Laryngeal cancer

Most laryngeal cancers are squamous cell carcinomas. Glottic tumors start at the vocal cords; supraglottic tumors arise above them; subglottic tumors start below. Persistent hoarseness, swallowing discomfort, a neck lump or referred ear pain may lead to investigation. New breathing difficulty needs urgent assessment.

Laryngoscopy shows the lesion and vocal-cord movement; biopsy establishes the diagnosis. CT or MRI helps assess deeper spread, cartilage and neck nodes. Additional imaging is selected according to disease extent rather than ordered identically for every small vocal-cord lesion.

The current AJCC system for laryngeal cancer remains the 8th edition. Record the subsite, local extent, nodal findings and distant spread. Vocal-cord fixation, cartilage invasion and extension outside the larynx can change the treatment discussion. The HPV-associated oropharyngeal staging system is not the staging system for a primary laryngeal cancer.

Before deciding on organ preservation, assess aspiration, swallowing, weight loss, existing airway support and voice. A larynx already functioning poorly may remain unsafe after an anatomically successful treatment. Hearing, kidney function and general fitness also affect whether cisplatin-based chemoradiation is feasible.

For suitable early glottic cancers, transoral laser surgery or radiation can be curative options. Endoscopic exposure, tumor extent, expected voice quality, treatment visits and future salvage options help guide the choice. Partial laryngeal surgery is appropriate for selected patients; the smallest operation is not necessarily the best functional choice.

Neck management differs by site. Small early glottic tumors have a relatively low nodal risk, whereas supraglottic disease more often requires treatment of neck lymph-node regions even when no node is obviously enlarged. A plan for the primary tumor should therefore include a separate explanation of the neck strategy.

Concurrent chemoradiation can preserve the larynx in selected locally advanced cancers. The aim is durable control with useful breathing and swallowing, not simply avoidance of an operation. Induction chemotherapy is used in selected preservation strategies, but is not a required first step for every patient.

For extensive T4a disease or severe pretreatment laryngeal dysfunction, initial total laryngectomy may offer a more appropriate route. Selected less bulky cases require an individualized discussion. Ask the team to compare expected cancer control, aspiration risk, feeding dependence and the likelihood of later salvage surgery.

The postoperative report should document margins, lymph nodes and extranodal extension. Positive margins or extranodal extension commonly support postoperative chemoradiation when tolerable; other adverse features may support radiation alone. A clear margin does not, by itself, determine whether additional treatment is needed.

The US pembrolizumab label includes eligible adults with resectable locally advanced head-and-neck squamous cancer and PD-L1 CPS at least 1: treatment before surgery, then with postoperative radiation with or without cisplatin, followed by pembrolizumab alone. This is a defined surgical pathway, not a reason to add immunotherapy routinely to every larynx-preserving radiation plan. Suitability and local authorization must be checked.

A suspicious post-treatment finding needs evaluation for recurrence and treatment-related injury. After previous radiation, salvage surgery—including total laryngectomy—may still offer a curative approach for selected localized recurrence. Reirradiation requires specialist assessment of prior doses, tissue damage and expected benefit.

For metastatic or unresectable recurrent squamous cancer, US first-line pembrolizumab alone requires CPS at least 1; pembrolizumab with platinum and fluorouracil has no such PD-L1 threshold. Nivolumab has a role after platinum progression. Previous PD-1 exposure, symptom urgency and treatment tolerance matter; changing to another PD-1 drug after resistance is not automatically effective.

After total laryngectomy, the permanent neck stoma is the breathing route: the lungs are no longer connected to the mouth and nose. This differs from a tracheostomy with the larynx retained. Carry clear medical identification and ensure carers understand the airway arrangement. Any emergency team must know that the person breathes through the neck.

Natural vocal-cord speech is lost, but rehabilitation may use a tracheoesophageal voice prosthesis, an electrolarynx or esophageal speech. Discuss the options with a speech-language therapist before surgery where possible. Stoma humidification, cleaning, protection from water and equipment supplies need a practical home-care plan.

Radiation or partial surgery can affect voice and swallowing even when the larynx remains. Dental care, nutrition support and tailored swallowing rehabilitation should be integrated into treatment. Coughing with meals, recurrent chest infections or continued weight loss merit review for swallowing problems.

Follow-up assesses recurrence, second cancers and late treatment effects. Thyroid testing can be needed after neck irradiation or thyroid surgery. Stopping tobacco and addressing alcohol use support recovery. Seek prompt assessment for new airway difficulty, significant bleeding or an obstructed stoma rather than waiting for a routine appointment.

• Biopsy, exact laryngeal subsite, TNM stage and the staging edition.
• Endoscopy findings, vocal-cord mobility and original imaging files.
• Airway, aspiration, weight and speech/swallowing assessments; kidney and hearing results if systemic treatment is being considered.
• Previous operative pathology, radiation plans and systemic-treatment dates; PD-L1 CPS when relevant.