Laryngeal cancer

Glottis cancer is divided into the following stages:

• Stage 1: The tumour resides only within the vocal cords.
• Stage 2: The tumour spreads to either the top or the bottom of the larynx or both. This prevents the vocal cords from moving properly.
• Stage 3:
  • The tumour is either only within the larynx or has spread to the surrounding areas, while the vocal cords are unable to move.
  • Cancer has spread to one nearby lymph node on the same side of the neck as the tumour. This lymph node is not larger than 3 cm.

Subglottis cancer is divided into the following stages:

• Stage 1: The tumour resides only within the subglottis.
• Stage 2: The tumour spreads to the vocal cords making it difficult for them to move normally.
• Stage 3:
  • The tumour has only invaded the larynx but the vocal cords are unable to move.
  • The tumour has spread to the surrounding lymph node on the same side of the neck as the tumour. 
• Stage 4: Stage 4 can be further divided into three stages—4A, 4B or 4C—depending on which areas has the tumour invaded, the number, size and location of the lymph nodes invaded by the tumour and the spread of tumour outside the lymph nodes to the body parts farther away from the larynx.

Supraglottis cancer is divided into the following stages:

• Stage 1: The tumour is restricted to one part of the supraglottis.
• Stage 2: The tumour has spread in two parts of the supraglottis: cancer has either spread into the vocal cords or has spread into the tissue around the supraglottis.
• Stage 3:
  • The tumour is within the larynx but has caused fixation of the vocal cords, making it difficult for the vocal cords to move.
  • The tumour has spread to the surrounding lymph node on the same side of the neck as the tumour.

In the case of total laryngectomy, the patient will not be able to speak properly due to the absence of vocal cords. The patient's caregiver needs to take extra care to ensure that the patient gets adequate support throughout the recovery period—it can be frustrating to lose something so central as their voice, which the patient would have lived with their whole life. 

Once the throat is healed, the person can be taken to a speech and language therapist (SLT) to help restore their voice. The doctors may use voice prosthesis which is an artificial valve that is implanted into the neck of the patient. When the person wishes to speak, they need to cover their stoma and breathe out through the valve. This valve produces noise which can be used to speak out words just like the natural way. However, the voice would be lower-pitched than the normal voice. This prosthesis can be placed in the same surgery where the surgeon would remove the larynx. 

Another technique that the SLT might use is the oesophageal speech technique. In this, the person is asked to push air through the oesophagus (food pipe). While the air moves through the oesophagus, it vibrates and produces a voice. 

The SLT may also use another device called the electrolarynx which is a battery-operated electrical device which vibrates and produces sound. The device is held under the chin and as the person moves their mouth and lips, the vibrations are translated into words. 

In the case of total laryngectomy, the surgeon creates a permanent hole in the patient's throat to help them breathe—this hole is called a stoma. It is quite common for the stoma to produce an excess amount of mucus during the first few months of healing. This excessive mucus can make it difficult for the patient to breathe.

A caregiver needs to make sure that the stoma is cleaned at least once a day or else it would become crusty and pose a risk of infections. In some cases, the doctors may place a tube attached to the stoma to help the patient breathe. Once the mucus production settles down, the tube is removed from the stoma.  

Patients need to remember that they will now need to cover their stoma with a tissue when they cough or sneeze, rather than covering their mouth or nose. This is because mucus or saliva will come out of the stoma.

In case the patient is unable to do so themselves, a caregiver must cover the stoma whenever the patient sneezes or coughs as the patient's saliva and mucus can come out of the stoma.

In biological therapy, the doctor gives certain medications that target and disrupt the growth and reproduction of cancerous cells in the patient. Cetuximab is one such medicine which is used in combination with radiotherapy to treat more advanced laryngeal cancer, which does not get better with chemotherapy.

Cetuximab is given intravenously (through the vein) for up to seven weeks. The person taking cetuximab may present with mild side effects such as skin rashes, diarrhoea, breathlessness and feeling sick. Some people may also present with some serious allergic reactions such as swelling in the tongue and the throat which can block the airway and can be potentially life-threatening.

Immunotherapy is a type of treatment which uses the patient's own immune system to fight against cancer. In this therapy, the doctor uses substances that are either made by the body or made in a laboratory which can boost, direct, and restore the body's natural defence system against cancer. An example of immunotherapy for cancer is CAR T-cell therapy.

Chemotherapy is the most commonly used therapy against any cancer. It involves the use of some strong cancer-killing medications which damage the DNA of the cancerous cells and prevent the cells from multiplying. Chemotherapy can either be used prior to surgery to reduce the size of the tumour or after the surgery to kill the residual cancer cells. It can also be given along with radiotherapy.

Chemotherapy medicines are usually given as an injection into a vein (intravenously) once in every three to four weeks, for up to six months. 

Chemotherapy not only kills the cancerous cells but also damages the healthy tissues which lead to various side effects in the body. Some of the common side effects of chemotherapy are:

• Hair loss
• Constant feeling of being sick
• Loss of appetite
• Nausea and vomiting
• Diarrhoea
• Ulcers in the mouth
• Sore throat
• Fatigue

Chemotherapy can also weaken your immune system, thus making you prone to other infections and illnesses along with cancer.

Surgical treatment of laryngeal cancer involves removing the part of the larynx which has the tumour which is medically called laryngectomy. The surgical procedure used can vary, depending on the part of the larynx infected by cancer:

• Cordectomy (removal of vocal cords only)
• Supraglottic laryngectomy (removal of supraglottis only)
• Hemilaryngectomy (removal of half of the voice box) 
• Partial laryngectomy (removal of only the infected part of the voice box)
• Total laryngectomy (removal of the entire larynx) 
• Laser surgery to remove the tumour present on the larynx

Even after the surgical treatment, the patient may require additional chemotherapy or radiation therapy to kill any cancer cells left after the surgery.

The three most common types of surgery that are used to treat laryngeal cancer are:

• Endoscopic resection of the tumour: Endoscopic resection is mostly used for early-stage laryngeal cancer. This is the least aggressive surgery out of all the other surgery options for laryngeal cancer. In this surgery, the surgeon uses a special microscope which gives a better and magnified view of the larynx. This helps the surgeon to find and remove the cancerous part with the help of either a laser or other small instruments.
  After the procedure, some people may complain of sore mouth and throat along with slight pain, but this usually goes away in a few weeks. However, there is a risk that after the procedure, there can be a permanent change in some people's voice.
• Partial laryngectomy: Some laryngeal cancers can be treated with the help of a partial laryngectomy. In this surgery, the doctor removes only the affected parts of the larynx and tries to protect the vocal cords as much as possible. The person will be able to talk after this surgery; however, the voice would be hoarse or weak.
  After the surgery, some people may have trouble breathing. To curb this, the surgeon may perform a temporary tracheostomy—that is, create a temporary hole in the neck to attach a tube which can help the person breathe. The tube is removed once the larynx has healed and the hole also heals on its own.
• Total laryngectomy: A total laryngectomy is usually done in the advanced stages when cancer has completely taken over the larynx. In this surgery, the surgeon removes the entire larynx, along with the surrounding lymph nodes, as in most of the cases, cancer spreads to them as well.
  After the surgery, the patient is unable to speak as the vocal cords of the person are removed completely. The person will have to undergo speech therapy after the removal of the vocal cords. 
  Another procedure done in total laryngectomy is the formation of a permanent hole in the neck, called a stoma. This stoma helps the person to breathe after the surgery. The person is given proper training on how the stoma works and how to keep it clean.

In radiotherapy, doctors use controlled doses of high-energy radiation to destroy the cancerous cells. This treatment is mostly used in the early stages of cancer or after cancer surgery to prevent the return of cancerous cells. 

Sometimes radiotherapy is given along with chemotherapy. In radiotherapy, the beams are precisely targeted to the larynx. The patient is made to wear a plastic mask that holds the head in the right position throughout the session. Usually, hyperfractionated radiation therapy is used for the treatment of laryngeal cancer. In hyperfractionated radiation therapy, a smaller dose of radiation is divided into two doses and thus the treatment is given twice a day. 

The course of treatment usually lasts for three to seven weeks. The beams kill the cancerous cells, but they also affect the healthy tissues of the body. As a result, the patient may complain of various side effects such as sunburn-like rashes, mouth ulcers, dry mouth, loss of taste, loss of appetite and fatigue. For these, the doctor may give the patient medicines like anaesthetic gels, artificial saliva and betadine solution for ulcers, loss of taste and sore throat.