Staging and Treatment of Throat Cancer

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Various Parts of Throat

Throat consists of 4 parts – Oropharynx, Nasopharynx, Hypopharynx and Larynx. The figure below shows the structures in throat, namely nasopharynx, oropharynx and larynx. parts of throat-nasopharynx, oropharynx, larynx, hypopharynx Larynx (voice box) houses the vocal cords. It extends from epiglottis (superiorly) and continues into trachea inferiorly, as shown in the figure below. anatomy of larynx Oropharynx comprises the soft palate, tonsils, the base of the tongue, and oropharyngeal wall. oropharynx anatomy Nasopharyx extends from base of the skull to upper surface of soft palate (as shown in figure above). Below is a cross-section at the level of nasopharynx that shows parapharyngeal space and paranasal sinuses. nasopharynx anatomy

 

Read about Risk Factors for Head and Neck cancer here.

Staging and Treatment of Oropharyngeal Cancer

Oropharynx comprises the soft palate, tonsils, the base of the tongue, and oropharyngeal wall. oropharynx anatomy Oropharynx has significant lymphatic supply and most cases of oropharyngeal cancer are associated with lymph node involvement at diagnosis. HPV-16 infection plays a vital role in the disease prognosis.

TNM Staging of Oropharyngeal Cancer

T STAGING

Tis – Carcinoma in situ or cancerous lesion is present only in the superficial layer of the oropharynx.

T1 – The primary tumor is </=2 cm in size. t1 -tumor size upto 2 cm T2 – The primary tumor is >2 cm but </=4 cm in size. t2-tumor size 2 cm to 4 cm T3 – The primary tumor is >4 cm in size or has invaded into the lingual surface of the epiglottis. t3-tumor size upto 4 cmT4a – The primary tumor has invaded any of the adjacent structure, such as larynx, hard palate, or mandible. t4a-invades hard palate t4a-invades larynx t4a-invades mandible t4a - invades medial pterygoid muscle t4a-invades tongue T4b – The primary tumor of any size that has invaded a vital structure, such as pterygoid plates, lateral nasopharynx, or skull base and/or surrounds the carotid artery. t4b-invades lateral pterygoid ptergoid plates or carotid t4b-invades medial pterygoid muscle t4b-invades skull base oropharyngeal cancer T staging infographic

N STAGING

N0 – No spread of tumor to nearby lymph nodes

N1 – The disease has spread to a single ipsilateral lymph node measuring </=3 cm without extranodal involvement. n1-single ipsilateral lymph node upto 3 cm N2a – The disease has spread to a single ipsilateral lymph node measuring >3 cm and </= 6 cm n2a-single ipsilateral lymph node 3 cm to 6 cm N2b – Metastasis to multiple ipsilateral nodes, none >6 cm n2b-multiple ipsilateral lymph nodes upto 6 cm N2c – Metastasis to bilateral/contralateral lymph nodes, all measuring <6 cm without extranodal involvement. n2c-bilateral or contralateral lymph nodes upto 6 cm N3 – The disease has spread to lymph nodes measuring >6 cm or significant extranodal involvement. n3-lymph node more than 6 cm n3 - lymph node with extranodal extension head and neck cancer N staging

M STAGING

M0 – No spread to distant body parts

M1 – Disease has spread to distant body parts

4 Stages of Oropharyngeal Cancer

STAGE TNM    
0 Tis N0 M0    
I T1 N0 M0    
II T2 N0 M0    
III T3 N0 M0    
  T1-3 N1 M0    
IVA T1-3 N2 M0    
  T4a N0-2 M0    
IVB Any T N3 M0    
  T4b Any N M0    
IVC Any T Any N M1    

 

Survival Rate/ Life Expectancy according to Stage

Survival rates  is calculated based on whether the disease is Localised, Regional or Distant.

Localised

  • Cancer is limited to the oropharynx
  • 5 year survival 84%.

Regional

  • Cancer has spread to nearby structures or lymph nodes
  • 5 year survival 65%.

Distant

  • Cancer has spread to distant body parts.
  • 5 year survival 39%.

Treatment of Oropharyngeal Cancer

Treatment depends on stage of the disease, location, HPV status, performance status of patient, patient’s preference, along with other factors. Treatment options based on stage are discussed below.

treatment of non metastatic oropharyngeal cancer

Stage I and II

For Stage I and II cancers, radiotherapy is considered as the preferred treatment. Surgical resection is also an option. Chemoradiation is also an option that may be used either alone or after surgery in patients with adverse risk factors.

Stage III to IVB

For Stage III to IVB cancer, a combination of radiotherapy and chemotherapy or targeted therapy is usually employed as the first-line treatment. Induction chemotherapy may be required in some cases. Surgical resection may also be an option in some cases.

Stage IVC

For Stage IVC cancer, chemotherapy, immunotherapy or targeted therapy are the treatment options. Radiation therapy may be employed as palliative treatment.

treatment for metastatic head and neck cancer

Staging and Treatment of Hypopharyngeal Cancer

Hypopharynx is a muscular tube located between the oropharynx and the esophagus. It is the lower part of the pharynx that lies just behind the larynx and comprised of the pyriform sinus, the posterior pharyngeal wall, and the postcricoid area. The swallowed food and fluids are passed into the esophagus via the hypopharynx. Cancers of the hypopharynx are rare and are rarely diagnosed early due to an asymptomatic presentation.

TNM Staging of Hypopharyngeal Cancer

T STAGING

Tis – Tumor only in the superficial layer of the hypopharynx.

T1 – Tumor </=2 cm in size. t1-less than 2 cm T2 – Tumor is >2 cm but </=4 cm in size. T2-2 cm to 4 cm T3 – Tumor is >4 cm in size or invades into the lingual surface of the epiglottis. T3-more than 4 cm T4a – Tumor invades any of the adjacent structure, such as larynx, hard palate, or mandible. T4a-invades cricoid cartilage T4a-invades hyoid bone T4a-invades thyroid cartilage T4b – Tumor invades pterygoid plates, lateral nasopharynx, or skull base and/or surrounds the carotid artery. T4b-encases carotid artery T4b-invades prevertebral fascia hypopharyngeal cancer T staging

N STAGING

Same as oropharyngeal cancer (as discussed above).

M STAGING

M0 – No spread to distant body parts.

M1 – Tumor has spread to distant body part(s)

4 Stages of Hypopharyngeal Cancer

STAGE TNM    
0 Tis N0 M0    
I T1 N0 M0    
II T2 N0 M0    
III T3 N0 M0    
  T1-3 N1 M0    
IVA T1-3 N2 M0    
  T4a N0-2 M0    
IVB Any T N3 M0    
  T4b Any N M0    
IVC Any T Any N M1    

Survival Rate/ Life Expectancy of Hypopharyngeal Cancer

Survival rates are calculated based on whether the disease is Localised, Regional or Distant.

Localised

  • Cancer is limited to the hypopharynx
  • 5 year survival 59%.

Regional

  • Cancer has spread to nearby structures or lymph nodes
  • 5 year survival 33%.

Distant

  • Cancer has spread to distant body parts.
  • 5 year survival 21%.

Treatment of Hypopharyngeal Cancer

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 hypopharyngeal cancer, but the final decision is taken after clinical assessment of the patient by an oncologist.

treatment of non metastatic hypopharynx cancerStage 0

For Stage 0 cancers, surgical resection of the involved site is considered as the standard treatment. The patient should be followed-up closely after treatment for any sign of recurrence.

Stage I and II

For Stage I and II cancers, surgery is considered as the preferred treatment. Surgical resection of the involved site along with lymph node dissection is generally employed. Radiation therapy with or without chemotherapy may be employed after the primary treatment to kill any remaining cancer cells or in the presence of any adverse prognostic features. The patient should be followed-up closely after treatment for any sign of recurrence.

Stage III to IVA

For Stage III to IVA cancers, any of the following 3 approaches can be utilized as the preferred treatment: 1) Start treatment with chemotherapy alone (induction therapy) followed by radiation therapy or radiotherapy + chemotherapy based on the extent of tumor shrinkage with primary treatment. 2) Surgery is employed as the first-line treatment and involves the resection of the primary tumor along with any affected lymph nodes. This is followed by radiation therapy or radiotherapy + chemotherapy based on the presence of any adverse prognostic features. 3) Chemotherapy + radiotherapy or radiotherapy alone can be employed as the primary treatment. Surgery may be employed to remove any remnant cancer tissue.

Stage IVB

For Stage IVB cancer, radiotherapy along with chemotherapy is usually employed as the first-line treatment. Surgery may be employed if the tumor shrinks sufficiently that it can be removed with surgery. Radiation therapy may be employed as palliative treatment.

Stage IVC

For Stage IVC cancer, chemotherapy, immunotherapy or targeted therapy are the treatment options. Radiation therapy may be employed as palliative treatment.

metastatic disease treatment infographic

Staging and Treatment of Laryngeal Cancer

The larynx, also known as the voice box, comprises 3 subsites: supraglottis, glottis, and subglottis. Vocal cords help in speaking and are located in the glottis. The larynx is present in the neck, above the tracheal opening where it prevents ingested food and fluids from entering the trachea. Lymphatic supply to supraglottis is superior to that in glottis and subglottis. Cancers in glottis are usually diagnosed at an early stage due to the presenting symptom of hoarseness of voice. Most of the laryngeal cancers are associated with smoking and alcohol consumption.

TNM Staging

T STAGING

Tis – Carcinoma in situ or cancerous lesion is present only in the superficial laryngeal layer.

T1 – The primary tumor is limited to one part of the supraglottis with normal vocal cord movement.

T2 – The primary tumor is present in more than one part of the supraglottis/glottis with normal vocal cord movement.

T3 – 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.

T4a – The primary tumor has invaded an adjacent structure, such as the outer cortex of the thyroid cartilage, trachea, strap muscles, thyroid, or esophagus.

T4b – The primary tumor that has invaded a vital structure, such as prevertebral space, mediastinal structure, or surrounds the carotid artery.

GLOTTIC LARYNX T STAGING

glottic larynx T staging-t1, t2, t3 glottic larynx T staging-T4

SUPRAGLOTTIC LARYNX T STAGING

supraglottic larynx T staging- T1, T2, T3 supraglottic larynx T staging-T4

SUBGLOTTIC LARYNX T STAGING

subglottic larynx T staging-T1, T2, T3 subglottic larynx T staging-T4

N STAGING

Same as oropharyngeal cancer (as discussed above).

M STAGING

M0 – No spread to distant body parts.

M1 – Tumor has spread to distant body part(s)

4 Stages of Laryngeal Cancer

Based on the TNM classification discussed above, laryngeal cancer is assigned a stage from I to IV.

STAGE TNM    
0 Tis N0 M0    
I T1 N0 M0    
II T2 N0 M0    
III T3 N0 M0    
  T1-3 N1 M0    
IVA T1-3 N2 M0    
  T4a N0-2 M0    
IVB Any T N3 M0    
  T4b Any N M0    
IVC Any T Any N M1    

Survival Rate/ Life Expectancy of Laryngeal Cancer

Survival rates are calculated based on whether the disease is Localised, Regional or Distant.

For Supraglottic Cancer

5 year survival is as follows.

  • Localised Disease- 61%.
  • Regional Disease – 47%.
  • Distant Disease – 30%.

For Glottic Cancer

5 year survival is as follows.

  • Localised Disease- 83%.
  • Regional Disease – 48%.
  • Distant Disease – 42%.

For Subglottic Cancer

5 year survival is as follows.

  • Localised Disease- 60%.
  • Regional Disease – 33%.
  • Distant Disease – 45%.

Treatment of Laryngeal Cancer

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.

treatment of non metastatic laryngeal cancer

Stage 0

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.

Stage I and II

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.

Stage III to IVA

For Stage III to IVA cancers, any of the following 3 approaches can be utilized as the preferred treatment: 1) Start treatment with chemotherapy (induction therapy) followed by surgery or radiotherapy + chemotherapy 2) Surgical resection followed by radiation therapy or radiotherapy + chemotherapy based on the presence of any adverse prognostic features. 3) Chemotherapy + radiotherapy or radiotherapy alone can be employed as the primary treatment. Surgery may be employed to remove any remnant cancer tissue.

Stage IVB

For Stage IVB cancer, 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.

Stage IVC

For Stage IVC cancer, chemotherapy, immunotherapy or targeted therapy are the  treatment options. Radiation therapy may be employed as palliative treatment.

treatment of metastatic laryngeal cancer

Staging and Treatment of Nasopharyngeal Cancer

The upper part of the pharynx behind the nose is known as nasopharynx. Nasopharyngeal cancers are rare and are mostly reported in specific geographical regions, such as Southeast Asia, Micronesia/Polynesia, Eastern Asia, and North Africa. These are 2 to 3 times more common in men than women.

Based on the appearance of cancer cells, nasopharyngeal cancers are divided into 3 categories:

  • Keratinizing SCC,
  • Non-keratinizing differentiated carcinoma, and
  • Undifferentiated carcinoma.

Epstein-Barr Virus (EBV) has been reported to play a role in the development of nasopharyngeal cancers. EBV testing is usually employed in the diagnostic work-up of the nasopharyngeal cancers and may include detection of EBV protein in plasma using PCR or any other technique.

TNM Staging of Nasopharyngeal Cancer

T STAGING

T1 – The primary tumor is limited to the nasopharynx, or extension to the oropharynx and/or nasal cavity without para-pharyngeal involvement. T1, confined to nasopharynx T1, extends to nasal cavity T1, extends to oropharynx T2 – The primary tumor has invaded into the para-pharyngeal space, and/or an adjacent structure such as medial pterygoid, lateral pterygoid, or prevertebral muscles. T2, extends to parapharyngeal space T3 – The primary tumor has invaded into the skull base, cervical vertebra, pterygoid structures, and/or paranasal sinuses. T3, extends to skull base T3, invades pterygoid structures T3, invades pterygoid structures nasopharyngeal cancer anatomy and T staging  T1 to T3 T4 – The primary tumor has invaded into the cranium, cranial nerves, hypopharynx, orbit, parotid gland, and/or extensive invasion beyond the lateral pterygoid muscle. T4, intracranial extensio T4, extends to hypopharynx nasopharyngeal-cancer-T-staging T3 and T4

N STAGING

N0 – No spread to nearby lymph nodes

N1 – Spread to cervical lymph node(s) on one side and/or retropharyngeal lymph node(s) with lymph nodes measuring </=6 cm. N1-unilateral upto 6 cm nodes or retropharyngeal nodes N2 – The disease has spread to cervical lymph node(s) one both sides and/or retropharyngeal lymph node(s) with lymph nodes measuring </=6 cm. N2-bilateral cervical lymph nodes upto 6 cm N3a – The disease has spread to cervical lymph node(s) on one or both sides with lymph nodes measuring >6 cm. N3a - cervical lymph nodes upto 6 cm N3b – Cervical lymph node metastasis below cricoid cartilage. N3b - cervical lymph nodes below cricoid cartilage nasopharyngeal cancer N staging

M STAGING

M0 – No spread of disease to distant sites

M1 – Spread of the disease to distant sites

4 Stages of Nasopharyngeal Cancer

Based on the TNM classification discussed above, nasopharyngeal cancer is assigned a stage from I to IV.

STAGE TNM    
I T1 N0 M0    
II T2 N0-1 M0    
  T0-1 N1 M0    
III T3 N0-2 M0    
  T0-2 N2 M0    
IVA Any T N3 M0    
  T4 N0-2 M0    
IVB Any T Any N M1    

Survival Rate/ Life Expectancy of Nasopharyngeal Cancer

Survival rates are calculated based on whether the disease is Localised, Regional or Distant.

Localised

  • Cancer is limited to the nasopharynx
  • 5 year survival 82%.

Regional

  • Cancer has spread to nearby structures or lymph nodes
  • 5 year survival 73%.

Distant

  • Cancer has spread to distant body parts.
  • 5 year survival 48%.

Treatment of Nasopharyngeal Cancer

Apart from the stage of disease, the selection of treatment usually depends upon the stage, performance status of the patient, along with other factors. Following are the preferred treatment approaches for different stages of nasopharyngeal cancer, but the final decision is taken after clinical assessment of the patient by an oncologist.

Non Metastatic nasopharyngeal cancer treatment

Stage I

For Stage I cancer, radiotherapy is considered as the preferred treatment. Prophylactic radiation treatment to nearby lymph nodes is also generally recommended to be employed as the primary treatment.

Stage II to IVA

For Stage II to IVA cancers (locoregionally advanced disease), a combination of radiotherapy and chemotherapy is usually employed as the first-line treatment. This may be followed by more chemotherapy to treat any remaining cancer cells. Chemotherapy may also be given first (induction therapy), followed by a combination of radiotherapy and chemotherapy.

Stage IVB

For Stage IVB cancer, chemotherapy, immunotherapy or targeted therapy are the treatment options. Radiation therapy may be employed as palliative treatment.

treatment for metastatic nasopharyngeal cancer

Read about Staging and Treatment of Oral Cancer.

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