Head and Neck Cancer is a spectrum of disease covering malignant disease of the upper aerodigestive tract, salivary glands and thyroid. They comprise of 3% of all the new cancers seen in the UK per year. They are therefore relatively rare and should be treated by individuals that deal with this spectrum of disease regularly in a centre that has the complete infrastructure necessary to support a patient through their treatment.
This article on laryngeal cancer / head and neck cancer is written by Francis Vaz, ENT and Head & Neck Surgeon, London.
Laryngeal cancer is the commonest Head and Neck Cancer in the Western world and represents 1% of all malignancies in men. Each year, in excess of 2000 patients are diagnosed in the UK with laryngeal cancer and whilst the treatment for early laryngeal cancer is extremely successful there are approximately 800 deaths per year related to laryngeal cancer. This is why they should be treated by people who see and treat this sort of cancer frequently and work within a department that has the specialists to manage patients well.
The major risk factor for laryngeal cancer is smoking but a synergistic effect from high alcohol ingestion can increase the risk. Laryngeal cancer is five times more common in men than women with a peak incidence occurring in the sixth/seventh decades of life. The commonest type of laryngeal cancer is a squamous cell carcinoma although other malignant and benign cancers are sometimes seen.
Clinical Assessment and Investigation
As part of the management of a patient with laryngeal cancer a patient often starts by seeing an ENT surgeon. The presenting feature most often is one of a change in voice. The ENT surgeon will take a careful history and then examine the patient performing a flexible nasolaryngoscopy (fibreoptic examination of the larynx) in the Out-Patient setting.
Special investigations will be undertaken in the form of a CT Scan of the larynx, neck and chest. Sometimes an Ultrasound of the neck will be performed and a date will be booked to examine the patient under anaesthesia to examine the larynx more closely and to biopsy it.
The treatment options following the diagnosis will depend on the stage of the tumour. Simplified, the staging is looked at as follows:
T1 (a) Limited to one site
T1 (b) In two sites but one region
T2 Involving two or more regions
T3 Within the larynx but with fixation of one of the vocal cords
T4 Spread outside the larynx
Treatment Options are dependent on the stage, fitness and age of the patient.
Transoral laser surgery
For an early laryngeal cancer, this is a very feasible option of treatment where the primary laryngeal cancer can be lasered out and the specimen examined by the pathologist. Biopsies are also taken from the periphery of the specimen to see if there has been complete removal. It is quite commonly followed up with a repeat endoscopy and biopsy 6 weeks later to reassess the area that was surgically excised.
Clearly, resecting part of the larynx will have an effect on the voicebox. Typically, patients already have a distorted voice that will never be normal again. No clinical trials have been completed with regards to showing if transoral laser surgery is better for voice compared with radiotherapy alone and we await the results being compiled from a trial in Australia for this information. The benefits of this are that it involves one or two inpatient stays for the endoscopies and laser surgery versus the multiple visits over 4 weeks for radiotherapy; the other treatment option for early laryngeal cancer.
Radiotherapy is the use of ionising radiation to treat cancers. The radiation damages the structure of the DNA in cells both normal and cancerous. This means that normal tissues will be damaged. However, the cancerous cells are more susceptible to the damage and cannot repair their DNA as efficiently and therefore succumb more usually to the effects of the radiotherapy.
Early laryngeal cancers can be treated with external beam narrow field radiotherapy. This is typically delivered in fractions to reduce the toxic effects of the radiotherapy and is done so over approximately 4 weeks and with 20 fractions. This requires a mould of the face and head and neck to be created for the patient that they use every time their radiotherapy is delivered to ensure accurate treatment.
For larger laryngeal cancers, wider fields are delivered to encompass the lymph nodes that drain from the larynx and are usually the first route of spread of the tumour. In addition, larger doses of radiotherapy can be delivered over a longer time frame typically 6 weeks. Chemotherapy can also be given to enhance the effect of the radiotherapy and increase the efficacy of the radiotherapy.
This is the operation that most people dread with laryngeal cancer. Many things have changed with this operation over the years and nowadays I can say that in excess of 90% of my patients who require this operation should have intelligible voice and will normally have a soft diet. It is, however, an operation where the voice box is removed and swallowing tube is reconstructed. It is reserved for large T4 or T3 laryngeal cancers in the first treatment setting and for the recurrent or residual disease that can occur after radiotherapy.
The voice box is removed in the operation and the airway (trachea) is fashioned in front of the neck making the patient a neck breather for the rest of their lives. Care post-operatively of this breathing tube by the patient is imperative as the normal humidification of the mouth and nose is not connected but is easily done by the use of a heat and moisture exchanger or the use of a moistened neck scarf.
A voice valve is also inserted into the breathing tube that will allow air to be directed into the mouth to voice. Good quality of voice can be achieved in most laryngectomy cases but requires the cooperation of the patient, surgeon and speech and language therapist.
Typically the patient is in for approximately 2-3 weeks and then there is a period of a couple of months of rehabilitation in the outpatient setting before the patient is feeling completely confident and competent with all aspects of post laryngectomy care. However, laryngectomees can get back to normal working lives (depending on their occupations) as there are only a few restrictions post laryngectomy.
Laryngeal cancer, by virtue of the fact it is rare, needs to be treated through a centre that has the specialists within it to treat and look after a patient throughout their management plan.
Making the diagnosis of laryngeal cancer requires skilled clinicians, surgeons and oncologists. They take a detailed, systematic history and recognise risk factors. Appropriate special investigations, reported by experts in their fields is essential. This includes dedicated Head and Neck radiologists to look at the variety of X-Rays taken for patients, dedicated pathologists looking at specimens and biopsies and dedicated cytopathologists looking at cells extracted from head and neck lumps by a process called fine needle aspiration cytology. Patients should be discussed in a multidisciplinary forum such that unilateral decisions are not made. These will include not just the specialists named above such as the surgeons, oncologists, pathologists and radiologists but also the other very important aspects to a Head and Neck Cancer Centre including Clinical Nurse Specialists, Speech and Language Therapists and Dieticians.
The overall outcome is dependent on the stage of the disease. Many laryngeal cancers are treatable and the cure rates for early laryngeal cancer are exceptionally favourable. The key to good management is to be treated by members of a team that see this type of disease process regularly.