Review

Laryngeal Cancer in the Modern Era: Evolving Trends in

Diagnosis, Treatment, and Survival Outcomes
Alexandru-Romulus Hut 1,2 , Eugen Radu Boia 2,3, *, Diana Para 1 , Gheorghe Iovanescu 2 , Delia Horhat 2,3 ,
Loredan Mikša 2 , Maria Chiriac 2 , Raphaël Galant 4 , Alexandru Catalin Motofelea 1,5
and Nicolae Constantin Balica 2,3

1 Department of Doctoral Studies, “Victor Babes” University of Medicine and Pharmacy Timisoara,
Eftimie Murgu Square No. 2, 300041 Timisoara, Romania; [email protected] (A.-R.H.);
[email protected] (D.P.); [email protected] (A.C.M.)
2 ENT Department, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square
No. 2, 300041 Timisoara, Romania; [email protected] (G.I.); [email protected] (D.H.);
[email protected] (L.M.); [email protected] (M.C.); [email protected] (N.C.B.)
3 ENT Department, Emergency City Hospital, 300254 Timisoara, Romania
4 Hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cité,
20 Rue Leblanc, 75015 Paris, France; [email protected]
5 Center for Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, “Victor Babes”
University of Medicine and Pharmacy, 300041 Timisoara, Romania
* Correspondence: [email protected]

Abstract: Background/Objectives: Laryngeal cancer (LC), predominantly squamous cell

carcinoma (SCC), represents a considerable health burden worldwide. Tumour subsite
heterogeneity (supraglottic, glottic, subglottic) influences clinical behavior and outcomes.
This review synthesizes current knowledge on epidemiology, risk factors, diagnostics, his-
tological variants, biomarkers, treatment modalities, and survival. Results: This narrative
review synthesizes current literature on the epidemiology, risk factors, diagnosis, histologi-
cal variants, biomarkers, and prognosis of LC. The review highlights the critical influence
of tumour sites (supraglottic, glottic, subglottic) on metastatic patterns and survival. Key
risk factors of LC include tobacco and alcohol use, human papillomavirus (HPV) infection,
and occupational exposures. The diagnostic process encompasses clinical examination,
Academic Editor: Waseem Jerjes
endoscopy, biopsy, and imaging. Several biomarkers that aid in diagnosis, treatment plan
Received: 12 April 2025
determination, and prognosis prediction have been established. These biomarkers include
Revised: 8 May 2025
Accepted: 9 May 2025 long noncoding RNAs, cell cycle regulators, apoptosis regulators, oncogenes, tumour sup-
Published: 12 May 2025 pressor genes, growth factor pathway components, angiogenic factors, structural proteins,
Citation: Hut, A.-R.; Boia, E.R.; Para, sex hormone receptors, and immunological markers. Current treatment modalities range
D.; Iovanescu, G.; Horhat, D.; Mikša, from organ-preserving surgery and radiotherapy to combined chemoradiotherapy and
L.; Chiriac, M.; Galant, R.; Motofelea, total laryngectomy. Finally, survival data are presented and stratified by stage and subsite.
A.C.; Balica, N.C. Laryngeal Cancer in Conclusions: The review underscores the need for a multidisciplinary approach to LC
the Modern Era: Evolving Trends in
management, integrating clinical, pathological, and molecular information to optimize
Diagnosis, Treatment, and Survival
patient outcomes.
Outcomes. J. Clin. Med. 2025, 14, 3367.
https://doi.org/10.3390/
jcm14103367 Keywords: laryngeal cancer; squamous cell carcinoma; epidemiology; risk factors;
biomarkers; treatment
Copyright: © 2025 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons 1. Introduction
Attribution (CC BY) license Cancers of the head and neck collectively represent the seventh most common type
(https://creativecommons.org/
of cancer worldwide, encompassing a diverse array of tumours that originate within the
licenses/by/4.0/).

J. Clin. Med. 2025, 14, 3367 https://doi.org/10.3390/jcm14103367

J. Clin. Med. 2025, 14, 3367 2 of 32

upper aerodigestive tract [1]. According to global cancer statistics for 2022, laryngeal
cancer (LC) is among the most prevalent cancers, with 188,960 new cases and 103,216
deaths reported [2]. The vast majority of these—between 85% and 95%—are classified as
squamous cell carcinomas (SCC) [3]. The epidemiology of LC reveals a substantial burden.
In 2022, global incidence rates reached over 165,598 cases in men and over 23,362 in women,
with associated deaths exceeding 90,256 and 12,960, respectively [2].
Geographically, Cuba (7.8 per 100,000) and Montenegro (7.0 per 100,000) report the
highest incidence rates, while Eswatini (0.18 per 100,000) and Cameroon (0.31 per 100,000)
have the lowest. Asia is the most prevalent continent for LC, followed by Europe, whilst
the epidemiologic burden in Africa remains low [4]. Within Europe, a high-prevalence
region, incidence varies considerably; Spain reports rates above 12 per 100,000, while the
UK’s rates are below 5 per 100,000 [5]. In Romania, oral malignant tumors are prevalent,
with approximately 2388 new cases annually [6].
Regarding LC mortality, Cuba (3.9 per 100,000) and Montenegro (3.5 per 100,000) also
register high mortality rates, in contrast to Iceland (0.08 per 100,000) and Martinique (0.11
per 100,000), which have the lowest [4]. These variations are linked to socioeconomic factors,
with higher incidence in areas with lower average incomes and education [7]. Regarding
gender differences, in 2021, the age-standardized DALY rate of LC in males was approx-
imately 7.13 times higher than that in females, with males experiencing 282.12 cases per
100,000 individuals, compared to 39.59 cases per 100,000 individuals in females [8]. Higher
Human Development Index (HDI) regions tend to have higher incidence but lower mortal-
ity, reflecting disparities in healthcare access and quality, while lower Sociodemographic
Index (SDI) regions experience higher mortality rates [9,10]. Key etiological factors include
tobacco smoking [11,12], alcohol consumption [13–15], high-risk human papillomavirus
(HPV) infection [16], and occupational exposures such as asbestos [17,18].
Characteristic clinical manifestations often prompt the diagnosis of LC. These symp-
toms, which can vary significantly depending on the tumour’s location and size, commonly
include a persistent lump or non-healing sore, ongoing throat pain, difficulty swallowing
(dysphagia), and alterations in voice quality, such as hoarseness [19]. Despite significant
advancements in instruments like flexible laryngoscopes, surgical techniques, and chemora-
diation therapy, the mortality rate remains high; the 5-year survival rate is 64% because
approximately two-thirds of patients are diagnosed with advanced cancer, leading to a
poor prognosis [20]. Furthermore, even with improvements in treatment modalities, the
American Cancer Society has reported a tendency for the 5-year survival rate for laryngeal
cancer patients to decline [21].
Treatment options for LC include surgery, radiation therapy, and chemotherapy, used
alone or in combination [22,23]. Recent advancements in immunotherapy and targeted
therapy have significantly impacted laryngeal cancer treatment, offering hope for patients
with recurrent or advanced disease. These therapies improve progression-free and over-
all survival rates, particularly in combination. The integration of immunotherapy with
targeted therapies like anti-EGFR has shown promising results in tumor response, and is
increasingly considered for managing recurrent locoregionally advanced squamous cell
carcinoma of the head and neck, including laryngeal cancer [24]. A complex interplay
of factors determines a patient’s prognosis in LC, broadly categorized as relating to the
host, the tumour itself, or the treatment strategy [25]. Host factors encompass individual
characteristics such as age, sex, nutritional status, general health and physical condition,
coexisting medical conditions’ presence, and the immune response’s robustness. Tumour-
related factors include the primary location of cancer, its TNM stage (which reflects the
size, involvement of lymph nodes, and presence of distant metastasis), the microscopic
grade (degree of abnormality), and whether any other primary cancers are present con-
J. Clin. Med. 2025, 14, 3367 3 of 32

currently [25]. While current staging systems predominantly focus on tumour-related

characteristics, a complete and accurate assessment of prognosis requires consideration of
host and tumour factors. In addition, correctly determining the treatment plan is essential
for accurately estimating the prognosis [26].
This review explore recent advancements in molecular biomarkers, histopathologi-
cal subtypes, and innovative therapeutic approaches particularly immuno- and targeted
therapies to enhance prognostic stratification and inform treatment decisions in laryngeal
cancer. Our objectives are to assess emerging biomarkers for personalized risk evaluation,
delineate the clinical and molecular diversity of LC subtypes, and propose an integrated
management framework that optimizes both survival and functional outcomes.

2. Materials and Methods

To identify relevant literature, a comprehensive search was conducted using electronic
databases such as PubMed/MEDLINE, Scopus, and Web of Science. The search strategy
combined both Medical Subject Headings (MeSH) and free-text terms related to “laryngeal
cancer”, “laryngeal carcinoma”, and “squamous cell carcinoma”, along with additional
terms addressing specific aspects of the review (for example, “epidemiology”, “risk factors”,
“diagnosis”, “histological variants”, “biomarkers”, “treatment”, “survival”, and “quality of
life”). Searches were performed to capture all publications available from the inception of
each database until March 2025. In order to ensure a comprehensive review, reference lists
from the identified articles, including relevant review articles and original studies, were
also examined.
Articles were considered eligible if they addressed key aspects of laryngeal cancer,
particularly those relating to squamous cell carcinoma—and if they included information on
epidemiology, risk factors, diagnostic methods, treatment strategies, prognostic biomarkers,
survival outcomes, or quality-of-life measures. Only studies published in peer-reviewed
journals and written in English were included. The review focused on original research
articles, systematic reviews, meta-analyses, and established clinical guidelines. Articles
such as isolated case reports or very small case series, studies focused solely on other head
and neck cancers without specific details regarding LC, or non-peer-reviewed materials,
abstracts, or conference proceedings with limited methodological detail were excluded
from this review.
Because this review takes a narrative approach, the extracted data were synthesized
qualitatively rather than quantitatively. Major themes were identified and then organized
into coherent subsections that correspond to the different facets of LC. This approach
facilitated an integrated discussion of the complex interplay between epidemiological
trends, clinical parameters, molecular insights, treatment options, and patient outcomes.

3. Results
3.1. Risk Factors of LC
A combination of lifestyle and environmental factors significantly influences LC
development (Figure 1).
Undoubtedly, tobacco use is the most prominent risk factor [27]. The risk of LC
increases substantially with both the duration and intensity of smoking, exhibiting a dose-
response relationship. However, this relationship may not be perfectly linear, with a
possible “saturation effect” at very high levels of consumption (more than 20 years and
over 30 cigarettes per day) [11,12]. Smoking cessation reduces risk, but it remains elevated
for up to 15 years after quitting [28]. The synergistic effect of tobacco’s carcinogens is
amplified by human papillomavirus [16]. Cigarette smoking correlates with a sevenfold
risk increase of LC [11]. Passive smoking also contributes to LC deaths [28]. Smokers have
J. Clin. Med. 2025, 14, 3367 4 of 32

J. Clin. Med. 2025, 14, x FOR PEER REVIEW likelihood of dying from LC [29]. Black smokers demonstrate a higher risk4level
a higher of 35

than white smokers [30].

Figure 1.1. Overview

Figure Overview of
of Key
Key Lifestyle,
Lifestyle, Viral,
Viral, and
and Environmental
Environmental Risk
Risk Factors
Factors in
inLaryngeal
Laryngeal Cancer
Cancer
Development.
Development.

Excessive alcohol
Undoubtedly, consumption
tobacco use is the is most
a significant independent
prominent risk factorrisk factor
[27]. The for
riskLC,
of ex-
LC
hibiting a clear dose–response relationship where both the amount and duration of
increases substantially with both the duration and intensity of smoking, exhibiting a dose- intake
proportionally elevate the
response relationship. risk [13–15].
However, Alcohol accounts
this relationship may notfor abesubstantial portionwith
perfectly linear, of la-a
ryngeal cancer-related mortality, especially in regions with high alcohol consumption
possible “saturation effect” at very high levels of consumption (more than 20 years and
levels [31]. In Europe, approximately 30% of individuals who died from LC were identified
over 30 cigarettes per day) [11,12]. Smoking cessation reduces risk, but it remains elevated
as alcoholics [31]. Moreover, the global contribution of alcohol to the incidence of LC may
for up to 15 years after quitting [28]. The synergistic effect of tobacco s carcinogens is
be on the rise [32].
amplified by human papillomavirus [16]. Cigarette smoking correlates with a sevenfold
While traditional risk factors like tobacco and alcohol remain significant, emerging con-
risk increase of LC [11]. Passive smoking also contributes to LC deaths [28]. Smokers have
cerns and socioeconomic disparities require further attention. Although initially marketed
a higher likelihood of dying from LC [29]. Black smokers demonstrate a higher risk level
as a safer alternative, e-cigarettes have raised concerns due to the presence of potentially
than white smokers [30].
carcinogenic substances in some e-liquids [33]. A Korean study found formaldehyde and
Excessive alcohol consumption is a significant independent risk factor for LC,
acetaldehyde in all 225 tested e-liquids [34]. Both of the compounds are classified as Group
exhibiting a clear dose–response relationship where both the amount and duration of
1 carcinogens with links to head and neck cancers [35]. N′ -nitrosonornicotine (NNN), a
intake proportionally elevate the risk [13–15]. Alcohol accounts for a substantial portion
TSNA, has been shown to induce head and neck tumours in animal studies [36]. PAHs, like
of laryngeal cancer-related mortality, especially in regions with high alcohol consumption
1-hydroxypyrene (1-HOP) and benzopyrene, have demonstrated carcinogenic effects on
levels [31]. In Europe, approximately 30% of individuals who died from LC were
the upper respiratory tract in animal models [36,37]. While in vivo studies on e-cigarettes
identified as alcoholics [31]. Moreover, the global contribution of alcohol to the incidence
and laryngeal mucosa are limited, one study in rats showed non-statistically significant
of LC may be on the rise [32].
hyperplasia and metaplasia after four weeks of exposure to e-cigarette aerosols [38].
While traditional risk factors like tobacco and alcohol remain significant, emerging
Opium, classified as a human carcinogen by the IARC (International Agency for
concerns and socioeconomic disparities require further attention. Although initially
Research on Cancer), has shown preliminary links to increased head and neck squamous
marketed as a safer alternative, e-cigarettes have raised concerns due to the presence of
cell carcinoma (HNSCC) risk, including LC, although more research is needed to solidify
potentially carcinogenic substances in some e-liquids [33]. A Korean study found
this connection. The mechanism likely involves the carcinogenic alkaloids present in opium,
formaldehyde and acetaldehyde in all 225 tested e-liquids [34]. Both of the compounds
which can induce DNA damage and mutations upon metabolic activation [39,40].
are classified as Group 1 carcinogens with links to head and neck cancers [35]. N′-
Beyond tobacco and alcohol, certain viral infections, notably high-risk strains of human
nitrosonornicotine (NNN), a TSNA, has been shown to induce head and neck tumours in
papillomavirus (HPV), have been implicated in LC development [41].
animal studies [36]. PAHs, like 1-hydroxypyrene (1-HOP) and benzopyrene, have
Over the past few decades, HPV has been recognized as a key etiological agent, espe-
demonstrated carcinogenic effects on the upper respiratory tract in animal models [36,37].
cially in oropharyngeal squamous cell carcinoma (OPSCC), where HPV-positive tumors
While in vivo studies on e-cigarettes and laryngeal mucosa are limited, one study in rats
showed non-statistically significant hyperplasia and metaplasia after four weeks of
exposure to e-cigarette aerosols [38].
J. Clin. Med. 2025, 14, 3367 5 of 32

form a distinct clinical and molecular subgroup compared with their HPV-negative coun-
terparts [42]. However, the etiological role of HPV in LC appears to vary significantly by
geographic region, with a lower prevalence in some areas, suggesting it is not always a
primary cause [43–45]. Moreover, EBV has been suggested as a risk factor for LC. EBV’s
genome and latent protein EBNA have been found in malignant laryngeal cells, suggesting
a potential role as a risk factor or cofactor, though its presence in LSCC can be inconsis-
tent [46]. EBV, like HPV, can produce oncoproteins that disrupt cell cycle control and
promote uncontrolled cell growth, contributing to carcinogenesis [47].
Other identified risk factors include occupational exposure to asbestos [17,18] and
possibly nickel or ionizing radiation [48]. Chewing betel, particularly in combination with
tobacco and alcohol, substantially elevates risk, specifically in specific populations like
Taiwan [49,50]. Helicobacter pylori infection has also been linked to an increased risk of
LC [51], as has gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux
(LPR), likely due to chronic inflammation. Chronic inflammation leads to the release of
reactive oxygen species (ROS) and inflammatory mediators, which can damage DNA,
promote cell proliferation, and create a microenvironment conducive to tumour develop-
ment [52–54]. Moreover, metabolic syndrome and its associated components (high blood
glucose, increased waist circumference, elevated triglycerides, high blood pressure, and
low HDL cholesterol) have also been identified as independent risk factors [55,56].
The oral and throat microbiome is emerging as a significant factor. Differences in bac-
terial composition, particularly elevated levels of genera like Fusobacterium, Prevotella, and
Streptococcus, have been observed in LC patients compared to healthy individuals [57,58].
Fusobacterium, an invasive anaerobe, may contribute to chronic inflammation and carcino-
genesis, and shifts in the oral microbiome could serve as an early marker of LC [58,59]. The
microbiome’s influence extends to immune system modulation, metabolic regulation, and
even cancer promotion, with interactions with alcohol and tobacco further contributing
to LSCC development. Certain bacteria can produce carcinogenic metabolites, exacerbate
inflammation, and suppress anti-tumor immune responses [60–63].
LC outcomes are significantly worsened by delays in diagnosis and treatment. Socioe-
conomic disparities such as lack of health insurance and limited healthcare access delaying
cancer screening contribute to these delays and to the number of deaths from modifiable
risk factors such as tobacco, alcohol and occupational exposures [64,65]. Men tend to have
an increased risk of LC [66–68] and have a poor prognosis in comparison to women [69].
Preventive measures, particularly reducing tobacco and alcohol consumption and im-
proving access to screening, are crucial for mitigating the burden of this disease [70,71].
Furthermore, in 2021, attributable deaths due to tobacco, occupational risks, and alcohol
were 66.46%, 5.92%, and 12.4%, respectively. While deaths attributable to these factors have
generally decreased since 1990, deaths due to occupational risks have increased in females.
The proportion of LC deaths attributable to tobacco was highest in high-middle sociodemo-
graphic index (SDI) regions (76.15%), while high SDI regions had the highest proportions
attributable to occupational risks (11.56%) and alcohol (19.31%) [72]. Country-specific data
reveals that Armenia (middle SDI) had the highest proportion of LC deaths attributable to
tobacco (83.86%), while the UK (high SDI) had the highest proportion linked to occupational
risks (20.11%), and Czechia (high SDI) had the highest proportion attributable to alcohol
(27.35%). These disparities highlight the complex interplay between individual behaviours,
environmental exposures, and access to preventative care and treatment, underscoring the
need for targeted interventions [72].
J. Clin. Med. 2025, 14, 3367 6 of 32

3.2. Histological Subtypes of LC

Laryngeal squamous cell carcinoma (LSCC), the most prevalent malignancy of the
larynx, demonstrates a spectrum of differentiation, broadly categorized as keratinizing
or non-keratinizing. Keratinizing SCC, typically encompassing well-differentiated and
moderately differentiated forms, exhibits significant keratin production, often forming
characteristic keratin pearls and demonstrating abundant intracellular keratin. In contrast,
non-keratinizing SCC, usually associated with poorly differentiated tumours, lacks this
well-developed keratinization; in these cases, immunohistochemical markers like CK5/6,
p63, p40, and EMA are crucial to confirm the epithelial origin [73]. Beyond this broad
distinction, laryngeal SCC encompasses several distinct variants, each with unique mor-
phological features, clinical behaviours, and prognostic implications, as summarized in
Table 1.

Table 1. Histopathological and Prognostic Features of Laryngeal SCC Variants.

Microscopic Features & Immunohistochemistry/Special

Variant Gross Appearance Prognosis
Keratinization Studies
Invasive nests of squamous cells
Variable appearance: may be with variable differentiation;
In poorly differentiated cases: Stage-dependent survival
ulcerated or smooth; abnormal keratinization
CK5/6, p63, p40, and EMA rates (e.g., Glottic: 80–85%,
Conventional SCC endophytic, exophytic, or (prominent in well-differentiated
positivity help confirm Supraglottic: 65–75%,
polypoid; colour from red to types); desmoplastic reaction;
epithelial origin. Subglottic: ~40%).
tan-white; firm texture. possible perineural/vascular
invasion.
Well-demarcated pushing border
Excellent outlook with 5-year
Warty, broad-based, and with blunt, club-shaped rete ridges;
Lacks evidence of survival rates of
Verrucous Carcinoma fungating mass; firm-to-hard minimal atypia and rare mitoses;
transcriptionally active HPV. approximately 85–95% (stage
texture; generally tan or white. abundant keratin forming
is key).
“church-spire” structures.
Polypoid and bulky, projecting Dominantly exophytic/papillary Diagnosis is usually made on Generally favorable outcome
outward with papillary or growth pattern with malignant morphology; additional with roughly 85% 5-year
Papillary/Exophytic SCC
fungiform features; texture features; surface keratinization; studies are not typically survival, better than
may vary from soft to firm. possible koilocytic atypia. required. conventional SCC.
Biphasic pattern showing both
Often presents as a polyp-like conventional SCC and atypical Approximately 70% of cases
Generally excellent,
Spindle Cell mass with areas of surface spindle cell components; high cell show AE1/AE3, EMA, p63,
sometimes even better than
(Sarcomatoid) SCC ulceration; firm, fibrous density, pleomorphism, and and/or p40 positivity;
conventional SCC.
texture. increased mitoses; keratinization is frequent p53 overexpression.
often focal.
Deep invasive lobules of basaloid
cells with a high Consistent epithelial marker
nuclear-to-cytoplasmic ratio; expression (e.g.,
Tends to have a worse overall
Firm to hard mass, frequently palisading at the periphery; abrupt pan-cytokeratin, p63, p40) and
Basaloid SCC prognosis compared to
with central necrosis. squamous differentiation with focal p53 overexpression; typically
conventional SCC.
keratinization; comedonecrosis is negative for neuroendocrine
common; may show hyaline markers.
stroma.
Infiltrative growth with two
distinct components: a When matched for stage,
conventional squamous carcinoma Glandular areas are positive outcomes are similar to
Adenosquamous Typically presents as a
element and an adenocarcinoma for mucin, supporting a dual conventional SCC, though the
Carcinoma submucosal, indurated mass.
(glandular) component; abrupt or differentiation profile. lesion may behave more
focal keratinization (keratin pearls aggressively.
may be seen).

In contrast, papillary/exophytic SCC (PSCC/ESCC) demonstrates a predominantly

exophytic or papillary growth pattern with frank cytomorphologic malignancy [74]. Verru-
cous carcinoma (VC) is a well-differentiated, slow-growing form characterized by a pushing
border of infiltration, abundant keratinization, and a lack of cytologic atypia [75]. Spindle
cell (sarcomatoid) SCC (SCSCC) is a biphasic tumour with both epithelial and spindle cell
components, often presenting as a polypoid mass [76,77]. Basaloid SCC (BSCC) is a high-
grade variant with a prominent basaloid component and often aggressive behaviour [78].
Adenosquamous carcinoma (ASC) is characterized by an admixture of SCC and adenocar-
cinoma components [79–81]. Distinguishing between keratinizing and non-keratinizing
SCC and accurately classifying these variants is essential for guiding treatment decisions
and predicting patient outcomes. Careful histological evaluation, often supplemented by
immunohistochemistry, is paramount.
J. Clin. Med. 2025, 14, 3367 7 of 32

3.3. Diagnosis
Accurate diagnosis of LC relies on a thorough patient history, a comprehensive phys-
ical examination, and appropriate diagnostic procedures. The patient’s history should
include detailed inquiries about risk factors like tobacco and alcohol use, current medica-
tions, and any coexisting medical conditions that might influence treatment decisions [82].
The clinical presentation of LC varies considerably depending on the tumour’s location and
size. Glottic tumours often present early with hoarseness, while supraglottic tumours may
manifest later with symptoms such as pain, persistent hoarseness, or dysphagia (difficulty
swallowing) [82]. The diagnostic modalities of LC are summarized in Table 2. Direct
visualization of the larynx is essential, typically achieved through indirect laryngoscopy,
flexible fiberoptic laryngoscopy, or video stroboscopy. Videostroboscopy, in particular,
demonstrates high sensitivity (96.8%) and specificity (92.8%) in predicting the invasiveness
of laryngeal lesions [83]. Tissue confirmation through biopsy of the primary tumour or
fine-needle aspiration of suspicious lymph nodes is crucial for definitive diagnosis. Imag-
ing studies play a vital role in staging cancer. Computed tomography (CT) is valuable
for assessing bone involvement, while positron emission tomography combined with CT
(PET/CT) helps detect recurrences, local and nodal spread, and distant metastases [84].
Magnetic resonance imaging (MRI) offers superior sensitivity (80%) and specificity (92.9%)
compared to CT (60% sensitivity, 85.7% specificity) in evaluating cartilage and soft tissue
invasion [85]. Narrow-band imaging (NBI) has also emerged as a highly sensitive (97%)
and specific (92.5%) technique for identifying both LC and its precursor lesions [86].

Table 2. Diagnostic Modalities in Laryngeal Cancer: Techniques, Strengths, and Limitations.

Method Description Advantages Limitations

The essential first step is to
Patient history, physical exam Cannot visualize the larynx
Clinical Examination identify symptoms and risk
(neck palpation, etc.) directly; subjective.
factors.
Direct visualization of the It can be uncomfortable and
Indirect, flexible fiberoptic,
Laryngoscopy larynx; videostroboscopy may require local anaesthesia
video stroboscopy
assesses vocal fold vibration. and inter-observer variability.
A tissue sample from the The gold standard for Invasive; potential for
Biopsy primary tumour or lymph definitive diagnosis allows for complications (bleeding,
nodes (fine-needle aspiration) histological analysis. infection); sampling error.
CT: assesses bone
CT: radiation exposure; MRI:
involvement; MRI: superior
cost, claustrophobia; PET/CT:
Imaging CT, MRI, PET/CT for soft tissue and cartilage;
cost, availability, radiation
PET/CT: detects recurrences
exposure.
and metastases.
Uses specific wavelengths of High sensitivity and It requires specialized
Narrow-band Imaging (NBI) light to enhance visualization specificity for identifying LC equipment; it may not detect
of mucosal changes and precursor lesions. deep invasion.
Minimally invasive; potential Biomarker validation is
Analysis of biomarkers in
for early detection, prognosis, ongoing; standardization is
Liquid Biopsy blood/saliva (CTCs, ctDNA,
and monitoring treatment needed; it may not replace
exosomes, microbiome)
response. tissue biopsy.
Potential to improve It requires large datasets for
Machine learning/deep
diagnostic accuracy and training, the “black box”
AI-Assisted Diagnosis learning applied to imaging
efficiency; personalized risk nature of some algorithms,
(histology, endoscopy)
assessment. and ethical considerations.

Traditional diagnostic approaches for LC, such as imaging and tissue biopsy, are
fundamental but can be limited in detecting early-stage disease. Over the last decade, there
has been increasing interest in using liquid biopsies to detect cancer-specific biomarkers
in patients’ body fluids [87,88]. Liquid biopsy has been reported to play roles in early
malignancy detection in diverse tumor types [89,90]. As a rapid and noninvasive approach,
J. Clin. Med. 2025, 14, 3367 8 of 32

liquid biopsies have emerged as an exciting investigational avenue to obtain information

on cancer diagnosis, treatment response, and progression [91,92]. Liquid biopsies are
minimally invasive tests analyzing biomarkers in fluids like blood and saliva. These
biomarkers, including circulating tumour cells (CTCs), circulating tumour DNA (ctDNA),
exosomes carrying microRNAs (miRNAs), and even oral microbiome constituents, offer
potential for earlier detection, refined prognosis, and real-time monitoring of treatment
response in HNSCC, and specifically LC [93,94].
Since LC is frequently diagnosed at later stages, methods for earlier identification are
critical. Research has demonstrated that ctDNA, fragments of DNA released by tumour
cells, are detectable in the plasma and saliva of patients with LSCC, with levels correlating
to the disease stage [95]. Epigenetic modifications, such as aberrant DNA methylation,
also hold diagnostic promise. Studies have identified specific gene methylation patterns
in plasma or serum associated with the early detection of respiratory cancers, including
LSCC [96–99]. Furthermore, analysis of the oral microbiome, specifically detecting certain
microbiota in mouthwash, has emerged as a novel liquid biopsy approach for LSCC [58].
Moreover, liquid biopsies provide valuable prognostic information for LC patients
and enable monitoring of treatment response. Analyzing circulating tumour cells (CTCs),
circulating tumour DNA (ctDNA), and microRNAs (miRNAs) is key. Higher preoperative
CTC counts [100–102] and ctDNA hypermethylation [98] correlate with worse outcomes in
LSCC. Changes in these markers and specific miRNAs [103–106] are linked to treatment
and survival. Furthermore, liquid biopsies allow for minimally invasive, repeated sampling
to dynamically monitor treatment efficacy and detect recurrence. Changes in CTC and
ctDNA levels indicate treatment response or resistance [100,101,107].
Traditional diagnostic methods, relying on clinical examination, endoscopy, and
histopathological analysis of biopsies, can be time-consuming and subject to inter-observer
variability [108]. AI, particularly through machine learning (ML) and deep learning (DL)
techniques, offers the potential to improve diagnostic accuracy and efficiency. In LC, vari-
ous imaging modalities are used to train AI algorithms. Studies have utilized histological
whole-slide images (WSI) [109] and endoscopic/clinical imaging [110]. For example, stimu-
lated Raman scattering histology integrated with DL algorithms has shown an accuracy of
90% in diagnosing laryngeal SCC [111]. Other approaches have used traditional ML tech-
niques to classify laryngeal tissues as normal or malignant based on textural information
from narrow-band endoscopic images, achieving high recall rates [110]. These AI-driven
diagnostic tools have the potential to assist clinicians in earlier and more accurate detection
of LC, potentially leading to improved patient outcomes.
In addition, AI models, particularly deep neural networks (DNNs), can analyze
diverse clinical data to provide more personalized risk assessments. A study by Choi
et al., (2023) demonstrated that a DNN model incorporating various clinical factors signifi-
cantly outperformed models using only the TNM stage for predicting survival in LSCC
patients [111]. This aligns with previous findings highlighting the importance of factors
like age, performance status, and lifestyle choices [112,113]. Unlike traditional regression
models [114,115], AI can better handle the complex, non-linear relationships between these
factors and survival outcomes, leading to more accurate and individualized predictions
that could improve treatment strategies.

3.4. Molecular Biomarkers in Laryngeal Squamous Cell Carcinoma

Biomarkers, measurable indicators of biological states, are increasingly vital in under-
standing LSCC. They can refine diagnosis, predict prognosis, and guide treatment. Research
has explored a wide range of molecules as potential biomarkers in LSCC, categorized by
their biological roles: long noncoding RNAs (lncRNAs), cell cycle regulators, apoptosis
J. Clin. Med. 2025, 14, 3367 9 of 32

regulators, oncogenes and tumour suppressors, growth factor pathway components, angio-
genic factors, structural proteins, sex hormone signalling components, and immunological
markers [116]. Table 3 summarize the important biomarkers and their function in laryngeal
cell cancer.

Table 3. Molecular Biomarkers in Laryngeal SCC: Biological Roles and Clinical Implications.

Biomarker (Symbol) Primary Function LC-Specific Application Clinical Impact

Overexpression correlates with
IHC to identify tumors with high
BCL2 Suppresses apoptosis radio-/chemo-resistance and poorer
anti-apoptotic tone
OS and DFS [117–121]
High CD44+ fraction associates with
Regulates cell–cell/ECM CSC enrichment assays; marker
CD44 increased recurrence and metastasis
interactions; CSC marker for minimal residual disease
[122–124]
Reduced expression predicts invasion,
Mediates calcium-dependent
E-cadherin (CDH1) IHC loss as indicator of EMT nodal spread, and worse prognosis
cell–cell adhesion
[125–128]
Inhibits CDK4/6; surrogate of p16 IHC to stratify HPV+ vs. p16 positivity correlates with better
p16 (CDKN2A)
HPV-driven oncogenesis HPV− tumors OS in HPV-associated LC [129]
Low p27 levels associate with
IHC gauge of intact
p27 (CDKN1B) Restrains cyclin-CDK activity aggressive phenotype and reduced
growth-inhibitory signaling
DFS [130]
FISH/IHC for gene amplification Overexpression predicts lymph node
Cyclin D1 (CCND1) Drives G1 –S cell-cycle transition
and overexpression metastasis and shorter DFS [131]
IHC/FISH to select patients for High EGFR expression correlates with
RTK regulating proliferation,
EGFR EGFR-targeted therapies poor prognosis; targetable with
survival, angiogenesis
(cetuximab, TKIs) cetuximab [132]
Elevated Ki-67 (>30–40%) predicts
Ki-67 index quantification in
Ki-67 (MKI67) Marks actively cycling cells high tumor grade and reduced
biopsy specimens
survival [133–136]
High PCNA levels associate with
Cofactor for DNA polymerase δ IHC metric of S-phase fraction
PCNA rapid growth and adverse
during replication and proliferative activity
outcome [137]
Elevated SPP1 correlates with
Serum/plasma ELISA and tissue
SPP1 (Osteopontin) Adhesion molecule and cytokine metastasis, chemoresistance, and
IHC
shorter OS [138]
TP53 mutation denotes higher
Orchestrates DNA-damage Mutational analysis by NGS/IHC
p53 (TP53) recurrence risk and poor prognosis
response, apoptosis, senescence for risk stratification
[131,139,140]
High VEGFA expression correlates
Stimulates angiogenesis and IHC/ELISA to assess angiogenic
VEGFA with microvessel density and reduced
vascular permeability [141] index
OS [142–144]
IHC/genomic profiling for
Mediates TGF-β Loss correlates with invasion, EMT,
TGF-βR receptor or SMAD pathway
growth-inhibitory signaling and poor survival [145–147]
defects
High CD105+ microvessel count
Accessory TGF-β receptor
Endoglin (CD105) IHC microvessel density marker predicts aggressive behavior and
controlling angiogenesis
reduced OS [126,148–150]
Integrates integrin and Overexpression linked to metastasis,
IHC and activity assays; under
FAK (PTK2) growth-factor signals to regulate diminished DFS, and poorer OS
investigation as therapeutic target
motility [151–154]
Ligand-activated TFs mediating AR+ tumors may be less aggressive;
Hormone receptors (ER, PR, IHC detection to explore
hormone-driven growth and PRLR elevation correlates with poorer
AR, PRLR) endocrine manipulation
differentiation survival [155,156]
CSC, cancer stem cell; ECM, extracellular matrix; IHC, immunohistochemistry; FISH, fluorescence in situ hy-
bridization; RTK, receptor tyrosine kinase; TKIs, tyrosine kinase inhibitors; NGS, next-generation sequencing;
DFS, disease-free survival; OS, overall survival; ELISA, enzyme-linked immunosorbent assay.

Alterations that enhance the function of the epidermal growth factor receptor (EGFR)
axis and defects that diminish the function of the transforming growth factor-β receptor
(TGF-βR) axis collectively promote unregulated cellular proliferation, reduced apoptosis,
and increased cell survival. In the context of EGFR, overexpression or activating muta-
tions result in the receptor being persistently active, thereby continuously stimulating
the RAS–RAF–MEK–ERK and PI3K–AKT signaling pathways. This activation leads to
the upregulation of pro-proliferative markers such as Cyclin D1 and Ki-67, as well as
anti-apoptotic proteins like Bcl-2, while concurrently downregulating cell-cycle inhibitors
 and increased cell survival. In the context of EGFR, overexpression or activating muta-
tions result in the receptor being persistently active, thereby continuously stimulating the
J. Clin. Med. 2025, 14, 3367 RAS–RAF–MEK–ERK and PI3K–AKT signaling pathways. This activation leads to the up-
10 of 32
regulation of pro-proliferative markers such as Cyclin D1 and Ki-67, as well as anti-apop-
totic proteins like Bcl-2, while concurrently downregulating cell-cycle inhibitors such as
p27. as
such Conversely, the loss
p27. Conversely, theofloss
TGF-βR signaling,
of TGF-βR due todue
signaling, receptor mutations
to receptor or disruptions
mutations or disrup-
in theinSMAD
tions the SMADpathway, impairs
pathway, its normal
impairs growth-inhibitory
its normal growth-inhibitoryfunctions, resulting
functions, in de-
resulting in
creased levels
decreased of of
levels p53p53andand
p27. ThisThis
p27. lossloss
effectively removes
effectively critical
removes regulatory
critical mechanisms
regulatory mecha-
that inhibit
nisms cell-cycle
that inhibit progression
cell-cycle and apoptosis.
progression TheseThese
and apoptosis. opposing molecular
opposing events
molecular con-
events
verge within
converge the the
within nucleus, driving
nucleus, DNA
driving DNAreplication, promoting
replication, promotingsurvival under
survival stress
under con-
stress
ditions, and
conditions, ultimately
and ultimately contributing
contributingtotothethedevelopment
developmentandand aggressiveness laryngeal
aggressiveness of laryngeal
cancer(Figure
cancer (Figure2).2).

Figure2.2.Core
Figure CoreMolecular
MolecularPathways
PathwaysDriving
DrivingLaryngeal
LaryngealSquamous
SquamousCell
CellCarcinoma
CarcinomaPathogenesis.
Pathogenesis.

Biomarkers
Biomarkers in in laryngeal
laryngeal squamous
squamous cell
cell carcinoma
carcinoma (LSCC)
(LSCC) encompass
encompass aawidewiderange
range
of
of molecules
molecules that
that modulate
modulate keykey cellular
cellular processes
processes andand may
may impact
impact tumor
tumor behavior
behavior and and
clinical
clinicaloutcomes.
outcomes.
Long
Long noncoding
noncoding RNAs RNAs (lncRNAs)
(lncRNAs) areare RNA
RNA molecules
molecules that
that do
do not
notcode
codefor
forproteins
proteins
but
butregulate
regulategene
geneexpression
expressionandandvarious
variouscellular
cellularfunctions.
functions.Their
Theirdysregulation
dysregulationisislinked
linked
to
tocancer
cancerdevelopment,
development,including
includingLSCC,
LSCC, where
wheremanymanylncRNAs
lncRNAs are are upregulated
upregulatedin in tumor
tumor
tissues. Thisoverexpression
tissues. This overexpressionoftenoftenpromotes
promotestumortumor progression,
progression, enhances
enhances metastasis,
metastasis, re-
reduces radiosensitivity,and
duces radiosensitivity, andworsens
worsens overall
overall survival,
survival, partly by activating
activating pathways
pathways such such
as
as Wnt,
Wnt, Sox-2, andandTGF-β1
TGF-β1[145–147,157].
[145–147,157].Owing
Owing to to their
their stability
stability in body
in body fluids
fluids and andease
ease of detection
of detection by non-invasive
by non-invasive methods,
methods, lncRNAs
lncRNAs are considered
are considered promising
promising biomarker
biomarker can-
candidates [158].
didates [158].
The cell cycle, which is frequently disrupted in cancer, offers several potential biomark-
ers. Ki-67, a nuclear protein expressed during all active phases of the cell cycle but absent
in resting cells, serves as a direct marker of proliferation. In LSCC, elevated Ki-67 levels are
associated with poorly differentiated tumors, advanced TNM stages, increased recurrence
risk, and shorter disease-free survival [133–136]. However, its relationship with radiother-
apy response is complex; while high levels might imply increased radiosensitivity in some
studies [159,160], other reports suggest that low Ki-67 can be linked to better local control in
early-stage tumors, possibly due to factors like DNA repair capacity and hypoxia [161,162].
Cyclin D1, which drives the G1 to S phase transition by complexing with CDKs 4 and 6, is
commonly overexpressed in LSCC and correlates with lymph node metastasis and poorer
survival; its overexpression may also occur alongside TP53 mutations [131,139,140]. In
contrast, the cyclin-dependent inhibitor p27 is frequently underexpressed in LSCC, with
J. Clin. Med. 2025, 14, 3367 11 of 32

low levels linked to tumor recurrence and poorer outcomes [140,163]. An inverse relation-
ship between cyclin D1 and p27 is evident, with patients displaying cyclin D1 positivity
alongside p27 negativity often faring worse [116]. In addition, p16—a CDKI closely related
to the HPV 16 status frequently seen in head and neck cancers—is typically downregulated
in tumors with high cyclin D1, and its presence tends to indicate better treatment response
and survival [164].
Deregulation of apoptotic pathways is another hallmark of LSCC. Bcl-2, an intra-
cellular membrane protein that inhibits apoptosis by modulating cytochrome C release
and interacting with pro-apoptotic proteins, shows conflicting associations. While some
studies report no correlation between Bcl-2 expression and clinical outcomes [117–121],
other investigations have linked its overexpression to lymph node metastasis, advanced
stage, poor differentiation, increased recurrence, and radioresistance [165]. A meta-analysis
by Silva et al., (2023) even suggests that Bcl-2 overexpression may be associated with poorer
lymph node metastasis, overall survival (OS), and disease-free survival (DFS), although
these findings should be interpreted with caution because of study variability and potential
bias [166].
Tumor suppressor and oncogenes also play crucial roles in LSCC. The tumor sup-
pressor p53, which activates cell cycle arrest, DNA repair, senescence, or apoptosis in
response to stress, is mutated in approximately 60–80% of LSCC cases [167–169]. These
mutations are frequently linked to more aggressive disease features; however, consensus on
the prognostic role of p53 remains elusive due to heterogeneous and sometimes conflicting
study results [170–173].
Growth factor signaling contributes further to LSCC progression. Epidermal growth
factor receptor (EGFR), a transmembrane receptor tyrosine kinase that binds ligands such
as EGF and TGF-α, triggers intracellular pathways leading to increased cell proliferation,
angiogenesis, and survival. EGFR overexpression in LSCC is associated with progression
to malignancy, a higher risk of metastasis, and reduced survival, particularly when found
together with high levels of cyclin D1 and Ki-67 [173–177]. Similarly, alterations in the TGF-
β pathway—most notably the loss of TGF-β receptor II expression in lesions progressing to
invasive carcinoma—reduce the growth-suppressive effects of TGF-β and promote tumor
advancement [169–178].
Angiogenesis, a process vital for tumor growth and metastasis, is reflected by several
markers in LSCC. Vascular endothelial growth factor (VEGF) increases vascular permeabil-
ity and stimulates endothelial cell proliferation and migration, and its upregulation in LSCC
correlates with dysplasia progression, local recurrence, metastasis, and shorter disease-free
survival, though some studies find no significant association [126,150,179–182]. Additional
angiogenic markers such as angiogenin and CD105 (endoglin) are also implicated, with
their elevated expression correlating with recurrence, advanced disease, and poorer clinical
outcomes [126,148–150,183,184].
Structural proteins that maintain cell adhesion and tissue integrity are also signifi-
cant. E-cadherin, a transmembrane glycoprotein essential for cell-cell adhesion, is often
downregulated in LSCC, correlating with poorer tumor differentiation, increased risk of
nodal metastasis, and advanced tumor stage; reduced expression may also be linked to
shorter disease-free survival [125–127,185]. The cell surface glycoprotein CD44, a known
marker of cancer stem cells, is similarly associated with higher tumor grade and poorer
5-year survival [122–124]. Overexpression of focal adhesion kinase (FAK) and cortactin—an
actin-binding protein involved in cell motility and invasion—has been linked to aggressive
behavior and recurrence in LSCC [126,151–154].
The role of sex hormone signaling in LSCC remains debated. Estrogen receptors
(ERα and ERβ, including variants such as ERα66 and ERα36) display variable expression
J. Clin. Med. 2025, 14, 3367 12 of 32

patterns; while early-stage LSCC tumors may show increased levels compared to normal
tissue, advanced stages often exhibit a shift in receptor subtype expression that correlates
with a more unfavorable prognosis [155,186,187]. Likewise, progesterone receptor (PR)
expression is higher in poorly differentiated LSCC and those with nodal metastasis, whereas
androgen receptor (AR) expression is typically reduced in invasive tumors. Elevated
prolactin receptor (PRLR) expression has also been noted in LSCC and correlates with
poorer survival outcomes [155,156].
Immunological biomarkers reflect the critical role of the host immune response in
modulating tumor growth. Tumor-infiltrating lymphocytes (TILs), particularly cytotoxic
CD8+ T cells, are associated with improved survival in LSCC—even in cases of tobacco-
related disease [188–190]. LSCC continues to have a poor prognosis, with a 5-year survival
rate of 50 to 60% and suboptimal functional outcomes. The expression of PD-L1 and the
tumor microenvironment markers (CD4, CD8, CD68, and CD163) were examined in LSCC
using immunohistochemistry. PD-L1 expression demonstrated a statistically significant
positive correlation with all the tumor microenvironment cells studied. Higher expressions
of CD68 and CD163 were significantly associated with worse clinical outcomes in LSCC
patients [191]. To determine which LSCC patients might benefit from immunomodulation
therapies, it is crucial to understand the relationship between PD-L1 expression, immune
cell distribution, and prognosis. Conversely, the expression of programmed death-ligand 1
(PD-L1) on tumor and immune cells, which aids tumors in evading immune attacks, has
been linked to clinical outcomes and may make tumors amenable to immune checkpoint
inhibitor therapy [140,192–195].
Emerging biomarkers in LSCC continue to broaden our understanding of tumor biol-
ogy. Among these, heat shock proteins (HSPs) have diverse roles: HSP27 and HSP70 are
linked to advanced tumor stage, chemoresistance (particularly to cisplatin), and radiother-
apy resistance [196–201] whereas HSP47 appears to function as a tumor suppressor, with
higher expression correlating with better prognosis and longer overall survival [202]. Met-
allothioneins (MTs), especially the MT1 and MT2 isoforms, are found at higher levels in ma-
lignant laryngeal lesions than in benign or dysplastic ones, and genetic variations in MT2A
may increase LSCC risk, making them potential early biomarkers [203–206]. Components of
the oxidative stress response, such as nuclear factor erythroid 2-related factor 2 (Nrf2) and
heme oxygenase-1 (HO-1), are also implicated; increased nuclear Nrf2 expression correlates
with cisplatin resistance, while HO-1 may counteract cisplatin-induced apoptosis, although
its prognostic role in LSCC is still under investigation [207–212]. Cyclooxygenase-2 (COX-2)
is another emerging marker; its elevated expression in LSCC is linked to enhanced an-
giogenesis, inflammatory signaling, and resistance to radiotherapy, and it is associated
with poorer clinical outcomes [213–219]. Lastly, several microRNAs (miRNAs)—such as
Hs_miR-21_5p, Hs_miR-218_3p, and Hs_miR-210_3p, which are expressed exclusively in
malignant laryngeal lesions—are implicated in regulating tumor cell migration, invasion,
and treatment resistance, further supporting their utility as precise biomarkers [220–227].

3.5. Metastatic Patterns of LC

LC metastasis predominantly follows a lymphatic route, with the specific pattern
of spread heavily influenced by the primary tumour’s location within the larynx. The
supraglottis, possessing a rich lymphatic network and a midline position, exhibits a high
likelihood of bilateral lymph node involvement. Lymphatic drainage from the supraglottis
flows through the thyrohyoid membrane into the jugular chain, making the jugular lymph
nodes the primary recipients of metastases. Specifically, the sub-digastric (level II), mid-
jugular (level III), and lower jugular (level IV) nodes are most frequently affected. In
contrast, posterior cervical nodes (level V) are rarely involved, and submandibular (level
J. Clin. Med. 2025, 14, 3367 13 of 32

IB) and submental (level IA) nodes are seldom involved. Approximately 55% of patients
with supraglottic carcinoma present with clinically involved lymph nodes at diagnosis,
with 16% showing bilateral involvement.
Furthermore, up to half of clinically node-negative patients may harbour occult nodal
metastases. The risk of lymph node involvement increases with tumour size and grade,
reaching approximately 40% for T1 and T2 tumours and 60% for T3 and T4 lesions [228–230].
In contrast, the subglottis has a less developed lymphatic network, resulting in a lower
incidence of lymph node metastasis (20% to 50%). Subglottic lymphatic channels drain
anteriorly through the cricothyroid membrane to the middle and lower jugular or Delphian
nodes and posterolaterally to the paratracheal nodes. The true vocal cords are almost
devoid of lymphatics, leading to a very low incidence of nodal metastasis in early-stage (T1)
glottic cancers, approaching zero. This incidence increases with stage: 2% for T2, 15–20% for
T3, and 20–30% for T4 lesions. Occult nodal involvement is found in approximately 16% of
clinically node-negative T3 and T4 glottic cancers [229,230]. Glottic cancer spread typically
involves extension into the supraglottis or subglottis, leveraging their more prosperous
lymphatic supply. Distant metastasis is relatively uncommon in LC, occurring in 10–20% of
patients, predominantly those with supraglottic and subglottic primaries, although autopsy
studies reveal a higher rate of subclinical metastases. The lung is the most frequent site
of distant metastasis, followed by bone (20% of patients with distant disease) and liver
(10% clinically). Brain metastases are rare [229–231]. Because of the high risk of second
primary cancers in these patients, tissue confirmation of suspected metastases is essential.
Factors increasing the risk of distant metastasis include lymph node involvement, low
neck metastases, advanced stage, and extranodal extension (ENE), with ENE potentially
increasing the risk tenfold [19,232].

3.6. Recent Trials Further Investigating Biomarkers in LC

Several clinical trials are investigating the role of biomarkers in LSCC treatment and
prognosis. One study focusing on locally advanced LSCC treated with radiotherapy found
that high pre-treatment expression of the hypoxia marker HIF-1α, along with the pres-
ence of regional lymph node metastases, were independent predictors of locoregional
recurrence [233]. Another trial examining advanced LC patients primarily treated with
surgery found that while high tumour tissue expression of CD4+ and CD8+ T cells ini-
tially appeared to improve survival, only higher serum levels of the cytokine IL-8 were a
significant negative predictor of disease-specific survival in multivariate analysis [234]. A
third study examined inflammatory biomarkers in LSCC patients undergoing definitive
radiotherapy, finding that pre-treatment C-reactive protein (CRP) levels were a significant
predictor of progression-free survival, while neutrophil-to-lymphocyte ratio (NLR) and
ECOG performance status predicted overall survival. Additionally, this study identified
that monocyte-to-lymphocyte ratio (MLR), pan-immune inflammatory value (PIV), and
CRP levels were significantly higher in patients with lymphatic metastasis [235].

3.7. Treatment
The treatment of LC is a multifaceted endeavor, with approaches tailored to the
cancer’s stage, location, and the patient’s overall condition. For early-stage (T1-T2, N0,
M0) LCs, treatments often aim to preserve the larynx. These can involve laryngeal-sparing
surgeries, which selectively remove cancerous tissue, or definitive radiotherapy (RT),
employing high-energy beams to eradicate cancer cells [236]. Table 4 summarizes the
treatment modalities of LC.
J. Clin. Med. 2025, 14, 3367 14 of 32

Table 4. Treatment Modalities for LC.

Treatment Modality Description Indications Advantages Disadvantages

Surgery
It preserves the larynx and It may not be suitable for
Laryngeal Sparing Selective removal of Early-stage (T1, T2, N0,
potentially improves voice advanced disease due to
Surgery cancerous tissue. M0)
and swallowing function. the risk of recurrence.
Minimally invasive; good
oncological outcomes; Limited by tumour extent
Early-stage vocal fold
Transoral Laser CO2 laser resection better postoperative and and location; requires
cancers (Tis, T1, T2);
Microsurgery (TLM) through the mouth. QoL outcomes than open specialized equipment
selected advanced cases.
surgery or radiotherapy; and expertise.
cost-effective.
Role in glottic cancer less
Selected supraglottic
Minimally invasive; defined; potential for
Transoral Robotic Surgery Robotic-assisted surgery cancers (cT1,T2, some
improved visualization exposure issues, higher
(TORS) through the mouth. cT3,T4a); oropharyngeal
and manoeuvrability. costs, and complications
cancers.
compared to TLM.
Extensive tumour
Permanent loss of natural
invasion; significant
Complete removal of the Definitive tumour voice requires
Total Laryngectomy (TL) pre-existing swallowing
larynx. removal. tracheostomy, which has a
dysfunction; failed organ
significant impact on QoL.
preservation.
Radiation Therapy (RT)
Potential for side effects
High-energy beams to Early-stage disease; (mucositis, xerostomia,
Definitive RT Preserves larynx.
eradicate cancer cells. alternative to surgery. dysphagia); risk of
recurrence.
It requires specialized
Conformal radiation Locally advanced disease Reduced toxicities
Intensity-Modulated RT equipment and expertise;
delivery, minimizing dose (often combined with compared to conventional
(IMRT) there is potential for late
to surrounding tissues. chemotherapy). RT.
effects.
Radiation using protons,
Investigational; potential Limited availability, cost,
with the potential for It may reduce side effects
Proton Therapy for locally advanced and lack of robust
reduced dose to compared to IMRT.
disease. comparative data.
surrounding tissues.
Not established for
Investigational; potential
Stereotactic Body RT High doses of radiation in laryngeal preservation;
for early-stage glottic Short treatment course.
(SBRT) a few fractions. potential for severe
cancers (clinical trial only).
toxicities.
Chemotherapy
Superior larynx
Cisplatin chemotherapy Locally advanced disease preservation rates Significant toxicities
Concurrent
combined with radiation (standard of care for compared to induction (mucositis, nephrotoxicity,
Chemoradiotherapy (CRT)
therapy. larynx preservation). chemotherapy or radiation myelosuppression).
alone.
Carboplatin/fluorouracil, Cetuximab may have
Alternative Systemic cetuximab (for Patients not candidates for It may be better tolerated inferior overall survival
Therapies platinum-ineligible cisplatin. than cisplatin. compared to cisplatin in
patients). certain cases.
Investigational; potential
Pembrolizumab, for locally advanced Limited availability; cost;
It may reduce side effects
Immunotherapy Nivolumab (checkpoint disease. approved for lack of robust comparative
compared to IMRT.
inhibitors) recurrent or metastatic data.
disease.
Secures the airway in
Creating a hole in the neck In cases of significant Patient will have to
Tracheostomy patients and allows
to breathe tumor obstruction relearn to speak
patients to get CRT.

Currently, the standard treatment for locally advanced LC, when aiming for lar-
ynx preservation, is concurrent chemoradiation therapy (CRT). This approach combines
high-dose cisplatin chemotherapy with radiation therapy, delivered simultaneously. The
effectiveness of this concurrent approach was established by the RTOG 91-11 trial, which
demonstrated superior larynx preservation rates compared to induction chemotherapy fol-
lowed by radiation or radiation alone [237]. Intensity-modulated radiation therapy (IMRT)
is a widely used technique that allows for highly conformal treatment plans, minimizing
radiation dose to sensitive structures like the spinal cord, oesophagus, and salivary glands,
thereby reducing toxicities [238].
J. Clin. Med. 2025, 14, 3367 15 of 32

Beyond the standard CRT approach, several other therapies and considerations are
relevant in the treatment of LC. For early-stage disease, definitive radiotherapy alone or
laryngeal-sparing surgery may be sufficient [236].
Alternative systemic therapies may be considered for patients who are not candidates
for cisplatin. Although cetuximab, an EGFR inhibitor, can enhance radiation’s effects, it
has shown inferior overall survival compared to cisplatin in certain head and neck can-
cers [239]. Thus, for platinum-ineligible cases, carboplatin and fluorouracil, or cetuximab
alone, might be considered based on improvements in survival compared to radiation
alone in clinical trials.
Immunotherapy, specifically with checkpoint inhibitors like pembrolizumab and
nivolumab, is currently approved for recurrent or metastatic head and neck squamous
cell carcinoma (HNSCC) [240]. Pembrolizumab and nivolumab received FDA approval in
2016 [240,241]. In the pivotal CheckMate 141 Asian subset, nivolumab conferred a median
overall survival of 12.1 months vs. 6.2 months with investigator’s choice therapy, and the
estimated 2-year OS rates were 22.7% vs. 0%, respectively; notably, patients who devel-
oped any treatment-related adverse events particularly skin-related disorders experienced
superior survival, suggesting that early immune-related toxicity may predict benefit [242].
Multiple clinical trials are actively investigating the role of these agents in combination
with radiation therapy for locally advanced LC, exploring their potential as alternative
radiosensitizers [243,244]. For example, the multinational, Phase III, double-blind, placebo-
controlled JAVELIN Head and Neck 100 trial (NCT02952586) is assessing whether adding
the PD-L1 inhibitor avelumab to standard cisplatin-based chemoradiotherapy improves
progression-free and overall survival compared with chemoradiotherapy plus placebo in
patients with high-risk, nonmetastatic, locoregionally advanced HNSCC [245].
Similarly, the Phase III, double-blind, placebo-controlled KEYNOTE-412 trial
(NCT03040999) evaluated the addition of pembrolizumab (200 mg q3w) to standard
cisplatin-based chemoradiotherapy (70 Gy in 35 fractions) in 804 patients with newly
diagnosed, high-risk, unresected, locoregionally advanced HNSCC. Pembrolizumab was
given one dose before CRT, two doses during CRT, and up to 14 maintenance doses there-
after. After a median follow-up of 47.7 months, median event-free survival was not reached
in the pembrolizumab arm versus 46.6 months in the placebo arm (hazard ratio 0.83 [95%
CI 0.68–1.03]; log-rank p = 0.043, above the prespecified threshold of p ≤ 0.024), and median
overall survival was not reached in either arm. Grade ≥3 adverse events occurred in
92% of pembrolizumab-treated versus 88% of placebo-treated patients, with similar safety
profiles and no new signals [246]. This trial highlights the challenge of integrating PD-1
inhibitors into definitive CRT for locally advanced HNSCC and underscores the need for
biomarker-driven strategies.
Pembrolizumab, a highly selective humanized monoclonal antibody, is designed to
disrupt the PD-1 immune checkpoint pathway. It works by binding to the PD-1 receptor on
T cells, preventing it from interacting with its ligands, PD-L1 and PD-L2, which are often
expressed on tumour cells and other cells in the tumour microenvironment. This blockade
releases the “brake” on the immune system, allowing T cells to become activated and attack
cancer cells. In the context of recurrent or metastatic head and neck squamous cell carci-
noma (HNSCC), including LSCC, the Keynote 040 study investigated the effectiveness of
pembrolizumab against standard treatments. In this trial, 247 participants were randomly
assigned to receive either pembrolizumab or one of the following standard-of-care thera-
pies: methotrexate (40–60 mg/m2 ), docetaxel (30–40 mg/m2 ), or cetuximab (250 mg/m2
weekly after an initial 400 mg/m2 loading dose). The median overall survival for patients
treated with pembrolizumab was 8.4 months, compared to 6.9 months for those receiving
standard therapy. This difference represented a statistically significant improvement in
J. Clin. Med. 2025, 14, 3367 16 of 32

survival for the pembrolizumab group, with a hazard ratio (HR) of 0.80 (95% CI 0.65–0.98;
p = 0.0161) [247]. The benefit of pembrolizumab was even more pronounced in patients
whose tumours had a high proportion of cells expressing PD-L1, as indicated by a tumour
proportion score (TPS) of 50% or greater. In this subgroup, the median overall survival was
11.6 months with pembrolizumab versus 6.6 months with standard care, demonstrating
a more substantial and statistically significant improvement (HR: 0.53, 95% CI 0.35–0.81;
p = 0.014) [247].
CTLA-4 inhibitors, such as ipilimumab and tremelimumab, block the CTLA-4 immune
checkpoint on T cells preventing its engagement with CD 80/86—and thereby sustain T-cell
activation to enhance antitumor immunity. In CheckMate 651 (NCT02741570), 947 patients
with previously untreated R/M SCCHN were randomized to first-line nivolumab + ipili-
mumab versus the EXTREME regimen. Neither the overall population (median OS 13.9 vs.
13.5 months; HR 0.95; p = 0.4951) nor the PD-L1 CPS ≥ 20 subgroup (17.6 vs 14.6 months;
HR 0.78; p = 0.0469) met the primary OS endpoint, although nivolumab + ipilimumab had
fewer grade 3–4 treatment-related adverse events (28.2% vs. 70.7%) [248]. In the phase III
KESTREL trial (NCT02551159), neither tumor PD-L1 expression (TC ≥ 50%/IC ≥ 25% or
TC ≥ 25%) nor a low neutrophil-to-lymphocyte ratio (≤7) enriched for improved outcomes
with first-line durvalumab (D) or durvalumab + tremelimumab (D + T) versus EXTREME.
However, in patients whose blood tumor mutational burden was ≥16 mut/Mb, D + T
achieved a median OS hazard ratio of 0.69 (95% CI 0.39–1.25) and a complete response rate
of 8.6% versus 4.3% with EXTREME, suggesting bTMB may help identify those most likely
to benefit from checkpoint blockade [249].
In the phase III KESTREL trial (NCT02551159), first-line durvalumab monother-
apy or durvalumab plus tremelimumab was compared with EXTREME in recur-
rent/metastatic HNSCC, and archival tumors or blood were assayed for PD-L1, blood
tumor mutational burden (bTMB), and neutrophil-to-lymphocyte ratio (NLR). PD-L1
expression (TC ≥ 50%/IC ≥ 25% or TC ≥ 25%) and NLR ≤ 7 failed to enrich for either
overall survival or response rates, whereas in the bTMB ≥ 16 mut/Mb subgroup, durval-
umab plus tremelimumab achieved an OS hazard ratio of 0.69 (95% CI 0.39–1.25) versus
EXTREME and doubled the complete response rate (8.6% vs. 4.3%), suggesting high
bTMB may identify patients most likely to benefit from PD-L1/CTLA-4 blockade.
In the phase III CheckMate 651 trial, first-line nivolumab plus ipilimumab did not
improve overall survival compared with the EXTREME regimen in patients with recurrent
or metastatic SCCHN, yielding a median OS of 13.9 versus 13.5 months in the intent-to-
treat population (HR 0.95, p = 0.495) and 17.6 versus 14.6 months in those with PD-L1
CPS ≥ 20 (HR 0.78, p = 0.047), despite a substantially lower rate of grade 3–4 treatment-
related adverse events (28.2% vs. 70.7%). Among responders, the duration of response was
markedly longer with nivolumab/ipilimumab (32.6 vs. 7.0 months), but progression-free
survival and response rates were similar between arms.
Proton therapy represents another evolving radiation modality. It offers the potential
for a more favourable therapeutic window compared to photons due to the Bragg Peak
phenomenon, where the majority of the radiation dose is deposited at a specific depth,
minimizing the dose beyond the target. However, access to proton therapy is limited,
and prospective, multi-institutional data comparing it to IMRT are still emerging [250].
Stereotactic body radiation therapy (SBRT), which delivers very high doses of radiation in a
few fractions, is being investigated for early-stage glottic cancers but is not yet established
for laryngeal preservation and should only be used within a clinical trial [251].
While many treatments focus on larynx preservation, total laryngectomy (TL) remains
a crucial option, particularly for patients with extensive tumour invasion, significant
pre-existing swallowing dysfunction, or those who are not candidates for or have failed
J. Clin. Med. 2025, 14, 3367 17 of 32

organ preservation approaches. Total laryngectomy involves the complete removal of

the larynx (voice box), resulting in permanent loss of natural voice production. This
procedure necessitates the creation of a permanent tracheostoma, an opening in the neck,
for breathing. While a significant intervention, TL can be the most effective treatment for
achieving complete tumour removal in certain cases. After a total laryngectomy, patients
require relearning for tasks like speaking [252].
In addition, a tracheostomy can secure the airway in patients with significant tumour
obstruction, allowing them to undergo CRT instead of requiring a total laryngectomy [253].
Minimally invasive surgical techniques have significantly advanced, offering patients
less invasive options with potentially improved functional outcomes. Two prominent
techniques are transoral laser microsurgery (TLM) and transoral robotic surgery (TORS).
TLM employs a CO2 laser to precisely resect laryngeal tumours through the mouth,
avoiding external incisions. Unlike open partial laryngectomy, TLM focuses on removing
the tumour with margins while preserving normal structures to optimize function. The
European Laryngological Society (ELS) has a classification system for cordectomies, with
six types based on resection depth and area [254].
TLM’s primary indication is early-stage vocal fold cancers (Tis, T1, and T2), with
consideration for some advanced cases [255]. Limitations include tumours with reduced
vocal fold mobility from cricoarytenoid joint fixation/infiltration (though usable with
muscle infiltration without joint fixation), cricoid cartilage resection, and the necessity
to preserve at least one cricoarytenoid unit [256,257]. TLM has also been applied to
supraglottic and hypopharyngeal tumours, demonstrating comparable oncological results
and better functional outcomes (less tracheotomy, faster swallowing, shorter hospital stays)
than open surgeries [258,259].
TLM is a gold standard for early vocal fold cancers due to high disease-free survival,
local/regional control, and larynx preservation rates, sometimes exceeding those of radio-
therapy. It offers better postoperative and quality-of-life outcomes than open surgery or
radiotherapy and is more cost-effective [260–262].
TORS uses the da Vinci system, providing 3D visualization, enhanced instrument ma-
noeuvrability, tremor reduction, and improved movement. TORS received FDA approval in
2009 for specific laryngeal, oropharyngeal, and oral carcinomas and benign tumours. TORS
is commonly used for cT1-T2 and some selected cT3-T4a oropharyngeal and supraglottic
cancers with adequate visualization and instrument access. TORS supraglottic laryngec-
tomy shows similar oncological results to open procedures, with good functional outcomes
(rapid oral diet resumption, low permanent tracheotomy rates) [263,264].
TORS’s role in glottic cancer is less defined. Studies are controversial, with the current
robotic instrument length not ideally suited. Research indicates that TORS for glottic cancer
has exposure issues, higher costs, increased feeding tube and tracheotomy needs, and more
complications than TLM [265–267].

3.8. Survival
The prognosis for patients with LC is strongly correlated with the disease stage at
initial diagnosis and treatment. Other factors that play a role in survival are the patient’s
general health and smoking cessation. In the United States, the overall 5-year survival
rate for LC is 61% [268]. Survival rates decline significantly with the advancing stage. For
diseases confined to the larynx (stages I and II), the 5-year survival rate is 78%. However,
regional lymph node metastases (stage III) reduce the 5-year survival to 46%, and distant
metastases lower it to 34% [269]. Survival outcomes also vary by laryngeal subsite. Glottic
cancer generally has the most favourable prognosis, followed by supraglottic cancer, with
subglottic tumours having the least favourable outlook [113]. Specifically, the overall 5-year
J. Clin. Med. 2025, 14, 3367 18 of 32

survival for glottic SCC is 77%, reaching 84% for localized disease (stages I and II) but
decreasing to 52% with nodal involvement (stage III) and 45% with distant spread [270].
For supraglottic SCC, the overall 5-year survival is 45%, with rates of 61% for localized
disease, 46% for stage III, and 30% for metastatic disease [271,272]. Subglottic SCC has an
overall 5-year survival rate of 49%, 59% for stages I and II, 38% for stage III, and 44% for
metastatic disease [273,274].
The accurate prediction of prognosis in LC is crucial for tailoring treatment strategies.
While the TNM staging system provides a foundation, it does not fully capture the het-
erogeneity of the disease, particularly regarding the impact of lymph node involvement.
Therefore, integrating both clinical factors and biomarkers into comprehensive prognostic
models is an area of active investigation. Recent efforts have focused on developing nomo-
grams which is a statistical tools that combine multiple variables to provide individualized
risk assessments. For instance, Juan et al., (2024) [275] developed and validated nomo-
grams specifically for early-stage LSCC to predict postoperative recurrence-free survival
(RFS) and overall survival (OS). Their models incorporated readily available preoperative
blood markers (platelet counts, fibrinogen, platelet-to-lymphocyte ratio, systemic immune-
inflammation index, and hemoglobin) alongside clinicopathological characteristics (tumor
diameter and differentiation degree). These nomograms demonstrated superior predictive
accuracy compared to T staging alone [275].
Similarly, Shi et al., (2017) [276] developed nomograms for LSCC patients undergoing
neck dissection, incorporating the lymph node ratio (LNR)—a factor reflecting both the
extent of nodal disease and the thoroughness of the dissection—along with a compre-
hensive set of clinical and pathological factors, including T stage, N stage, tumor size
and demographics. Their models, validated both internally and externally, also showed
improved predictive performance for both OS and cancer-specific survival (CSS) compared
to models without LNR and to traditional TNM staging [276]. These studies highlight that
readily available clinical parameters and biomarkers can significantly enhance prognos-
tication in LSCC, there is a need for further investigations into developing new scoring
systems. Further research that include novel biomarkers discussed in the review may
improve current scoring system and therefore, be used by clinicians to decide the optimal
personalized treatment.
Quality-of-life (QoL) outcomes are paramount in the treatment of LC, particularly
when comparing organ-preserving approaches versus TL. For early-stage (T1-T2) glottic
cancers, both TLM and RT aim for larynx preservation, but their impact on voice and QoL
can differ. A meta-analysis by Qasem et al., (2024) [277] found no significant difference
between TLM and RT in overall voice-related QoL measures, including the Voice Handicap
Index-30 (VHI-30). However, TLM was associated with significantly better outcomes
in specific acoustic parameters like jitter and shimmer, suggesting potentially improved
voice stability [277]. In more advanced T3 glottic cancers, TLM can still be an option,
and Chien et al., (2020) [278] showed that carefully selected T3 glottic SCC patients could
achieve satisfactory QoL and larynx preservation rates after CO2 TLM. Even after total
laryngectomy, where the larynx is removed, voice rehabilitation is crucial for QoL [278].
However, Wulff et al., (2020) [279], in a systematic review, found that individuals who
underwent TL generally reported worse health-related quality of life (HRQoL) compared
to a male normative reference population, though the reported symptom burden was often
mild. The heterogeneity and generally low quality of existing studies highlight a need
for more rigorous research in this area [279]. These studies, overall, emphasize a need for
individualized assessment when choosing a treatment and obtaining a high level of QoL.
Table 5 shows a summary of survival data provided within this section.
J. Clin. Med. 2025, 14, 3367 19 of 32

Table 5. Survival Rates and Prognostic Factors in LC.

Factor Subcategory/Details Impact on Survival

Showed the best prognosis. 5-year survival:
Stage (TNM) I & II (localized)
78% [269].
III (regional lymph node Showed an intermediate prognosis. 5-year
involvement) survival: 46% [269].
Showed the poorest prognosis. 5-year survival:
IV (distant metastases)
34% [269].
Generally best prognosis; overall 5-year
Laryngeal Subsite Glottic survival: 77%; localized: 84%; nodal
involvement: 52%; distant spread: 45% [270].
Overall 5-year survival: 45%; localized: 61%;
Supraglottic
stage III: 46%; metastatic: 30% [270].
Worst prognosis; overall 5-year survival: 49%;
Subglottic stages I & II: 59%; stage III: 38%; metastatic:
44% [270].
Lymph Node Status N0 (no nodal involvement) Better prognosis.
Significantly worse prognosis; higher risk of
N+ (nodal involvement)
recurrence and distant metastasis.
Significantly increases risk of distant metastasis
Extranodal Extension (ENE)
(potentially tenfold).
Histological Grade Well-differentiated Generally better prognosis.
Generally worse prognosis; higher risk of
Poorly differentiated
recurrence and metastasis.
Age, general health, performance Poorer general health, older age, and continued
Patient Factors
status, comorbidities, smoking smoking associated with worse outcomes.
Can provide additional prognostic information
See Table 3 (multiple biomarkers
Biomarkers beyond TNM staging; potential for
with varying prognostic value)
personalized risk assessment.
Nomograms incorporating clinical
Prognostic Models Can improve prognostication in LSCC.
factors and biomarkers
Overall, voice-related QoL measures are not
significantly different between TLM and RT,
TLM patients demonstrated better outcomes in
specific acoustic measures. Carefully selected
QoL TLM, RT, and TL T3 glottic SCC patients achieve satisfactory
QoL and larynx preservation rates after CO2
TLM. Individuals who underwent TL reported
worse HRQoL compared to a male normative
reference population.

4. Conclusions
LC, a complex and heterogeneous disease, presents significant diagnosis, treatment,
and prognostication challenges. This review has highlighted the crucial role of accurate stag-
ing in guiding treatment decisions, incorporating both clinical and pathological findings.
The distinct histological variants of LSCC, each with unique characteristics and behaviors,
necessitate careful pathological evaluation. The expanding knowledge of biomarkers offers
the potential for improved risk stratification and personalized treatment approaches, al-
though further validation is needed for many of these markers. While treatment strategies
J. Clin. Med. 2025, 14, 3367 20 of 32

have evolved, with a growing emphasis on organ preservation, the advanced-stage disease
continues to pose a significant challenge.
Recognizing that no single specialist can address every nuance of LC care, it is essential
to integrate multidisciplinary team (MDT) decision-making throughout the patient journey.
Regular MDT reviews, which bring together head and neck surgeons, radiation and medical
oncologists, radiologists, pathologists, and allied health professionals, ensure that emerging
biomarkers and novel therapies are interpreted within a comprehensive clinical context.
Future research in LC must address several critical gaps to advance the field. A pri-
mary focus should be the rigorous validation of promising biomarkers, moving beyond
exploratory studies to establish their clinical utility in diverse patient populations and treat-
ment settings. This includes standardizing assays and determining optimal cut-off values
for clinical decision-making. Simultaneously, the development of novel targeted therapies
is crucial, particularly those addressing specific molecular alterations driving tumor growth
and resistance. Emphasis should also be on personalized medicine. This means creating
strategies that are individualized and focus on the combination of specific tumoral factors
and host factors. This personalized approach necessitates integrating comprehensive ge-
nomic and proteomic profiling with detailed clinical data to tailor treatment selection and
predict response to therapies. Finally, optimizing treatment strategies, including refining
radiation techniques, exploring immunotherapy combinations, and developing strategies
to overcome resistance, is essential to improve patient outcomes and quality of life.

Author Contributions: Conceptualization, A.-R.H. and E.R.B.; methodology, A.-R.H.; software, D.P.;
validation, G.I., D.H. and L.M.; formal analysis, G.I.; investigation, D.H. and N.C.B.; resources,
R.G.; data curation, D.P.; writing—original draft preparation, A.-R.H.; writing—review and editing,
A.C.M. and N.C.B.; visualization, M.C.; supervision, A.C.M.; project administration, E.R.B.; funding
acquisition, E.R.B. All authors have read and agreed to the published version of the manuscript.

Funding: This research received no external funding.

Acknowledgments: We would like to acknowledge “Victor Babes” University of Medicine and

Pharmacy for their support in covering the costs of publication for this research paper.

Conflicts of Interest: The authors declare no conflicts of interest.

References
1. Mody, M.D.; Rocco, J.W.; Yom, S.S.; Haddad, R.I.; Saba, N.F. Head and Neck Cancer. Lancet 2021, 398, 2289–2299. [CrossRef]
[PubMed]
2. Bray, F.; Laversanne, M.; Sung, H.; Ferlay, J.; Siegel, R.L.; Soerjomataram, I.; Jemal, A. Global Cancer Statistics 2022: GLOBOCAN
Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J. Clin. 2024, 74, 229–263. [CrossRef]
[PubMed]
3. Ciolofan, M.S.; Vlăescu, A.N.; Mogoantă, C.-A.; Ionit, ă, E.; Ionit, ă, I.; Căpitănescu, A.-N.; Mitroi, M.-R.; Anghelina, F. Clinical,
Histological and Immunohistochemical Evaluation of Larynx Cancer. Curr. Health Sci. J. 2017, 43, 367–375. [CrossRef]
4. Ferlay, J.; Ervik, M.; Lam, F.; Laversanne, M.; Colombet, M.; Mery, L.; Piñeros, M.; Znaor, A.; Soerjomataram, I.; Bray, F.; et al. Lyon,
France: International Agency for Research on Cancer. Available online: https://gco.iarc.who.int/media/globocan/factsheets/
cancers/14-larynx-fact-sheet.pdf (accessed on 14 March 2025).
5. Zuo, J.-J.; Tao, Z.-Z.; Chen, C.; Hu, Z.-W.; Xu, Y.-X.; Zheng, A.-Y.; Guo, Y. Characteristics of Cigarette Smoking without Alcohol
Consumption and Laryngeal Cancer: Overall and Time-Risk Relation. A Meta-Analysis of Observational Studies. Eur. Arch.
Oto-Rhino-Laryngol. 2017, 274, 1617–1631. [CrossRef] [PubMed]
6. Kis, A.M.; Watz, C.G.; Motofelea, A.C.; Chiriac, S.; Poenaru, M.; Dehelean, C.A.; Borza, C.; Ionita, I. Challenges of Pharyngeal
Cancer Screening in Lower-Income Countries during Economic and Social Transitions: A Population-Based Analysis. Eur. J.
Investig. Health Psychol. Educ. 2023, 13, 2226–2237. [CrossRef]
7. Tang, J.A.; Lango, M.N. Diverging Incidence Trends for Larynx and Tonsil Cancer in Low Socioeconomic Regions of the US. Oral.
Oncol. 2019, 91, 65–68. [CrossRef]
J. Clin. Med. 2025, 14, 3367 21 of 32

8. Liao, L.; Wang, H.; Cui, W.; Zhang, Q.; He, X.; Wang, L.; Xiong, Y.; Jiang, L.; Xie, Y. Global, Regional and National Burden and
Trends of Larynx Cancer among Adults Aged 55 and Older from 1990 to 2021: Results from the Global Burden of Disease Study
2021. BMC Public. Health 2025, 25, 906. [CrossRef]
9. Wang, J.-Y.; Zhang, Q.-W.; Wen, K.; Wang, C.; Ji, X.; Zhang, L. Temporal Trends in Incidence and Mortality Rates of Laryngeal
Cancer at the Global, Regional and National Levels, 1990–2017. BMJ Open 2021, 11, e050387. [CrossRef]
10. Balogun, O.; Rodin, D.; Ngwa, W.; Grover, S.; Longo, J. Challenges and Prospects for Providing Radiation Oncology Services in
Africa. Semin. Radiat. Oncol. 2017, 27, 184–188. [CrossRef]
11. Chang, C.-P.; Chang, S.-C.; Chuang, S.-C.; Berthiller, J.; Ferro, G.; Matsuo, K.; Wünsch-Filho, V.; Toporcov, T.N.; de Carvalho, M.B.;
La Vecchia, C. Age at Start of Using Tobacco on the Risk of Head and Neck Cancer: Pooled Analysis in the International Head
and Neck Cancer Epidemiology Consortium (INHANCE). Cancer Epidemiol. 2019, 63, 101615. [CrossRef]
12. Di Credico, G.; Edefonti, V.; Polesel, J.; Pauli, F.; Torelli, N.; Serraino, D.; Negri, E.; Luce, D.; Stucker, I.; Matsuo, K. Joint Effects of
Intensity and Duration of Cigarette Smoking on the Risk of Head and Neck Cancer: A Bivariate Spline Model Approach. Oral.
Oncol. 2019, 94, 47–57. [CrossRef] [PubMed]
13. LoConte, N.K.; Brewster, A.M.; Kaur, J.S.; Merrill, J.K.; Alberg, A.J. Alcohol and Cancer: A Statement of the American Society of
Clinical Oncology. J. Clin. Oncol. 2018, 36, 83–93. [CrossRef] [PubMed]
14. Berdzuli, N.; Ferreira-Borges, C.; Gual, A.; Rehm, J. Alcohol Control Policy in Europe: Overview and Exemplary Countries. Int. J.
Environ. Res. Public Health 2020, 17, 8162. [CrossRef] [PubMed]
15. Bagnardi, V.; Rota, M.; Botteri, E.; Tramacere, I.; Islami, F.; Fedirko, V.; Scotti, L.; Jenab, M.; Turati, F.; Pasquali, E. Alcohol
Consumption and Site-Specific Cancer Risk: A Comprehensive Dose–Response Meta-Analysis. Br. J. Cancer 2015, 112, 580–593.
[CrossRef]
16. He, J.; Meng, H.; Yao, G.; Fu, Y.; Geng, J. New Research Progress of HPV and Larynx Cancer. Progress. Mod. Biomed. 2017, 17,
5989–5992.
17. Peng, W.; Mi, J.; Jiang, Y. Asbestos Exposure and Laryngeal Cancer Mortality. Laryngoscope 2016, 126, 1169–1174. [CrossRef]
18. Hall, A.L.; Kromhout, H.; Schüz, J.; Peters, S.; Portengen, L.; Vermeulen, R.; Agudo, A.; Ahrens, W.; Boffetta, P.; Brennan, P.
Laryngeal Cancer Risks in Workers Exposed to Lung Carcinogens: Exposure–Effect Analyses Using a Quantitative Job Exposure
Matrix. Epidemiology 2020, 31, 145–154. [CrossRef]
19. Haddad, G.; Sataloff, R.T.; Hamdan, A.-L. Laryngeal Metastatic Lesions: A Literature Review. J. Voice 2024, 38, 1458–1464.
[CrossRef]
20. Santos, A.; Santos, I.C.; dos Reis, P.F.; Rodrigues, V.D.; Peres, W.A.F. Impact of Nutritional Status on Survival in Head and Neck
Cancer Patients After Total Laryngectomy. Nutr. Cancer 2022, 74, 1252–1260. [CrossRef]
21. Siegel, R.; Ma, J.; Zou, Z.; Jemal, A. Cancer Statistics, 2014. CA Cancer J. Clin. 2014, 64, 9–29. [CrossRef]
22. Hoffmann, T.K. Systemic therapy strategies for head-neck carcinomas: Current status. Laryngo Rhino Otol. 2012, 91 (Suppl. 1),
S23–S143. [CrossRef]
23. Baird, B.J.; Sung, C.K.; Beadle, B.M.; Divi, V. Treatment of Early-Stage Laryngeal Cancer: A Comparison of Treatment Options.
Oral. Oncol. 2018, 87, 8–16. [CrossRef]
24. Zhang, Y.; Li, Y.; Fu, Q.; Han, Z.; Wang, D.; Umar Shinge, S.A.; Muluh, T.A.; Lu, X. Combined Immunotherapy and Targeted
Therapies for Cancer Treatment: Recent Advances and Future Perspectives. Curr. Cancer Drug Targets 2023, 23, 251–264. [CrossRef]
[PubMed]
25. Bradford, C.R.; Ferlito, A.; Devaney, K.O.; Mäkitie, A.A.; Rinaldo, A. Prognostic Factors in Laryngeal Squamous Cell Carcinoma.
Laryngoscope Investig. Otolaryngol. 2020, 5, 74–81. [CrossRef] [PubMed]
26. Bray, F.; Ferlay, J.; Soerjomataram, I.; Siegel, R.L.; Torre, L.A.; Jemal, A. Global Cancer Statistics 2018: GLOBOCAN Estimates of
Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J. Clin. 2018, 68, 394–424. [CrossRef]
27. Lortet-Tieulent, J.; Sauer, A.G.; Siegel, R.L.; Miller, K.D.; Islami, F.; Fedewa, S.A.; Jacobs, E.J.; Jemal, A. State-Level Cancer
Mortality Attributable to Cigarette Smoking in the United States. JAMA Intern. Med. 2016, 176, 1792–1798. [CrossRef]
28. Permitasari, A.L.; Satibi, S.; Kristina, S.A. National Burden of Cancers Attributable to Secondhand Smoking in Indonesia. Asian
Pac. J. Cancer Prev. 2018, 19, 1951–1955.
29. Allegra, E.; Bianco, M.R.; Ralli, M.; Greco, A.; Angeletti, D.; De Vincentiis, M. Role of Clinical-Demographic Data in Survival
Rates of Advanced Laryngeal Cancer. Medicina 2021, 57, 267. [CrossRef]
30. Voltzke, K.J.; Lee, Y.-C.A.; Zhang, Z.-F.; Zevallos, J.P.; Yu, G.-P.; Winn, D.M.; Vaughan, T.L.; Sturgis, E.M.; Smith, E.; Schwartz, S.M.
Racial Differences in the Relationship between Tobacco, Alcohol, and the Risk of Head and Neck Cancer: Pooled Analysis of US
Studies in the INHANCE Consortium. Cancer Causes Control 2018, 29, 619–630. [CrossRef]
31. Manthey, J.; Shield, K.D.; Rylett, M.; Hasan, O.S.M.; Probst, C.; Rehm, J. Global Alcohol Exposure between 1990 and 2017 and
Forecasts until 2030: A Modelling Study. Lancet 2019, 393, 2493–2502. [CrossRef]
J. Clin. Med. 2025, 14, 3367 22 of 32

32. Grevers, X.; Ruan, Y.; Poirier, A.E.; Walter, S.D.; Villeneuve, P.J.; Friedenreich, C.M.; Brenner, D.R.; Team, C.S. Estimates of the
Current and Future Burden of Cancer Attributable to Alcohol Consumption in Canada. Prev. Med. 2019, 122, 40–48. [CrossRef]
[PubMed]
33. Szukalska, M.; Szyfter, K.; Florek, E.; Rodrigo, J.P.; Rinaldo, A.; Mäkitie, A.A.; Strojan, P.; Takes, R.P.; Suárez, C.; Saba, N.F.; et al.
Electronic Cigarettes and Head and Neck Cancer Risk-Current State of Art. Cancers 2020, 12, 3274. [CrossRef] [PubMed]
34. Lim, H.-H.; Shin, H.-S. Measurement of Aldehydes in Replacement Liquids of Electronic Cigarettes by Headspace Gas
Chromatography-Mass Spectrometry. Bull. Korean Chem. Soc. 2013, 34, 2691–2696. [CrossRef]
35. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans; World Health Organization; International Agency for
Research on Cancer. Tobacco Smoke and Involuntary Smoking; IARC: Lyon, France, 2004; ISBN 9283212835.
36. Jethwa, A.R.; Khariwala, S.S. Tobacco-Related Carcinogenesis in Head and Neck Cancer. Cancer Metastasis Rev. 2017, 36, 411–423.
[CrossRef]
37. Khariwala, S.S.; Carmella, S.G.; Stepanov, I.; Fernandes, P.; Lassig, A.A.; Yueh, B.; Hatsukami, D.; Hecht, S.S. Elevated Levels of
1-hydroxypyrene and N′ -nitrosonornicotine in Smokers with Head and Neck Cancer: A Matched Control Study. Head Neck 2013,
35, 1096–1100. [CrossRef]
38. Salturk, Z.; Çakır, Ç.; Sünnetçi, G.; Atar, Y.; Kumral, T.L.; Yıldırım, G.; Berkiten, G.; Uyar, Y. Effects of Electronic Nicotine Delivery
System on Larynx: Experimental Study. J. Voice 2015, 29, 560–563. [CrossRef]
39. Sheikh, M.; Shakeri, R.; Poustchi, H.; Pourshams, A.; Etemadi, A.; Islami, F.; Khoshnia, M.; Gharavi, A.; Roshandel, G.; Khademi,
H. Opium Use and Subsequent Incidence of Cancer: Results from the Golestan Cohort Study. Lancet Glob. Health 2020, 8,
e649–e660. [CrossRef]
40. Mohebbi, E.; Hadji, M.; Rashidian, H.; Rezaianzadeh, A.; Marzban, M.; Haghdoost, A.A.; Naghibzadeh Tahami, A.; Moradi,
A.; Gholipour, M.; Najafi, F. Opium Use and the Risk of Head and Neck Squamous Cell Carcinoma. Int. J. Cancer 2021, 148,
1066–1076. [CrossRef]
41. Tsimplaki, E.; Argyri, E.; Sakellaridis, A.; Kyrodimos, E.; Xesfyngi, D.; Panotopoulou, E. Oropharyngeal and Laryngeal but
Not Oral Cancers Are Strongly Associated with High-risk Human Papillomavirus in 172 Greek Patients. J. Med. Virol. 2017, 89,
170–176. [CrossRef]
42. Sabatini, M.E.; Chiocca, S. Human Papillomavirus as a Driver of Head and Neck Cancers. Br. J. Cancer 2020, 122, 306–314.
[CrossRef]
43. Nahet, A.; Boublenza, L.; Hassaine, H.; Masdoua, N.; Pretet, J.-L.; Belglaiaa, E.; Mougin, C. HPV DNA Genotyping: A Study of
Anogenital, Head and Neck and Skin Cancers in a Population from West Algerian. HPV Detection in Different Cancers from an
Algerian Population. Bull. Cancer 2016, 103, 455–460. [CrossRef] [PubMed]
44. Kariche, N.; Hortal, M.T.; Benyahia, S.; Alemany, L.; Moulaï, N.; Clavero, O.; Muñoz, M.; Ouahioune, W.; Djennaoui, D.; Touil-
Boukoffa, C. Comparative Assessment of HPV, Alcohol and Tobacco Etiological Fractions in Algerian Patients with Laryngeal
Squamous Cell Carcinoma. Infect. Agents Cancer 2018, 13, 1–8. [CrossRef] [PubMed]
45. Chen, W.-C.; Chuang, H.-C.; Lin, Y.-T.; Huang, C.-C.; Chien, C.-Y. Clinical Impact of Human Papillomavirus in Laryngeal
Squamous Cell Carcinoma: A Retrospective Study. PeerJ 2017, 5, e3395. [CrossRef]
46. De Lima, M.A.P.; Silva, Á.D.L.; do Nascimento Filho, A.C.S.; Cordeiro, T.L.; Bezerra, J.P.d.S.; Rocha, M.A.B.; Pinheiro, S.d.F.L.;
Pinheiro, R.F.F., Jr.; Gadelha, M.d.S.V.; da Silva, C.G.L. Epstein-Barr Virus-Associated Carcinoma of the Larynx: A Systematic
Review with Meta-Analysis. Pathogens 2021, 10, 1429. [CrossRef]
47. Vazquez-Guillen, J.M.; Palacios-Saucedo, G.C.; Alanis-Valdez, A.Y.; Huerta-Escobedo, A.; Zavala-Pompa, A.; Rivera-Morales, L.G.;
Martinez-Torres, A.C.; Gonzalez-Villasana, V.; Serna-Hernandez, J.C.; Hernandez-Martinez, S.J. p16INK4a and pRb Expression in
Laryngeal Squamous Cell Carcinoma with and without Infection by EBV or Different Genotypes of HPV: A Retrospective Study.
Infect. Agents Cancer 2023, 18, 43. [CrossRef]
48. Igissin, N.; Zatonskikh, V.; Telmanova, Z.; Tulebaev, R.; Moore, M. Laryngeal Cancer: Epidemiology, Etiology, and Prevention: A
Narrative Review. Iran. J. Public Health 2023, 52, 2248–2259. [CrossRef]
49. Wu, Y.-H.; Yen, C.-J.; Hsiao, J.-R.; Ou, C.-Y.; Huang, J.-S.; Wong, T.-Y.; Tsai, S.-T.; Huang, C.-C.; Lee, W.-T.; Chen, K.-C. A
Comprehensive Analysis on the Association between Tobacco-Free Betel Quid and Risk of Head and Neck Cancer in Taiwanese
Men. PLoS ONE 2016, 11, e0164937. [CrossRef]
50. Chang, C.; Siwakoti, B.; Sapkota, A.; Gautam, D.K.; Lee, Y.A.; Monroe, M.; Hashibe, M. Tobacco Smoking, Chewing Habits,
Alcohol Drinking and the Risk of Head and Neck Cancer in Nepal. Int. J. Cancer 2020, 147, 866–875. [CrossRef]
51. Zhou, J.; Zhang, D.; Yang, Y.; Zhou, L.; Tao, L. Association between Helicobacter Pylori Infection and Carcinoma of the Larynx or
Pharynx. Head Neck 2016, 38, E2291–E2296. [CrossRef]
52. Eells, A.C.; Mackintosh, C.; Marks, L.; Marino, M.J. Gastroesophageal Reflux Disease and Head and Neck Cancers: A Systematic
Review and Meta-Analysis. Am. J. Otolaryngol. 2020, 41, 102653. [CrossRef]
53. Parsel, S.M.; Wu, E.L.; Riley, C.A.; McCoul, E.D. Gastroesophageal and Laryngopharyngeal Reflux Associated with Laryngeal
Malignancy: A Systematic Review and Meta-Analysis. Clin. Gastroenterol. Hepatol. 2019, 17, 1253–1264. [CrossRef] [PubMed]
J. Clin. Med. 2025, 14, 3367 23 of 32

54. Sereg-Bahar, M.; Jerin, A.; Hocevar-Boltezar, I. Higher Levels of Total Pepsin and Bile Acids in the Saliva as a Possible Risk Factor
for Early Laryngeal Cancer. Radiol. Oncol. 2015, 49, 59–64. [CrossRef] [PubMed]
55. Kim, S.-Y.; Han, K.; Joo, Y.-H. Metabolic Syndrome and Incidence of Laryngeal Cancer: A Nationwide Cohort Study. Sci. Rep.
2019, 9, 667. [CrossRef]
56. Kim, H.-B.; Kim, G.-J.; Han, K.; Joo, Y.-H. Changes in Metabolic Syndrome Status and Risk of Laryngeal Cancer: A Nationwide
Cohort Study. PLoS ONE 2021, 16, e0252872. [CrossRef]
57. Gong, H.-L.; Shi, Y.; Zhou, L.; Wu, C.-P.; Cao, P.-Y.; Tao, L.; Xu, C.; Hou, D.-S.; Wang, Y.-Z. The Composition of Microbiome in
Larynx and the Throat Biodiversity between Laryngeal Squamous Cell Carcinoma Patients and Control Population. PLoS ONE
2013, 8, e66476. [CrossRef]
58. Yu, S.; Chen, J.; Zhao, Y.; Yan, F.; Fan, Y.; Xia, X.; Shan, G.; Zhang, P.; Chen, X. Oral-Microbiome-Derived Signatures Enable
Non-Invasive Diagnosis of Laryngeal Cancers. J. Transl. Med. 2023, 21, 438. [CrossRef]
59. Li, Y.; Tan, X.; Zhao, X.; Xu, Z.; Dai, W.; Duan, W.; Huang, S.; Zhang, E.; Liu, J.; Zhang, S.; et al. Composition and Function of Oral
Microbiota between Gingival Squamous Cell Carcinoma and Periodontitis. Oral. Oncol. 2020, 107, 104710. [CrossRef]
60. Kau, A.L.; Ahern, P.P.; Griffin, N.W.; Goodman, A.L.; Gordon, J.I. Human Nutrition, the Gut Microbiome and the Immune System.
Nature 2011, 474, 327–336. [CrossRef]
61. Kelly, D.; Mulder, I.E. Microbiome and Immunological Interactions. Nutr. Rev. 2012, 70, S18–S30. [CrossRef]
62. Arthur, J.C.; Perez-Chanona, E.; Mühlbauer, M.; Tomkovich, S.; Uronis, J.M.; Fan, T.-J.; Campbell, B.J.; Abujamel, T.; Dogan,
B.; Rogers, A.B.; et al. Intestinal Inflammation Targets Cancer-Inducing Activity of the Microbiota. Science 2012, 338, 120–123.
[CrossRef]
63. Hayes, R.B.; Ahn, J.; Fan, X.; Peters, B.A.; Ma, Y.; Yang, L.; Agalliu, I.; Burk, R.D.; Ganly, I.; Purdue, M.P.; et al. Association of Oral
Microbiome With Risk for Incident Head and Neck Squamous Cell Cancer. JAMA Oncol. 2018, 4, 358–365. [CrossRef] [PubMed]
64. McMaughan, D.J.; Oloruntoba, O.; Smith, M.L. Socioeconomic Status and Access to Healthcare: Interrelated Drivers for Healthy
Aging. Front. Public Health 2020, 8, 231. [CrossRef] [PubMed]
65. Fullmer, T.; Wilde, D.C.; Shi, J.W.; Wagner, T.; Skinner, H.; Eicher, S.A.; Sandulache, V.C.; Hernandez, D.J. Demographic and
Tumor Characteristic Impact on Laryngeal Cancer Outcomes in a Minority Underserved Patient Population. Otolaryngol. Head
Neck Surg. 2020, 162, 888–896. [CrossRef]
66. Lu, Y.; Li, P.; Luo, G.; Liu, D.; Zou, H. Cancer Attributable to Human Papillomavirus Infection in China: Burden and Trends.
Cancer 2020, 126, 3719–3732. [CrossRef]
67. Buttmann-Schweiger, N.; Deleré, Y.; Klug, S.J.; Kraywinkel, K. Cancer Incidence in Germany Attributable to Human Papillo-
mavirus in 2013. BMC Cancer 2017, 17, 1–8. [CrossRef]
68. Senkomago, V. Human Papillomavirus–Attributable Cancers—United States, 2012–2016. MMWR. Morb. Mortal. Wkly. Rep. 2019,
68, 724–728. [CrossRef]
69. Wang, N.; Lv, H.; Huang, M. Impact of Gender on Survival in Patients with Laryngeal Squamous Cell Carcinoma: A Propensity
Score Matching Analysis. Int. J. Clin. Exp. Pathol. 2020, 13, 573–581.
70. Hashim, D.; Genden, E.; Posner, M.; Hashibe, M.; Boffetta, P. Head and Neck Cancer Prevention: From Primary Prevention to
Impact of Clinicians on Reducing Burden. Ann. Oncol. 2019, 30, 744–756. [CrossRef]
71. Andersson, T.M.L.; Engholm, G.; Pukkala, E.; Stenbeck, M.; Tryggvadottir, L.; Storm, H.; Weiderpass, E. Avoidable Cancers in the
Nordic Countries—The Impact of Alcohol Consumption. Eur. J. Cancer 2018, 103, 299–307. [CrossRef]
72. Zhou, T.; Wang, X.; Zhu, Q.; Zhou, E.; Zhang, J.; Song, F.; Xu, C.; Shen, Y.; Zou, J.; Zhu, H.; et al. Global Trends and Risk Factors
of Laryngeal Cancer: A Systematic Analysis for the Global Burden of Disease Study (1990–2021). BMC Cancer 2025, 25, 296.
[CrossRef]
73. Liberale, C.; Soloperto, D.; Marchioni, A.; Monzani, D.; Sacchetto, L. Updates on Larynx Cancer: Risk Factors and Oncogenesis.
Int. J. Mol. Sci. 2023, 24, 12913. [CrossRef] [PubMed]
74. Dutta, R.; Husain, Q.; Kam, D.; Dubal, P.M.; Baredes, S.; Eloy, J.A. Laryngeal Papillary Squamous Cell Carcinoma. Otolaryngol.
Head Neck Surg. 2015, 153, 54–59. [CrossRef] [PubMed]
75. MacNeil, S.D. Non-Squamous Laryngeal Cancer. Otolaryngol. Clin. N. Am. 2023, 56, 345–359. [CrossRef] [PubMed]
76. Dubal, P.M.; Marchiano, E.; Kam, D.; Dutta, R.; Kalyoussef, E.; Baredes, S.; Eloy, J.A. Laryngeal Spindle Cell Carcinoma: A
Population-Based Analysis of Incidence and Survival. Laryngoscope 2015, 125, 2709–2714. [CrossRef]
77. Gerry, D.; Fritsch, V.A.; Lentsch, E.J. Spindle Cell Carcinoma of the Upper Aerodigestive Tract. Ann. Otol. Rhinol. Laryngol. 2014,
123, 576–583. [CrossRef]
78. Fritsch, V.A.; Lentsch, E.J. Basaloid Squamous Cell Carcinoma of the Larynx: Analysis of 145 Cases with Comparison to
Conventional Squamous Cell Carcinoma. Head Neck 2013, 36, 164–170. [CrossRef]
79. Kass, J.I.; Lee, S.C.; Abberbock, S.; Seethala, R.R.; Duvvuri, U. Adenosquamous Carcinoma of the Head and Neck: Molecular
Analysis Using CRTC-MAML FISH and Survival Comparison with Paired Conventional Squamous Cell Carcinoma. Laryngoscope
2015, 125, E371–E376. [CrossRef]
J. Clin. Med. 2025, 14, 3367 24 of 32

80. Kusafuka, K.; Muramatsu, K.; Iida, Y.; Mori, K.; Miki, T.; Suda, T.; Fuke, T.; Kamijo, T.; Onitsuka, T.; Nakajima, T. MUC Expression
in Adenosquamous Carcinoma of the Head and Neck Regions of Japanese Patients: Immunohistochemical Analysis. Pathol. Int.
2014, 64, 104–114. [CrossRef]
81. Schick, U.; Pusztaszeri, M.; Betz, M.; Ghadjar, P.; Demiroz, C.; Kaanders, J.H.A.M.; Ozsahin, M. Adenosquamous Carcinoma of
the Head and Neck: Report of 20 Cases and Review of the Literature. Oral. Surg. Oral. Med. Oral. Pathol. Oral. Radiol. 2013, 116,
313–320. [CrossRef]
82. Jones, T.M.; De, M.; Foran, B.; Harrington, K.; Mortimore, S. Laryngeal Cancer: United Kingdom National Multidisciplinary
Guidelines. J. Laryngol. Otol. 2016, 130, S75–S82. [CrossRef]
83. El-Demerdash, A.; Fawaz, S.A.; Sabri, S.M.; Sweed, A.; Rabie, H. Sensitivity and Specificity of Stroboscopy in Preoperative
Differentiation of Dysplasia from Early Invasive Glottic Carcinoma. Eur. Arch. Oto-Rhino-Laryngol. 2015, 272, 1189–1193.
[CrossRef] [PubMed]
84. Gupta, T.; Master, Z.; Kannan, S.; Agarwal, J.P.; Ghsoh-Laskar, S.; Rangarajan, V.; Murthy, V.; Budrukkar, A. Diagnostic
Performance of Post-Treatment FDG PET or FDG PET/CT Imaging in Head and Neck Cancer: A Systematic Review and
Meta-Analysis. Eur. J. Nucl. Med. Mol. Imaging 2011, 38, 2083–2095. [CrossRef] [PubMed]
85. Sarkar, A.; Sharma, N.; Raghavan, A. Role of Computed Tomography, Magnetic Resonance Imaging, and Endoscopy in Prether-
apeutic Evaluation of Laryngeal Tumors. Astrocyte 2016, 2, 172. Available online: https://go.gale.com/ps/i.do?id=GALE%
7CA466753779&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=23490977&p=AONE&sw=w&userGroupName=anon~
c07fdcb8&aty=open-web-entry (accessed on 14 March 2025). [CrossRef]
86. De Vito, A.; Meccariello, G.; Vicini, C. Narrow Band Imaging as Screening Test for Early Detection of Laryngeal Cancer: A
Prospective Study. Clin. Otolaryngol. 2016, 42, 347–353. [CrossRef] [PubMed]
87. Siravegna, G.; Marsoni, S.; Siena, S.; Bardelli, A. Integrating Liquid Biopsies into the Management of Cancer. Nat. Rev. Clin. Oncol.
2017, 14, 531–548. [CrossRef]
88. Arantes, L.M.R.B.; De Carvalho, A.C.; Melendez, M.E.; Lopes Carvalho, A. Serum, Plasma and Saliva Biomarkers for Head and
Neck Cancer. Expert. Rev. Mol. Diagn. 2018, 18, 85–112. [CrossRef]
89. Cohen, J.D.; Li, L.; Wang, Y.; Thoburn, C.; Afsari, B.; Danilova, L.; Douville, C.; Javed, A.A.; Wong, F.; Mattox, A.; et al. Detection
and Localization of Surgically Resectable Cancers with a Multi-Analyte Blood Test. Science 2018, 359, 926–930. [CrossRef]
90. Cohen, J.D.; Javed, A.A.; Thoburn, C.; Wong, F.; Tie, J.; Gibbs, P.; Schmidt, C.M.; Yip-Schneider, M.T.; Allen, P.J.; Schattner, M.;
et al. Combined Circulating Tumor DNA and Protein Biomarker-Based Liquid Biopsy for the Earlier Detection of Pancreatic
Cancers. Proc. Natl. Acad. Sci. USA 2017, 114, 10202–10207. [CrossRef]
91. Russano, M.; Napolitano, A.; Ribelli, G.; Iuliani, M.; Simonetti, S.; Citarella, F.; Pantano, F.; Dell’Aquila, E.; Anesi, C.; Silvestris, N.;
et al. Correction to: Liquid Biopsy and Tumor Heterogeneity in Metastatic Solid Tumors: The Potentiality of Blood Samples. J.
Exp. Clin. Cancer Res. 2020, 39, 120. [CrossRef]
92. Guthrie, G.J.K.; Charles, K.A.; Roxburgh, C.S.D.; Horgan, P.G.; McMillan, D.C.; Clarke, S.J. The Systemic Inflammation-Based
Neutrophil–Lymphocyte Ratio: Experience in Patients with Cancer. Crit. Rev. Oncol./Hematol. 2013, 88, 218–230. [CrossRef]
93. Iacob, R.; Mandea, M.; Iacob, S.; Pietrosanu, C.; Paul, D.; Hainarosie, R.; Gheorghe, C. Liquid Biopsy in Squamous Cell Carcinoma
of the Esophagus and of the Head and Neck. Front. Med. 2022, 9, 827297. [CrossRef] [PubMed]
94. Yang, W.-Y.; Feng, L.-F.; Meng, X.; Chen, R.; Xu, W.-H.; Hou, J.; Xu, T.; Zhang, L. Liquid Biopsy in Head and Neck Squamous
Cell Carcinoma: Circulating Tumor Cells, Circulating Tumor DNA, and Exosomes. Expert. Rev. Mol. Diagn. 2020, 20, 1213–1227.
[CrossRef] [PubMed]
95. Payne, K.; Spruce, R.; Beggs, A.; Sharma, N.; Kong, A.; Martin, T.; Parmar, S.; Praveen, P.; Nankivell, P.; Mehanna, H. Circulating
Tumor DNA as a Biomarker and Liquid Biopsy in Head and Neck Squamous Cell Carcinoma. Head Neck 2018, 40, 1598–1604.
[CrossRef] [PubMed]
96. Vrba, L.; Oshiro, M.M.; Kim, S.S.; Garland, L.L.; Placencia, C.; Mahadevan, D.; Nelson, M.A.; Futscher, B.W. DNA Methylation
Biomarkers Discovered in Silico Detect Cancer in Liquid Biopsies from Non-Small Cell Lung Cancer Patients. Epigenetics 2020, 15,
419–430. [CrossRef]
97. Ooki, A.; Maleki, Z.; Tsay, J.-C.J.; Goparaju, C.; Brait, M.; Turaga, N.; Nam, H.-S.; Rom, W.N.; Pass, H.I.; Sidransky, D. A Panel
of Novel Detection and Prognostic Methylated DNA Markers in Primary Non–Small Cell Lung Cancer and Serum DNA. Clin.
Cancer Res. 2017, 23, 7141–7152. [CrossRef]
98. Schröck, A.; Leisse, A.; de Vos, L.; Gevensleben, H.; Dröge, F.; Franzen, A.; Wachendörfer, M.; Schröck, F.; Ellinger, J.; Teschke, M.
Free-Circulating Methylated DNA in Blood for Diagnosis, Staging, Prognosis, and Monitoring of Head and Neck Squamous Cell
Carcinoma Patients: An Observational Prospective Cohort Study. Clin. Chem. 2017, 63, 1288–1296. [CrossRef]
99. Sanchez-Cespedes, M.; Esteller, M.; Wu, L.; Nawroz-Danish, H.; Yoo, G.H.; Koch, W.M.; Jen, J.; Herman, J.G.; Sidransky, D. Gene
Promoter Hypermethylation in Tumors and Serum of Head and Neck Cancer Patients. Cancer Res. 2000, 60, 892–895.
100. Kawada, T.; Takahashi, H.; Sakakura, K.; Ida, S.; Mito, I.; Toyoda, M.; Chikamatsu, K. Circulating Tumor Cells in Patients with
Head and Neck Squamous Cell Carcinoma: Feasibility of Detection and Quantitation. Head Neck 2017, 39, 2180–2186. [CrossRef]
J. Clin. Med. 2025, 14, 3367 25 of 32

101. Nichols, A.C.; Lowes, L.E.; Szeto, C.C.T.; Basmaji, J.; Dhaliwal, S.; Chapeskie, C.; Todorovic, B.; Read, N.; Venkatesan, V.;
Hammond, A.; et al. Detection of Circulating Tumor Cells in Advanced Head and Neck Cancer Using the Cellsearch System.
Head Neck 2011, 34, 1440–1444. [CrossRef]
102. Rizzo, M.I.; Ralli, M.; Nicolazzo, C.; Gradilone, A.; Carletti, R.; Di Gioia, C.; De Vincentiis, M.; Greco, A. Detection of Circulating
Tumor Cells in Patients with Laryngeal Cancer Using ScreenCell: Comparative Pre- and Post-Operative Analysis and Association
with Prognosis. Oncol. Lett. 2020, 19, 4183–4188. [CrossRef]
103. Powrózek, T.; Mlak, R.; Brzozowska, A.; Mazurek, M.; Goł˛ebiowski, P.; Małecka-Massalska, T. miRNA-130a Significantly Improves
Accuracy of SGA Nutritional Assessment Tool in Prediction of Malnutrition and Cachexia in Radiotherapy-Treated Head and
Neck Cancer Patients. Cancers 2018, 10, 294. [CrossRef] [PubMed]
104. Cao, Y.-C.; Song, L.-Q.; Xu, W.-W.; Qi, J.-J.; Wang, X.-Y.; Su, Y. Serum miR-632 Is a Potential Marker for the Diagnosis and
Prognosis in Laryngeal Squamous Cell Carcinoma. Acta Oto-Laryngol. 2020, 140, 418–421. [CrossRef] [PubMed]
105. Wang, J.L.; Wang, X.; Yang, D.; Shi, W.J. The Expression of MicroRNA-155 in Plasma and Tissue Is Matched in Human Laryngeal
Squamous Cell Carcinoma. Yonsei Med. J. 2016, 57, 298–305. [CrossRef]
106. Wang, J.; Zhou, Y.; Lu, J.; Sun, Y.; Xiao, H.; Liu, M.; Tian, L. Combined Detection of Serum Exosomal miR-21 and HOTAIR as
Diagnostic and Prognostic Biomarkers for Laryngeal Squamous Cell Carcinoma. Med. Oncol. 2014, 31, 148. [CrossRef]
107. Cabanero, M.; Tsao, M.S. Circulating Tumour DNA in EGFR-Mutant Non-Small-Cell Lung Cancer. Curr. Oncol. 2018, 25, 38–44.
[CrossRef]
108. Mahmood, H.; Shaban, M.; Rajpoot, N.; Khurram, S.A. Artificial Intelligence-Based Methods in Head and Neck Cancer Diagnosis:
An Overview. Br. J. Cancer 2021, 124, 1934–1940. [CrossRef]
109. Zhang, L.; Wu, Y.; Zheng, B.; Su, L.; Chen, Y.; Ma, S.; Hu, Q.; Zou, X.; Yao, L.; Yang, Y.; et al. Rapid Histology of Laryngeal
Squamous Cell Carcinoma with Deep-Learning Based Stimulated Raman Scattering Microscopy. Theranostics 2019, 9, 2541–2554.
[CrossRef]
110. Moccia, S.; De Momi, E.; Guarnaschelli, M.; Savazzi, M.; Laborai, A.; Guastini, L.; Peretti, G.; Mattos, L.S. Confident Texture-Based
Laryngeal Tissue Classification for Early Stage Diagnosis Support. J. Med. Imaging (Bellingham Wash.) 2017, 4, 34502. [CrossRef]
111. Choi, N.; Kim, J.; Yi, H.; Kim, H.; Kim, T.H.; Chung, M.J.; Ji, M.; Kim, Z.; Son, Y.-I. The Use of Artificial Intelligence Models to
Predict Survival in Patients with Laryngeal Squamous Cell Carcinoma. Sci. Rep. 2023, 13, 9734. [CrossRef]
112. Brandstorp-Boesen, J.; Sørum Falk, R.; Boysen, M.; Brøndbo, K. Impact of Stage, Management and Recurrence on Survival Rates
in Laryngeal Cancer. PLoS ONE 2017, 12, e0179371. [CrossRef]
113. Mulcahy, C.F.; Mohamed, A.S.R.; Kanwar, A.; Hutcheson, K.A.; Ghosh, A.; Vock, D.; Weber, R.S.; Lai, S.Y.; Gunn, G.B. Age-adjusted
Comorbidity and Survival in Locally Advanced Laryngeal Cancer. Head Neck 2018, 40, 2060–2069. [PubMed]
114. Egelmeer, A.G.T.M.; Velazquez, E.R.; de Jong, J.M.A.; Oberije, C.; Geussens, Y.; Nuyts, S.; Kremer, B.; Rietveld, D.; René Leemans,
C.; de Jong, M.C.; et al. Development and Validation of a Nomogram for Prediction of Survival and Local Control in Laryngeal
Carcinoma Patients Treated with Radiotherapy Alone: A Cohort Study Based on 994 Patients. Radiother. Oncol. 2011, 100, 108–115.
[CrossRef] [PubMed]
115. Datema, F.R.; Ferrier, M.B.; Vergouwe, Y.; Moya, A.; Molenaar, J.; Piccirillo, J.F.; Baatenburg de Jong, R.J. Update and External
Validation of a Head and Neck Cancer Prognostic Model. Head Neck 2012, 35, 1232–1237. [CrossRef] [PubMed]
116. Cavaliere, M.; Bisogno, A.; Scarpa, A.; D’Urso, A.; Marra, P.; Colacurcio, V.; De Luca, P.; Ralli, M.; Cassandro, E.; Cassandro, C.
Biomarkers of Laryngeal Squamous Cell Carcinoma: A Review. Ann. Diagn. Pathol. 2021, 54, 151787. [CrossRef]
117. Gioacchini, F.M.; Alicandri-Ciufelli, M.; Rubini, C.; Magliulo, G.; Re, M. Prognostic Value of Bcl-2 Expression in Squamous Cell
Carcinoma of the Larynx: A Systematic Review. Int. J. Biol. Markers 2015, 30, 155–160. [CrossRef]
118. Rashad, U.M.; Hussein, M.R.; Algizawy, S.M. Alterations of P53 and Bcl-2 Protein Expression in the Recurrent Laryngeal and
Pharyngeal Squamous Cell Carcinoma. Am. J. Otolaryngol. 2011, 32, 210–214. [CrossRef]
119. Yildirim, S.; Cermik, H.; Işitmangil, T.; Baloglu, H.; Gungor, A.; Pekkafali, Z. Significance of P53 and Bcl-2 Immunoexpression in
the Prognosis of Laryngeal Squamous Cell Carcinoma. J. Int. Med. Res. 2002, 30, 597–600. [CrossRef]
120. Ozdek, A.; Sarac, S.; Akyol, M.U.; Sungur, A.; Yilmaz, T. C-Myc and Bcl-2 Expression In Supraglottic Squamous Cell Carcinoma
of the Larynx. Otolaryngol. Head Neck Surg. 2004, 131, 77–83. [CrossRef]
121. Jakstas, T.; Bartnykaite, A.; Padervinskis, E.; Vegiene, A.; Juozaityte, E.; Uloza, V.; Ugenskiene, R. The Association of TP53, BCL2,
BAX and NOXA SNPs and Laryngeal Squamous Cell Carcinoma Development. Int. J. Mol. Sci. 2024, 25, 11849. [CrossRef]
122. Chen, J.; Zhou, J.; Lu, J.; Xiong, H.; Shi, X.; Gong, L. Significance of CD44 Expression in Head and Neck Cancer: A Systemic
Review and Meta-Analysis. BMC Cancer 2014, 14, 15. [CrossRef]
123. Trapasso, S.; Allegra, E. Role of CD44 as a Marker of Cancer Stem Cells in Head and Neck Cancer. Biol. Targets Ther. 2012, 6,
379–383. [CrossRef]
124. Joshua, B.; Kaplan, M.J.; Doweck, I.; Pai, R.; Weissman, I.L.; Prince, M.E.; Ailles, L.E. Frequency of Cells Expressing CD44, a Head
and Neck Cancer Stem Cell Marker: Correlation with Tumor Aggressiveness. Head Neck 2011, 34, 42–49. [CrossRef] [PubMed]
J. Clin. Med. 2025, 14, 3367 26 of 32

125. Re, M.; Gioacchini, F.M.; Scarpa, A.; Cassandro, C.; Tulli, M.; Cassandro, E. The Prognostic Significance of E-Cadherin Expression
in Laryngeal Squamous-Cell Carcinoma: A Systematic Review. Acta Otorhinolaryngol. Ital. 2018, 38, 504–510. [CrossRef] [PubMed]
126. Li, J.; Zhang, G.; Yang, X.; Li, S.; Liu, X.; Yang, Q.; Li, Y.; Ye, J. Reduced E-Cadherin Expression Is Associated with Lymph Node
Metastases in Laryngeal Squamous Cell Carcinoma. Auris Nasus Larynx 2012, 39, 186–192. [CrossRef]
127. Akdeniz, O.; Akduman, D.; Haksever, M.; Ozkarakas, H.; Müezzinoglu, B. Relationships between Clinical Behavior of Laryngeal
Squamous Cell Carcinomas and Expression of VEGF, MMP-9 and E-Cadherin. Asian Pac. J. Cancer Prev. 2013, 14, 5301–5310.
[CrossRef]
128. Cappellesso, R.; Marioni, G.; Crescenzi, M.; Giacomelli, L.; Guzzardo, V.; Mussato, A.; Staffieri, A.; Martini, A.; Blandamura, S.;
Fassina, A. The Prognostic Role of the Epithelial-Mesenchymal Transition Markers E-Cadherin and Slug in Laryngeal Squamous
Cell Carcinoma. Histopathology 2015, 67, 491–500. [CrossRef]
129. CDKN2A Gene: MedlinePlus Genetics. Available online: https://medlineplus.gov/genetics/gene/cdkn2a/ (accessed on 8
May 2025).
130. Nowosad, A.; Besson, A. CDKN1B/P27 Regulates Autophagy via the Control of Ragulator and MTOR Activity in Amino
Acid-Deprived Cells. Autophagy 2020, 16, 2297–2298. [CrossRef]
131. Gioacchini, F.M.; Alicandri-Ciufelli, M.; Kaleci, S.; Magliulo, G.; Presutti, L.; Re, M. The Prognostic Value of Cyclin D1 Expression
in Head and Neck Squamous Cell Carcinoma. Eur. Arch. Oto-Rhino-Laryngol. 2014, 273, 801–809. [CrossRef]
132. Zhang, Z.; Tang, H.; Lin, J.; Hu, Y.; Luo, G.; Luo, Z.; Cheng, C.; Wang, P. Clinicopathologic and Prognostic Significance of Human
Epidermal Growth Factor Receptor in Patients with Gastric Cancer: An Updated Meta-Analysis. Oncotarget 2017, 8, 17202–17215.
[CrossRef]
133. Gioacchini, F.M.; Alicandri-Ciufelli, M.; Magliulo, G.; Rubini, C.; Presutti, L.; Re, M. The Clinical Relevance of Ki-67 Expression in
Laryngeal Squamous Cell Carcinoma. Eur. Arch. Oto-Rhino-Laryngol. 2014, 272, 1569–1576. [CrossRef]
134. Mirza, S.; Jeannon, J.P.; Soames, J.; Wilson, J.A. Is Ki67 a Marker for the Transformation of Laryngeal Dysplasia to Carcinoma?
Acta Oto-Laryngol. 2006, 126, 418–421. [CrossRef] [PubMed]
135. Acikalin, M.F.; Öner, Ü.; Tel, N.; Paşaoğlu, Ö.; Çakli, H.; Çolak, E. Prognostic Significance of Ki-67 Expression for Patients with
Laryngeal Squamous Cell Carcinoma Primarily Treated by Total Laryngectomy. Eur. Arch. Oto-Rhino-Laryngol. 2003, 261, 376–380.
[CrossRef] [PubMed]
136. Re, M.; Zizzi, A.; Ferrante, L.; Stramazzotti, D.; Goteri, G.; Gioacchini, F.M.; Olivieri, F.; Magliulo, G.; Rubini, C. P63 and Ki-67
Immunostainings in Laryngeal Squamous Cell Carcinoma Are Related to Survival. Eur. Arch. Oto-Rhino-Laryngol. 2014, 271,
1641–1651. [CrossRef] [PubMed]
137. Boehm, E.M.; Gildenberg, M.S.; Washington, M.T. The Many Roles of PCNA in Eukaryotic DNA Replication. In The Enzymes;
Academic Press: Cambridge, MA, USA, 2016; Volume 39, pp. 231–254.
138. Zhao, H.; Chen, Q.; Alam, A.; Cui, J.; Suen, K.C.; Soo, A.P.; Eguchi, S.; Gu, J.; Ma, D. The Role of Osteopontin in the Progression of
Solid Organ Tumour. Cell Death Dis. 2018, 9, 356. [CrossRef]
139. Leemans, C.R.; Snijders, P.J.F.; Brakenhoff, R.H. The Molecular Landscape of Head and Neck Cancer. Nat. Rev. Cancer 2018, 18,
269–282. [CrossRef]
140. Bradford, C.R.; Kumar, B.; Bellile, E.; Lee, J.; Taylor, J.; D’Silva, N.; Cordell, K.; Kleer, C.; Kupfer, R.; Kumar, P.; et al. Biomarkers in
Advanced Larynx Cancer. Laryngoscope 2014, 124, 179–187. [CrossRef]
141. Shibuya, M. Vascular Endothelial Growth Factor (VEGF) and Its Receptor (VEGFR) Signaling in Angiogenesis. Genes. Cancer
2011, 2, 1097–1105. [CrossRef] [PubMed]
142. Teknos, T.N.; Cox, C.; Yoo, S.; Chepeha, D.B.; Wolf, G.T.; Bradford, C.R.; Carey, T.E.; Fisher, S.G. Elevated Serum Vascular
Endothelial Growth Factor and Decreased Survival in Advanced Laryngeal Carcinoma. Head Neck 2002, 24, 1004–1011. [CrossRef]
143. Parikh, R.R.; Yang, Q.; Haffty, B.G. Prognostic Significance of Vascular Endothelial Growth Factor Protein Levels in T1-2 N0
Laryngeal Cancer Treated with Primary Radiation Therapy. Cancer 2007, 109, 566–573. [CrossRef]
144. Neuchrist, C.; Quint, C.; Pammer, A.; Burian, M. Vascular Endothelial Growth Factor (VEGF) and Microvessel Density in
Squamous Cell Carcinomas of the Larynx: An Immunohistochemical Study. Acta Otolaryngol. 1999, 119, 732–738. [CrossRef]
145. Cossu, A.M.; Mosca, L.; Zappavigna, S.; Misso, G.; Bocchetti, M.; De Micco, F.; Quagliuolo, L.; Porcelli, M.; Caraglia, M.; Boccellino,
M. Long Non-Coding RNAs as Important Biomarkers in Laryngeal Cancer and Other Head and Neck Tumours. Int. J. Mol. Sci.
2019, 20, 3444. [CrossRef] [PubMed]
146. Balas, M.M.; Johnson, A.M. Exploring the Mechanisms behind Long Noncoding RNAs and Cancer. Non-Coding RNA Res. 2018, 3,
108–117. [CrossRef] [PubMed]
147. Zhou, R.; Chen, K.K.; Zhang, J.; Xiao, B.; Huang, Z.; Ju, C.; Sun, J.; Zhang, F.; Lv, X.-B.; Huang, G. The Decade of Exosomal Long
RNA Species: An Emerging Cancer Antagonist. Mol. Cancer 2018, 17, 75. [CrossRef]
148. Zvrko, E.; Mikic, A.; Vuckovic, L. CD105 Expression as a Measure of Microvessel Density in Supraglottic Laryngeal Squamous
Cell Carcinoma. Eur. Arch. Oto-Rhino-Laryngol. 2009, 266, 1971–1976. [CrossRef]
J. Clin. Med. 2025, 14, 3367 27 of 32

149. Zvrko, E.; Mikic, A.; Vuckovic, L. Clinicopathologic Significance of CD105-Assessed Microvessel Density in Glottic Laryngeal
Squamous Cell Carcinoma. Auris Nasus Larynx 2010, 37, 77–83. [CrossRef]
150. Marioni, G.; Blandamura, S.; Loreggian, L.; Koussis, H.; Lionello, M.; Giacomelli, L.; Fasanaro, E.; Lovato, A.; Staffieri, A.
Laryngeal Carcinoma Prognosis after Postoperative Radiotherapy Correlates with CD105 Expression, but Not with Angiogenin
or EGFR Expression. Eur. Arch. Oto-Rhino-Laryngol. 2011, 268, 1779–1787. [CrossRef]
151. Villaronga, M.Á.; Hermida-Prado, F.; Granda-Díaz, R.; Menéndez, S.T.; Álvarez-Teijeiro, S.; Quer, M.; Vilaseca, I.; Allonca, E.;
Garzón-Arango, M.; Sanz-Moreno, V.; et al. Immunohistochemical Expression of Cortactin and Focal Adhesion Kinase Predicts
Recurrence Risk and Laryngeal Cancer Risk Beyond Histologic Grading. Cancer Epidemiol. Biomark. Prev. 2018, 27, 805–813.
[CrossRef]
152. Rodrigo, J.P.; Álvarez-Alija, G.; Menéndez, S.T.; Mancebo, G.; Allonca, E.; García-Carracedo, D.; Fresno, M.F.; Suárez, C.; García-
Pedrero, J.M. Cortactin and Focal Adhesion Kinase as Predictors of Cancer Risk in Patients with Laryngeal Premalignancy. Cancer
Prev. Res. 2011, 4, 1333–1341. [CrossRef]
153. Marioni, G.; Lionello, M.; Marchese-Ragona, R.; Fasanaro, E.; Valentini, E.; Zanoletti, E.; Stritoni, P.; Ramacciotti, G.; Guzzardo, V.;
Giacomelli, L.; et al. Cortactin and Phosphorylated Cortactin Tyr421 and Tyr466 Expression in Supraglottic Laryngeal Carcinomas
and Lymph Node Metastases. Int. J. Biol. Markers 2017, 33, 79–86. [CrossRef] [PubMed]
154. Gibcus, J.H.; Mastik, M.F.; Menkema, L.; de Bock, G.H.; Kluin, P.M.; Schuuring, E.; van der Wal, J.E. Cortactin Expression Predicts
Poor Survival in Laryngeal Carcinoma. Br. J. Cancer 2008, 98, 950–955. [CrossRef]
155. Fei, M.; Zhang, J.; Zhou, J.; Xu, Y.; Wang, J. Sex-Related Hormone Receptor in Laryngeal Squamous Cell Carcinoma: Correlation
with Androgen Estrogen-α and Prolactin Receptor Expression and Influence of Prognosis. Acta Oto-Laryngol. 2017, 138, 66–72.
[CrossRef] [PubMed]
156. Kalyi, V.V.; Goncharuk-Khomyn, M.Y. Analysis of the Role and Impact of Sex Hormones in Diagnostics and Assessment of
Clinical Progress of Laryngeal Cancer. Morphologia 2016, 10, 41–45. [CrossRef]
157. Ulitsky, I.; Bartel, D.P. lincRNAs: Genomics, Evolution, and Mechanisms. Cell 2013, 154, 26–46. [CrossRef] [PubMed]
158. Ziegler, C.; Kretz, M. The More the Merrier-Complexity in Long Non-Coding RNA Loci. Front. Endocrinol. 2017, 8, 90. [CrossRef]
159. Ahmed, W.A.; Suzuki, K.; Imaeda, Y.; Horibe, Y. Ki-67, P53 and Epidermal Growth Factor Receptor Expression in Early Glottic
Cancer Involving the Anterior Commissure Treated with Radiotherapy. Auris Nasus Larynx 2008, 35, 213–219. [CrossRef]
160. Aras, S.; Ozkanli, S.; Erdem, E.; Gokalp, S.; Erdogan, C.E. Investigation of Low and High Dose Rate X-Ray Effects on Histopatho-
logical Changes and Prognostic Importance of Ki-67 in Laryngeal Cancer Radiotherapy. Appl. Radiat. Isot. 2023, 197, 110823.
[CrossRef]
161. Sakata, K.; Oouchi, A.; Nagakura, H.; Akiba, H.; Tamakawa, M.; Koito, K.; Hareyama, M.; Asakura, K.; Satoh, M.; Ohtani, S.
Accelerated Radiotherapy for T1, 2 Glottic Carcinoma: Analysis of Results with KI-67 Index. Int. J. Radiat. Oncol. Biol. Phys. 2000,
47, 81–88. [CrossRef]
162. Liu, X.-Y.; Hanjing, S.; Zhang, B.-H.; Luo, X.-Y. Expression of P16 and Ki67 in Laryngeal Squamous Cell Carcinoma and Their
Clinical Significance. Front. Oncol. 2024, 14, 1430830. [CrossRef]
163. DE Almeida, M.R.; Pérez-Sayáns, M.; Suárez-Peñaranda, J.M.; Somoza-Martín, J.M.; García-García, A. P27(Kip1) Expression as a
Prognostic Marker for Squamous Cell Carcinoma of the Head and Neck. Oncol. Lett. 2015, 10, 2675–2682. [CrossRef]
164. Allegra, E.; Bianco, M.R.; Mignogna, C.; Caltabiano, R.; Grasso, M.; Puzzo, L. Role of P16 Expression in the Prognosis of Patients
with Laryngeal Cancer: A Single Retrospective Analysis. Cancer Control 2021, 28, 10732748211033544. [CrossRef]
165. Lee, L.-A.; Fang, T.-J.; Li, H.-Y.; Chuang, H.-H.; Kang, C.-J.; Chang, K.-P.; Liao, C.-T.; Chen, T.-C.; Huang, C.-G.; Yen, T.-C. Effects
of Epstein-Barr Virus Infection on the Risk and Prognosis of Primary Laryngeal Squamous Cell Carcinoma: A Hospital-Based
Case-Control Study in Taiwan. Cancers 2021, 13, 1741. [CrossRef] [PubMed]
166. Silva, F.F.V.e.; Caponio, V.C.A.; Camolesi, G.C.V.; Padín-Iruegas, M.E.; Lorenzo-Pouso, A.I.; Lima, K.C.; Vieira, S.L.S.; Chamorro-
Petronacci, C.M.; Suaréz-Peñaranda, J.M.; Pérez-Sayáns, M. Correlation of Bcl-2 Expression with Prognosis and Survival in
Patients with Head and Neck Cancer: A Systematic Review and Meta-Analysis. Crit. Rev. Oncol./Hematol. 2023, 187, 104021.
[CrossRef] [PubMed]
167. Chan, J.Y.K.; Zhen, G.; Agrawal, N. The Role of Tumor DNA as a Diagnostic Tool for Head and Neck Squamous Cell Carcinoma.
Semin. Cancer Biol. 2019, 55, 1–7. [CrossRef] [PubMed]
168. Petitjean, A.; Mathe, E.; Kato, S.; Ishioka, C.; Tavtigian, S.V.; Hainaut, P.; Olivier, M. Impact of Mutant P53 Functional Properties
on TP53 Mutation Patterns and Tumor Phenotype: Lessons from Recent Developments in the IARC TP53 Database. Human.
Mutat. 2007, 28, 622–629. [CrossRef]
169. Leemans, C.R.; Braakhuis, B.J.M.; Brakenhoff, R.H. The Molecular Biology of Head and Neck Cancer. Nat. Rev. Cancer 2010, 11,
9–22. [CrossRef]
170. Poeta, M.L.; Manola, J.; Goldwasser, M.A.; Forastiere, A.; Benoit, N.; Califano, J.A.; Ridge, J.A.; Goodwin, J.; Kenady, D.; Saunders,
J.; et al. TP53 Mutations and Survival in Squamous-Cell Carcinoma of the Head and Neck. N. Engl. J. Med. 2007, 357, 2552–2561.
[CrossRef]
J. Clin. Med. 2025, 14, 3367 28 of 32

171. Ioachim, E. Expression Patterns of Cyclins D1, E and Cyclin-Dependent Kinase Inhibitors P21waf1/Cip1, P27kip1 in Colorectal
Carcinoma: Correlation with Other Cell Cycle Regulators (pRb, P53 and Ki-67 and PCNA) and Clinicopathological Features. Int.
J. Clin. Pract. 2008, 62, 1736–1743. [CrossRef]
172. Basyuni, S.; Nugent, G.; Ferro, A.; Barker, E.; Reddin, I.; Jones, O.; Lechner, M.; O’Leary, B.; Jones, T.; Masterson, L.; et al. Value of
P53 Sequencing in the Prognostication of Head and Neck Cancer: A Systematic Review and Meta-Analysis. Sci. Rep. 2022, 12,
20776. [CrossRef]
173. Tan, A.; Eskiizmir, G.; Kamiloglu, U.; Sarioglu, S. P53 and PTEN Expression Evaluation with Molecular Evident Recent Criteria in
Laryngeal Carcinoma. Medicine 2023, 102, e33676. [CrossRef]
174. Chong, C.R.; Jänne, P.A. The Quest to Overcome Resistance to EGFR-Targeted Therapies in Cancer. Nat. Med. 2013, 19, 1389–1400.
[CrossRef]
175. Lionello, M.; Staffieri, A.; Marioni, G. Potential Prognostic and Therapeutic Role for Angiogenesis Markers in Laryngeal
Carcinoma. Acta Oto-Laryngol. 2012, 132, 574–582. [CrossRef] [PubMed]
176. Kontić, M.; Čolović, Z.; Paladin, I.; Gabelica, M.; Barić, A.; Pešutić-Pisac, V. Association between EGFR Expression and Clinical
Outcome of Laryngeal HPV Squamous Cell Carcinoma. Acta Oto-Laryngol. 2019, 139, 913–917. [CrossRef] [PubMed]
177. Marijić, B.; Braut, T.; Babarović, E.; Krstulja, M.; Maržić, D.; Avirović, M.; Kujundžić, M.; Hadžisejdić, I. Nuclear EGFR Expression
Is Associated with Poor Survival in Laryngeal Carcinoma. Appl. Immunohistochem. Mol. Morphol. 2021, 29, 576–584. [CrossRef]
[PubMed]
178. Kapral, M.; Strzalka, B.; Kowalczyk, M.; Jurzak, M.; Mazurek, U.; Gierek, T.; Paluch, J.; Markowski, J.; Swiatkowska, L.; Weglarz,
L. Transforming Growth Factor Beta Isoforms (TGF-Beta1, TGF-Beta2, TGF-Beta3) Messenger RNA Expression in Laryngeal
Cancer. Am. J. Otolaryngol. 2008, 29, 233–237. [CrossRef]
179. Mosch, B.; Reissenweber, B.; Neuber, C.; Pietzsch, J. Eph Receptors and Ephrin Ligands: Important Players in Angiogenesis and
Tumor Angiogenesis. J. Oncol. 2010, 2010, 135285. [CrossRef]
180. Shigyo, H.; Nonaka, S.; Katada, A.; Bandoh, N.; Ogino, T.; Katayama, A.; Takahara, M.; Hayashi, T.; Harabuchi, Y. Inducible Nitric
Oxide Synthase Expression in Various Laryngeal Lesions in Relation to Carcinogenesis, Angiogenesis, and Patients’ Prognosis.
Acta Oto-Laryngol. 2007, 127, 970–979. [CrossRef]
181. Rueda, A.; Cazorla, O.; Pérez, L.; Álvarez, M.; Redondo, M.; Gallego, E.; Sáez, M.; Medina, J.A.; Solano, J.; Matilla, A. Vascular
Endothelial Growth Factor and Vascular Endothelial Growth Factor Receptor-2 Tumor Expression in Patients with Advanced
Laryngeal Cancer after Induction Chemotherapy for Organ Preservation. Head Neck 2010, 33, 808–816. [CrossRef]
182. Bonhin, R.G.; Rocha, V.B.C.; Carvalho, G.M.d.; Guimarães, A.C.; Crespo, A.N.; Chone, C.T.; Amstalden, E.M.I. Correlation
between Vascular Endothelial Growth Factor Expression and Presence of Lymph Node Metastasis in Advanced Squamous Cell
Carcinoma of the Larynx. Braz. J. Otorhinolaryngol. 2015, 81, 58–62. [CrossRef]
183. Yoshioka, N.; Wang, L.; Kishimoto, K.; Tsuji, T.; Hu, G. A Therapeutic Target for Prostate Cancer Based on Angiogenin-Stimulated
Angiogenesis and Cancer Cell Proliferation. Proc. Natl. Acad. Sci. USA 2006, 103, 14519–14524. [CrossRef]
184. Marioni, G.; Marino, F.; Blandamura, S.; D’Alessandro, E.; Giacomelli, L.; Guzzardo, V.; Lionello, M.; De Filippis, C.; Staffieri, A.
Neoangiogenesis in Laryngeal Carcinoma: Angiogenin and CD105 Expression Is Related to Carcinoma Recurrence Rate and
Disease-free Survival. Histopathology 2010, 57, 535–543. [CrossRef]
185. Carico, E.; Radici, M.; Bucci, B.; Firrisi, L.; Fabiano, A.; Salerno, G.; Giovagnoli, M.R.; Vecchione, A. p16INK4/Ki-67 Dual-Staining
Expression as a Prognostic Indicator in Laryngeal Cancer. J. Cancer Prev. Curr. Res. 2014, 1, 68–72. [CrossRef]
186. Verma, A.; Schwartz, N.; Cohen, D.J.; Boyan, B.D.; Schwartz, Z. Estrogen Signaling and Estrogen Receptors as Prognostic
Indicators in Laryngeal Cancer. Steroids 2019, 152, 108498. [CrossRef] [PubMed]
187. Schwartz, N.; Verma, A.; Muktipaty, C.; Bivens, C.; Schwartz, Z.; Boyan, B.D. Estradiol Receptor Profile and Estrogen Responsive-
ness in Laryngeal Cancer and Clinical Outcomes. Steroids 2019, 142, 34–42. [CrossRef]
188. Ou, D.; Adam, J.; Garberis, I.; Blanchard, P.; Nguyen, F.; Levy, A.; Casiraghi, O.; Gorphe, P.; Breuskin, I.; Janot, F.; et al. Clinical
Relevance of Tumor Infiltrating Lymphocytes, PD-L1 Expression and Correlation with HPV/P16 in Head and Neck Cancer
Treated with Bio- or Chemo-Radiotherapy. Oncoimmunology 2017, 6, e1341030. [CrossRef]
189. Vassilakopoulou, M.; Avgeris, M.; Velcheti, V.; Kotoula, V.; Rampias, T.; Chatzopoulos, K.; Perisanidis, C.; Kontos, C.K.; Giotakis,
A.I.; Scorilas, A.; et al. Evaluation of PD-L1 Expression and Associated Tumor-Infiltrating Lymphocytes in Laryngeal Squamous
Cell Carcinoma. Clin. Cancer Res. 2016, 22, 704–713. [CrossRef]
190. Wang, J.; Wang, S.; Song, X.; Zeng, W.; Wang, S.; Chen, F.; Ding, H. The Prognostic Value of Systemic and Local Inflammation in
Patients with Laryngeal Squamous Cell Carcinoma. OncoTargets Ther. 2016, 9, 7177–7185. [CrossRef]
191. Tudor, F.; Marijić, B.; Babarović, E.; Hadžisejdić, I. Significance of PD-L1 and Tumor Microenvironment in Laryngeal Squamous
Cell Cancer. Cancers 2024, 16, 2645. [CrossRef]
192. Economopoulou, P.; de Bree, R.; Kotsantis, I.; Psyrri, A. Diagnostic Tumor Markers in Head and Neck Squamous Cell Carcinoma
(HNSCC) in the Clinical Setting. Front. Oncol. 2019, 9, 827. [CrossRef]
J. Clin. Med. 2025, 14, 3367 29 of 32

193. Syn, N.L.; Teng, M.W.L.; Mok, T.S.K.; Soo, R.A. De-Novo and Acquired Resistance to Immune Checkpoint Targeting. Lancet Oncol.
2017, 18, e731–e741. [CrossRef]
194. Francisco, L.M.; Sage, P.T.; Sharpe, A.H. The PD-1 Pathway in Tolerance and Autoimmunity. Immunol. Rev. 2010, 236, 219–242.
[CrossRef]
195. Ritprajak, P.; Azuma, M. Intrinsic and Extrinsic Control of Expression of the Immunoregulatory Molecule PD-L1 in Epithelial
Cells and Squamous Cell Carcinoma. Oral. Oncol. 2015, 51, 221–228. [CrossRef] [PubMed]
196. Karam, J.; Fadous-Khalifé, M.C.; Tannous, R.; Fakhreddine, S.; Massoud, M.; Hadchity, J.; Aftimos, G.; Hadchity, E. Role of
Krüppel-like Factor 4 and Heat Shock Protein 27 in Cancer of the Larynx. Mol. Clin. Oncol. 2017, 7, 808–814. [CrossRef] [PubMed]
197. Kaigorodova, E.V.; Zavyalova, M.V.; Bychkov, V.A.; Perelmuter, V.M.; Choynzonov, E.L. Functional State of the Hsp27 Chaperone
as a Molecular Marker of an Unfavorable Course of Larynx Cancer. Cancer Biomark. 2016, 17, 145–153. [CrossRef]
198. Lee, J.-H.; Sun, D.; Cho, K.-J.; Kim, M.-S.; Hong, M.-H.; Kim, I.-K.; Lee, J.-S.; Lee, J.-H. Overexpression of Human 27 kDa Heat
Shock Protein in Laryngeal Cancer Cells Confers Chemoresistance Associated with Cell Growth Delay. J. Cancer Res. Clin. Oncol.
2006, 133, 37–46. [CrossRef] [PubMed]
199. Rappa, F.; Pitruzzella, A.; Marino Gammazza, A.; Barone, R.; Mocciaro, E.; Tomasello, G.; Carini, F.; Farina, F.; Zummo, G.;
Conway de Macario, E.; et al. Quantitative Patterns of Hsps in Tubular Adenoma Compared with Normal and Tumor Tissues
Reveal the Value of Hsp10 and Hsp60 in Early Diagnosis of Large Bowel Cancer. Cell Stress Chaperones 2016, 21, 927–933.
[CrossRef]
200. Xu, J.; Wang, K.; Zhang, X.; Qiu, Y.; Huang, D.; Li, W.; Xiao, X.; Tian, Y. HSP70: A Promising Target for Laryngeal Carcinoma
Radiaotherapy by Inhibiting Cleavage and Degradation of Nucleolin. J. Exp. Clin. Cancer Res. 2010, 29, 106. [CrossRef]
201. Orasan, A.; Negru, M.-C.; Morgovan, A.I.; Fleser, R.C.; Sandu, D.; Sitaru, A.M.; Motofelea, A.-C.; Balica, N.C. Strategies to
Mitigate Cisplatin-Induced Ototoxicity: A Literature Review of Protective Agents, Mechanisms, and Clinical Gaps. Audiol. Res.
2025, 15, 22. [CrossRef]
202. Song, X.; Liao, Z.; Zhou, C.; Lin, R.; Lu, J.; Cai, L.; Tan, X.; Zeng, W.; Lu, X.; Zheng, W.; et al. HSP47 Is Associated with the
Prognosis of Laryngeal Squamous Cell Carcinoma by Inhibiting Cell Viability and Invasion and Promoting Apoptosis. Oncol. Rep.
2017, 38, 2444–2452. [CrossRef]
203. Si, M.; Lang, J. The Roles of Metallothioneins in Carcinogenesis. J. Hematol. Oncol. 2018, 11, 107. [CrossRef]
204. Ioachim, E.; Assimakopoulos, D.; Peschos, D.; Zissi, A.; Skevas, A.; Agnantis, N.J. Immunohistochemical Expression of Metalloth-
ionein in Benign Premalignant and Malignant Epithelium of the Larynx: Correlation with P53 and Proliferative Cell Nuclear
Antigen. Pathol.—Res. Pract. 1999, 195, 809–814. [CrossRef]
205. Nowinska, K.; Chmielewska, M.; Piotrowska, A.; Pula, B.; Pastuszewski, W.; Krecicki, T.; Podhorska-Okołow, M.; Zabel, M.;
Dziegiel, P. Correlation between Levels of Expression of Minichromosome Maintenance Proteins, Ki-67 Proliferation Antigen and
Metallothionein I/II in Laryngeal Squamous Cell Cancer. Int. J. Oncol. 2015, 48, 635–645. [CrossRef] [PubMed]
206. Starska, K.; Krześlak, A.; Forma, E.; Olszewski, J.; Lewy-Trenda, I.; Osuch-Wójcikiewicz, E.; Bryś, M. Genetic Polymorphism of
Metallothionein 2A and Risk of Laryngeal Cancer in a Polish Population. Med. Oncol. 2014, 31, 75. [CrossRef] [PubMed]
207. Emanuele, S.; Celesia, A.; D’Anneo, A.; Lauricella, M.; Carlisi, D.; De Blasio, A.; Giuliano, M. The Good and Bad of Nrf2: An
Update in Cancer and New Perspectives in COVID-19. Int. J. Mol. Sci. 2021, 22, 7963. [CrossRef]
208. Namani, A.; Matiur Rahaman, M.; Chen, M.; Tang, X. Gene-Expression Signature Regulated by the KEAP1-NRF2-CUL3 Axis Is
Associated with a Poor Prognosis in Head and Neck Squamous Cell Cancer. BMC Cancer 2018, 18, 46. [CrossRef] [PubMed]
209. Xia, D.; Zhang, X.-R.; Ma, Y.-L.; Zhao, Z.-J.; Zhao, R.; Wang, Y.-Y. Nrf2 Promotes Esophageal Squamous Cell Carcinoma (ESCC)
Resistance to Radiotherapy through the CaMKIIα-Associated Activation of Autophagy. Cell Biosci. 2020, 10, 90. [CrossRef]
210. Sheth, S.; Farquhar, D.R.; Schrank, T.P.; Stepp, W.; Mazul, A.; Hayward, M.; Lenze, N.; Little, P.; Jo, H.; Major, M.B.; et al.
Correlation of Alterations in the KEAP1/CUL3/NFE2L2 Pathway with Radiation Failure in Larynx Squamous Cell Carcinoma.
Laryngoscope Investig. Otolaryngol. 2021, 6, 699–707. [CrossRef]
211. Li, C.; Wu, H.; Wang, S.; Zhu, J. Expression and Correlation of NRF2, KEAP1, NQO-1 and HO-1 in Advanced Squamous Cell
Carcinoma of the Larynx and Their Association with Clinicopathologic Features. Mol. Med. Rep. 2016, 14, 5171–5179. [CrossRef]
212. Zhou, Z.; Xu, J.; Bao, X.; Shi, J.; Liu, B.; Chen, Y.; Li, J. Nuclear Nrf2 Activity in Laryngeal Carcinoma Is Regulated by SENP3 After
Cisplatin-Induced Reactive Oxygen Species Stress. J. Cancer 2019, 10, 3427–3434. [CrossRef]
213. Cui, J.; Jia, J. Natural COX-2 Inhibitors as Promising Anti-Inflammatory Agents: An Update. Curr. Med. Chem. 2021, 28, 3622–3646.
[CrossRef]
214. Li, M.; Li, M.; Wei, Y.; Xu, H. Prognostic and Clinical Significance of Cyclooxygenase-2 Overexpression in Endometrial Cancer: A
Meta-Analysis. Front. Oncol. 2020, 10, 1202. [CrossRef]
215. Kourelis, K.; Vandoros, G.; Kourelis, T.; Papadas, T.; Goumas, P.; Sotiropoulou-Bonikou, G. Low COX2 in Tumor and Upregulation
in Stroma Mark Laryngeal Squamous Cell Carcinoma Progression. Laryngoscope 2009, 119, 1723–1729. [CrossRef] [PubMed]
J. Clin. Med. 2025, 14, 3367 30 of 32

216. Chen, Y.-F.; Luo, R.-Z.; Li, Y.; Cui, B.-K.; Song, M.; Yang, A.-K.; Chen, W.-K. High Expression Levels of COX-2 and P300 Are
Associated with Unfavorable Survival in Laryngeal Squamous Cell Carcinoma. Eur. Arch. Otorhinolaryngol. 2013, 270, 1009–1017.
[CrossRef] [PubMed]
217. Du, J.; Feng, J.; Luo, D.; Peng, L. Prognostic and Clinical Significance of COX-2 Overexpression in Laryngeal Cancer: A
Meta-Analysis. Front. Oncol. 2022, 12, 854946. [CrossRef] [PubMed]
218. Sackett, M.K.; Bairati, I.; Meyer, F.; Jobin, E.; Lussier, S.; Fortin, A.; Gélinas, M.; Nabid, A.; Brochet, F.; Têtu, B. Prognostic
Significance of Cyclooxygenase-2 Overexpression in Glottic Cancer. Clin. Cancer Res. 2008, 14, 67–73. [CrossRef]
219. Klatka, J.; Grywalska, E.; Hymos, A.; Guz, M.; Polberg, K.; Roliński, J.; Stepulak, A. Cyclooxygenase-2 Inhibition Enhances
Proliferation of NKT Cells Derived from Patients with Laryngeal Cancer. Anticancer Res. 2017, 37, 4059–4066. [CrossRef]
220. Kinoshita, T.; Hanazawa, T.; Nohata, N.; Kikkawa, N.; Enokida, H.; Yoshino, H.; Yamasaki, T.; Hidaka, H.; Nakagawa, M.;
Okamoto, Y.; et al. Tumor Suppressive microRNA-218 Inhibits Cancer Cell Migration and Invasion through Targeting Laminin-332
in Head and Neck Squamous Cell Carcinoma. Oncotarget 2012, 3, 1386–1400. [CrossRef]
221. Bruzgielewicz, A.; Osuch-Wojcikiewicz, E.; Niemczyk, K.; Sieniawska-Buccella, O.; Siwak, M.; Walczak, A.; Nowak, A.; Majsterek,
I. Altered Expression of miRNAs Is Related to Larynx Cancer TNM Stage and Patients’ Smoking Status. DNA Cell Biol. 2017, 36,
581–588. [CrossRef]
222. Xu, Y.; Lin, Y.-P.; Yang, D.; Zhang, G.; Zhou, H.-F. Clinical Significance of miR-149 in the Survival of Patients with Laryngeal
Squamous Cell Carcinoma. BioMed Res. Int. 2016, 2016, 8561251. [CrossRef]
223. Karatas, O.F. Antiproliferative Potential of miR-33a in Laryngeal Cancer Hep-2 Cells via Targeting PIM1. Head Neck 2018, 40,
2455–2461. [CrossRef]
224. Chen, H.; Cai, X.; Du, B.; Cai, J.; Luo, Z. MicroRNA-150-5p Inhibits the Proliferation and Invasion of Human Larynx Epidermiod
Cancer Cells Though Regulating Peptidyl-Prolyl Cis/Trans Isomerase. Braz. J. Otorhinolaryngol. 2023, 89, 383–392. [CrossRef]
225. Luo, M.; Sun, G.; Sun, J. MiR-196b Affects the Progression and Prognosis of Human LSCC through Targeting PCDH-17. Auris
Nasus Larynx 2019, 46, 583–592. [CrossRef] [PubMed]
226. Zhang, F.; Cao, H. MicroRNA-143-3p Suppresses Cell Growth and Invasion in Laryngeal Squamous Cell Carcinoma via Targeting
the k-Ras/Raf/MEK/ERK Signaling Pathway. Int. J. Oncol. 2018, 54, 689–701. [CrossRef] [PubMed]
227. Maia, D.; de Carvalho, A.C.; Horst, M.A.; Carvalho, A.L.; Scapulatempo-Neto, C.; Vettore, A.L. Expression of miR-296-5p as
Predictive Marker for Radiotherapy Resistance in Early-Stage Laryngeal Carcinoma. J. Transl. Med. 2015, 13, 262. [CrossRef]
[PubMed]
228. Oztürkcan, S.; Katilmiş, H.; Ozdemir, I.; Tuna, B.; Güvenç, I.A.; Dündar, R. Occult Contralateral Nodal Metastases in Supraglottic
Laryngeal Cancer Crossing the Midline. Eur. Arch. Oto-Rhino-Laryngol. 2009, 266, 117–120. [CrossRef]
229. Koroulakis, A.; Agarwal, M. Laryngeal Cancer. In StatPearls [Internet]; StatPearls Publishing: St. Petersburg, FL, USA, 2024.
230. Sharbel, D.D.; Abkemeier, M.; Groves, M.W.; Albergotti, W.G.; Byrd, J.K.; Reyes-Gelves, C. Occult Metastasis in Laryngeal
Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis. Ann. Otol. Rhinol. Laryngol. 2021, 130, 67–77. [CrossRef]
231. Khan, U.; MacKay, C.; Rigby, M.; Trites, J.; Corsten, M.; Taylor, S.M. Management of Positive Resection Margins Following
Transoral Laser Microsurgery for Glottic Cancer. Laryngoscope Investig. Otolaryngol. 2023, 8, 1579–1583. [CrossRef]
232. Kjems, J.; Zukauskaite, R.; Johansen, J.; Eriksen, J.G.; Lassen, P.; Andersen, E.; Andersen, M.; Farhadi, M.; Overgaard, J.; Vogelius,
I.R. Distant Metastases in Squamous Cell Carcinoma of the Pharynx and Larynx: A Population-Based DAHANCA Study. Acta
Oncol. 2021, 60, 1472–1480. [CrossRef]
233. Van den Bovenkamp, K.; van der Vegt, B.; Halmos, G.B.; Slagter-Menkema, L.; Langendijk, J.A.; van Dijk, B.A.C.; Schuuring, E.;
van der Laan, B.F.A.M. The Relation between Hypoxia and Proliferation Biomarkers with Radiosensitivity in Locally Advanced
Laryngeal Cancer. Eur. Arch. Oto-Rhino-Laryngol. 2023, 280, 3801–3809. [CrossRef]
234. Jotic, A.; Milovanovic, J.; Savic-Vujovic, K.; Radin, Z.; Medic, B.; Folic, M.; Pavlovic, B.; Vujovic, A.; Dundjerovic, D. Immune Cell
and Biochemical Biomarkers in Advanced Laryngeal Cancer. Dose Response 2022, 20, 15593258221115537. [CrossRef]
235. Koca, T.; Cetmi, D.A.; Aksoy, R.; Korcum, A.F. The Predictive Role of Inflammatory Biomarkers in Patients with Larynx Cancer
Undergoing Definitive Radiotherapy. Technol. Cancer Res. Treat. 2024, 23, 15330338241280433. [CrossRef]
236. Siegel, R.L.; Miller, K.D.; Fuchs, H.E.; Jemal, A. Cancer Statistics, 2021. CA Cancer J. Clin. 2021, 71, 7–33. [CrossRef] [PubMed]
237. Forastiere, A.A.; Zhang, Q.; Weber, R.S.; Maor, M.H.; Goepfert, H.; Pajak, T.F.; Morrison, W.; Glisson, B.; Trotti, A.; Ridge, J.A.;
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. JCO 2013, 31, 845–852. [CrossRef] [PubMed]
238. Eisbruch, A.; Harris, J.; Garden, A.S.; Chao, C.K.S.; Straube, W.; Harari, P.M. Multi-Institutional Trial of Accelerated Hypofraction-
ated Intensity-Modulated Radiation Therapy for Early-Stage Oropharyngeal Cancer (RTOG 00-22). Int. J. Radiat. Oncol. Biol. Phys.
2010, 76, 1333–1338. [CrossRef] [PubMed]
239. Gillison, M.L.; Trotti, A.M.; Harris, J.; Eisbruch, A.; Harari, P.M.; Adelstein, D.J.; Jordan, R.C.K.; Zhao, W.; Sturgis, E.M.; Burtness,
B.; et al. Radiotherapy plus Cetuximab or Cisplatin in Human Papillomavirus-Positive Oropharyngeal Cancer (NRG Oncology
RTOG 1016): A Randomised, Multicentre, Non-Inferiority Trial. Lancet 2019, 393, 40–50. [CrossRef]
J. Clin. Med. 2025, 14, 3367 31 of 32

240. Burtness, B.; Harrington, K.J.; Greil, R.; Soulières, D.; Tahara, M.; Castro, G. Pembrolizumab Alone or with Chemotherapy versus
Cetuximab with Chemotherapy for Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (KEYNOTE-048): A
Randomised, Open-Label, Phase 3 Study. Lancet 2019, 394, 1915–1928. [CrossRef]
241. NCI. FDA Approves Nivolumab for Head and Neck Cancer. Available online: https://www.cancer.gov/news-events/cancer-
currents-blog/2016/fda-nivolumab-scchn (accessed on 4 May 2025).
242. Yen, C.-J.; Kiyota, N.; Hanai, N.; Takahashi, S.; Yokota, T.; Iwae, S.; Shimizu, Y.; Hong, R.-L.; Goto, M.; Kang, J.-H.; et al. Two-Year
Follow-up of a Randomized Phase III Clinical Trial of Nivolumab vs. the Investigator’s Choice of Therapy in the Asian Population
for Recurrent or Metastatic Squamous Cell Carcinoma of the Head and Neck (CheckMate 141). Head Neck 2020, 42, 2852–2862.
[CrossRef]
243. Lee, N.Y.; Ferris, R.L.; Psyrri, A.; Haddad, R.I.; Tahara, M.; Bourhis, J.; Harrington, K.; Chang, P.M.H.; Lin, J.C.; Razaq, M.A.;
et al. Avelumab plus Standard-of-Care Chemoradiotherapy versus Chemoradiotherapy Alone in Patients with Locally Advanced
Squamous Cell Carcinoma of the Head and Neck: A Randomised, Double-Blind, Placebo-Controlled, Multicentre, Phase 3 Trial.
Lancet Oncol. 2021, 22, 450–462. [CrossRef]
244. Antonia, S.J.; Villegas, A.; Daniel, D.; Vicente, D.; Murakami, S.; Hui, R.; Yokoi, T.; Chiappori, A.; Lee, K.H.; de Wit, M.; et al.
Durvalumab after Chemoradiotherapy in Stage III Non–Small-Cell Lung Cancer. N. Engl. J. Med. 2017, 377, 1919–1929. [CrossRef]
245. Yu, Y.; Lee, N.Y. JAVELIN Head and Neck 100: A Phase III Trial of Avelumab and Chemoradiation for Locally Advanced Head
and Neck Cancer. Future Oncol. 2019, 15, 687–694. [CrossRef]
246. Machiels, J.-P.; Tao, Y.; Licitra, L.; Burtness, B.; Tahara, M.; Rischin, D.; Alves, G.; Lima, I.P.F.; Hughes, B.G.M.; Pointreau, Y.;
et al. Pembrolizumab plus Concurrent Chemoradiotherapy versus Placebo plus Concurrent Chemoradiotherapy in Patients with
Locally Advanced Squamous Cell Carcinoma of the Head and Neck (KEYNOTE-412): A Randomised, Double-Blind, Phase 3
Trial. Lancet Oncol. 2024, 25, 572–587. [CrossRef]
247. Cohen, E.E.W.; Soulières, D.; Le Tourneau, C.; Dinis, J.; Licitra, L.; Ahn, M.-J.; Soria, A.; Machiels, J.-P.; Mach, N.; Mehra, R.
Pembrolizumab versus Methotrexate, Docetaxel, or Cetuximab for Recurrent or Metastatic Head-and-Neck Squamous Cell
Carcinoma (KEYNOTE-040): A Randomised, Open-Label, Phase 3 Study. Lancet 2019, 393, 156–167. [CrossRef] [PubMed]
248. Haddad, R.I.; Harrington, K.; Tahara, M.; Ferris, R.L.; Gillison, M.; Fayette, J.; Daste, A.; Koralewski, P.; Zurawski, B.; Taberna, M.;
et al. Nivolumab Plus Ipilimumab Versus EXTREME Regimen as First-Line Treatment for Recurrent/Metastatic Squamous Cell
Carcinoma of the Head and Neck: The Final Results of CheckMate 651. J. Clin. Oncol. 2023, 41, 2166–2180. [CrossRef] [PubMed]
249. Seiwert, T.Y.; Wildsmith, S.; Fayette, J.; Harrington, K.; Gillison, M.; Ahn, M.-J.; Takahashi, S.; Weiss, J.; Machiels, J.-P.; Baxi, S.;
et al. Outcomes in Biomarker-Selected Subgroups from the KESTREL Study of Durvalumab and Tremelimumab in Recurrent or
Metastatic Head and Neck Squamous Cell Carcinoma. Cancer Immunol. Immunother. 2024, 73, 70. [CrossRef] [PubMed]
250. Li, X.; Lee, A.; Cohen, M.A.; Sherman, E.J.; Lee, N.Y. Past, Present and Future of Proton Therapy for Head and Neck Cancer. Oral.
Oncol. 2020, 110, 104879. [CrossRef]
251. Kang, B.-H.; Yu, T.; Kim, J.H.; Park, J.M.; Kim, J.-I.; Chung, E.-J.; Kwon, S.K.; Kim, J.H.; Wu, H.G. Early Closure of a Phase 1
Clinical Trial for SABR in Early-Stage Glottic Cancer. Int. J. Radiat. Oncol. Biol. Phys. 2019, 105, 104–109. [CrossRef]
252. Chotipanich, A. Total Laryngectomy: A Review of Surgical Techniques. Cureus 2021, 13, e18181. [CrossRef]
253. Campbell, G.; Glazer, T.A.; Kimple, R.J.; Bruce, J.Y. Advances in Organ Preservation for Laryngeal Cancer. Curr. Treat. Options
Oncol. 2022, 23, 594–608. [CrossRef]
254. Remacle, M.; Van Haverbeke, C.; Eckel, H.; Bradley, P.; Chevalier, D.; Djukic, V.; de Vicentiis, M.; Friedrich, G.; Olofsson, J.; Peretti,
G.; et al. Proposal for Revision of the European Laryngological Society Classification of Endoscopic Cordectomies. Eur. Arch.
Oto-Rhino-Laryngol. 2007, 264, 709. [CrossRef]
255. Canis, M.; Ihler, F.; Martin, A.; Wolff, H.A.; Matthias, C.; Steiner, W. Organ Preservation in T4a Laryngeal Cancer: Is Transoral
Laser Microsurgery an Option? Eur. Arch. Oto-Rhino-Laryngol. 2013, 270, 2719–2727. [CrossRef]
256. Peretti, G.; Piazza, C.; Mora, F.; Garofolo, S.; Guastini, L. Reasonable Limits for Transoral Laser Microsurgery in Laryngeal Cancer.
Curr. Opin. Otolaryngol. Head Neck Surg. 2016, 24, 135–139. [CrossRef]
257. Day, A.T.; Sinha, P.; Nussenbaum, B.; Kallogjeri, D.; Haughey, B.H. Management of Primary T1–T4 Glottic Squamous Cell
Carcinoma by Transoral Laser Microsurgery. Laryngoscope 2016, 127, 597–604. [CrossRef] [PubMed]
258. Weiss, B.G.; Ihler, F.; Wolff, H.A.; Schneider, S.; Canis, M.; Steiner, W.; Welz, C. Transoral Laser Microsurgery for Treatment for
Hypopharyngeal Cancer in 211 Patients. Head Neck 2017, 39, 1631–1638. [CrossRef] [PubMed]
259. Canis, M.; Martin, A.; Ihler, F.; Wolff, H.A.; Kron, M.; Matthias, C.; Steiner, W. Results of Transoral Laser Microsurgery for
Supraglottic Carcinoma in 277 Patients. Eur. Arch. Oto-Rhino-Laryngol. 2013, 270, 2315–2326. [CrossRef] [PubMed]
260. Hoffmann, C.; Cornu, N.; Hans, S.; Sadoughi, B.; Badoual, C.; Brasnu, D. Early Glottic Cancer Involving the Anterior Commissure
Treated by Transoral Laser Cordectomy. Laryngoscope 2015, 126, 1817–1822. [CrossRef]
261. Breda, E.; Catarino, R.; Monteiro, E. Transoral Laser Microsurgery for Laryngeal Carcinoma: Survival Analysis in a Hospital-based
Population. Head Neck 2014, 37, 1181–1186. [CrossRef]
J. Clin. Med. 2025, 14, 3367 32 of 32

262. Vilaseca, I.; Aviles-Jurado, F.X.; Valduvieco, I.; Berenguer, J.; Grau, J.J.; Baste, N.; Muxí, Á.; Castillo, P.; Lehrer, E.; Jordana,
M. Transoral Laser Microsurgery in Locally Advanced Laryngeal Cancer: Prognostic Impact of Anterior versus Posterior
Compartments. Head Neck 2021, 43, 3832–3842. [CrossRef]
263. Hans, S.; Chekkoury-Idrissi, Y.; Circiu, M.P.; Distinguin, L.; Crevier-Buchman, L.; Lechien, J.R. Surgical, Oncological, and
Functional Outcomes of Transoral Robotic Supraglottic Laryngectomy. Laryngoscope 2020, 131, 1060–1065. [CrossRef]
264. Lechien, J.R.; Fakhry, N.; Saussez, S.; Chiesa-Estomba, C.-M.; Chekkoury-Idrissi, Y.; Cammaroto, G.; Melkane, A.E.; Barillari, M.R.;
Crevier-Buchman, L.; Ayad, T.; et al. Surgical, Clinical and Functional Outcomes of Transoral Robotic Surgery for Supraglottic
Laryngeal Cancers: A Systematic Review. Oral. Oncol. 2020, 109, 104848. [CrossRef]
265. Lechien, J.R.; Baudouin, R.; Circiu, M.P.; Chiesa-Estomba, C.M.; Crevier-Buchman, L.; Hans, S. Transoral Robotic Cordectomy for
Glottic Carcinoma: A Rapid Review. Eur. Arch. Oto-Rhino-Laryngol. 2022, 279, 5449–5456. [CrossRef]
266. Remacle, M.; Prasad, V.M.N. Preliminary Experience in Transoral Laryngeal Surgery with a Flexible Robotic System for Benign
Lesions of the Vocal Folds. Eur. Arch. Oto-Rhino-Laryngol. 2018, 275, 761–765. [CrossRef]
267. Hans, S.; Chebib, E.; Lisan, Q.; Chekkoury-Idrissi, Y.; Distinguin, L.; Circiu, M.P.; Crevier-Buchman, L.; Lechien, J.R. Oncological,
Surgical and Functional Outcomes of Transoral Robotic Cordectomy for Early Glottic Carcinoma. J. Voice 2023, 37, 801.e3–801.e7.
[CrossRef] [PubMed]
268. Steuer, C.E.; El-Deiry, M.; Parks, J.R.; Higgins, K.A.; Saba, N.F. An Update on Larynx Cancer. CA Cancer J. Clin. 2017, 67, 31–50.
[CrossRef] [PubMed]
269. Li, M.M.; Zhao, S.; Eskander, A.; Rygalski, C.; Brock, G.; Parikh, A.S.; Haring, C.T.; Swendseid, B.; Zhan, K.Y.; Bradford, C.R.
Stage Migration and Survival Trends in Laryngeal Cancer. Ann. Surg. Oncol. 2021, 28, 7300–7309. [CrossRef]
270. Patel, T.R.; Eggerstedt, M.; Toor, J.; Tajudeen, B.A.; Husain, I.; Stenson, K.; Al-Khudari, S. Occult Lymph Node Metastasis in
Early-stage Glottic Cancer in the National Cancer Database. Laryngoscope 2021, 131, E1139–E1146. [CrossRef]
271. Nahavandipour, A.; Jakobsen, K.K.; Grønhøj, C.; Hebbelstrup Jensen, D.; Kim Schmidt Karnov, K.; Klitmøller Agander, T.; Specht,
L.; von Buchwald, C. Incidence and Survival of Laryngeal Cancer in Denmark: A Nation-Wide Study from 1980 to 2014. Acta
Oncol. 2019, 58, 977–982. [CrossRef]
272. Petrakos, I.; Kontzoglou, K.; Nikolopoulos, T.P.; Papadopoulos, O.; Kostakis, A. Glottic and Supraglottic Laryngeal Cancer:
Epidemiology, Treatment Patterns and Survival in 164 Patients. J. Buon 2012, 17, 700–705.
273. Yang, F.; He, L.; Rao, Y.; Feng, Y.; Wang, J. Survival Analysis of Patients with Subglottic Squamous Cell Carcinoma Based on the
SEER Database. Braz. J. Otorhinolaryngol. 2023, 88, S70–S80. [CrossRef]
274. MacNeil, S.D.; Patel, K.; Liu, K.; Shariff, S.; Yoo, J.; Nichols, A.; Fung, K.; Garg, A.X. Survival of Patients with Subglottic Squamous
Cell Carcinoma. Curr. Oncol. 2018, 25, e569. [CrossRef]
275. Juan, X.; Jiali, H.; Ziqi, L.; Liqing, Z.; Han, Z. Development and Validation of Nomogram Models for Predicting Postoperative
Prognosis of Early-Stage Laryngeal Squamous Cell Carcinoma. Curr. Probl. Cancer 2024, 49, 101079. [CrossRef]
276. Shi, X.; Hu, W.-P.; Ji, Q.-H. Development of Comprehensive Nomograms for Evaluating Overall and Cancer-Specific Survival of
Laryngeal Squamous Cell Carcinoma Patients Treated with Neck Dissection. Oncotarget 2017, 8, 29722–29740. [CrossRef]
277. Qasem, M.; Qasem, N.; Kinshuck, A.; Milinis, K. Long-Term Laryngeal Function and Quality of Life Following Treatment of Early
Glottic Cancer: A Meta-Analysis. Otolaryngol. Head Neck Surg. 2025, 172, 375–385. [CrossRef] [PubMed]
278. Chien, P.-J.; Hung, L.-T.; Wang, L.-W.; Yang, M.-H.; Chu, P.-Y. Oncologic Results and Quality of Life in Patients with T3 Glottic
Cancer after Transoral Laser Microsurgery. Eur. Arch. Oto-Rhino-Laryngol. 2021, 278, 2983–2992. [CrossRef] [PubMed]
279. Wulff, N.B.; Højager, A.; Wessel, I.; Dalton, S.O.; Homøe, P. Health-related Quality of Life Following Total Laryngectomy: A
Systematic Review. Laryngoscope 2021, 131, 820–831. [CrossRef] [PubMed]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.