AJCC Staging Moments

AJCC TNM Staging 7th Edition

Supraglottic Larynx Case #2

Contributors: Jatin P. Shah, MD Memorial Sloan-Kettering Cancer Center, New York, New York Carol R. Bradford, MD University of Michigan Medical Center, Ann Arbor, Michigan James Brierley, MB Princess Margaret Hospital/University Health Network, Toronto, Ontario

Larynx Case # 2Presentation of New Case

• Newly diagnosed larynx cancer patient

• Presentation at Cancer Conference for treatment recommendations and clinical staging

Larynx Case # 2History & Physical

• 73 yr old male who presented with chronic hoarseness, SOB, dysphagia

• No smoking hx

• No family history of ca

Larynx Case # 2Imaging & Endoscopy Results

• CT neck– Right laryngeal region mass with– Extension to paraglottic space– Prominent 1.4cm level III right neck

node

• CT chest and CT brain– Negative

• Laryngoscopy & bx– Large tumor involving right false vocal cord extending to true

vocal cord and medial wall of pyriform sinus on the same side– Vocal cord is mobile– No contralateral spread

Used with permission. Becker, M, Moulin G, Kurt A, et al. Atypical Sqamous Cell Carcinoma of the Larynx and Hypopharynx: Radiologic Features. European Radiology. 1998; 8:1544.

Larynx Case # 2Diagnostic Procedure

• Procedure– Biopsy right false vocal cord during laryngoscopy

• Pathology Report– Squamous cell ca– Poorly differentiated, Grade 3

• Human papillomavirus (HPV) - neg

Larynx Case # 2Clinical Staging

• Clinical staging – Uses information from the physical exam, imaging,

and diagnostic laryngoscopy

• Purpose– Select appropriate treatment– Estimate prognosis

Larynx Case # 2Clinical Staging

• Synopsis- patient with supraglottic lesion extending to glottis, medial wall of pyriform sinus with normal vocal cord mobility, clinically involved nodes

• What is the clinical stage?– T____– N____– M____– Stage Group______

Larynx Case # 2Clinical Staging

• Clinical Stage correct answer– cT2– cN1– cM0– Stage Group III

• Based on stage, treatment is selected

• Review NCCN treatment guidelines for this stage

Larynx Case # 2Clinical Staging

• Rationale for staging choices– cT2

• Invades more than one adjacent subsite• Invades region outside supraglottis (pyriform sinus)• Vocal cord is mobile• No cartilage invasion

– cN1 because a single ipsilateral lymph node <3 cm was clinically positive on imaging studies

– cM0 because there was nothing to suggest distant metastases; if there was, appropriate tests would be performed before developing a treatment plan

Prognostic FactorsClinically Significant

• Applicable to this case

– Head & Neck nodes Level: III

– Clinical location of cervical nodes: above level of cricoid and medial to lateral border of SCM

– Extracapsular spread (ECS) clinical: neg

– Human papillomavirus (HPV) status: neg

• There are no prognostic factors required for staging

Larynx Case # 2Pathologic Staging

• This patient was recommended for radiation rx & chemotherapy, no surgery

• Pathologic staging is not completed since there was no resection meeting the pathologic classification requirements

Prognostic FactorsClinically Significant

• Applicable to this case

– Size of lymph nodes: <3cm clinically

– Extracapsular extension from lymph nodes: none seen clinically or radiologically

– Lymph node levels involved: III

– Extracapsular spread (ECS) pathologic: n/a

– Human papillomavirus (HPV) status: neg

• There are no prognostic factors required for staging

AJCC Cancer Staging AtlasT2 Invasion of more than one adjacent subsite or outside supraglottis

Larynx Case # 2Recap of Staging

• Summary of correct answers– Clinical stage cT2 N1 M0 Stage Group III– Pathologic stage unknown

• The staging classifications have a different purpose and therefore can be different. Do not go back and change the clinical staging based on pathologic staging information.

Staging Moments Summary

• Review site-specific information if needed

• Clinical Staging– Based on information before treatment– Used to select treatment options

• Pathologic Staging– Based on clinical data PLUS surgery and pathology

report information– Used for selection of adjuvant treatment and prognosis– Used to evaluate end-results (survival)