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STAGING OF HEAD AND NECK CANCER
Table 61.18a Clinical nodal (N) stage for HPV-related (p16-positive) oropharyngeal cancer
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastases
N1 One or more ipsilateral lymph nodes, none larger than 6 cm
N2 Contralateral or bilateral lymph nodes, none larger than 6 cm
N3 Lymph node(s) larger than 6 cm
Table 61.18b Pathologic N stage for HPV-related (p16-positive) oropharyngeal cancer
Nx Regional lymph nodes cannot be assessed
pN0 No regional lymph node metastases
pN1 Metastasis in 4 or fewer lymph nodes
pN2 Metastasis in more than 4 lymph nodes
e natural history and response to treatment of cervical nodal metastases from the nasopharynx are dierent in terms of their impact on prognosis; thus, they justify a dierent N
classication (Table 61.19).
Table 61.19 N staging for nasopharyngeal cancer
N – Regional lymph nodes
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Unilateral metastasis, in cervical lymph node(s), and/or unilateral or bilateral
N2 Bilateral metastasis in cervical lymph node(s), 6 cm or less in greatest dimension,
N3 Metastasis in cervical lymph node(s) greater than 6 cm in dimension and/or
Note: Midline nodes are considered ipsilateral nodes, and the supraclavicular triangle is dened by
the lines joining the following three points: the superior margin of the clavicle at its sternal and
acromial ends, and the point where the line of the neck meets the shoulder.
metastasis in retropharyngeal lymph nodes, 6 cm or less in greatest dimension,
above the caudal border of cricoid cartilage
above the caudal border of cricoid cartilage
extension below the caudal border of cricoid cartilage
KEY POINTS
• Staging of head and neck cancer is a system designed to express the relative severity,
or extent, of the disease. It is meant to facilitate an estimation of prognosis and to
provide useful information for treatment decisions.
• Classication of the anatomical extent of head and neck cancer as determined
clinically and histopathologically is called the TNM system.
• Radiological investigations to evaluate the primary site should be performed prior to
biopsy to avoid the effect of upstaging from the oedema caused by biopsy trauma.
• The clinical (pretreatment) classication (cTNM) based on examination, imaging,
endoscopy, and biopsy should be clearly documented in the case le only when all the
information is collated.
• Individual TNM classications should be assembled into four stage groups (stages I–
IV), each with similar survival outcomes.
• The AJCC/UICC staging manual should be available in every theatre, multidisciplinary
team meeting, and clinic to assist in applying the correct stage.
318 Head and Neck
LARYNGEAL MALIGNANCY
62. LARYNGEAL MALIGNANCY
e most common type of laryngeal cancer is squamous cell carcinoma. e incidence is
higher in men, and the cancer is most common aer the age of 60 and less common before
age 40. Smoking remains the most common aetiological factor, with alcohol an independent
risk factor, but in combination the two have a multiplicative risk. Aer smoking cessation,
the risk reduces and reaches the level of never smokers aer 20 years.
Clinical Presentation
Glottic cancer alters the voice early by aecting wave patterns along the vocal cord.
Supraglottic lesions may be asymptomatic until they are quite large, and their initial presentation with a neck lump due to nodal metastasis is common. Voice alteration is dierent in
quality from that seen with glottic and subglottic cancer, with altered phonation progressing
to a ‘hot potato’ voice. Early symptoms from subglottic disease can be vague, with a feeling
of globus or foreign body sensation in the throat.
With increasing lesion size, maximum phonation time decreases, the voice becomes breathy
(cord xation), aspiration may be seen, and eventually the patient develops airway obstruction with dyspnea and stridor. Dysphagia, odynophagia, haemoptysis, and referred otalgia
signify advanced disease.
Assessment
An initial assessment is made using the exible nasoendoscope; the information gathered is
oen complementary to what is gained during rigid endoscopy and includes cord mobility
and a panoramic view of the larynx.
Imaging for laryngeal mass lesions should include cross-sectional imaging and chest imaging. Magnetic resonance imaging (MRI) has higher sensitivity than computed tomography
(CT) in assessing cartilage invasion.
Rigid endoscopic assessment under general anaesthesia not only should assess the extent of
the tumour and take a biopsy, but also should be done by a surgeon who can make the decision whether the tumour can be resected transorally. Anatomical constraints may make even
small tumours unresectable.
Laryngeal Dysplasia
e clinical signicance of laryngeal dysplasia lies in its propensity for malignant transformation (between 11% and 25%). e British Association of Otolaryngologists Head and
Neck Surgeons have generated consensus on the management of this condition and followup (Figures 62.1 and 62.2).
Early-Stage Laryngeal Cancers
It is currently believed that in early cancers, surgery and radiotherapy as single modalities
oer equivalent survival outcomes. Both treatment options should be considered and discussed in the multidisciplinary team and with the patient.
Voice outcomes are comparable for T1 glottic cancers treated by either modality. Even in
patients who undergo a type III cordectomy, vocal function oen returns to pre-operative
levels. Transoral laser microsurgery (TLM) is a same-day procedure, whilst radiotherapy
involves several weeks of daily treatment. For these reasons, lesions that are limited to one
vocal cord (T1a) and accessible for resection with adequate margins are commonly treated
by TLM. When the tumour involves the anterior commissure or extends across two subsites
(T1b or T2), voice outcome is more variable with TLM, and the choice between radiotherapy
and TLM is made depending on patient factors (e.g. occupation, distance away from hospital) and tumour factors (e.g. access for resection).
Head and Neck 319
LARYNGEAL MALIGNANCY
Cold steel or CO
Should be mounted,
orientated, and presented
on an anatomical template
to a pathologist for photo
documentation
Excision
Consider radiotherapy if:
1) 2 or more recurrences
2) still smoking
3) high anaesthetic risk
4) patient preference
5) persistent or recurrent widespread
disease (especially in smokers)
moderate dysplasia
Single Foci
laser excision
Focal mild or
2
Laryngeal dysplasia
management
Modify risk factors:
smoking and reflux
Laryngeal dysplasia
follow-up post
excision
(see follow-up
guideline)
Residual or
persistant disease
Severe dysplasia
or CIS
Manage as T1
carcinoma with
resection
Multiple Foci,
confluent leukoplakia
Multiple biopsies for
histological mapping
and staged resection
with low threshold
for re-biopsy
Widespread mild or
moderate dysplasia
Should be mounted,
orientated, and presented
on an anatomical template
to a pathologist for photo
documentation
Observe or excise.
Excision is favoured for:
1) heterogeneous texture
2) erythroplakia
3) features of proliferation
4) symptomatic disease
Figure 62.1 Management of laryngeal dysplasia based on a multiprofessional consensus.
Laryngeal dysplasia
Follow-up post excision
Low risk
1) Mild or moderate
with no:
i) smoking
ii) persistent hoarseness
iii) visible lesion
Minimum 6 month
follow-up. Advise to
return if change in
voice or other ‘throat’
symptoms appear
High risk
1) WHO severe
dysplasia or CIS
2) Mild or moderate
dysplasia + one or
more of:
i) smoking
ii) persistent hoarseness
iii) visible lesion
Year 1: 2–3 monthly
Year 2: 3–4 monthly
Year 3: 3–4 monthly
Year 4: 6 monthly
Year 5: 6 monthly
Residual or persistent
(see dysplasia
management guideline)
Minimum follow-up standards:
1) Flexible nasal endoscopy
2) Colour photo documentation led in patient notes
3) Low-risk lesions can be followed up by general ENT surgeons
in peripheral clinics
Figure 62.2 The follow-up of laryngeal dysplasia based on a multiprofessional consensus.
T3 Laryngeal Cancer
Non-Surgical Treatment
Radiation therapy alone or in combination with systemic therapy (concurrent chemotherapy or cetuximab) oers organ preservation in appropriately selected patients without
320 Head and Neck
LARYNGEAL MALIGNANCY
compromising survival. e landmark VA study (see further reading) showed t hat in patients
responding to induction chemotherapy, the laryngeal preservation rate was 64% at 2 years,
with similar survival rates at 2 years (68%) as surgery followed by radiotherapy. Salvage laryngectomy rates were signicantly lower for T3 disease than for T4 disease (29% versus 56%).
A higher proportion of patients with a xed cord underwent salvage laryngectomy.
A subsequent trial by the Intergroup RTOG 91–11 demonstrated that laryngeal preservation
rates with concurrent chemoradiotherapy was superior to sequential induction chemotherapy followed by radiotherapy and to radiotherapy alone (88% versus 75% versus 70%) with
similar survival rates. is benet decreases with age and is non-signicant over 70 years of
age and therefore less appropriate in patients above this age.
Partial Laryngectomy
e current evidence suggests both open partial laryngectomy and TLM can be useful organpreserving methods for the treatment of T3 squamous cell laryngeal cancer.
Total Laryngectomy
Total laryngectomy is a bona de treatment for T3 laryngeal disease, especially in patients
who have a xed cord. For endolaryngeal tumours with no pathological evidence of neck
disease, a total laryngectomy with adequate margins is all that will be needed. ese patients
will not need reconstructive interventions because adequate pharynx will be available to create an adequately wide neopharynx.
T4 Laryngeal Cancer
ere is general agreement that laryngeal cancer that extends outside the framework of the
larynx should be treated by primary surgery—most commonly, a total laryngectomy. e
reasons for this consensus are that tumours invading the cartilage do not respond well to
radiation, and even if tumour control is achieved, there is a high risk of a nonfunctional
larynx, chondronecrosis, and gastrostomy dependence.
Neck Management
For glottic cancer, estimates for the incidence of microscopic lymph node metastasis by disease
stage are: <5% (T1), 7% (T2), 14% (T3), and 33% (T4). For T1 tumours, treatment of the primary
site alone will suce. T2 tumours are less prone to metastatic spread, but, given the ~7% risk
of occult spread, there is no consensus on whether the neck should be treated in this setting.
For all supraglottic cancers and advanced glottic tumours, the neck needs to be addressed
even if there is no clinical or radiological evidence of disease. For midline supraglottic cancers, both sides of the neck should be treated.
Adjuvant Treatment
Post-operative radiotherapy in patients at risk of locoregional recurrence can improve
locoregional control and survival. Indications are: pT4 tumours, close or involved resection
margins, involved node larger than 3 cm, multiple positive nodes, extracapsular spread, perineural invasion, and vascular invasion. Adjuvant chemoradiotherapy should be considered
with a positive resection margin and/or extracapsular spread.
Recurrent Disease
Residual or recurrent laryngeal cancer following radiotherapy is aggressive and carries a
poor prognosis. Options for those with recurrent cancer are based on the initial treatment
received and the stage of the recurrent disease. Salvage total laryngectomy is oen recommended, even for early cancers.
Open partial laryngectomy has been demonstrated to have very good outcomes with recurrent cancer. TLM’s role is limited in recurrent cases, due to the diculty of identifying the
extent of the tumour and interpreting resection margins. It is suggested that, where suitable,
patients should be oered open partial laryngectomy in preference to TLM for recurrent
Head and Neck 321
LARYNGEAL MALIGNANCY
tumours, unless the cancer is limited to the mid cord. In cases not suitable for open partial
laryngectomy, total laryngectomy should be oered.
Transoral Laser Microsurgery (TLM)
TLM is a minimally invasive surgical approach to functional laryngeal preservation. Patient
selection is key to the success of the technique, as inadequate endoscopic access to facilitate
satisfactory oncologic resection is the main contraindication to TLM.
For glottic cancer, the specimens resected by TLM will have much smaller margins than the
margins obtained in open surgery, with margins of 1 mm being acceptable. Working closely
with the pathologist is vital for correct interpretation of specimens. For supraglottic cancer,
surgical margins of at least 5 mm are required. Glottic and supraglottic transoral resections
should be classied using the European Laryngological Society system (Table 62.1). ere is
usually no need to reconstruct the surgical defect; the tumour bed is le exposed and readily
accessible for additional resections to achieve negative margins.
Small supercial T1a glottic tumours may be excised en bloc with the CO2 laser (see
Figure 62.3). More complex tumours benet from an initial cut through tumour to assess
depth of invasion. e way that the laser cuts through normal tissue is very dierent from
Table 62.1 European Laryngological Society classication of cordectomies
Denition Type Description
Subepithelial
cordectomy
I
Resection passing
through the
supercial lamina
propria
Subligamental
cordectomy
Transmuscular
cordectomy
322 Head and Neck
II
III Resection through
Resection including
vocal ligament
vocalis muscle
LARYNGEAL MALIGNANCY
Table 62.1 (Continued)
Denition Type Description
Total cordectomy IV Resection from the
vocal process to
the anterior
commissure—
depth reaches or
includes the
internal
perichondrium of
the thyroid
cartilage
Extended total
cordectomy
Va Resection includes
the contralateral
vocal fold and
anterior
commissure
Vb Resection includes
the arytenoids
Vc
Resection includes
the subglottis
(Continued)
Head and Neck 323
LARYNGEAL MALIGNANCY
Table 62.1 (Continued)
Denition Type Description
Vd Resection includes
the ventricle and
false cords
Anterior
commissurectomy
VI Resection of the
anterior
commissure
Figure 62.3 Transoral laser microsurgery for T1a glottic carcinoma. (a) Pre-operative. (b) Tumour
divided to assess depth. (c) The deep margin followed with the laser. (d) Post-resection.
324 Head and Neck
HYPOPHARYNX
its cut through tumour, and the dierence can be appreciated under the operating microscope. Once the deep margin of the tumour is identied, it can be followed and the tumour
removed.
Open Partial Laryngectomy
e goal of open partial laryngectomy is complete tumour removal, while preserving the
functional integrity and separation of larynx and pharynx. Preservation of at least one functional cricoarytenoid unit is essential. e cricoarytenoid unit consists of an arytenoid cartilage, the cricoid cartilage, the associated musculature, and the nerve supply from the superior
and recurrent laryngeal nerves for that unit. It is the cricoarytenoid unit, not the vocal folds,
that allows for physiologic speech and swallowing without the need for a tracheostoma.
Procedures that can be applied to glottic disease include several vertical hemilaryngectomy
modications and horizontal supracricoid laryngectomy with cricohyoidoepiglottopexy
(CHEP). For supraglottic disease, supraglottic laryngectomy and supracricoid laryngectomy
with cricohyoidopexy (CHP) may be considered.
Further Reading
Department of Veterans Aairs Laryngeal Cancer Study Group, Wolf GT, Fisher SG, Hong
WK, Hillman R, Spaulding M, Laramore GE, Endicott JW, McClatchey K, Henderson
WG. Induction chemotherapy plus radiation compared with surgery plus radiation in
patients with advanced laryngeal cancer. N Engl J Med 1991; 324(24): 16 85 –1690.
Mehanna H, Paleri V, Robson A, Wight R, Helliwell T. Consensus statement by otorhinolar-
yngologists and pathologists on the diagnosis and management of laryngeal dysplasia.
Clin Otolaryngol 2010; 35(3): 170–176.
Steiner W. Results of curative laser microsurgery of laryngeal carcinomas. Am J Otolaryngol
1993; 14: 116 –121.
63. HYPOPHARYNX
Introduction
e hypopharynx is the caudal part of the pharynx, also called laryngopharynx, extending from the hyoid bone to the lower margin of the cricoid cartilage. Hypopharyngeal
cancers are distinctly dierent from laryngeal cancers in terms of presentation, management, and prognosis. Hypopharyngeal cancers make up 5–10% of head and neck cancers,
and the presentation is oen vague, with up to 80% presenting as stage III or IV disease.
ese factors lead to overall poorer outcomes than are experienced with other head and
neck cancers.
Epidemiology
Hypopharyngeal cancers are rare, making up less than 0.5% of all cancers and tend to occur
in individuals over 50 years old.
Subsites of cancer (in order of most frequent to least) are:
Piriform sinus (PS)
•
Posterior pharyngeal wall (PPW)
•
Postcricoid area (PC)
•
PS and PPW lesions are more common in males, whereas PC lesions are predominant in
females.
Head and Neck 325
HYPOPHARYNX
Table 63.1 Common sites of hypopharyngeal tumour local extension
Primary site Local affected area
Lateral wall PS Thyroid cartilage
Medial wall PS Paraglottic space, impeding vocal cord movement
Pyriform apex Via cricothyroid membrane to involve thyroid gland or recurrent laryngeal nerve
PC Cricoid and/or tracheal cartilages
Via cricothyroid membrane to involve thyroid gland
High risk of extension to cervical oesophagus with submucosal spread or skip
lesions due to rich oesophageal submucosal lymphatic plexus
PPW Prevertebral fascia, and tending to be exophytic into the lumen
Etiology
Hypopharyngeal cancer has multifactorial etiology, including:
Tobacco.
•
Alcohol.
•
Age (mean age of presentation is 65 years).
•
Human papillomavirus (HPV) is present in 10.9% of hypopharyngeal cancers
•
(although HPV-associated cancer is more common in the oropharynx).
Iron-deciency dysphagia (associated with Plummer-Vinson syndrome) for PC
•
tumours.
Local Spread
Tumours at dierent subsites of the hypopharynx tend to locally extend in individual ways
(Table 63.1). e local eects have signicant impact on therapeutic options. It is obvious
from the table that PC tumours vary substantially in symptoms and subsequent treatment.
It is important to note that lateral PS and PC tumours are the tumours most likely to aect
laryngeal cartilage in the table.
Regional Spread
Hypopharyngeal tumours have the highest propensity for early nodal metastases: up to 70%
of patients may have lymph node metastases at presentation. ere is also a high incidence of
occult nodal metastases, up to 40% in early disease. erefore, it is essential to treat the neck.
Distant Spread
Among all head and neck cancers, hypopharyngeal primaries have the highest incidence of
distant metastases at presentation (17–24%) and during follow-up, with more than 50% of
failures due to distant metastases.
Symptomatology
Hypopharyngeal tumours are detected late, because the patients are oen asymptomatic in
the early stages. e earliest symptom may be mild non-specic throat discomfort. In fact,
globus sensation may be the only presenting complaint, with normal clinical ndings. Half
of patients present with a neck mass.
Investigations
Endoscopy via exible transnasal oesophagoscopy or rigid endoscopy.
•
Fine-needle aspiration cytology (FNAC) for palpable neck node.
•
Cross-sectional imaging by computed tomography (CT) or magnetic resonance imag-
•
ing (MRI), depending on local protocols. Chest CT is indicated in all patients to examine for synchronous tumours.
PET CT is a useful imaging modality in the assessment for distant metastasis.
•
For staging of hypopharyngeal cancer, see Chapter 61.
326 Head and Neck
HYPOPHARYNX
Occult metastasis in
Present in 60%
(Zbären et al 1997)
limits (especially PC)
of PC cases
Primay manifestation
in 65%-80% cases
(Lefebvre et al 1987, Koo et al 2006)
Rich lymphatics leading
to high rates of metastasis
30-40% cases in clinically
N0 necks
(Shah et al 1976, Shah et al 1993,
Driscoll et al 1983)
Nodal
Proximity to larynx
and the risk to
cause dysfunction
Aggressive due to
vascularity & lack of
barriers to tumour spread
Tumour
Up to 20 mm away from
primary tumour in PC
(Ho et al 1997)
Substantial submucosal
spread beyond mucosal
Factors Determining Treatment
in Hypopharyngeal Cancer
Performance Status (PS)
Implications on multiple
facets of treatment
Laryngeal anatomy,
physiology, protection
Increasing risks of aspiration
and dysphagia, which can
lead to respiratory compromise
and a nutritionally depleted
state respectively
More than 75% patients
who present in stage III/IV
disease will go on to receive
multimodality treatment
The higher/worse the PS,
the greater the risk
of morbidity or failure
to complete treatment
TORS/TOLM
Technically demanding,
resource heavy and require
intensive training with
mentorship
Aim to reduce morbidity
of multimodal treatment
without compromising
oncological outcomes
Resources/Expertise
resection
Need appropriate case
selection and training in
surgical resection with
reconstructive techniques.
Failure to do so will have
signicant deleterious
eects on patients.
Radiation and chemotherapyPartial laryngopharyngeal
Patients often present
nutritionally depleted
and will experience higher
rates of toxicity and
therefore greater rates
of non-compliance
leading to poorer
outcomes
Figure 63.1 Factors determining treatment in hypopharyngeal cancer.
Factors Determining Treatment in Hypopharyngeal Cancer
Treatment decisions in cancer are guided by the biology of the disease and the peculiarities of
the organ aected. Tumour and nodal factors, performance status of the patient, resources,
and technical expertise dictate the management (Figure 63.1).
Treatment of Early Hypopharyngeal Cancers
Early cancers are potentially curable, and the goals of treatment should be to maximise
chances of cure with function preservation. Stage I/II (T1 and T2) hypopharyngeal cancers
should be treated with a single modality, either radiation therapy or larynx conservation
surgery. Figure 63.2 gives an overall view of options for management of early disease.
ere are some advantages of transoral over open approaches: transoral approaches avoid
disruption of laryngeal skeleton and so tissues; allow preser vation of innervation, which aids
with swallowing outcomes; and prevent orocervical stula formation. However, contraindications include: oral submucous brosis, full-thickness involvement of the pharyngeal muscles,
or involvement of thyroid cartilage, base of tongue, arytenoids, or cervical oesophagus.
Treatment of Advanced Hypopharyngeal Cancer
In advanced hypopharyngeal cancers with cord xity and/or cartilage erosion (T3/T4a), the
main issue is treating the disease whilst preserving the laryngea l form and function. In patients
with good performance status, no comorbidities, and intact laryngeal framework and function (T1–3,N0–2c), the standard of care is concurrent chemotherapy with radiation. In patients
with compromised laryngeal framework (T4a) or dysfunction, the standard of treatment is
surgery with adjuvant radiation therapy. Lastly, patients with intact laryngeal function but
extralaryngeal spread through the membranes without cartilage involvement undergoing neoajuvant chemotherapy with response assessment may be considered for organ preservation.
Non-Surgical Organ Preservation Strategies for Advanced Disease
Non-surgical organ preservation aims for good locoregional control with function preservation (i.e. no aspiration or need for tracheostomy and feeding tubes aer completion of treatment). However, careful patient selection is essential to ensure optimal results.
Head and Neck 327
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