Staging systems are used to describe the severity of cancer based on the size, extent of invasion, and spread to different body parts. It helps to determine treatment strategy and disease prognosis. TNM is the most commonly used system for staging laryngeal cancers. “T” stands for “Tumor Size”, “N” for “Lymph Nodes”, and “M” for “Metastasis”. Numbers and/or letters after T (is, 1, 2, 3, 4a, and 4b), N (0, 1, 2, and 3), and M (0 and 1) provide more details about each of these factors. Once T, N, and M categories are determined through different diagnostic techniques, this information is combined to assign an overall stage (from 0 to IV) to the disease.
Apart from the stage of disease, the selection of treatment usually depends upon the location of disease, patient’s preference, performance status of the patient, along with other factors. Following are the preferred treatment approaches for different stages of laryngeal cancer, but the final decision is taken after clinical assessment of the patient by an oncologist.
|Stage||TNM Score||Stage Description
|0||Tis N0 M0||Carcinoma in situ or cancerous lesion is present only in the superficial laryngeal layer.||For Stage 0 cancers, endoscopic surgical resection of the involved tissue or radiotherapy is considered as the preferred treatment. The patient should be followed-up closely after treatment for any sign of recurrence.|
|I||T1 N0 M0||The primary tumor is limited to one part of the supraglottis with normal vocal cord movement. No spread to nearby lymph nodes or distant body parts.||For Stage I and II cancers, radiotherapy is considered as the preferred treatment. Surgical resection (partial laryngectomy) may also be employed as the primary treatment. Chemotherapy along with radiation therapy is usually employed after the primary treatment to kill any remaining cancer cells.|
|II||T2 N0 M0||The primary tumor is present in more than one part of the supraglottis/glottis with normal vocal cord movement. No spread to nearby lymph nodes or distant body parts.|
|III||T3 N0 M0
|The primary tumor is limited to the larynx with no movement in the vocal cord and/or it has invaded into the post-cricoid area, para-glottic space, pre-epiglottic space, or the inner part of the thyroid cartilage. No spread to nearby lymph nodes or distant body parts.||For Stage III to IVA cancers, a combination of radiotherapy and chemotherapy or targeted therapy is usually employed as the first-line treatment. Alternatively, surgery followed by chemotherapy + radiotherapy or radiotherapy alone can be employed as the primary treatment. Surgery usually involves a complete removal of the larynx along with the affected lymph nodes.
Some physicians prefer to start treatment with chemotherapy alone (induction therapy). In case of shrinkage of the tumor, further treatment may involve radiotherapy with or without chemotherapy. In case of no shrinkage, surgery may be employed.
|T1-3 N1 M0||The primary tumor is limited to the larynx with or without normal vocal cord movement or invasion in the adjacent structures. The disease has spread to a single ipsilateral lymph node measuring </=3 cm without extranodal involvement. No spread to distant body parts.|
|IVA||T1-3 N2 M0||The primary tumor is limited to the larynx with or without normal vocal cord movement or invasion in the adjacent structures. The disease has spread to a single ipsilateral lymph node measuring either </=3 cm with extranodal involvement or >3 cm but <6 cm without extranodal involvement; or to multiple ipsilateral or bilateral/contralateral lymph nodes, all measuring <6 cm without extranodal involvement. No spread to distant body parts.|
|T4a N0-2 M0||The primary tumor has invaded an adjacent structure, such as the outer cortex of the thyroid cartilage, trachea, strap muscles, thyroid, or esophagus. The disease might have spread to single, multiple, or bilateral/contralateral lymph nodes, all measuring <6 cm without extranodal involvement. No spread to distant body parts.|
|IVB||Any T N3 M0||The primary tumor that might have invaded an adjacent structure or a vital structure. The disease has spread to lymph nodes measuring >6 cm or significant extranodal involvement. No spread to distant body parts.||For Stage IVB to IVC cancers, radiotherapy combined with chemotherapy or targeted therapy is usually employed as the first-line treatment. Palliative treatment to relieve symptoms may be employed, as appropriate.|
|T4b Any N M0||The primary tumor that has invaded a vital structure, such as prevertebral space, mediastinal structure, or surrounds the carotid artery. The disease might or might not have spread to lymph nodes. No spread to distant body parts.|
|IVC||Any T Any N M1||The primary tumor that might have invaded an adjacent structure or a vital structure. The disease might or might not have spread to lymph nodes. The disease has spread to a distant body part, such as the lungs.|
Palliative Treatment: It helps in improving the overall quality of life by providing relief from the symptoms and by reducing the suffering caused by HNC and its treatment. It is generally given as supportive care for advanced staged HNCs, along with other treatments. It may include but not limited to: using drugs or other interventions to reduce pain, bleeding, and other symptoms; surgical interventions like gastrostomy or tracheostomy to support nutrition or respiration; support and counselling for speech, swallowing, and oral hygiene-related problems; and radiation therapy to palliate pain, bleeding, obstructive problems, etc.
It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Sometimes, patient’s choice and health condition are also important to make a treatment choice. Following are ultimate goals for Staging and Treatment of Laryngeal Cancer:
- Prolongation of life.
- Reduction of symptoms.
- Improvement of overall quality of life.
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