Stage IV Throat Cancer: Prognosis and Treatment Options - Otolaryngology

Dr. Ye Dawei reply Otolaryngology

---

1.
Radiation therapy + chemotherapy
2.
It has metastasized.

3.
Laryngeal cancer can be detected early.
The larynx is the human organ for voice production, composed of hard tissue, cartilage, and soft tissue, located at the upper end of the trachea.
The main functions of the larynx are threefold: breathing, swallowing, and phonation.
In Taiwan, approximately 500 people are diagnosed with laryngeal cancer each year, making it the 1st to 5th most common cancer.
The most affected age group is between 40 to 60 years, with a predominance in males.
The most likely causes of laryngeal cancer are habitual smoking and alcohol consumption.
Additionally, frequent exposure to certain carcinogens may also lead to this disease; however, laryngeal cancer is a type of cancer that can be detected early.
Typically, stage I and II laryngeal cancers can not only be cured but also allow the majority of patients to retain all functions of the larynx.
Symptoms of laryngeal cancer include persistent hoarseness, which may be an early sign.
Difficulty breathing, pain, and difficulty swallowing may occur if the tumor invades the esophagus, affecting the base of the tongue or pharyngeal tissues, with pain potentially radiating to the same side of the ear.
Neck lumps are caused by cancer cells metastasizing to the cervical lymph nodes.
Laryngeal cancer and supraglottic cancer are more likely to metastasize to the neck, while subglottic cancer is less common.
Coughing up blood-stained sputum is due to ulceration, erosion, and inflammation of the tumor tissue, leading to increased secretions that become trapped in the trachea and pharynx.

Classification of laryngeal cancer: The assessment of tumor size and location before treatment significantly impacts the treatment approach and prognosis for patients.
Generally, laryngeal cancer can be classified into glottic cancer, supraglottic cancer, and subglottic cancer, with glottic cancer being the most common, accounting for over half of cases and being the easiest to detect early.
Supraglottic cancer follows, while subglottic cancer is rare.
The cure rate for laryngeal cancer is very high; if the tumor is located in the supraglottic area, hoarseness will appear early.
Generally, early-stage laryngeal cancer patients have an 80% chance of cure, while the cure rate for later stages drops to around 50%.

Examination of laryngeal cancer: For the examination of laryngeal cancer, indirect laryngoscopy is commonly used in outpatient settings.
This involves the physician inserting a small mirror with a long handle into the mouth, allowing visualization of the tumor's location and size in the throat through reflection.
If visualization is difficult, a flexible fiberoptic scope can provide clearer images with minimal discomfort.
However, a definitive diagnosis requires a microlaryngoscopy performed under general anesthesia in the operating room, where suspicious tumor tissue can be biopsied and sent to the pathology department for examination.

Radiation therapy: The main treatment methods for laryngeal cancer are radiation therapy and surgical treatment.
Generally, if the tumor is still small and has not caused fixation of one vocal cord, surgery or radiation therapy can be performed.
The greatest advantage of radiation therapy is its ability to preserve laryngeal function, with survival rates comparable to surgical treatment.
Therefore, radiation therapy is typically performed first, and if treatment fails or recurs, surgical intervention is considered.
Radiation therapy involves using a specific energy level of radiation to target the affected area, destroying tumor tissue while causing minimal damage to surrounding normal cells.
During treatment, side effects may include dry skin, redness, nausea, vomiting, and fatigue; however, with proper nutrition and adequate rest, recovery can be swift.

Surgical treatment: For advanced laryngeal cancer, if vocal cord fixation has occurred and cartilage is invaded, surgical treatment or combined radiation therapy is necessary.
In some cases, partial laryngectomy may suffice to preserve laryngeal function, but most advanced laryngeal cancers require total laryngectomy, which involves removing the entire larynx.
This procedure disconnects the airway between the oropharynx and trachea, preventing air from entering and exiting the lungs.
To address breathing issues, a stoma is created in the lower neck, connecting the trachea to the neck opening, allowing air to flow directly into the lungs.
This opening is called a tracheostomy.
After surgery, drainage tubes are placed on either side of the wound for about three to four days, and they can be removed once the daily drainage is less than 10 cc.
However, patients must temporarily receive nutrition via a nasogastric tube for ten days before resuming normal eating, while breathing and coughing must occur through the tracheostomy.

Combined radiation and surgical treatment: In early-stage glottic cancer, there are few lymphatic vessels on the vocal cords, resulting in minimal cervical lymphatic metastasis.
However, supraglottic and subglottic cancers have abundant lymphatics, leading to rapid lymphatic spread.
Besides total laryngectomy, patients may have a chance of recovery.
For advanced patients with greater tumor depth, in addition to total laryngectomy, cervical lymphadenectomy or hypopharyngectomy, preoperative or postoperative radiation therapy is also needed for better treatment outcomes.

How to speak after laryngectomy? Speaking is the primary way humans express emotions.
Patients who require total laryngectomy often fear losing their vocal cords and being unable to speak, leading them to refuse surgery and delay treatment opportunities.
In recent years, advancements in technology and surgical techniques have gradually overcome the challenges of post-operative speech loss.
As long as patients are mentally alert and follow the guidance of speech therapists, they can fluently resume speaking.

There are generally three methods: The first method involves using various techniques to inject air into the upper esophagus.
As the air is expelled, it passes through the esophagus and pharynx, causing muscle contractions in that area, vibrating the mucosa and air column to produce low-pitched sounds, known as esophageal speech.
By mimicking normal speaking mouth movements, patients can produce esophageal speech.
Typically, patients can learn to say three-word phrases within three months and speak fluently after ten months, although about half of patients may not succeed in training.

The second method involves using an artificial voice device, which can be utilized by nearly all patients.
For those learning esophageal speech, it can assist in voice production.
The main types include pneumatic artificial larynx and electronic artificial larynx.
With a few practice sessions and normal mouth movements, patients can begin to speak.

The third method involves the installation of a voice prosthesis to aid in phonation.
Before installation, the physician creates a small hole between the patient's trachea and esophageal wall.
After two days, the voice prosthesis is inserted and secured.
When speaking, the patient covers the tracheostomy, allowing air exhaled from the lungs to pass through the voice prosthesis into the esophagus and hypopharynx.
As the air is expelled, it causes muscle contractions in that area, vibrating the mucosa and air column to produce sound.
This method of tracheoesophageal speech is learned quickly, with a louder volume than traditional esophageal speech and longer sentences.
However, it must be removed and cleaned daily, and a backup tube should be immediately inserted into the hole during removal to prevent rapid narrowing.

Returning to normal life: Most patients who have undergone total laryngectomy may initially struggle to adapt to changes in breathing and speaking methods, leading to psychological barriers and feelings of depression and anxiety.
However, with the support of family and healthcare professionals, most patients can return to work, resume normal outdoor activities, and reintegrate into social life.
Participation in "laryngectomee clubs" for regular meetings, where physicians, speech therapists, and nursing staff share the latest healthcare knowledge and conduct follow-up examinations, can help patients realize they are not alone and connect with others facing similar challenges, allowing for the exchange of life experiences.

Director of the Department of Otolaryngology, Dr.
Yeh Da-Wei.

---

Reply Date: 2007/08/01