A Critical Reappraisal of Primary and Recurrent Advanced Laryngeal Cancer Staging

Abstract

Objectives: Laryngeal squamous cell carcinoma (LSCC) can involve different anatomic subunits with peculiar surgical and prognostic implications. Despite conflicting outcomes for the same stage of disease, the current staging system considers different lesions in a single cluster. The aim of this study was to critically discuss clinical and pathologic staging of primary and recurrent advanced LSCC in order to define current staging pitfalls that impede a precise and tailored treatment strategy. Methods: Thirty patients who underwent total laryngectomy in the past 3 years for primary and recurrent advanced squamous cell LSCC were analyzed, comparing endoscopic, imaging, and pathologic findings. Involvement of the different laryngeal subunits, vocal-fold motility, and spreading pattern of the tumor were blindly analyzed. The diagnostic accuracy and differences between clinicoradiologic and pathologic findings were studied with standard statistical analysis. Results: Discordant staging was performed in 10% of patients, and thyroid and arytenoid cartilage were the major diagnostic pitfalls. Microscopic arytenoid involvement was significantly more present in case of vocal-fold fixation (P = .028). Upstaging was influenced by paraglottic and pre-epiglottic space cancer involvement, posterior commissure, subglottic region, arytenoid cartilage, and penetration of thyroid cartilage; on the contrary, involvement of the inner cortex or extralaryngeal spread tended to be down-staged. Radiation-failed tumors less frequently involved the posterior third of the paraglottic space (P = .022) and showed a significantly worse pattern of invasion (P < .001). Conclusions: Even with the most recent technologies, 1 in 10 patients with advanced LSCC in this case series was differently staged on clinical examination, with cartilage involvement representing the main diagnostic pitfall.

Survival Outcomes and Prognostic Factors of Open Partial Laryngeal Surgery: A Thirty Years’ Experience

“…39 In addition, from the oncological point of view, full-thickness thyroid cartilage involvement (ie, pT4 stage) is one of the most frequent pitfall in radiological staging and in OPHL II, but not in FLPL, the whole “thyroid box” is removed. 8 In brief, while nowadays TLM constitutes the first choice for cT1b LC with fewer complications and shorter length of stay compared to open procedures, insufficient transoral exposure (encountered in almost 10% of cases in a recent paper) 40 should prompt surgeon to offer OPLS as an oncologically valid option. 16,36…”

“…6 The key to successful outcomes following OPLS is a careful preoperative assessment, an accurate staging by endoscopic and radiological techniques along with a great surgical expertise that permits to switch intraoperatively to a more extensive OPLS procedure in case of positive frozen section margins. 1,7,8 Radical en-bloc resection of the tumor must ultimately be achieved while always preserving at least one fully functional cricoarytenoid unit (arytenoid + posterior cricoid cartilage along with posterior and lateral cricoarytenoid muscles and ipsilateral recurrent laryngeal nerve). 9 Complication rate of OPLS is not negligible even in experienced hands so that a careful discussion with the patient regarding benefits and drawbacks is mandatory.…”

Correlation Between Diagnostic Tests for Laryngeal Cancer Staging and Anatomopathological Staging: A Systematic Review Protocol

“…Considering diagnostic methods, histopathology is considered the gold standard for determining the presence of a malignant laryngeal tumor. However, anatomical clinical correlation by endoscopic evaluation and imaging tests (computed tomography, magnetic resonance imaging, and ultrasonography) contribute to determining the stage [11,15]. Thus, staging becomes more effective with the association of different high-sensitivity diagnostic methods.…”

“…The assessment of preoperative (or clinical) TNM staging requires a set of imaging tests (magnetic resonance imaging, computed tomography, ultrasonography, and endoscopy) that are signi cantly important in clinical management and therapeutic follow-up [9,10]. However, there is no consensus in requesting such tests, and diagnostic accuracy is still a trap in determining preoperative TNM staging compared to postoperative (pathological) staging, a more invasive method [11].…”

Clinical Versus Pathologic Laryngeal Cancer Staging and the Impact of Stage Change on Outcomes

“…On the other hand, overstaging may result in worse functional outcomes 6,7 . Small studies suggest that discordance between clinical and pathologic staging may be common for laryngeal cancer 8–11 . However, there are limited published studies evaluating the impact of upstaging or downstaging on perioperative outcomes 12 …”