AJCC Staging Moments

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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
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Larynx Case 2 Presentation of New Case

• Newly diagnosed larynx cancer patient
• Presentation at Cancer Conference for treatment
  recommendations and clinical staging

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Larynx Case 2 History Physical

• 73 yr old male who presented with chronic
  hoarseness, SOB, dysphagia
• No smoking hx
• No family history of ca

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Larynx Case 2 Imaging Endoscopy Results

• CT neck
• Right laryngeal region mass with
• Extension to paraglottic space
• Prominent 1.4cm level III right necknode
• 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 81544.
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Larynx Case 2 Diagnostic Procedure

• Procedure
• Biopsy right false vocal cord during laryngoscopy
• Pathology Report
• Squamous cell ca
• Poorly differentiated, Grade 3
• Human papillomavirus (HPV) - neg

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Larynx Case 2 Clinical Staging

• Clinical staging
• Uses information from the physical exam, imaging,
  and diagnostic laryngoscopy
• Purpose
• Select appropriate treatment
• Estimate prognosis

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Larynx Case 2 Clinical 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______

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Larynx Case 2 Clinical Staging

• Clinical Stage correct answer
• cT2
• cN1
• cM0
• Stage Group III
• Based on stage, treatment is selected
• Review NCCN treatment guidelines for this stage

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Larynx Case 2 Clinical 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 lt3 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

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Prognostic Factors Clinically 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

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Larynx Case 2 Pathologic 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

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Prognostic Factors Clinically Significant

• Applicable to this case
• Size of lymph nodes lt3cm 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

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AJCC Cancer Staging Atlas T2 Invasion of more
than one adjacent subsite or
outside supraglottis
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Larynx Case 2 Recap 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.

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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)