Treatment of Laryngeal Atypia and Early Cancer

Key Glossary Terms

Vocal Fold Atypia
Non-cancerous but irregular cells in vocal fold epithelium; often leads to cancer; often recurs after removal

Vocal Fold Early Cancer
Cancer of vocal fold epithelium that is confined to the vocal folds and has not spread

Vocal Fold Epithelium
Surface lining of vocal folds composed of squamous cells

Glossary

The overall management of atypia and early cancer is similar, each requiring the precise removal of all or part of the involved vocal fold tissue for microscopic examination [excisional biopsy]. Often the entire lesion is removed during excisional biopsy. If the entire lesion is removed – with an edge of normal tissue surrounding the abnormal tissue – no further treatment (chemotherapy or radiation therapy) is necessary.

Key Information

Voice Preservation and Cancer Treatment Possible

Unlike cancers in most other parts of the body, early vocal fold cancers do not always require removal of a significant amount of normal tissue when surgically treating lesions. Excision of the early cancer and preservation of normal tissue result in better voice outcomes.

90 to 95 Percent Cure Rate for Early-Stage Cancer

Early diagnosis and complete excision result in excellent cure rates.

After excision of a lesion, a microscopic analysis of the lesion's cell features will be performed to determine:

• Whether or not the lesion is cancerous
• Whether or not the resection successfully removed the entire lesion along with a non-cancerous surrounding margin

• General rule for surgical excision: As a general rule, any vocal fold lesion that has not penetrated through the basement membrane of the vocal fold epithelium is treated via surgical excision. By definition, atypia never invades lower than this point, although cancer may.
• Normal vocal fold "untouched" in surgical excision: Surgical excision may result in a better vocal outcome than radiation therapy (XRT) because the normal vocal fold is not touched in surgical excision, while both vocal folds are affected in radiation therapy.
• Radiation therapy is single-use: Use of radiation therapy in the treatment of early cancer may be undesirable, since XRT is a single-use cancer treatment and would be considered unnecessary for minimal microscopic disease. The excisional biopsy that is necessary to establish the diagnosis may be adequate treatment for a small lesion.

Key Information

• Treatment for vocal fold early cancer must be individualized.
• Decisions regarding the use of radiation therapy or surgery will depend upon the nature of the lesion (size, depth, location), a patient's vocal needs, the experience of the surgeon and radiation therapist, and other pertinent medical factors.

Both radiation therapy and phonomicrosurgical excision can cause a number of complications. Patients should discuss treatment and possible complications of treatment with their physician.

Complication	What Happens	Why It Occurs	Treatment
Hemorrhage	Bleeding; coughing up blood	Re-bleeding after surgery	If uncontrolled, need for surgical intervention
Airway obstruction	Blocked airway causing breathing difficulties	Can result from swelling, although rare	Establish temporary airway Remove excess tissue causing the blocked airway
Granuloma formation (For more information, see Vocal Fold Granuloma)	Inflammation-response growths on vocal folds over irritated areas	Usually occurs with reflux	Anti-reflux therapy Voice rest Surgical excision when necessary
Vocal fold scarring	Scar tissue formation in vocal folds	Scar-response to surgical excision	No definitive treatment at present
Excess hoarseness and dysphonia	Voice symptoms greater than expected after surgery	Lack of breath support, aerodynamic inefficiency	Voice therapy Medialization procedures

Radiation therapy can cause side effects and complications that affect voice outcomes. The area affected by XRT side effects or complications is larger than that affected by phonomicrosurgery because XRT treatment affects a broader area and does not distinguish between normal and cancerous cells. Current efforts increasingly try to target XRT to the cancerous lesion.

Complication	What Happens	Why It Occurs	Treatment
Fibrosis of the normal vocal fold epithelium	Fibrous tissue formation, resulting in loss of vocal fold pliability	Radiation therapy does not distinguish between normal and cancerous areas; also results from injury and inflammation	If reflux present, anti-reflux treatment
Vocal fold dryness (laryngitis sicca), which produces hoarseness	Dry mucous membranes, decreasing ability of vocal folds to vibrate	Destruction of mucous glands from radiation, which affects both cancer cells and normal cells	No reliable, definitive treatment at present

Rare	Very Rare
Chondroradionecrosis of the thyroid cartilage Arytenoid fixation Note: Both complications can drastically limit vocal fold function, impairing voice	Additional primary cancers over a period of years

• Anti-reflux therapy: After surgery, treatment for backflow of stomach fluids to the voice box area (laryngopharyngeal reflux) will be provided, since reflux frequently occurs post-surgery. The exposure of "raw" surgical wounds within the larynx to acidic stomach fluids that have backflowed to the area could significantly hamper healing and recovery and increase risk for complications. (For more information, see Reflux Laryngitis.)
• Antibiotics: As with most surgical procedures, preventive antibiotic treatment may be provided to minimize the risk of post-surgical infections.
• Analgesics: Reduction of pain after surgery helps recovery to proceed as quickly and painlessly as possible.
• Voice rest: Complete voice rest is usually advised for about two weeks, with modified voice use advised for two additional weeks, in order to optimize healing and the recovery of voice function.
• Voice therapy: Often, both preoperative and postoperative voice therapy are recommended to help patients recuperate from surgery and rehabilitate voice after surgery. (For more information, see Voice Therapy.)

Red Flag

Atypia Frequently Recurs

• Although removal of atypia typically precludes the later development of cancer, atypical epithelium frequently recurs and requires repeat endoscopic excisions.
• New phonosurgical developments in resection and reconstruction have facilitated improved voice outcomes despite repeated surgical removal of atypia.

Once the voice box has healed from removal of the lesion, vocal fold reconstruction can be done if/when necessary. Vocal fold reconstruction may involve medialization to help bring the vocal edge(s) to the middle, resulting in better glottic closure and allowing vocal fold vibration during sound production.

For both atypia and early cancer, follow-up monitoring after surgery is important to detect whether atypia has recurred (as it frequently does) or whether another primary cancer lesion has developed. Since a cancerous lesion poses more of a health risk than atypia, follow-up schedules for cancer are usually more rigorous.

The table below highlights a typical follow-up schedule for patients whose lesions have been successfully removed. This timeline can be varied depending on the specific clinical characteristics and needs of an individual patient.