Cancer of the Larynx

by Louis Rosenfeld, M.D.

A ssociute Professor of Ctinical Surgery, Vunderbilt University School of Medicine, Nashville, Tenn.

ANCER of the larynx is arbitrarily divided into two ana- C tomical categories, the intrinsic and the extrinsic. The former refers to lesions which arise on, and are limited in their extent to, the vocal cords. The latter refers to malig- nancies adjacent to the vocal cords within the larynx, such as the ventricles, the false cords, the vestibule, and the subglottic areas. Extrinsic laryngeal malignancies also arise nearby in such areas as the epiglottis, the arytenoids, the aryepiglottic folds, the pyriform sinuses, and the vallecula.

The intrinsic laryngeal cancers are highly favorable lesions in contrast to the more lethal extrinsic laryngeal carcinomas. These intrinsic cancers are usually microscopically mature, well-differentiated lesions which are not extremely aggressive and thus enlarge slowly. They are enclosed within the cartilagenous laryngeal box, which acts as a barrier to

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penetration into the soft tissues of the neck. They are surface lesions readily visualized with a mirror or laryngoscope, and definitive diagnosis by biopsy under local anesthesia is possible.

The diagnosis should be made early in the course of the disease. This is made possible by the cooperation of an intelligent patient and a physician cognizant that carcinoma is a most likely cause of persistent hoarseness. One must consider other causes of hoarseness, of course, such as chronic laryngitis, tuberculosis, leukoplakia, vocal cord polyps or papillomata, granulomas, contact ulcer, and vocal cord paralysis due to recurrent laryngeal nerve paralysis. However, carcinoma must be given foremost consideration in the differential diagnosis.

Treatment of intrinsic cancer is by three different modal- ities of therapy:

1. Irradiation, which is often successful in the treatment of the small early lesion limited to one vocal cord which still moves with phonation. This treatment has the advantage of saving the entire larynx. However, for an unknown reason, some 15 percent of these lesions do not respond to irradiation as well as anticipated. Complications of chondritis and stenosis may at times be a problem. Approximately 25 percent of these early small lesions which have been so treated will subsequently require laryngectomy.

2. Laryngofissure, or partial laryngectomy, is also suited to small lesions on one movable cord not extending to or across the anterior commissure. This treatment entails open- ing the larynx in the midline under local or general anes- thesia and excising the involved cord with surrounding laryngeal lining and, at times, the cartilagenous wall as well. A permanent thin, hoarse voice ensues, but it is quite

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satisfactory for normal communication, and the patient retains his normal airway. This operation is suited only to carefully selected cases. There have been approximately forty such operations performed at Vanderbilt University Hospital in the past thirty-five years with only two recurrences to our knowledge. These two patients subsequently had successful total laryngectomies.

3. Total laryngectomy, with or without an associated ipsilateral radical neck dissection, is the radical treatment of these lesions and offers the best chance of cure. It is always indicated when the carcinoma is large, has fixed the cord, extends to the other cord, invades the cartilagenous box, or penetrates into the soft tissues outside the larynx by either direct extension or metastasis. It entails sacrifice of the normal speech mechanism and a permanent trache- ostomy. Ncither of these, howevcr, is too great a price to pay for eradication of a lethal malignancy.

The prognosis is good for persons with intrinsic laryngeal carcinoma. Aided by early hoarseness, easy diagnosis, a low degree of aggressiveness of the cancer, enclosure of the lesion within a cartilagenous box, and satisfactory methods of treatment, we should cure almost 100 percent of such cases. Results arc not this good: the five-year survival rate in many large series of cases varies between 65 percent to 85 percent.

This difference between the potential and actual survival rate is due in large part to procrastination on the part of both patient and physician. Persistent hoarseness for two or three weeks should force one to seek medical advice, but unfortunately this is not always done. It is not unusual to have a person present himself with hoarseness of a year’s duration or longer.

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Then, some physicians are not familiar with the use of a simple laryngeal mirror and presuppose that the hoarseness is due to the presence of an inflammatory condition. Even when a mirror examination of the larynx and hypopharynx is performed, the presence of a lesion may be overlooked or misinterpreted. A direct laryngoscopy may be indicated but omitted. An inadequate biopsy may be taken, but the involved area missed. Microscopic proof of the presence of carcinoma is mandatory before treatment, and a second or even third biopsy is necessary if the clinical picture sug- gests malignancy.

In addition to these obstacles to early and correct diag- nosis, optimum therapy is not always possible. Some patients demand irradiation therapy rather than accept loss of the larynx, even when this treatment is less than ideal in their situation.

Extrinsic laryngeal carcinoma is a much more vicious disease. Both clinically and microscopically these neoplasms are much more aggressive. No such early warning as hoarse- ness heralds the onset of the disease, and the size these cancers may attain with little in the way of symptoms is often remarkable. The first warning may be pain in the throat or referred pain to the ear. One may have difficulty or pain on swallowing, may cough at times with a little blood-tinged saliva, may note hoarseness as the edema in- volves the vocal cords, or may experience shortness of breath due to encroachment on the airway. The first evidence of disease noted by the patient may be a mass in the ante- rolateral neck representing metastatic spread to cervical lymph nodes.

When a patient presents himself to a physician with a neck mass of undetermined origin, the hypopharynx and

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extrinsic larynx must be carefully surveyed in the search for the site of the primary disease. Here, as with intrinsic laryngeal carcinoma, the diagnosis is made by careful visual- ization of the involved area with a laryngeal mirror, followed by biopsy for microscopic proof by direct laryngoscopic examination, usually under local anesthesia. No therapy can be instituted without microscopic proof of the presence of carcinoma. If the first biopsy fails to confirm the anticipated diagnosis and the lesion appears sufficiently suspicious of cancer, a repeat or even a third biopsy is imperative.

The therapeutic approach to these lesions has changed in the past fifteen years. Formerly all were treated with deep irradiation, and the results were dismal; a mere 6 to 8 percent of the patients survived five years or more. The present approach is with radical surgery. This includes a radical neck dissection on the ipsilateral side. If lymph node enlargement is evident on the contralateral side, a bilateral radical neck dissection is performed either simul- taneously or in two stages spaced ten to fourteen days apart. Bilateral radical neck dissection was formerly considered incompatible with survival, but this concept has been proven false.

In addition to neck dissection, the entire larynx, half of the thyroid, as much of the hypopharynx as is deemed necessary, and often a portion of the upper cervical esoph- agus, are removed to secure an adequate margin about the lesion. Normal tissue of the hypopharynx at a distance from the lesion is carefully saved to facilitate reconstruction of the food passage. At times, so much of the hypopharynx must be removed that safe closure is impossible; in such instances it is necessary to leave a pharyngostome, or opening from the pharynx through the skin. This is closed at a later date either

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by mobilizing local tissue flaps or by transporting skin by means of a pedicle graft to close the defect. A permanent tracheostomy is constructed at the suprasternal notch, and alimentation is temporarily handled by means of a Levin tube inserted through the nose, past the hypopharyngeal suture line, and into the stomach, or by a catheter inserted into the cervical esophagus through the skin of the opposite side of the neck.

These operations are long and tedious, yet they are well tolerated by the patients. Advanced age is no contraindica- tion. We are frequently asked if such a radical procedure is really justified. One only has to care for the untreated or unsuccessfully treated patient in the terminal stages of the disease to know that no matter how great the effort or small the chance of success, the operation is worthwhile if there is a possibility of cure or extended palliation. No death is more horrible than that from uncontrolled hypopharyngeal malignancy.

What do we accomplish? As mentioned previously, in such cases salvage with irradiation alone was formerly only 6 to 8 percent. We have been employing this surgical approach for some thirteen years, and at present have used it in some 200 cases. The overall results have been gratifying, though far from perfect. Our overall five-year survival rate has been between 40 and 50 percent. There has also been worthwhile palliation in some few patients who expired of liver or lung metastases, but were spared the horror of local, ulcerated, foul bleeding cancer. We feel that the end-results warrant the effort. Most of the patients are well adjusted to their voice deficit and either learn esophageal speech or use a vibrator. Most have re-entered society as worthwhile citizens.

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