Laryngeal cancer: an overview for singing teachers.
Singing teachers need to be aware of the many health issues that potentially affect their students. Laryngeal cancer, though fortunately rare, can have a significant impact on voice. Laryngeal cancer accounts for only 1% of new cancer diagnoses in the United States, (1) but it can have profound effects on those who use their voices in a professional capacity. Early identification and intervention are crucial for effective voice preservation as well as overall survival. The singing teacher should be familiar with this disease process and be equipped to identify those most at risk so that early referral and knowledgeable support can be provided to singers who look to their teachers for answers.
The larynx has three main subdivisions: the supraglottis (above the vocal folds), the glottis (the vocal folds themselves), and the subglottis (below the vocal folds). The supraglottis extends from the tip of the epiglottis (the leaf- like cartilage that prevents food from entering the airway) to the apex of the ventricles (spaces between the false and true vocal folds) just above the vocal folds (Figure 1). It includes structures such as the epiglottis, aryepiglottic folds, arytenoid cartilages, false vocal folds, and ventricles.
The glottis extends from the ventricle to about 0.5-1 centimeter inferior to the free margin of the vocal folds. Glottic cancers of the larynx arise more commonly in the front half of the vocal folds and can invade backward, occasionally involving surrounding structures. Invasion of the vocalis (medial thyroarytenoid) muscle and cricoarytenoid joints can occur with deep and posterior spread, respectively. These types of invasion can lead to changes in voice quality by limiting movement of the vocal folds in addition to the more apparent effect on mucosal wave propagation. (2)
The subglottis begins one centimeter inferior to the free edge of the vocal fold. It spans the lumen of the cricoid cartilage and ends at the beginning of the trachea. Subglottic laryngeal cancers usually occur from direct extension of glottic lesions and can invade surrounding structures, causing significant breathing and voice problems.
Laryngeal cancer represents a change in cellular structure of the normal lining of the larynx. Progression usually occurs over time as a result of chronic irritants or risk factors. Nearly all laryngeal cancers are squamous cell carcinoma; however, adenocarcinoma, minor salivary gland tumors, carcinoid (or serotonin-producing) tumor, oat cell carcinoma, and undifferentiated carcinoma have also been described in the larynx. (3)
Laryngeal cancer affects an estimated 3.4 out of 100,000 individuals, has a male predominance, and usually occurs later in life, with almost 60% of cases occurring between the ages of 55 and 75. The incidence of and mortality from laryngeal cancer have decreased significantly over the past 10-15 years, likely as a result of increased awareness of risk factors and more rapid diagnosis. (4) Risk factors include smoking, alcohol, human papilloma virus infection, laryngopharyngeal reflux, and radiation exposure, among others (Table 1). The single most significant and preventable risk factor in the development of laryngeal cancer is smoking, which is associated with almost 95% of supraglottic and glottic cancer. A linear association exists between the number of cigarettes used and the risk of developing cancer. (5) The concurrent usage of tobacco and alcohol has a synergistic effect on the risk of developing laryngeal cancer.
While smoking and alcohol represent the two most important risk factors in the development of laryngeal cancer, infectious, inflammatory, and caustic factors also can play a role. Human papilloma virus, or HPV, is a well established cause of cervical cancer and has been linked to cancers of the oral cavity, oropharynx, and larynx. HPV interferes with DNA repair and programmed death of damaged cells. HPV's role in laryngeal cancer is still under investigation, but abundant evidence of HPV has been found in laryngeal specimens, especially in those without other more commonplace risk factors (namely tobacco and alcohol usage).
Laryngopharyngeal reflux disease, or LPR, is defined as the backflow of gastric contents out of the esophagus and into the larynx and pharynx. Because the larynx is extremely sensitive to changes in pH, repeated exposure to chemicals from the stomach leads to chronic irritation and, consequently, is thought to cause changes in the laryngeal mucosa that may progress to cancer. Although the exact role of LPR in the development of laryngeal cancer requires further study, enough evidence exists to suggest a link between the two entities. (6)
SIGNS AND SYMPTOMS
Regardless of location in the body of a cancer, local and nonspecific, systemic manifestations of malignancy may be present. Systemic or constitutional symptoms include fevers, chills, night sweats, and unexplained weight loss. Any of these symptoms, especially if prolonged and in the absence of an obvious cause, necessitates evaluation by a health care provider.
Patients with laryngeal cancer also present usually with local symptoms and signs that vary depending on the site of tumor involvement. For instance, patients with glottic cancer will present early with persistent vocal complaints such as hoarseness, while in patients with supraglottic cancer hoarseness occurs later; more typically, supraglottic cancer presents with ear pain, airway obstruction, or a neck mass. It is critical that the singing teacher be able to identify key symptoms (subjective) and signs (objective) so that patients can receive timely referrals for diagnosis and treatment.
Supraglottic cancers usually present later than other types of laryngeal cancer because vital structures typically are not affected until the mass has grown fairly large. This early asymptomatic growth and consequent delay in diagnosis result in these patients presenting with more advanced tumors than cancers in other laryngeal subsites.
If, however, the patient is fortunate enough to have symptoms early in the disease course, he or she may experience the sensation that something is caught in the throat (referred to as globus), throat pain, trouble swallowing (dysphagia), or even trouble breathing (dyspnea). These symptoms are hardly unique to laryngeal cancer and can be caused by more benign processes. Evaluation by an expert laryngologist can determine the cause of the symptoms quickly in most patients.
Later presentations of supraglottic carcinoma include airway obstruction, swallowing difficulties, severe throat pain, bloody secretions after coughing or vomiting, neck masses, and ear pain. The relatively large amount of space above the larynx allows tumors to grow to a fairly large size before patients become symptomatic. Tumor tissue can be brittle with a fragile blood supply leading to bleeding with even minimal trauma (e.g., coughing). Neck masses may represent the spread of tumor from the initial site of growth to the local lymphatics, or drainage pathways, a sign of advanced disease. One-sided ear pain, or otalgia, is an often unrecognized symptom of supraglottic cancer that is also often a sign of advanced disease. Persistent ear pain (>1-2 weeks) should trigger prompt referral for evaluation by an ear, nose and throat physician.
Cancer of the vocal folds themselves usually presents early due to the significant impact on the voice. Hoarseness is the predominant presenting symptom. Generally, any voice change that lasts over two weeks needs to be evaluated by an otolaryngologist. Other presenting symptoms of glottic cancer are aspiration, difficult or painful swallowing, breathing difficulties or noises, and persistent sore throat.
Subglottic cancers usually present with noisy breathing known as stridor. This noise varies from sounds like wheezing to those of wind passing through a narrow space. Stridor is caused by turbulent airflow due to an obstruction in its movement. In this case, the tumor prevents normal laminar airflow through the airway. This usually occurs on both inspiration and expiration, though it may be more prominent on one phase than the other. Other presenting symptoms of subglottic cancer include hoarseness (especially if it has spread to the glottis), bloody phlegm after coughing, persistent sore throat, and swallowing problems.
When signs and symptoms arise, patients often fail to recognize their significance. It is important to be perceptive and vigilant when it comes to both ourselves and those around us. When a singer displays symptoms out of the ordinary, especially in the presence of any of the risk factors discussed above, singing teachers should encourage a prompt otolaryngology evaluation to rule out a malignant process.
Seeing a physician for any medical problem can be anxiety provoking, but knowing what to tell singers to expect can help defuse some of that apprehension. The first step in the diagnosis of a laryngeal cancer is a thorough history and physical examination. Particularly important are the signs and symptoms described above. Additionally, information regarding smoking and alcohol use is exceptionally important, with special attention directed toward the duration and amount of consumption.
The physical examination of a patient with laryngeal cancer requires a comprehensive head and neck evaluation. The volume, quality, and range of the patient's voice will be noted by the physician, often concurrently with history gathering. When examining the head and neck, the nose and mouth are scrutinized as these are components of the airway and synchronous findings may clue the doctor into the etiology of the patient's problem. Meticulous examination of the patient's neck is performed looking for masses. Lymph nodes in the neck collect the cancerous cells and will enlarge, thus manifesting as a mass.
The location of the larynx within the neck requires special instrumentation for visualization. This process, called laryngoscopy, represents an essential part of the investigation that not only allows for visualization, but also can provide access for samples (biopsies) to be taken for microscopic pathological evaluation.
The first tool utilized for visualization of the larynx has been in use since 1854 when Manuel Garcia, a world renowned singing teacher, used a dental mirror to visualize his own vocal folds. (7) Mirror laryngoscopy is performed with the physician holding the tongue with one hand and an angled mirror placed in the back of the throat while phonating.
Laryngeal endoscopy has supplanted mirror laryngoscopy for laryngeal visualization due to superior optics and magnification. Laryngeal endoscopy can be performed either using a flexible tube carrying light or via a rigid telescope. Flexible laryngoscopy is performed transnasally (through the nose), effectively bypassing the gag reflex for many people. Rigid telescopes can also be placed transorally (through the mouth) with the physician firmly grasping the patient's tongue, much like the technique used in mirror laryngoscopy. Rigid laryngoscopy provides the most detailed picture, although sometimes not tolerated by those patients with an especially vigorous gag reflex.
Regardless of the method of visualization, the goal of laryngoscopy is to evaluate the larynx for any abnormalities. Typically with laryngeal cancer, irregularities may be subtle, such as color and texture changes, or more obvious, such as overt masses (Figure 2). When an irregularity concerning for cancer is detected, the next step is to obtain a sample to confirm or refute that suspicion. Biopsies can be performed either in the office during flexible laryngoscopy or in the operating room under local or general anesthesia. Samples are then examined carefully under a microscope by a pathologist who can render a diagnosis.
Once a cancer is confirmed on biopsy, the patient's cancer must be classified so that appropriate treatment can be prescribed. The TNM staging system is used for classifying cancers occurring all over the body. The "T" stands for tumor size. As seen in Table 2, the T stage escalates with tumors of increasing size and involvement of surrounding structures. The "N" represents degree of lymph node involvement and is based on their size, number, and distribution. Finally, "M" refers to metastasis and means disease has traveled beyond the confines of the initial, or primary, site, growing elsewhere in the body. Tumor staging is different for each laryngeal subsite, as is reflected in Table 2. (8)
To stage laryngeal cancer adequately, supplemental examinations are required, including radiographic and possibly interventional studies. Traditionally, computed tomography (CT) scans of the neck and chest have been used to evaluate for disease progression. Positron emission tomography (PET) is a study that reflects areas of abnormally increased metabolism in the body, a finding often indicative of malignancy. PET scans have been combined with CT scans recently to detect initial and recurrent laryngeal cancers more accurately. (9)
Historically, laryngeal tumors were all treated with surgical removal of most or all of the larynx, regardless of tumor size. Beginning in the 1970s, small laryngeal cancers were treated with radiation alone. In the 1990s, treatment regimens for larger cancer shifted with the application of concomitant chemotherapy and radiation protocols to laryngeal malignancy. These aptly named "organ-preservation" techniques had similar survival rates to surgery without the morbidity of life without a voice box. (10) More recently, advances in endoscopic, transoral (through the mouth) instrumentation and microsurgical techniques have allowed for surgical treatment of select tumors without external incisions or the risks associated with radiation.
The management of laryngeal cancers is dependent primarily on the staging of the tumor. Other factors such as patient age, overall health status, and personal preferences play important roles in the decision-making process. For example, an elderly patient with numerous comorbid conditions may not tolerate aggressive treatment as readily as a younger patient. Patients' treatment goals may vary and must also be considered when formulating a treatment plan. Also vital is the effect of tissue removal on normal function; although tumor eradication is paramount, one must account for the effect on the densely packed, critical structures within the larynx when considering surgical therapy. One must be aware that radiation also causes laryngeal injury and surgery may be a more effective long-term path to voice preservation in some cases.
A multidisciplinary approach to the treatment of laryngeal cancer is necessary to ensure each patient receives the most effective, individualized care available. The services of an otolaryngologist, radiation oncologist, speech pathologist, oncologist, radiologist, dietician, psychologist, nurse clinician, and others will be needed to ensure that all of the patient's needs are addressed during this difficult period. (11)
Early Laryngeal Cancer (Stage I and II)
Early laryngeal cancers (T1 and some T2 lesions) usually can be managed with single-modality treatment. Treatment options include either surgery or radiation. Many factors, particularly laryngeal subsite (i.e., how the patient will be affected after the affected structure is removed) and extent of disease, will determine which modality will be best for each individual. Early laryngeal cancers typically are treated with either primary external beam radiation or voice sparing surgery. This decision is also based on patient preference and the ease of removal via an endoscopic (transoral) approach. Both therapies have equal success in disease eradication and possibly voice preservation. (12) Although good research is lacking, transoral laser microsurgery has become a viable option allowing patients to reserve radiotherapy for surgical failure. (13) Surgery, although not without its own shortcomings, can prevent the unfortunate complications associated with radiation. These complications include mucositis, dysphagia, radionecrosis (breakdown of normal structures from radiation), and the potential for inducing cancer in surrounding areas (e.g., papillary thyroid cancer).
Advanced Laryngeal Cancer (Stage III and IV)
As mentioned, advanced laryngeal cancer is treated typically with organ preserving chemoradiotherapy or wide surgical resection. In most cases, well studied chemotherapy and radiotherapy protocols can be applied allowing the cancer to be treated without the need for radical surgery. In cases of stage IV laryngeal cancer, those with expected poor functional outcomes or with exceptionally bulky tumors, removal of the entire larynx (total laryngectomy) remains the treatment of choice. (14) Postoperative chemoradiotherapy usually is needed as well to allow for optimal cancer control. Radiation alone can be considered in patients who are unable to tolerate chemotherapy, as accelerated protocols can yield adequate result without the added side effects of chemotherapy.
In summary, laryngeal cancer represents an uncommon but significant disease. Patients with laryngeal cancer may present with seemingly pedestrian complaints such as hoarseness, globus, or ear pain. As professionals with frequent interaction with singers and other performers, singing teachers should be equipped with the knowledge necessary to identify those at risk and know how to counsel those in need of guidance. Early detection and treatment are vital for voice preservation and survival, and it is the responsibility of each of us to ensure that every singer has that opportunity.
(1.) L. A. G. Ries, M. P. Eisner, P. Kosary, and B. Hankey, "SEER Cancer Statistics Review, 1973-1998" (National Cancer Institute 2001).
(2.) N. R. Vasan, "Cancer of the Larynx, Paranasal Sinuses, and Temporal Bone," in K. J. Lee, ed., Essential Otolaryngology (New York: McGraw Hill, 2008), 676-707.
(4.) N. Howlader et al., "SEER Cancer Statistics Review, 1975-2008 (National Cancer Institute, 2011); http://seer.cancer. gov/csr/1975_2008/results_merged/sect_12_larynx.pdf (accessed July 20, 2011).
(5.) K. Rothman, C. Cann, D. Flanders, and M. Fried, "Epidemiology of Laryngeal Cancer," Epidemiology Reviews 2, no. 1 (1980): 195-209.
(6.) R. T. Sataloff, M. J. Hawkshaw, and R. Gupta, "Laryngo-pharyngeal Reflux and Voice Disorders: An Overview on Disease Mechanisms, Treatments, and Research Advances," Discovery Medicine 10, no. 52 (September 2010): 213-224.
(7.) H. von Leden, "A Cultural History of the Larynx and Voice," in R. T. Sataloff, ed., Professional Voice: The Science and Art of Clinical Care, 3rd ed. (San Diego: Plural Publishing, 2005).
(8.) "Larynx," in S. Edge, C. Byrd, and C. Compton, eds., AJCC Cancer Staging Manual, 7th ed. (New York: Springer, 2010), 57-62.
(9.) E. A. Chu and Y. J. Kim, "Laryngeal Cancer: Diagnosis and Preoperative Work-Up," Otolaryngologic Clinics of North America 41, no. 4 (August 2008): 673-695; A. Gordin et al., "The Role of FDG-PET/CT Imaging in Head and Neck Malignant Conditions: Impact on Diagnostic Accuracy and Patient Care," Otolaryngology--Head & Neck Surgery 137, no. 1 (July 2007): 130-137; R. M. Alvarez Perez et al., "Evaluation of Efficacy and Clinical Impact of Positron Emission Tomography with 18F Fluorodeoxyglucose (FDG) in Patients with Suspicion of Recurrent Laryngeal Carcinoma," Acta Otorinolaringologica Espanola 57, no. 3 (2006): 134-139.
(10.) [no authors listed], "Induction Chemotherapy Plus Radiation Compared with Surgery Plus Radiation in Patients with Advanced Laryngeal Cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group," New England Journal of Medicine 324, no. 24 (June 1991): 1685-1690.
(12.) K. M. Higgins, "What Treatment for Early-Stage Glottic Carcinoma among Adult Patients: CO2 Endolaryngeal Laser Excision versus Standard Fractionated External Beam Radiation is Superior in Terms of Cost Utility?" Laryngoscope 121, no. 1 (January 2011): 116-134.
(13.) M. Quer, X. Leon, and C. Orus, "Endoscopic Laser Surgery in the Treatment of Radiation Failure of Early Laryngeal Carcinoma," Head and Neck 22, no. 5 (August 2000): 520-523.
(14.) NCCN Practice Guidelines in Oncology--v.2.2011--Head and Neck Cancers. National Comprehensive Cancer Network; http://www.nccn.org/professionals/physician-gls/ pdf/head-and-neck.pdf (accessed July 31, 2011).
Joel E. Portnoy, MD was a fellow In the study of Laryngology and Care of the Professional Voice under Dr. Robert Thayer Sataloff. He Is an instructor on the faculty at the Drexel University College of Medicine In the Department of Otolaryngology--Head and Neck Surgery. He holds an undergraduate Bachelor of Science degree in Biology from the State University of New York at Binghamton where he graduated magna cum laude. He obtained his medical degree and completed his residency in Otolaryngology--Head and Neck Surgery at the State University of New York at Upstate Medical University in Syracuse. He has also been elected to the medical honor society, Alpha Omega Alpha. Though never formally trained, music has played an integral role in his upbringing; he has experience as a singer, guitar and orchestral string player, performing primarily in amateur and semiprofessional settings. He has aspirations of becoming a prominent laryngologist and applying his passion for music to his desire to help those in need. He hopes to continue to be an important contributor to the advancement of medical knowledge in addition to already achieving goals of becoming a loving husband and father.
Sameep Kadakia, BS is currently a fourth-year medical student who graduated from Drexel University College of Medicine in May 2012. He completed a Bachelor of Science degree at Drexel University. Growing up, he was not only raised in a family with a deep passion for music, but also went through training in Indian classical music for a number of years. His interest in music and time spent with Dr. Sataloff has driven his desire to study care of the professional voice. He is currently applying for a residency in Otolaryngology--Head and Neck Surgery.
Mary J. Hawkshaw, B.S.N., R.N., CORLN is Research Associate Professor in the Department of Otolaryngology--Head and Neck Surgery at Drexel University College of Medicine. She has been associated with Dr. Robert Sataloff, Philadelphia Ear, Nose & Throat Associates and the American Institute for Voice & Ear Research (AIVER) since 1986. She has served as Secretary/Treasurer of AIVER since 1988 and was named Executive Director of AIVER in January 2000. She has served on the Board of Directors of the Voice Foundation since 1990. Ms. Hawkshaw graduated from Shadyside Hospital School of Nursing in Pittsburgh, Pennsylvania and received a Bachelor of Science degree in Nursing from Thomas Jefferson University in Philadelphia. In collaboration with Dr. Sataloff, she has coauthored more than 65 book chapters, 160 articles, and 7 textbooks. She is on the Editorial Boards of the Journal of Voice and Ear, Nose and Throat Journal. She has been an active member of the Society of Otorhinolaryngology and Head--Neck Nurses since 1998. She is recognized nationally and internationally for her extensive contributions to care of the professional voice.
Robert T. Sataloff, MD, DMA is Professor and Chairman of the Department of Otolaryngology--Head and Neck Surgery and Senior Associate Dean for Clinical Academic Specialties at Drexel University College of Medicine. He is also on the faculty at Thomas Jefferson University, the University of Pennsylvania, Temple University, and the Academy of Vocal Arts. Dr. Sataloff was conductor of the Thomas Jefferson University Choir and Orchestra for nearly four decades. He is director of The Voice Foundation's annual symposium on Care of the Professional Voice. Dr. Sataloff is also a professional singer and singing teacher. He holds an undergraduate degree from Haverford College in Music Composition, graduated from Jefferson Medical College, received a DMA in Voice Performance from Combs College of Music, and completed his Residency in Otolaryngology--Head and Neck Surgery at the University of Michigan. He also completed a Fellowship in Otology, Neurotology, and Skull Base Surgery at the University of Michigan. Dr. Sataloff is Chairman of the Board of Directors of The Voice Foundation and of the American Institute for Voice and Ear Research. He is Editor-in-Chief of the Journal of Voice, Editor-in-Chief of the Ear, Nose and Throat Journal, an Associate Editor of the Journal of Singing, and on the Editorial Board of Medical Problems of Performing Artists and numerous major otolaryngology journals in the United States. Dr. Sataloff has written over 750 publications, including thirty-nine books. Dr. Sataloff's medical practice is limited to care of the professional voice and to otology/neurotology/ skull base surgery.
TABLE 1. Epidemiology of laryngeal cancer. Laryngeal Cancer Quick Reference Epidemiology Incidence 3.4 per 100,000 people Gender Men more than women Most common age range 60% between ages 55-75 Risk Factors Smoking Alcohol Human papillomavirus Reflux disease Radiation exposure Signs and Symptoms Chronic hoarseness Persistent ear pain Persistent neck mass Shortness of breath (feeling from the neck) Persistent swallowing difficulties Globus (foreign body sensation in the throat) Stridor (noisy breathing) Blood phlegm after coughing Persistent sore throat Unexplained fevers, night sweats, chills, and/or weight loss Treatment Surgery Radiation Chemotherapy Multimodality (combination of above) TABLE 2. American Joint Committee on Cancer (AJCC) TNM Staging System for the Larynx (7th ed., 2010). * Primary Tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ Supraglottis T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx T3 Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/ or inner cortex of thyroid cartilage T4a Moderately advanced local disease Tumor invades through the thyroid cartilage and/ or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) T4b Very advanced local disease Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Regional Lymph Nodes (N) ** NX Regional lymph nodes cannot be assessed N0; no regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N2a Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3 Metastasis in a lymph node, more than 6 cm in greatest dimension Glottis T1 Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility T1a Tumor limited to one vocal cord T1b Tumor involves both vocal cords T2 Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space, and/or inner cortex of the thyroid cartilage T4a Moderately advanced local disease Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) T4b Very advanced local disease Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Subglottis T1 Tumor limited to the subglottis T2 Tumor extends to vocal cord(s) with normal or impaired mobility T3 Tumor limited to larynx with vocal cord fixation T4a Moderately advanced local disease Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) T4b Very advanced local disease Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures. * Laryngeal cancer staging [adapted from AJCC Cancer Staging Manual, 7th edition (New York, NY: Springer, 2010), 57-62]. ** Note: Metastasis at level VII are considered regional lymph node metastases. Distant Metastasis (M) M0 No distant metastasis M1 Distant metastasis Anatomic Stage/Prognostic Groups Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T3 N0 M0 T1 N1 M0 T2 N1 M0 T3 N1 M0 Stage IVA T4a N0 M0 T4a N1 M0 T1 N2 M0 T2 N2 M0 T3 N2 M0 T4a N2 M0 Stage IVB T4b Any N M0 Any T N3 M0 Stage IVC Any T Any N M1
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|Title Annotation:||CARE OF THE PROFESSIONAL VOICE|
|Author:||Sataloff, Robert T.; Portnoy, Joel E.; Kadakia, Sameep; Hawkshaw, Mary J.|
|Publication:||Journal of Singing|
|Date:||Sep 1, 2013|
|Next Article:||Some reflections on speech-like singing and related contemporary approaches.|