Cellular Classification of Laryngeal Cancer


Cellular Classification of Laryngeal Cancer

Most laryngeal cancers are of squamous cell histology. Squamous cell subtypes include keratinizing and nonkeratinizing and well-differentiated to poorly differentiated grade. A variety of nonsquamous cell laryngeal cancers also occur.[1] These are not staged using the American Joint Cancer Committee staging system, and their management, which is not discussed here, can differ from that of squamous cell laryngeal cancers. In situ squamous cell carcinoma of the larynx is usually managed by a conservative surgical procedure such as mucosal stripping or superficial laser excision. Radiation therapy may also be appropriate treatment of selected patients with in situ carcinoma of the glottic larynx.

References

  1. Mendenhall WM, Werning JW, Pfister DG: Treatment of head and neck cancer. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Lippincott Williams & Wilkins, 2011, pp 729-80.

Stage Information for Laryngeal Cancer

In This Section

The staging system for laryngeal cancer is clinical and based on the best possible estimate of the extent of disease before treatment. The assessment of the primary tumor is based on inspection and palpation when possible and by fiberoptic laryngoscopy. Panendoscopy under anesthesia ensures careful clinical examination to determine clinical extent of local disease. The tumor must be confirmed histologically, and any other pathological data obtained on biopsy may be included. Head and neck magnetic resonance imaging, computed tomography, or positron emission tomography-computed tomography should be done before therapy to supplement inspection and palpation.[1] Additional radiographic studies may be included. The appropriate nodal drainage areas in the neck should be examined by careful palpation.

Definitions of TNM

The American Joint Committee on Cancer (AJCC) has designated staging by TNM (tumor, node, metastasis) classification to define laryngeal cancer.[2]

Table 1. Definition of Supraglottis, Glottis, and Subglottis Primary Tumor (T) for Laryngeal Cancer a,b

T Category

T Criteria

TX

Primary tumor cannot be assessed.

Tis

Carcinoma in situ.

Supraglottis


T1

Tumor limited to one subsite of supraglottis with normal vocal cord mobility.

T2

Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of the base of the tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.

T3

Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage.

T4

Moderately advanced or very advanced.

–T4a

Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).

–T4b

Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.

Glottis


T1

Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility.

–T1a

Tumor limited to one vocal cord.

–T1b

Tumor involves both vocal cords.

T2

Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.

T3

Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.

T4

Moderately advanced or very advanced.

–T4a

Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, cricoid cartilage, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).

–T4b

Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.

Subglottis


T1

Tumor limited to the subglottis.

T2

Tumor extends to vocal cord(s) with normal or impaired mobility.

T3

Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.

T4

Moderately advanced or very advanced.

–T4a

Moderately advanced local disease. Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus).

–T4b

Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.

aReprinted with permission from AJCC: Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp 149–61.


Table 2. Definition of Clinical (cN) Regional Lymph Nodes (N) for Laryngeal Cancer a,b

N Category

N Criteria

NX

Regional lymph nodes cannot be assessed.

N0

No regional lymph node metastasis.

N1

Metastasis in a single ipsilateral lymph node ≤3 cm in greatest dimension and ENE(–).

N2

Metastasis in a single ipsilateral node, >3 cm but not >6 cm in greatest dimension and ENE(–); or metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension and ENE(–); or metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension and ENE(–).

–N2a

Metastasis in a single ipsilateral node >3 cm but not >6 cm in greatest dimension and ENE(–).

–N2b

Metastases in multiple ipsilateral nodes, none >6 cm in greatest dimension and ENE(–).

–N2c

Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension and ENE(–).

N3

Metastasis in a lymph node >6 cm in greatest dimension and ENE(–); or metastasis in any lymph nodes(s) with clinically overt ENE(+).

–N3a

Metastasis in a lymph node >6 cm in greatest dimension and ENE(–).

–N3b

Metastasis in any lymph node(s) with clinically overt ENE(+).

ENE = extranodal extension.


aReprinted with permission from AJCC: Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp 149–61.


bA designation of "U" or "L" may be used for any N category to indicate metastasis above the lower border of the cricoid (U) or below the lower border of the cricoid (L). Similarly, clinical and pathological ENE should be recorded as ENE(–) or ENE(+).


Table 3. Definition of Pathological (pN) Regional Lymph Nodes (N) for Laryngeal Cancer a,b

N Category

N Criteria

NX

Regional lymph nodes cannot be assessed.

N0

No regional lymph node metastasis.

N1

Metastasis in a single ipsilateral lymph node ≤3 cm in greatest dimension and ENE(–).

N2

Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension and ENE(+); or metastasis in a single ipsilateral lymph node, >3 cm but not >6 cm in greatest dimension and ENE(–); or metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension and ENE(–); or metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension and ENE(–).

–N2a

Metastasis in a single ipsilateral node ≤3 cm in greatest dimension and ENE(+); or metastasis in a single ipsilateral node >3 cm but not >6 cm in greatest dimension and ENE.

–N2b

Metastases in multiple ipsilateral nodes, none >6 cm in greatest dimension and ENE(–).

–N2c

Metastases in bilateral or contralateral lymph node(s), none >6 cm in greatest dimension and ENE(–).

N3

Metastasis in a lymph node >6 cm in greatest dimension and ENE(–); or metastasis in a single ipsilateral node >3 cm in greatest dimension and ENE(+); or metastases in multiple ipsilateral, contralateral, or bilateral lymph nodes and any with ENE(+); or a single contralateral node of any size and ENE(+).

–N3a

Metastasis in a lymph node, >6 cm in greatest dimension and ENE(–).

–N3b

Metastasis in a single ipsilateral node >3 cm in greatest dimension and ENE(+); or metastases in multiple ipsilateral, contralateral, or bilateral nodes and any with ENE(+); or a single contralateral node of any size and ENE(+).

ENE = extranodal extension.


aReprinted with permission from AJCC: Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp 149–61.


bA designation of "U" or "L" may be used for any N category to indicate metastasis above the lower border of the cricoid (U) or below the lower border of the cricoid (L). Similarly, clinical and pathological ENE should be recorded as ENE(–) or ENE(+).


Table 4. Definition of Distant Metastasis (M) for Laryngeal Cancer a

M Category

M Criteria

M0

No distant metastasis.

M1

Distant metastasis.

aReprinted with permission from AJCC: Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp 149–61.


AJCC Prognostic Stage Groups

Table 5. Definition of TNM Stage 0 a

Stage

TNM

Description

0

Tis, N0, M0

Tis = Carcinoma in situ.



N0 (cN and pN) = No regional lymph node metastasis.



M0 = No distant metastasis.

T = primary tumor; N = regional lymph node; M = metastasis.



aReprinted with permission from AJCC: Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp 149–61.



Table 6. Definition of TNM Stage I a

Stage

TNM

Description

I

T1, N0, M0

Supraglottis



T1 = Tumor limited to one subsite of supraglottis with normal vocal cord mobility.



Glottis



T1 = Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility.



–T1a = Tumor limited to one vocal cord.



–T1b = Tumor involves both vocal cords.



Subglottis



T1 = Tumor limited to the subglottis.



N0 (cN and pN) = No regional lymph node metastasis.



M0 = No distant metastasis.

T = primary tumor; N = regional lymph node; M = metastasis; cN = clinical N; pN = pathological N.



aReprinted with permission from AJCC: Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp 149–61.



Table 7. Definition of TNM Stage II a

Stage

TNM

Description


II

T2, N0, M0

Supraglottis




T2 = Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of the base of the tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.




Glottis




T2 = Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.




Subglottis




T2 = Tumor extends to vocal cord(s) with normal or impaired mobility.




N0 (cN and pN) = No regional lymph node metastasis.




M0 = No distant metastasis.


T = primary tumor; N = regional lymph node; M = metastasis; cN = clinical N; pN = pathological N.




aReprinted with permission from AJCC: Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp 149–61.




Table 8. Definition of TNM Stage III a

Stage

TNM

Description

III

T3, N0, M0

Supraglottis



T3 = Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage.



Glottis



T3 = Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.



Subglottis



T3 = Tumor limited to larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.



N0 (cN or pN) = No regional lymph node metastasis.



M0 = No distant metastasis.


T1, T2, T3, N1, M0

Supraglottis



T1 = Tumor limited to one subsite of supraglottis with normal vocal cord mobility.



T2 = Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of the base of the tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.



T3 = Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage.



Glottis



T1 = Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility.



T1a = Tumor limited to one vocal cord.



T1b = Tumor involves both vocal cords.



T2 = Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.



T3 = Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.



Subglottis



T1 = Tumor limited to the subglottis.



T2 = Tumor extends to vocal cord(s) with normal or impaired mobility.



T3 = Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.



N1 (cN or pN) = Metastasis in a single ipsilateral node, ≤3 cm in greatest dimension and ENE (–).



M0 = No distant metastasis.

T = primary tumor; N = regional lymph node; M = metastasis; cN = clinical N; ENE = extranodal extension; pN = pathological N.



aReprinted with permission from AJCC: Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp 149–61.



Table 9. Definition of TNM Stage IVA, IVB, and IVC a

Stage

TNM

Description

IVA

T4a, N0, N1, M0

Supraglottis



–T4a = Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).



Glottis



–T4a = Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, cricoid cartilage, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).



Subglottis



–T4a = Moderately advanced local disease. Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus).



N0 (cN and pN) = Metastasis in a single ipsilateral node, ≤3 cm in greatest dimension and ENE (–).



N1 (cN and pN) = Metastasis in a single ipsilateral node, ≤3 cm in greatest dimension and ENE (–).



M0 = No distant metastasis.


T1, T2, T3, T4a, N2, M0

Supraglottis



T1 = Tumor limited to one subsite of supraglottis with normal vocal cord mobility.



T2 = Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of the base of the tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.



T3 = Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage.



–T4a = Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).



Glottis



T1 = Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility.



–T1a = Tumor limited to one vocal cord.



–T1b = Tumor involves both vocal cords.



T2 = Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.



T3 = Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.



–T4a = Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, cricoid cartilage, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).



Subglottis



T1 = Tumor limited to the subglottis.



T2 = Tumor extends to vocal cord(s) with normal or impaired mobility.



T3 = Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage.



–T4a = Moderately advanced local disease. Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, cricoid cartilage, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).



cN2 = Metastasis in a single ipsilateral node >3 cm but not >6 cm in greatest dimension and ENE(–); or metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension and ENE(–); or metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension and ENE(–).



‒cN2a = Metastasis in a single ipsilateral node, larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(–).



‒cN2b = Metastases in multiple ipsilateral nodes, none larger than 6 cm in greatest dimension and ENE(–).



‒cN2c = Metastasis in bilateral of contralateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(–).



pN2 = Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension and ENE(+); or metastasis in a single ipsilateral lymph node >3 cm but not >6 cm in greatest dimension and ENE(–); or metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension and ENE(–); or metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension and ENE(–).



‒pN2a = Metastasis in a single ipsilateral or contralateral node, 3 cm or smaller in greatest dimension and ENE(+); or metastasis in a single ipsilateral node, larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(–).



‒pN2b = Metastases in multiple ipsilateral nodes, none larger than 6 cm in greatest dimension and ENE(–).



‒pN2c = Metastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(–).



M0 = No distant metastasis.

IVB

Any T, N3, M0

Any T = See Table 1.



cN3 = Metastasis in a lymph node >6 cm in greatest dimension and ENE(–); or metastasis in any lymph node(s) with clinically overt ENE(+).



–cN3a = Metastasis in a lymph node >6 cm in greatest dimension and ENE(–).



–cN3b = Metastasis in any lymph node(s) with clinically overt ENE(+).



pN3 = Metastasis in a lymph node >6 cm in greatest dimension and ENE(–); or metastasis in a single ipsilateral node >3 cm in greatest dimension and ENE(+); or metastases in multiple ipsilateral, contralateral, or bilateral lymph nodes and any with ENE(+).



–pN3a = Metastasis in a lymph mode >6 cm in greatest dimension and ENE(–).



–pN3b = Metastasis in a single ipsilateral node >3 cm in greatest dimension and ENE(+); or metastases in multiple ipsilateral, contralateral, or bilateral lymph nodes and any with ENE(+).



M0 = No distant metastasis.


T4b, Any N, M0

Supraglottis



–T4b = Very advanced local disease. Tumor invades prevertebral space, encases carotid artery or invades mediastinal structures.



Glottis



–T4b = Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.



Subglottis



–T4b = Very advanced local disease. Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.



Any N = See Table 2 and Table 3.



M0 = No distant metastasis.

IVC

Any T, Any N, M1

Any T = See Table 1.



Any N = See Table 2 and Table 3.



M1 = Distant metastasis.

T = primary tumor; N = regional lymph node; M = metastasis; cN = clinical N; ENE = extranodal extension; pN = pathological N.



Reprinted with permission from AJCC: Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer, 2017, pp 149–61.



References

  1. Thabet HM, Sessions DG, Gado MH, et al.: Comparison of clinical evaluation and computed tomographic diagnostic accuracy for tumors of the larynx and hypopharynx. Laryngoscope 106 (5 Pt 1): 589-94, 1996. [PUBMED Abstract]
  2. Larynx. In: Amin MB, Edge SB, Greene FL, et al., eds.: AJCC Cancer Staging Manual. 8th ed. Springer; 2017, pp 149-61.


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