Unique head and neck staging case

[CUBuffsgrad98]

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Question regarding a case I just saw. Sent from ENT who felt this was early stage laryngeal. PET shows activity in larynx, pyriform sinus area on L. No nodes present. When I scoped him, it looked like cords, false cords, AE fold and pyriform sinus involved. Have to go have a difficult talk with ENT regarding this.

How would you stage this? Advanced laryngeal, advanced hypopharynx, or 2 separate tumors? What T stage? (N and M both 0 on PET).

 

[BobbyHeenan]

Tough case. Unless there is CLEAR amount of normal mucosa between the two lesions, I'd stage as one tumor.

You didn't mention cord mobility, but I would probably stage as "high volume" T2N0M0 assuming that the cord mobility is normal and assuming only the medial wall of pyriform is involved. I'd favor staging as larynx, and I say that because I obviously haven't seen the scope or CT/PET images and my gut tells me that if the tumor had started in the pyriform sinus and had that much mucosal spread you'd very likely see nodal disease.

I don't have the complete AJCC manual in front of me, but they mention "medial wall" of pyriform sinus as T2 for larynx cancer primary. If more than just the medial wall seems involved, then I'm not sure what the staging would be for larynx cancer.

Sometimes a good head and neck radiologist can help with discerning where the tumor likely started based upon pattern of invasion and invading/pushing tumor. If that's available to you that may help.

 

[CUBuffsgrad98]

It all looks relatively contiguous to me. The cord looked partially mobile. He is even more complicated as it has been almost 3 months since his diagnosis. He was being intubated for a triple bypass and the tumor (which was unknown at the time) obstructed this. He needed to be trached, which is still in place. His PET and scope are all recent from within a week. He has recovered well from his surgery, but has a small infection for which sternal wire needs to be removed.

How would you treat this guy? RT alone? Hypofx? Cover nodes (neg on PET)?

 

[Brim]

You should probably stage as hypopharynx, unless there's really clear evidence that there's 2 completely separate tumors (doubtful).

Per the NCCN Staging Manual (for Larynx): "The following anatomic definition of the larynx ... excludes cancers arising on the lateral or posterior pharyngeal wall, pyriform fossa, postcricoid area, or base of tongue."

However, if the bulk of the tumor is centered in the supraglottic larynx (false cords, AE folds), with only minimal pyriform sinus involvement, then it makes sense to stage as supraglottic. In these cases, with multiple site involvement, you can often go by the center of mass of the tumor to estimate the likely origin.

 

[CUBuffsgrad98]

It's very diffucult to tell where it is arising from. If I had to guess I would say true cord or false cord, but hard to say. How would people treat?

 

[BobbyHeenan]

It's very diffucult to tell where it is arising from. If I had to guess I would say true cord or false cord, but hard to say. How would people treat?

Given difficulty in assessing where it started and delay in therapy, I would be inclined to treat nodes. I would be very thorough in my documentation/consent though, and probably stage it as T2 supraglottis since I'd treat nodes.

I would probably treat IMRT: GTV plus 1.0 cm = CTV to 70 Gy @ 2 Gy/fraction and treat ipsi retropharyngeals (due to PS involvement), ipsilateral II-IV, and contralateral IIb-IV (aggressive parotid sparing) to 56 @ 1.6 Gy/fx. May also include stoma in 56 @ 1.6. Treat 6 fractions/week with no chemo.