1. 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

2. Larynx Case # 2 Presentation of New Case Newly diagnosed larynx cancer patient Presentation at Cancer Conference for treatment recommendations and clinical staging

3. Larynx Case # 2 History & Physical 73 yr old male who presented with chronic hoarseness, SOB, dysphagia No smoking hx No family history of ca

4. Larynx Case # 2 Imaging & Endoscopy Results CT neck –Right laryngeal region mass with –Extension to paraglottic space –Prominent 1.4cm level III right neck node 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; 8:1544.

5. 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

6. Larynx Case # 2 Clinical Staging Clinical staging –Uses information from the physical exam, imaging, and diagnostic laryngoscopy Purpose –Select appropriate treatment –Estimate prognosis

7. 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______

8. 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

9. 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 <3 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

10. 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

12. 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

13. Prognostic Factors Clinically Significant Applicable to this case –Size of lymph nodes: <3cm 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

14. AJCC Cancer Staging Atlas T2 Invasion of more than one adjacent subsite or outside supraglottis

15. 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.

16. 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)