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Laryngeal Cancer

Determining the Stage of the Cancer

The final step before discussing treatment options is a determination of the stage of the cancer. As with all cancers of the head and neck, doctors use the AJCC Cancer Staging Manual (7th Ed) to determine the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

At first, you will be given a clinical stage based on all of the available information.

  • Clinical staging (cTNM) is determined from any information your doctor might have about how extensive the cancer is BEFORE starting any treatment. Stage is determined based on your doctor’s physical exam, imaging studies, laboratory work and biopsies. Classification of clinical stage is described using the lowercase prefix c (e.g., cT, cN, cM).

If there is surgical removal of the cancer as part of your treatment, a pathologist will analyze the tumor and any lymph nodes that may have been removed. You will then be assigned a pathologic stage.

  • Pathologic staging (pTNM) provides more data. Classification of pathology stage is described using the lowercase prefix p (e.g., pT, pN, pM). This may or may not differ from the clinical stage.

There are also a number of other lowercase prefixes that might be used in the staging of your cancer.

  • The subscript y (yTNM) is used to assign a cancer stage after some sort of medical, systemic or radiation treatment is given (Posttherapy or Postneoadjuvant Stage). It is typically combined with either a clinical or pathologic stage. For example, ycT2N0M0 indicates that after some sort of non-surgical therapy, the new clinical stage is T2N0M0.
  • The subscript r (rTNM) is used when the tumor has recurred after some period of time in which it was gone. This is called Retreatment Classification Stage. Your doctor will use all the available information to assign you a retreatment stage.

T stage: the main tumor mass

Based on a physical examination and review of any imaging, your doctor should be able to give you a T stage that falls within one of the following categories.

Tx The doctor is unable to find primary tumor.
T0 There is no evidence of a primary tumor despite looking everywhere.
Tis Carcinoma in situ (or severe dysplasia); this means there are cancer type cells, but they have not yet invaded deep into tissue. This is more of a pre-cancer lesion.
T1 Supraglottis: The tumor is only at one subsite of the supraglottis, and the vocal cords move normally.Glottis: The tumor is only in the vocal cords with normal mobility. T1a refers to cancer involvement of only one cord. T1b refers to cancer involvement of both cords.Subglottis: The tumor is entirely within the subglottis.
T2 Supraglottis: The tumor invades more than one subsite of the supraglottis, or glottis, or a region outside the supraglottis (such as the base of the tongue, the valeculla or the inside wall of the piriform sinus) that is immediately next to where the tumor starts. Also, there is no fixation of the vocal cords.Glottis: The tumor is large enough that it goes to the supraglottis and/or subglottis, and/or there is decreased movement of the vocal cord.Subglottis: The tumor extends up to the vocal cord(s) with normal or decreased mobility.
T3 Supraglottis: The tumor is contained within the voice box, and there is vocal cord fixation and/or it invades any of the following regions: postcricoid area, preepiglottic space, paraglottic space and/or inner aspect of the thyroid cartilage.Glottis: The tumor is contained within the voice box with fixation of the vocal cord, and/or invasion of the paraglottic space and/or invasion of the inside aspect of the thyroid cartilage.Subglottis: The tumor is contained within the voice box and there is vocal cord fixation.
T4a Supraglottis: Moderate advanced local disease. Tumor invades through the thyroid cartilage and/or invades tissues outside of the voice box (such as the trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid gland or esophagus).Glottis: Moderate advanced local disease. Tumor invades through the thyroid cartilage and/or invades tissues outside of the voice box (such as the trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid gland or esophagus).Subglottis: Moderate advanced local disease. Tumor invades the thyroid or cricoid cartilage and/or invades tissues outside of the voice box (such as the trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid gland or esophagus).
T4b Supraglottis: Very advanced local disease. The tumor invades the pre-vertebral space, encases the carotid artery or invades structures in the upper chest area.Glottis: Very advanced local disease. The tumor invades the pre-vertebral space, encases the carotid artery or invades structures in the upper chest area.Subglottis: Very advanced local disease. The tumor invades the pre-vertebral space, encases the carotid artery or invades structures in the upper chest area.

 

38_1_supraglottis_Tstage

 

38_2_glottis_Tstage

 

38_3_subglottis_Tstage

N stage: spread of cancer to the lymph nodes in the neck

Next, your doctor will use all the available information and assign you an N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

06_Nstages (1)

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the nodes.
N1 It looks like there is a single node, on the same side of the main tumor, that is 3 centimeters or less in greatest size.
N2a Spread to a single node, on the same side as the main tumor, and it is more than 3 centimeters but less than or equal to 6 centimeters in greatest dimension.
N2b There is more than one lymph node that has cancer, on the same side as the main tumor, but none of them are more than 6 centimeters in size.
N2c There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck, but none are more than 6 centimeters.
N3 There is spread to one or more neck lymph nodes, and the size is more than 6 centimeters.

M stage: spread of cancer outside the head and neck

Finally, based on an assessment on the entire body, you will be assigned an M stage.

M0 No evidence of distant (outside the head and neck) spread.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

Your cancer stage

After TNM staging, your doctor can assign a cancer stage based on the following chart.

Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVB T4b Any N M0
Any T N3 M0
Stage IVC Any T Any N M1

Your clinical stage

Once the diagnostic tests are completed, before deciding what type of treatment you are going to undergo, you should be given a clinical stage that will look similar to the example below.

CLINICAL STAGE
Example
Site Larynx
Subsite Supraglottis
Type Squamous Cell Carcinoma
cT cT3
cN cN2b
cM cM0
cStage cIVa

* The lowercase subscript c indicates that this is a CLINICAL STAGE, the stage assigned based on all information available to your doctor before starting treatment.

After surgery, you should get a pathologic stage of your tumor. It will look almost like the clinical stage you received before starting treatment, but notice the “p” that indicates the stage group is based on an analysis of the entire tumor, with or without lymph nodes, under a microscope by a pathologist. In many cases, the pathologic stage will be the same as the clinical stage, but sometimes it will change.

After surgery, and after the pathologist has evaluated all of the tumor that was removed, you should be given a pathologic stage that looks something like this:

PATHOLOGIC STAGE
Example
Site Larynx
Subsite Supraglottis
Type Squamous Cell Carcinoma
pT pT3
pN pN2b
cM cM0
pStage pIVa
  • The lowercase subscript p indicates that this is a PATHOLOGIC STAGE, the stage assigned after tumor removal and confirmation of cancer by a pathologist.
  • Note also that the M stage is usually clinical, based on all available data without actually analyzing any tissue.
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12 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. ©National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.

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