Laryngeal cancer surgery ranges from laser removal through the mouth for early tumors to partial or total laryngectomy for advanced ones, with chemoradiation as the main alternative that can save the voice box. This guide covers how stage shapes the choice, the trials behind larynx preservation, voice after surgery, recovery and the stay in Istanbul.
About This Department
Ear, Nose and Throat
Laryngeal cancer found early is curable, in many patients with a laser through the mouth and no neck incision. For advanced cancer, the choice between surgery and chemoradiation decides whether the voice box survives.
Cancer of the larynx, the voice box, causes hoarseness early when it starts on the vocal cords. Doctors therefore find many of them small. For early tumors, transoral laser microsurgery removes the cancer through the mouth under a microscope, and meta-analyses found it preserved the larynx and survival at least as well as radiotherapy. For advanced tumors, landmark American trials showed that chemotherapy with radiation could save the larynx in many patients without lowering survival, while tumors that have destroyed the cartilage do better with surgery first. Surgeons, radiation oncologists and medical oncologists make the decision together. Send us your biopsy, scans and laryngoscopy video, and the head and neck team will tell you which treatment fits and how long to plan.
64%
Patients keeping the larynx after chemotherapy and radiation, with equal survival
6.3 times
Higher odds of larynx preservation with laser surgery than radiotherapy, T1 glottic cancer
A treatment strategy involving induction chemotherapy and definitive radiation therapy can be effective in preserving the larynx in a high percentage of patients, without compromising overall survival.
Veterans Affairs randomized trial of 332 patients, New England Journal of Medicine, 1991
Symptoms that need a throat examination
Hoarseness lasting more than three weeks, especially in a smoker, pain on swallowing, a lump in the neck, pain spreading to the ear, coughing blood or noisy breathing need examination of the larynx by an ear, nose and throat specialist.
The decreased survival recorded for patients with laryngeal cancer in the mid-1990s may be related to changes in patterns of management.
National Cancer Data Base review of 158,426 cases, The Laryngoscope, 2006
1
Diagnosis
Laryngoscopy in clinic, then a biopsy under general anesthesia, which also maps the extent of the tumor.
2
Staging
CT or MRI of the neck and a chest scan, sometimes PET-CT, to measure the tumor, check the cartilage and look for spread to lymph nodes.
3
The team decision
Surgeons, radiation oncologists, medical oncologists, speech therapists and the patient agree the plan, weighing cure, voice and swallowing.
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Treatment options by stage
Stage
Main options
Early, T1 and T2
Transoral laser surgery or radiotherapy alone
Advanced with a working larynx, T3 and some T4
Chemoradiation, or surgery with radiotherapy
Advanced with cartilage destroyed, T4
Total laryngectomy with radiotherapy or chemoradiation
How is early laryngeal cancer treated?
Transoral laser microsurgery
Laser surgery through the mouth removes small vocal cord cancers without any cut on the neck.
How it is done
Under general anesthesia, a metal tube is passed through the mouth to the larynx, and the surgeon works through it with a microscope and a carbon dioxide laser, removing the tumor with a margin of healthy tissue. A pathologist examines the removed tissue under the microscope to confirm that every edge is clear of cancer, and patients go home the next day and eat at once.
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Laser surgery against radiotherapy for T1 glottic cancer, 16 studies
Outcome
Odds ratio favoring laser surgery
Overall survival
1.52
Disease-specific survival
2.70
Larynx preservation
6.31
Local control
No difference
Laser surgery suits small tumors the surgeon can see completely through the tube, and keeps radiotherapy in reserve.
Radiotherapy suits tumors that are hard to expose, such as those at the front of the vocal cords in some anatomies.
Voice quality after both is similar for small tumors and can differ for larger ones.
1
Day of surgery
Admission, general anesthesia, 30 to 90 minutes of laser surgery.
2
The next day
Home, eating as usual. Voice rest for a few days.
3
Results
Pathology in a week. If a margin is close, a second short laser procedure or radiotherapy follows.
Voice after surgery
Hoarseness comes first. The voice improves over weeks to months as the vocal cord heals. Speech therapy helps. Patients with small tumors keep a serviceable voice in the large majority of cases.
Can the larynx be saved in advanced cancer?
The landmark trials
Two American trials changed treatment. The first compared chemotherapy followed by radiation with total laryngectomy and radiation. The second compared three non-surgical strategies, and set chemotherapy given with radiation as the standard for saving the larynx in suitable patients.
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Larynx preservation trials
Trial
Patients
Main findings
Veterans Affairs, 1991
332, stage III and IV
Two-year survival 68 percent in both groups. Larynx preserved in 64 percent of the chemotherapy group
RTOG 91-11, 10-year results, 2013
520, stage III and IV
Concurrent cisplatin and radiation preserved the larynx best. Overall survival similar between strategies
When is surgery the better first choice?
Partial laryngectomy
Partial laryngectomy removes selected intermediate tumors, open or through the mouth, and keeps part of the larynx and natural speech and swallowing. Many patients need a temporary breathing tube while swelling settles.
Total laryngectomy
When the tumor has destroyed the thyroid cartilage, spread outside the larynx, or left the larynx unable to protect the airway, removing the whole larynx with radiotherapy afterward gives the best chance of cure. The windpipe then opens on the front of the neck, and breathing no longer passes through the nose and mouth.
Cartilage destroyed by the tumor, or spread into the soft tissues of the neck.
A larynx that no longer works.
Cancer returning after radiotherapy, where salvage surgery is the main option.
A small valve placed between the windpipe and the gullet lets the majority speak again within weeks.
An electrolarynx held against the neck, or esophageal speech, are alternatives.
A filter over the opening warms and moistens the air and protects the lungs.
What the US national data showed
A review of 158,426 cases in the National Cancer Data Base found that survival for laryngeal cancer fell between the mid-1980s and mid-1990s, as treatment shifted from surgery toward chemoradiation. For T3 tumors without nodes, five-year relative survival was 65.2 percent after surgery with radiation and 59.2 percent after chemoradiation. For T3 glottic cancers alone, the two were identical. The authors called for further study, and the lesson most teams draw is careful selection, with surgery first for tumors that have destroyed cartilage.
Locoregional control and larynx preservation were significantly improved with concomitant cisplatin/RT compared with the induction arm or RT alone.
RTOG 91-11 long-term results, Journal of Clinical Oncology, 2013
The ten-year RTOG results
In RTOG 91-11, 520 patients with stage III or IV cancer of the glottis or supraglottis received induction chemotherapy then radiation, radiation with cisplatin at the same time, or radiation alone. Both chemotherapy strategies improved survival free of laryngectomy compared with radiation alone, concurrent treatment preserved the larynx best, and overall survival did not differ significantly. Deaths not related to the cancer were higher after concurrent treatment, a reminder that the intensive approach suits fit patients.
What are recovery, voice rehabilitation and the stay like?
Recovery depends on the operation.
Recovery after laser surgery and partial laryngectomy
After laser surgery, patients go home the next day. After partial laryngectomy, recovery takes one to two weeks in hospital, with a speech and swallowing therapist teaching safe swallowing before the breathing tube is removed.
Voice after total laryngectomy
The surgeon places the voice valve during the operation or later. A speech therapist trains the patient to cover the opening and speak. Conversation returns within weeks for the majority. The valve needs changing every few months in clinic, and families learn stoma care before discharge, practicing cleaning, changing the filter and what to do if the valve leaks, so that they leave confident and able to manage at home with the help of a local nurse or speech therapist, who receives a written summary of the valve type and size.
Follow-up
Laryngoscopy every one to three months in the first two years, when most recurrences appear, then every few months, with scans as needed. Blood tests check thyroid function after radiotherapy to the neck.
Follow-up continues for five years.
Stopping smoking matters
Smoking is the main cause of laryngeal cancer, and stopping improves healing, the success of radiotherapy and the chance of avoiding a second cancer. Support to stop is part of treatment.
Days, cost and the trip
Plan five to seven days in Istanbul for laser surgery, two to three weeks for partial or total laryngectomy, and around seven weeks if radiotherapy is given here. You can fly once the surgeon has checked the throat and, after laryngectomy, the stoma is stable and you can care for it. Cost depends on the operation, the hospital stay, any reconstruction and radiotherapy. Your own figure follows the free review of your file.
One coordinator plans the visit, from the visa invitation letter sent ten days ahead to the transfer and a hotel near the hospital for you and a companion. The team works in seven languages with halal meals and a prayer room available, and a female doctor is assigned on request when the schedule allows. Back home, the head and neck team reviews follow-up laryngoscopy and scans from your local doctors and stays reachable on the same WhatsApp number.
Our meta-analysis suggests that TLM is the superior modality in terms of overall survival, disease specific survival, and laryngeal preservation.
Meta-analysis of 16 studies, Journal of Otolaryngology Head and Neck Surgery, 2019
Laryngeal cancer surgery FAQ
Can laryngeal cancer be cured?
Many early cancers are cured with laser surgery or radiotherapy alone. Advanced cancers are treated with chemoradiation or surgery, with cure in a substantial share.
Is laser surgery as good as radiotherapy for early cancer?
For T1 glottic cancer, meta-analyses found laser surgery preserved the larynx and survival at least as well, without a neck incision.
Will I lose my voice?
Not with laser surgery or partial laryngectomy in the large majority. After total laryngectomy, a voice valve lets the majority speak again within weeks.
When is total laryngectomy needed?
When the tumor destroys the cartilage, spreads outside the larynx, leaves the larynx unable to protect the airway, or returns after radiotherapy.
How long will I stay in Istanbul?
Five to seven days for laser surgery, two to three weeks for laryngectomy.
Can my family come with me?
Yes, and their help matters.
References
Department of Veterans Affairs Laryngeal Cancer Study Group, Wolf GT, Fisher SG, et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. New England Journal of Medicine. 1991;324(24):1685-1690.
Forastiere AA, Zhang Q, Weber RS, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. Journal of Clinical Oncology. 2013;31(7):845-852.
Hoffman HT, Porter K, Karnell LH, et al. Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Laryngoscope. 2006;116(9 Pt 2 Suppl 111):1-13.
Mo HL, Li J, Yang X, et al. Transoral laser microsurgery versus radiotherapy for T1 glottic carcinoma: a systematic review and meta-analysis. Lasers in Medical Science. 2017;32(2):461-467.
Vaculik MF, MacKay CA, Taylor SM, et al. Systematic review and meta-analysis of T1 glottic cancer outcomes comparing CO2 transoral laser microsurgery and radiotherapy. Journal of Otolaryngology Head and Neck Surgery. 2019;48(1):44.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Prof. Dr. Ahmet BELCE, Biochemistry.
