tests will include standard Chest X-ray to look of pneumonia and signs of lung tumor. ACT scan of the neck basically combines hundreds of X-ray images and, when done in "thin slices" can show the location and size of a tumor over 1 cm. (1/2) large. It can also suggest whether cartilage or bone is invaded by cancer, and whether lymph nodes of the neck appear involved.

Magnetic Resonance Imaging (MRI) scaning of the neck is another excellent (though expensive) test for determining the size, shape, and spread of a tumor . This is wonderful for showing the soft tissues of the neck, and is being ordered more frequently prior to surgery. A barium swallow may be ordered if surgery is contemplated, in this test some contrast material (barium) is swallowed and X-rays are taken to see how well it goes down into the stomach. After surgery, a"modified barium swallow" is often ordered prior to letting the patient eat, to make sure the smaller volume of swallowed contrast goes into the stomach and not the lungs! Other tests like bone scans and brain CT scans should only be ordered if there are new symptoms in these areas to suggest spread of cancer there, which needs to be confirmed or denied. No scan absolutely proves cancer in any area, only a biopsy does - but a "positive" scan does lead to strong suspicion of spread.

What are the Types of Larynx Cancer?

Over 95% of cancers in the larynx area are called "epidermoid" type, mostly represented by something called "squamous cell carcinoma" . This means that the cell of origin for the cancer was the lining cells of the vocal cord area. This is the same type of cancer most commonly developing in the mouth, skin and lungs. The squamous cells look like small "fried eggs" under the microscope, and when they are dividing too quickly, and their central "nuclei" (where the genetic material is) looks dark and too large, cancer is diagnosed. Some variants of squamous cell cancer are"verrucous" (wart-like) and a "spindle cell" type. Radiation treatment may be less effective for these variant types. Another less common kind of glottic cancer arises from the glands that secrete mucous, this is called "adenocarcinoma" . This is the type of cancer most common in the digestive tract. The treatment for adenocarcinoma in the larynx is the same as for squamous cell.

Very rarely (<1% of cases) "sarcomas" which are cancers of the muscle, cartilage or fat arise, or"lymphomas" which come from the immune cells. The treatment for these rare types follows their therapy in other body areas where they are commoner.

How is the Extent of Larynx Cancer Gauged?

Like any cancer, the extent of larynx cancer is described by the"Stage" . These are how doctors communicate which each other how advanced the cancer is, and so that various treatments can be compared. The most commonly used system for larynx cancer is the American Joint Cancer Committee or "AJCC" system. In this system, the considerations are the size of the original tumor ("primary"), called the "T" stage, the amount of lymph node involvement, called the"N" (for n odes), and distant spread to other organs, called the"M" (for m etastasis). Thus, the AJCC uses the"TNM" system of staging. Since the larynx has three anatomical areas (supraglottis, glottis, subglottis) the "T" description for each is different, but the"N" and "M" are the same:

Supraglottic Cancer:

T1 means the cancer is confined to just one area above the vocal cords.
T2 means the cancer extends to more than one site, vocal cords move well.
T3 means the cancer interferes with vocal cord movement, or invades one of 3 special sites: the pre-epiglottic tissues, medial wall of the piriform sinus or the "post-cricoid" area.
T4 means the cancer has spread outside the larynx (local bone or cartilage).

Glottic Cancer:

T1 means the cancer is limited just to the true vocal cord(s); T1a is to one vocal cord and T1b is to both, the area where they come together (called the "commissure") may also be involved.
T2 means the cancer extends up to the supraglottis or down to the subglottis (that is has become "transglottic") or impairs the movement of the cords.
T3 means the vocal cord(s) are fixed into position (paralyzed) by the cancer.
T4 means the cancers extends locally beyond the larynx.

Subglottic Cancer:

T1 means the cancer is limited to the area below the vocal cords.
T2 means the cancer extends up to the vocal cords.
T3 means the vocal cord(s) are fixed (paralyzed) by the cancer.
T4 means the cancer extends locally beyond the larynx.

Lymph Node involvement (assessed by probing the neck with examiniing fingers) is categorized the same for all head and neck cancers:

N0 means there isno detectable spread to lymph nodes.
N1 means a single lymph node involved, less than 3 cm. (~1 and 1/2 inches).
N2 means single or multiple nodes involved, between 3 and 6 cm.
N3 means any neck lymph node is bigger than 6 cm. (~3 inches) across.

Distant Spread (metastasis) is simply categorized as M0 (absent) or M1 (present).

The Stage Groupings tell the actual stage of the cancer using the above data, and so are the "bottom line" information used for treatment decisions:

Stage 0 means the cancer does not invade locally, but is merely microscopic.
Stage I is T1N0M0 - very limited cancer - see above for exact definition by area.
Stage II is T2N0M0 - a larger but still localized cancer - no lymph nodes involved.
Stage III is either T3N0M0 or T1-T3, N1,M0 (either a large local cancer, or one local lymph node involved even with a smaller cancer.
Stage IV is any T4, N2 or N3 disease, or any M1 (distant spread). This means a large local cancer, extensive lymph node involvement, or any metastasis.

What is the Historical Survival From Larynx Cancer?

This will depend upon many factors, but overall averages are given below. Some things that seem to affect survival include:

Age (patients under 40 years old or over 70 tend to do worse).
Type of Cancer (high grade does worse)
Location of Cancer (glottis does best, followed by supraglottic then subglottic).
Condition of the patient (other "co-morbid" factors like lung or heart disease).
Treatment chosen, and compliance with that treatment.
Smoking - people who quit do better, even quitting after the cancer is found.

The conventional survivals (in textbooks) are given by stage:

The above figures are somewhat "skewed" by the inclusion of glottic cancer, which is 3 times more common that the other types and tends to do better than other areas. Many people live many years with incurable cancers, and no one can predict how well (or poorly) any individual patient will do. We are M.D.'s, not M.Dieties!

What is the Conventional Treatment for Larynx Cancer?

The classical modern modern treatments for larynx cancer aresurgery, radiation, and less commonly chemotherapy. More than one treatment method may be used on a given patient. The treatment chosen will depend upon the cancer's stage, as well as the condition and wishes of the patient, preferences of the treating doctor, and the facilities available. Each method of treatment (called"modality" ) is now discussed in detail, along with it's uses for particular stages of cancer.

Surgery is the oldest method of treating head and neck cancers, and is still widely practiced today. The doctors doing this type of surgery are called "otolaryngologists" (also called ENTs) who do surgery, or "head and neck surgeons" for short. This type of doctor is usually the first referral after a primary care doctor suspects cancer. They do the evaluation procedures (previously described) and await a pathology report to confirm cancer. If cancer is proven, they assign it's stage based upon their workup.

There are a variety of surgical procedures for larynx cancer, starting from the most simple (such as vocal cord scraping) for very early disease to radical operations that completely remove the voicebox (total laryngectomy) and dissect the neck to remove lymph nodes. The most common operations and their usefulness is now described:

Vocal Cord Scraping is used to remove the earliest cancers, which are not known to have invaded into the vocal cord. This is the same operation as is used for hoarseness from vocal cord polyps, and can be done with a sharp endoscopic knife or laser. Procedures to scrape or "strip" the vocal cords are the easiest and least side-effect prone surgery, done on an outpatient basis. The cords are locally anesthetized and the operation takes only about 1/2 hour. Side effects include tenderness (especially when the voice is used) and some local swelling (edema). Patients are advised to rest their voices and to quit smoking. Serious complications, such as vocal cord swelling (edema) leading to blocking breathing are very rare (<1%). Full healing time is about 3 weeks. Patients are told to return for further examinations to make sure the cancer doesn't grow back, which is a risk of vocal cord scraping. You see, vocal cord scraping presumes the cancer doesn't invade (stage 0) which was told by the biopsy report. However, the biopsy may have missed areas of invasion, which are not then removed by a scraping procedure, leading to the cancer growing back. It may even be difficult to tell a relapse of the cancer from chronic inflammation after surgery.

Thus, vocal cord scraping is only done for low grade, superficial cancers with close follow-up to detect early relapse.

Hemilaryngectomy may be considered if the cancer invades, but is still small. This is a more extensive operation to remove the affected vocal cord and is an uncommon operation. This is because most such cancers are better treated with radiation, as will be discussed. Hemilaryngectomy is appropriate for either salvage of a failure after radiation, and perhaps for verrucous carcinoma which does not respond well to radiation. It involves making an incision in the "Adam's Apple" area to exposure the vocal cords, and removing one along the cancer. The problems with this operation include a death risk of 1%, infection risk or poor healing in 10%, and worsening of voice quality. Sometimes the larynx fails to then close properly, and in patient's with reflux of stomach acid up into the esophagus (i.e. from a hiatal hernia) the acid can then back up into the lungs, causing a chemical pneumonia. This is especially a risk for those on depressant medications (like sleeping pills), who drink lots of alcohol, or who's level of alertness is generally poor. Hemilaryngectomy can only be used for small cancers on one side of the larynx; for these patient's the cure rate is over 90%. However, if the cancer is found to be larger, then the only surgery to be done is removal of both vocal cords ("total laryngectomy"), with complete loss of natural voice. Again, hemilaryngectomy will almost never be the first therapy, owing to the superior voice quality and and less risk of larynx loosening ("incompetency") with radiation.

Total Laryngectomy is a radical operation which removes the entire larynx, and obviously natural speech is totally lost. This operation was once used for any cartilage invading or extensive larynx cancer, but (as will be seen) it is now more appropriate for saving the patient's life after radiation and chemotherapy failure. Some patients who come in with locally advanced disease, however, are still recommended to have total laryngectomy as the first therapy. A total lymph node dissection of the neck is also done along with this operation. The patient is required to be in generally good health with no recent heart attack (in the past 6 months) and decent lung function. It takes several weeks to recover from, and leaves considerable scarring in the neck area. A main risk with total laryngectomy is that food will be "aspirated" from the stomach into the lungs, especially when lying down, leading to "aspiration pneumonia". Breathing is no longer through the mouth, but through a hole ("stoma") in the neck. The stoma must be kept clean and well cared for so an infection doesn't develop. A tube, or at least a button, is placed into the stoma to keep it open. Since original speech is lost, the patient must learn to communicate by other means. Learning how to form understandable words by burping up swallowed air is possible, but the voice produced is disturbing to many. A hand-held artificial speech device can pick up and amplify vibrations from the neck, producing a very mechanical sounding voice. New technology is applying these devices continually to the neck, so the patient needn't hold up a machine to speak. Many patients merely write down what they want to say on a pad, since the voice they produce by mechanical means isn't understandable to many. However, with practice and determination, artificial voice quality will improve. Many new devices for artificial speech are in testing to sound less "robotic".

Sometimes the vocal cords can be preserved when the cancer is in the supra-glottic area (above the vocal cords). This operation,"supra-glottic laryngectomy" will preserve speech, but will also preserve the cancer if it has migrated down toward the vocal cords. If this occurs, a "total laryngectomy" can be used in attempting to save the patients life. With supra-glottic laryngectomy, a less radical dissection of the neck can often be done, with less scarring. It is always appropriate to do some "exploration" of the neck to "rule-out" cancer spread to the lymph nodes there, but just the upper portion may be dissected with the supra-glottic laryngectomy. These lesser explorations of the neck have names like "supra-omohyoid dissection", meaning it is limited to an area above the mid-neck. If cancer is found in the lymph nodes there, however, then the dissection will be carried further, or at least subsequent radiation to the neck will be given to mop-up remaining cancer cells.

While radical surgery to the larynx and neck is a major procedure, it should not be withheld if the patient is in good enough medical condition, and it is felt that only surgery can save the patient's life. The current idea is to try more limited surgeries after shrinking down the cancer with chemotherapy and radiation, as will be seen.

Radiation Therapy is a crucial and effective treatment for head and neck cancers, and particularly larynx cancer. It is administered by a"radiation oncologist", a cancer specialist physician. Radiation Oncology departments are usually in the basement of hospitals, or may be if free-standing buildings. The patient comes in for initial consultation, usually referred by an ENT doctor. This may be before, after, or instead of surgery, depending upon the site and extent of the cancer and the condition of the patient. If radiation treatments are appropriate, the patient is scheduled for a"simulation" on a replica treatment machine at which time the area for therapy is marked out. A special"mask" may be made of plastic to place over the patients face (a hole is cut for breathing) so that marks do not need to be placed on the face and neck, but on the mask instead. X-rays are taken to confirm position, the patient is aligned with special laser lights. The "simulation" usually takes about 1 hour, and may be gotten in conjunction with a "treatment planning CT scan" of the neck. The patient then goes home.

Information from the simulation and scans is put into a "treatment planning computer" which helps develop a treatment"plan". This plan tells how much radiation is going to the cancer area and how much to surrounding normal tissues. It tells what angles the treatment should be given at, and what type of blocking should be used to protect areas that don't require treatment. This is all checked by a radiation physicist.

The patient is given an appointment to return to the department for the "treatment start". This takes about 40 minutes for the first day. The patient lies still on a hard table and aligned with laser lights, to the marks on their skin or the mask. Verification X-rays are taken to confirm positioning, comparing it with the simulation. If everything lines up, the technician leaves the room and turns on the machine. Treatments are given with a "Linear Accelerator" or less commonly the older Cobalt-60 machine. A beam of photons (light) and sometimes electrons is shone on the tumor cells, which kills them when they try to divide. Each treatment takes only about 15 minutes total per day, Monday throught Friday, for 5 to 7 weeks. The machine is actually only on for a couple of minutes per day. If a treatment is missed, it can be tacked on to the end so that the same total prescribed dose of radiation is given. This total dose is 50 to 75 Gray (units of radiation) given at a rate of about 2 Gray per day.

The actual treatments are painless; the patient does not get "radiation sickness", nauseated, lose their scalp hair, become sterile, or become "radioactive". The side effects of radiation are divided into"acute" and "late" reactions. Acute reactions occur during the treatment period, and commonly include skin redness and irritation after about 2 weeks of treatment. This progresses to throat soreness with swallowing, the patient is advised not to eat sharp foods. If the soreness is to severe to eat, medicine like numbing lidocaine or codeine syrup may be tried. If this doesn't help enough, the patient may require atemporary feeding tube ("PEG") placed into the stomach for their nutrition. The mouth my become dry and the salivary glands swollen with therapy. The worse (but very rare) complication is acute larynx swelling blocking off breathing, which is obviously a medical emergency requiring urgent treatment. Acute reactions disappear after treatment is completed. Late reactions are more concerning because they tend to be permanent. The more small doses ("fractions") the radiation is broken down into, the less chance for late reactions. This is a major reason the treatment is given over several weeks. Late reactions include skin changes like thinning and a more "wooden" texture, continuous dry mouth ("xerostomia") if the salivary glands were treated, and possible (though very rare) spinal cord damage causing paralysis. Paralysis occurs in less than 1% of patients treated for head and neck cancer. Very rarely a second cancer, caused by radiation, may arise years later at the therapy site.

In general, radiation is well tolerated and effective treatment. It has been shown to be most effective when given after surgery for locally advanced head and neck cancers, that is taking out the bulk of the cancer first. For instance, if lymph nodes are more than 3 cm. large, they should be removed surgically prior to radiation to have the best chance for control. However, if the lymph nodes are merely suspected to be involved but are not markedly enlarged, radiation is over 90% effective at killing the cancer in them. An advantage of giving the radiation after surgery is that the extent of the tumor is known, this can help in designing an appropriate radiation "treatment field".

Disadvantages of waiting until after surgery include:

a) A more radical surgery may be needed.
b) Radiation is not as effective in tissue after surgery, since the blood supply and oxygenation isn't as good after surgery.
c) Radiation may cause the surgical wounds to break down is given before adequate healing time (4 - 6 weeks).

For the most common type of cancer, of the true vocal cords in early stages, radiation alone is over 90% effective at curing the cancer while maintaining good voice quality. For larger cancers which require surgery and radiation, radiation adds at least 20% to ultimate control of the cancer. As with any therapy, radiation is most effective when done "early", without waiting for the patient to fail after surgery. For the most basic type of vocal cord cancer, later surgery can "salvage" (cure) 80% of patients failing radiation, and radiation can salvage 50% of patients failing initial surgery. You can see the necessity of working with an expert radiation oncologist for larynx cancer!

Chemotherapy has not been considered conventional therapy, and is not used alone to cure larynx cancer. Instead, it is used along with other treatments to help get local control and hopefully cure. The agents most commonly used are5-Fluorouracil ("5-FU"), Platinum, Adriamycin and Taxol. These may be used alone or in combination with each other. They circulate through the body, and each has it's particular side effects. Most notably, they can cause infection, diarrhea, hair loss and sterility by killing any quickly dividing cells. That's what chemotherapy does - it indiscriminately kills all quickly dividing cells, and works on cancer since most types of cancer cells divide and grow more quickly than normal cell. Also, normal cells can often repair damage from both chemotherapy and radiation, while cancer cells cannot. Chemotherapy is often very effective and encouraging when first used, since the tumor shrinks dramatically.

Unfortunately, cancer cells tend to become resistant to chemotherapy, so it is poorly effective alone in trying to cure head and neck cancers. It does, however, have a firm place in the latest treatment for locally advanced larynx cancer, as part of the multimodality treatment regiments described below. Obviously, patients getting chemotherapy must be carefully monitored and seek immediate care for any fevers.

For early larynx cancers, radiation therapy is the treatment of choice . It is so effective (over 95%) for vocal cord cancers that there is nearly universal agreement about it's being the best therapy (except for the uncommon "verrucous" carcinoma, which some feel responds poorly to radiation). For early supraglottic and subglottic cancers the cure rate is not as high, but is still above 80% with competent radiation treatment, so it is the best available therapy. Modern treatment planning computers that analyze the radiation dose to the larynx in three dimensions, and better machines (and personnel) to deliver the therapy have greatly advanced the effectiveness of radiation. If radiation fails (patients are carefully monitored after therapy is complete) then they most often can be saved by surgery, albeit at the cost of the side-effects described above. Basically, any patient with larynx cancer should be seen at some point for at least an opinion from a competent radiation oncologist.

Combination Therapy "Multimodality" is the best treatment for advanced larynx cancers, if the patient can tolerate it. Joining treatments like radiation and chemotherapy together add to each others effectiveness, but also to their side-effects. For example, the skin reaction will be more severe when chemotherapy has been given prior to radiation. Nonetheless, this reaction shows that normal cells are dying, and thus the cancer cells are dying too! As mentioned, with successful treatment the normal cells can grow back, but the cancer cells won't.It used to be a foregone conclusion that people with locally advanced larynx cancer would lose their larynx (and voice) but this is no longer true! The famous "Veteran's Hospital Study" in the 1980's showed that if chemotherapy and radiation was given prior to surgery, that much more limited surgery could be done (if any way needed at all!) and that 70% of patients with advanced larynx cancer could keep their larynx! This study has been confirmed by others, and the newest way of dealing with advanced larynx cancer is "neoadjuvant chemotherapy" with a "platinum based" regimen and concurrent radiation therapy.

Several doses chemotherapy can be given prior to starting radiation, to sensitize the cancer cells to the radiotherapy. This is called"induction chemotherapy". The acute side effects (skin reddening and peeling, throat soreness, trouble swallowing) may bedramatic with this aggressive therapy, so the patient may be advised to get a temporary feeding tube ("PEG") inserted into their stomach even before treatment starts.

The radiation may be divided up into more than one treatment per day ("hyperfractionation") separated 6 hours apart; this is inconvenient but reduces the late effects and a higher total dose of radiation can be safely administered. After the tumor has shrunk (and perhaps disappeared) a very limited surgery can be done to remove any residual thus saving the larynx, for 70% or so of patients. If the tumor has not responded to the combination therapy, then the (originally routine) laryngectomy can still be done to save the patients life, with no decrease in effectiveness as if it had been done as the first treatment. Thus, modern treatment for larynx cancer offers more hope than ever before, with close cooperation between the head and neck surgeon, medical oncologist, radiation oncologist, nutritionist, speech therapist, and other professionals.