Squamous Cell Carcinoma of the Larynx: Understanding Your Pathology Report

Section Editor: Jason Wasserman MD PhD FRCPC
July 26, 2026

Squamous cell carcinoma is the most common type of cancer of the larynx, also known as the voice box. The larynx sits in the neck and is essential for breathing, swallowing, and speaking. It starts in squamous cells, the flat cells that line the inner surface of the larynx.

The larynx is divided into three regions, and which one the cancer starts in matters a great deal, because it affects symptoms, treatment, and outlook:

Supraglottis. The upper part, above the vocal cords, including the epiglottis (the flap that keeps food out of the airway).
Glottis. The middle part, containing the vocal cords themselves.
Subglottis. The lower part, from below the vocal cords down to the top of the windpipe.

Cancers of the glottis are often found early, because even a small tumor on a vocal cord causes hoarseness. Cancers of the supraglottis and subglottis tend to grow larger before causing symptoms, so they are more often found at a later stage.

This article explains the findings you are likely to see on a pathology report for squamous cell carcinoma of the larynx, what each one means, and why it matters for your care.

What causes squamous cell carcinoma of the larynx?

Squamous cell carcinoma of the larynx develops when the squamous cells lining the larynx are damaged repeatedly over many years. Each round of damage and repair leaves small errors in the cells’ genetic material, and once enough build up, the cells begin to grow without normal control. The main causes are:

Tobacco. The single most important risk factor, in any form.
Alcohol. Heavy use raises risk on its own, and combining heavy drinking with smoking raises it far more than either alone.
Workplace exposures. Long-term exposure to asbestos, wood dust, paint fumes, or similar substances.
Previous radiation to the neck. Radiation given years earlier for another condition can raise the risk of a cancer developing in the treated area.

These same exposures also cause keratinizing squamous dysplasia of the larynx, a precancerous change that can develop into invasive cancer over time.

Unlike cancers of the oropharynx (the tonsils and base of the tongue), most squamous cell carcinomas of the larynx are not caused by human papillomavirus (HPV). For this reason, HPV and p16 testing are not routinely performed on laryngeal tumors, and you should not expect to see those results on your report.

What are the symptoms of squamous cell carcinoma of the larynx?

The symptoms of squamous cell carcinoma of the larynx depend on which part of the voice box is affected and how far the tumor has grown. Common symptoms include:

Hoarseness or a change in the voice lasting more than two weeks, often the earliest sign of a cancer on the vocal cords
A lump or a feeling of fullness in the throat
Difficulty or pain with swallowing
Ear pain on one side that is not caused by an ear infection
Shortness of breath or noisy breathing if the tumor narrows the airway
A lasting cough, or coughing up blood
Unexplained weight loss or tiredness
A lump in the neck, which may mean the cancer has spread to a lymph node

Any lasting change in voice or swallowing should be assessed by an ear, nose, and throat specialist.

How is the diagnosis made?

The diagnosis of squamous cell carcinoma of the larynx is made when a pathologist examines a tissue sample under the microscope. The sample is obtained by biopsy during a procedure called microlaryngoscopy, in which a thin scope is passed through the mouth under general anesthetic so the surgeon can see the vocal cords directly and take samples from any abnormal areas.

Under the microscope, the pathologist looks for squamous cells that have broken through the epithelium, the surface lining, and grown into the tissue beneath. The biopsy confirms the diagnosis and usually gives an idea of the grade, but features such as cartilage invasion, the full size of the tumor, and the margins can only be assessed accurately after the whole tumor has been removed. Once cancer is confirmed, imaging such as a CT scan or MRI of the neck, and PET-CT for more advanced disease, shows how far the tumor extends and whether lymph nodes are involved.

Histologic grade

The grade describes how closely the cancer cells still resemble normal squamous cells and how much keratin they produce. Keratin is a tough protein that normal squamous cells make. Your report will use one of these terms:

Well differentiated. The cells closely resemble normal squamous cells and produce abundant keratin. These tumors tend to grow more slowly.
Moderately differentiated. The cells vary more in size and shape and produce less keratin.
Poorly differentiated. The cells look very different from normal squamous cells and produce little or no keratin. These tumors tend to grow more quickly and spread more readily.

Most laryngeal squamous cell carcinomas are well or moderately differentiated. Grade is one of the findings your treatment team considers, but it is a weaker predictor than the stage of the cancer, the margins, and whether lymph nodes contain cancer.

Tumor extension into nearby structures

Your report will describe how far the cancer has grown from where it started. Squamous cell carcinoma of the larynx begins in the surface lining and, as it grows, can reach progressively deeper structures: first the soft tissue beneath the lining, then the cartilage that forms the framework of the voice box (the thyroid cartilage at the front and the ring-shaped cricoid cartilage below it), and eventually beyond the larynx into the thyroid gland, the esophagus, or the soft tissues of the neck.

Growth through cartilage or beyond the larynx raises the tumor stage and generally means a larger operation. Your report or your surgeon will also describe whether the vocal cords still move normally. A vocal cord that has stopped moving, described as fixed, indicates the tumor has grown into the muscles that move the cord, and this raises the stage even when the cartilage is not involved.

Perineural invasion

Perineural invasion means cancer cells are growing along or around a nerve. Nerves provide a path that cancer cells can follow beyond the visible edge of the tumor. Your report will state whether perineural invasion is present or absent. When present, it is associated with a higher chance of the cancer returning at the original site, and it is one of the findings the treatment team weighs when considering radiation after surgery.

Lymphovascular invasion

Lymphovascular invasion means cancer cells have entered a small blood vessel or lymphatic channel near the tumor. These vessels can carry cancer cells to the lymph nodes or, less often, to distant organs. Your report will state whether it is present or absent. When present, it points to a higher chance that cancer cells have reached the lymph nodes.

Surgical margins

Margins are the cut edges of the tissue removed during surgery. The pathologist inks these edges and examines how close the tumor comes to each one.

Negative (clear) margin. No cancer cells at the inked edge. This suggests the tumor was removed completely.
Close margin. Cancer cells come within a few millimeters of the edge without reaching it. This raises the chance of the cancer returning at the same site.
Positive (involved) margin. Cancer reaches the inked edge, meaning some may remain. This is one of the main reasons the treatment team considers further surgery or radiation.

Margins in the larynx are reported separately by location, because each is approached differently by the surgeon. These include the mucosal margins at the surface lining, the deep soft tissue margin at the deepest part of the removed tissue, and, when cartilage has been removed, the cartilage margin.

Lymph nodes

Lymph nodes are small immune organs that filter fluid draining from the tissues. The larynx drains to lymph nodes on both sides of the neck, so a neck dissection to remove a group of these nodes is often performed as part of surgery. How likely the cancer is to have reached them depends partly on where it started: the supraglottis has a rich network of lymphatic channels and spreads to nodes relatively often, while the vocal cords themselves have very few, so early glottic cancers rarely spread to lymph nodes.

The pathologist examines each node and reports:

How many lymph nodes were examined and how many contained cancer. Usually written as a ratio, such as 2 of 26. The risk of recurrence rises with the number of involved nodes.
The size of the largest deposit of cancer. Measured in millimeters.
Extranodal extension. This means cancer cells have broken through the outer capsule of a lymph node into the surrounding tissue. It is one of the most important adverse findings on the report and is among the findings most likely to lead the treatment team to recommend chemotherapy given together with radiation after surgery.

If no cancer is found in any lymph node, your report will say so. This is a favorable finding.

PD-L1

PD-L1 is a protein that some cancer cells display on their surface to avoid being attacked by the immune system. Immunotherapy drugs called checkpoint inhibitors, such as pembrolizumab (Keytruda) and nivolumab (Opdivo), block this signal so the immune system can recognize and attack the cancer.

PD-L1 testing is not needed to make the diagnosis. It is generally performed when the cancer cannot be removed by surgery, has returned after treatment, or has spread to distant parts of the body. The result is reported as a Combined Positive Score, or CPS, a number that reflects how many cells in and around the tumor show PD-L1. A CPS of less than 1 is considered negative. A CPS of 1 or higher is considered positive and means immunotherapy may be an option, and a higher score suggests the cancer is more likely to respond. Your report will give the specific number. You can read more in the article on PD-L1 testing in cancer.

Pathologic stage (pTNM)

The pathologic stage describes how far the cancer has spread, based on the tissue examined under the microscope. It uses the TNM system, which has three parts: T for the size and extent of the primary tumor, N for spread to the lymph nodes in the neck, and M for spread (metastasis) to more distant parts of the body. The letter “p” in front, as in pT and pN, means the stage was determined by examining tissue rather than by imaging alone.

Tumor stage (pT)

The exact criteria for the T category depend on which part of the larynx the cancer started in, because each region has different boundaries. The general pattern is the same across all three, and it is based on how far the tumor has spread within and beyond the larynx and whether the vocal cords still move.

pT1. Tumor confined to one part of the larynx, with the vocal cords moving normally. For cancers of the vocal cords, your report may specify pT1a if one cord is involved or pT1b if both are.
pT2. Tumor has extended into a neighboring part of the larynx or an adjacent area, or vocal cord movement is reduced.
pT3. Tumor is still confined to the larynx but a vocal cord has stopped moving, or the tumor has grown into certain deeper spaces or the inner surface of the thyroid cartilage.
pT4a. Tumor has grown through the cartilage or beyond the larynx into nearby structures such as the windpipe, the thyroid gland, the esophagus, or the soft tissues of the neck.
pT4b. Tumor has grown into deeper structures such as the space in front of the spine, or surrounds the carotid artery. These tumors usually cannot be removed completely by surgery.

Nodal stage (pN)

pN0. No cancer found in any lymph node.
pN1. Cancer in a single lymph node on the same side as the tumor, 3 cm or smaller, without extranodal extension.
pN2. Cancer in a larger node, in more than one node, or in nodes on both sides of the neck, in ways set out by the staging system. This category also includes a single small node on the same side that shows extranodal extension.
pN3. Cancer in a node larger than 6 cm, or extranodal extension in any node beyond the situation covered by pN2.

Your report may not include the M category, because spread to distant parts of the body is usually determined by imaging rather than by the pathologist. Your treatment team combines the pathology findings with your scans to arrive at the overall stage. You can read more in the article on TNM staging.

What is the prognosis for squamous cell carcinoma of the larynx?

Prognosis means the likely course and outcome of a disease. For squamous cell carcinoma of the larynx, prognosis depends on where in the larynx the cancer started, the stage at diagnosis, the findings on the pathology report, and whether tobacco and alcohol use continue after treatment.

Where the cancer started makes a real difference. Cancers of the vocal cords are usually found early, because hoarseness appears even with a small tumor, and the vocal cords have very few lymphatic channels, so these cancers spread to lymph nodes less often. Early vocal cord cancer is highly curable, with reported five-year survival above 85%, and many people keep a normal or near-normal voice. Cancers of the supraglottis tend to be found later and reach the lymph nodes more often, so survival for advanced disease is lower. Cancers of the subglottis are the least common and generally carry the least favorable outlook, largely because they are usually found at an advanced stage.

Across all three regions, the findings on your report associated with a higher risk of the cancer returning are:

Extranodal extension. One of the strongest adverse findings, and a common reason for adding chemotherapy to radiation after surgery.
Positive or close margins. Substantially increase the chance of the cancer returning at the original site.
Cartilage invasion. Reflects deep local growth and often means a larger operation.
Perineural invasion. Associated with a higher rate of the cancer returning locally.
Multiple involved lymph nodes. Risk rises with each additional node containing cancer.

One factor is within your control. Continuing to smoke after treatment is associated with substantially higher rates of the cancer returning and lower survival, and it raises the risk of a second, separate cancer developing in the head, neck, or lungs. Stopping tobacco and reducing alcohol are among the most effective steps available, and support for quitting is a standard part of care.

What happens after the diagnosis?

After the diagnosis is confirmed, your pathology report is reviewed together with your imaging and overall health, usually by a team that includes ear nose and throat surgeons, radiation oncologists, medical oncologists, and pathologists. The report does not decide treatment on its own, but several of its findings shape the options the team will discuss with you.

Treatment depends heavily on the size and location of the tumor. Early cancers of the vocal cords can often be treated with radiation alone or with surgery through the mouth using a laser, both of which aim to preserve the voice. Larger tumors may require removal of part of the larynx, or in some cases the whole larynx in an operation called a total laryngectomy, which permanently changes how you breathe and speak. For some advanced tumors, radiation combined with chemotherapy may be discussed as an alternative to surgery, with the aim of preserving the larynx. When the report shows high-risk findings such as positive or close margins, extranodal extension, perineural invasion, or several involved lymph nodes, radiation with or without chemotherapy after surgery is usually considered. For cancer that has returned or spread, options include chemotherapy, the targeted drug cetuximab, and immunotherapy.

Supportive care is a central part of treatment here, more so than for many cancers, because the larynx is essential to breathing, swallowing, and speech. Speech and swallowing therapy, nutrition support, and dental assessment before radiation are all standard. If a total laryngectomy is needed, a speech-language pathologist will work with you on the options for producing speech afterward. Follow-up involves regular examination of the larynx and periodic imaging, most intensively in the first two to three years.

Questions to ask your doctor

Which part of my larynx did the cancer start in: the supraglottis, glottis, or subglottis?
What is the histologic grade?
Did the tumor grow into cartilage or beyond the larynx?
Do my vocal cords still move normally?
Were the surgical margins clear?
Was perineural or lymphovascular invasion found?
How many lymph nodes were removed, and how many contained cancer?
Was extranodal extension present?
What are my pT and pN categories, and what is my overall stage?
Was PD-L1 testing done, and what was the CPS result?
What are my treatment options, and is preserving my voice possible?
Is radiation or chemotherapy being considered after surgery?
How will my speech, swallowing, and breathing be supported?
What help is available to me for stopping tobacco and reducing alcohol?
How often will I be followed, and for how long?