Workup/Staging

Question 1

How do pts with LCX typically present?

Answer 1

Hoarseness, odynophagia/sore throat, otalgia (via the Arnold nerve/CN X), aspiration/choking, and neck mass

Question 2

What is the typical workup for pts presenting with a possible laryngeal mass?

Answer 2

Possible laryngeal mass workup: H&P (voice change, habits, indirect/direct laryngoscopy), CXR, CT/MRI, PET, basic labs, EUA + triple endoscopy, and Bx of the primary +/– FNA of the neck mass

Question 3

What does the loss of the laryngeal click on palpation of the thyroid cartilage indicate?

Answer 3

Loss of the laryngeal click on exam indicates postcricoid extension (or postcricoid tumor).

Question 4

What does pain in the thyroid cartilage indicate on exam?

Answer 4

Pain on palpation of the thyroid cartilage indicates tumor invasion into the thyroid cartilage.

Question 5

What imaging modality is best to assess for bony or cartilage erosion in pts with LCX?

Answer 5

CT scan is best for assessing bony/cartilage erosion (bone window).

Question 6

What is the incidence of nodal involvement for T1, T2, and T3–T4 glottic cancer?

Answer 6

T1: 0%–2%

T2: 2%–7%

T3–T4: 15%–30%

Question 7

What is the incidence of nodal involvement for supraglottic lesions according to T stage?

Answer 7

T1–T2: 27%–40%

T3–T4: 55%–65% (Wang CC, Radiation therapy for head and neck neoplasms 1996)

Question 8

What proportion of pts with supraglottic cancer present with unilat vs. bilat nodal Dz?

Answer 8

∼55% of supraglottic cancer pts present with unilat nodal Dz, and 16% present with bilat nodal involvement. (Lindberg R et al., Cancer 1972)

Question 9

What % of pts with subglottic cancer present with nodal involvement?

Answer 9

20%–50% of subglottic pts present with nodal Dz (generally the prelaryngeal/Delphian, lower jugular, pretracheal or upper mediastinal nodes).

Question 10

Describe the T staging for cancers of the supraglottic larynx (AJCC 8th edition, 2017).

Answer 10

T1: 1 subsite with normal VC mobility

T2: more than 1 adjacent subsite of supraglottis or glottis or region outside supraglottis (base of tongue, vallecula, medial wall of pyriform sinus) without fixation of larynx

T3: Larynx-confined with cord fixation and/or invasion of postcricoid area, pre-epiglottic space, paraglottic space and/or inner cortex thyroid cartilage

T4a (resectable): through outer cortex thyroid cartilage and/or beyond larynx (trachea, ST of neck, extrinsic muscles of tongue, strap muscles, thyroid, esophagus)

T4b: invasion of prevertebral space, encased carotid, mediastinum

Question 11

Describe the T staging for cancers of the glottic larynx (AJCC 8th edition, 2017).

Answer 11

T1: limited to TVCs (+/– commissure involvement), normal mobility (T1a: 1 cord, T1b: both)

T2: extends to supra- or subglottis or impaired vocal cord mobility

T3: fixed vocal cords, confined to larynx and/or paraglottic space invasion and/or inner cortex thyroid cartilage

T4a–b: same as above/for supraglottic lesions

Question 12

What is the T-staging breakdown for cancers of the subglottic larynx (AJCC 8th edition, 2017)?

Answer 12

T1: tumor limited to subglottis

T2: extension to vocal cords, with normal or impaired mobility

T3: limited to larynx with vocal cord fixation or paraglottic space extension, invasion of inner cortex thyroid cartilage

T4a–b: same as above

Question 13

What is the clinical nodal staging for LCX (AJCC 8th edition, 2017)?

Answer 13

N1: single ipsi, ≤3 cm, ENE(–)

N2a: single ipsi >3 cm and ≤6 cm ENE(–)

N2b: multiple ipsi, ≤6 cm and ENE(–)

N2c: bilat or contralat, ≤6 cm and ENE(–)

N3a: >6 cm and ENE(–)

N3b: clinically overt ENE(+)

Question 14

What is the pathologic nodal staging for LCX (AJCC 8th edition, 2017)?

Answer 14

N1: single ipsi, ≤3 cm, ENE(–)

N2a: single ipsi or contralat ≤3 cm and ENE(+) or single ipsi >3 cm and ≤ 6 cm ENE(–)

N2b: multiple ipsi, ≤6 cm and ENE(–)

N2c: bilat or contralat, ≤6 cm and ENE(–)

N3a: >6 cm and ENE(–)

N3b: single ipsi >3 cm ENE(+) or multiple ipsi/contralat/bilat nodes any with ENE(+)

Question 15

Describe the overall stage groupings for LCX (AJCC 8th edition, 2017).

Answer 15

Stages I: T1N0

Stage II: T2N0

Stage III: T3N0 or N1

Stage IVA: T4a or N2

Stage IVB: T4b or N3

Stage IVC: M1

Question 16

With what stage of Dz do most pts with HPxC present?

Answer 16

Most pts (>80%) present with stage III or IV Dz (lesions often remain asymptomatic until advanced Dz).

Question 17

What % of pts with HPxC present with DMs?

Answer 17

∼2%–4% of HPxC pts present with DMs. ∼20%–30% develop DMs within 2 yrs despite Tx.

Question 18

With what Sx do most HPxC pts present?

Answer 18

Neck mass, sore throat, dysphagia, hoarseness (direct vocalis or cricoarytenoid joint invasion), and otalgia (Arnold nerve/CN X involvement)

Question 19

What is the typical workup for pts who present with hoarseness?

Answer 19

Hoarseness workup: H&P (check for thyroid click), labs, CT/MRI, PET, neck FNA, EUA + triple endoscopy, and Bx of the primary mass

Question 20

Describe the T staging of HPxC (AJCC 8th edition, 2017).

Answer 20

T1: 1 site of HPX and/or ≤2 cm

T2: more than 1 subsite or 2–4 cm without hemilarynx fixation

T3: >4 cm or fixation of hemilarynx or esophageal extension

T4a: invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, central STs (prelaryngeal strap muscles and SQ fat)

T4b: invades prevertebral fascia, encases carotid artery, or mediastinal structures

Question 21

What is the nodal staging breakdown for HPxC (AJCC 8th edition, 2017)?

Answer 21

Same system as used for p16 negative OPX

N1: single ipsi, ≤3 cm, ENE(–)

N2a: single ipsi, >3 cm, ≤6 cm, ENE(–)

N2b: multiple ipsi, ≤6 cm, ENE(–)

N2c: any bilat or contralat, ≤6 cm, ENE(–)

N3a: any >6 cm, ENE(–)

N3b: any clinically overt ENE(+)

Question 22

Describe the overall stage groupings for HPxC.

Answer 22

Stage I: T1N0

Stage II: T2N0

Stage III: T3N0 or N1

Stage IVA: T4a or N2

Stage IVB: T4b or N3

Stage IVC: M1