Supraglottic Cancer Workup

  • Author: Joshua D Hornig, MD, FRCSC; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Nov 29, 2011
 

Laboratory Studies

  • No specific laboratory studies are necessary for the workup of patients with supraglottic cancer. However, a number of tests may be indicated to evaluate the general health of these individuals.
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Imaging Studies

  • An accurate assessment of the anatomical extent of tumor is needed, not only to select treatment modalities but also to compare therapeutic results of different modalities. For example, cancer that extends through a boundary, such as the thyroid cartilage or pyriform apex, demands more aggressive treatment than a lesion without such extension. Clinical examination is notoriously inadequate for mapping tumor extent. Forty percent of diagnoses made based on clinical examination are inaccurate. As a result, radiographic assessment is important in the pretreatment workup of patients with laryngeal cancer.
  • Imaging studies help to define spread to the preepiglottic space (which characterizes T3 carcinoma) and also help to define thyroid cartilage invasion or extralaryngeal submucosal extension (which characterizes T4 carcinoma).
    • CT scans and MRI are useful studies in evaluating the spread of supraglottic lesions (see CT Scan, Larynx).
    • CT scans and MRI help to assess involvement of the base of tongue and spread to regional lymph nodes.
    • Both the preepiglottic and paraglottic space contain mostly fat; hence, CT scans with contrast or MRI, especially T1-weighted images, show tumor infiltration into these areas.
    • Having been shown superior to clinical examination in demonstrating positive lymph nodes, CT scans and MRI can help gauge cartilage invasion and help define metastatic spread to the neck.
    • MRI and CT scans are useful in measuring lymph node size; both can show areas of central lucency, which is consistent with tumor involvement.
    • Although MRI is somewhat superior with respect to soft-tissue contrast resolution, CT scanning has a faster imaging time, which can reduce motion artifact.
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Diagnostic Procedures

  • To obtain tissue diagnosis and help assess the extent of the disease, direct laryngoscopy is often performed in the operating room.
  • Videostroboscopy can be helpful in detecting subtle infiltration of the vocal folds.
  • Panendoscopy (ie, laryngoscopy, bronchoscopy, esophagoscopy, nasopharyngoscopy) has traditionally been the criterion standard used to diagnose second primary lesions. Panendoscopy is controversial, however. Some argue that bronchoscopy and esophagoscopy have only a slightly increased yield over chest radiography and barium swallow and that bronchoscopy and esophagoscopy are thus not worth the risks of endoscopy. This controversy notwithstanding, most practitioners would agree that direct laryngoscopy, usually under anesthesia, is essential for staging purposes and in obtaining biopsy samples necessary for tissue diagnosis. In the image below laryngoscopic view of the larynx can be seen. Laryngoscopic view of the larynx. Note the followiLaryngoscopic view of the larynx. Note the following supraglottic structures: epiglottis, aryepiglottic folds, arytenoids, and false folds.
  • If intraoperative laryngoscopy and biopsy is not appropriate, ultrasonography-guided fine needle aspiration of endolaryngeal advanced supraglottic carcinomas can be performed in the clinical setting without any preparation. According to Lopchinseky et al, this allows for a rapid diagnosis and does not have the costs, side effects, or risks of a direct laryngoscopy.[10]
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Histologic Findings

The mucosa of the supraglottis is composed of nonkeratinizing, stratified, squamous epithelium. Inferiorly, at the level of the laryngeal aditus, this epithelium changes to ciliated, pseudostratified, columnar epithelium at the false folds and the ventricle.

Squamous cell carcinoma (SCC) is classified as well-differentiated, moderately differentiated, or poorly differentiated. Histological findings include anaplastic-appearing cells below the basement membrane with a variable degree of keratin products and intracellular bridges. Microscopic view of squamous cell carcinoma is seen in the image below.

Histological specimen of squamous cell carcinoma (Histological specimen of squamous cell carcinoma (SCC).
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Staging

Staging of tumors of the supraglottis follows the 2003 definitions of the tumor, node, metastases (TNM) classification elaborated by the American Joint Committee on Cancer and the International Union Against Cancer.

  • Supraglottic cancer T-staging
    • Tis - In situ
    • T1 - Limited to 1 subsite with normal cord mobility
    • T2 - Invades mucosa of more than 1 adjacent subsite of supraglottis or glottis or region outside the supraglottis, without fixation of the larynx
    • T3 - Limited to larynx with vocal cord fixation and/or invades the postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid erosion
    • T4a - Invades through the thyroid cartilage and/or invades tissues beyond the larynx
    • T4b - Invades prevertebral space, encases carotid artery, or invades mediastinal structures
  • Node status in supraglottic cancer
    • N0 - No nodes
    • N1 - Metastasis in a single ipsilateral node that is greater than or equal to 3 cm
    • N2a - Metastasis in a single ipsilateral node more than 3 cm but not more than 3-6 cm in greatest dimension
    • N2b - Metastasis in multiple ipsilateral nodes with none more than 6 cm in greatest dimension
    • N2c - Metastasis in bilateral or contralateral nodes, none more than 6 cm in largest dimension
    • N3 - Metastasis in a lymph node that is larger than 6 cm in greatest dimension

Table. Staging of Supraglottic Cancer (Open Table in a new window)

StageTumor SpreadNode InvolvementDistant Metastases
Stage 0TisN0M0
Stage IT1N0M0
Stage IIT2N0M0
Stage IIIT3N0M0
T1N1M0
T2N1M0
T3N1M0
Stage IVAT4aN0M0
T4aN1M0
T1N2M0
T2N2M0
T3N2M0
T4aN2M0
Stage IVBT4bAny NM0
Any TN3M0
Stage IVCAny TAny NM1
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Contributor Information and Disclosures
Author

Joshua D Hornig, MD, FRCSC  Assistant Professor of Otolaryngology-Head and Neck Surgery, Facial Plastics, Microvascular Reconstruction, Head and Neck Oncology, Department of Otolaryngolog-Head and Neck Surgery, Hollings Cancer Center, Medical University of South Carolina College of Medicine

Joshua D Hornig, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Medical Association, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Christina ST Wilhoit, EMT, CCRP  Program Coordinator for Head and Neck Surgery Clinical Trials, Department of Otolaryngology, Hollings Cancer Center, Medical University of South Carolina

Disclosure: Nothing to disclose.

Jonathan E Sonne, MD  Consulting Staff, Department of Facial Plastic and Reconstructive Surgery, The Woodruff Institute

Jonathan E Sonne, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Cosmetic Surgery, American Academy of Facial Plastic and Reconstructive Surgery, American Medical Association, and Florida Medical Association

Disclosure: Nothing to disclose.

Steven D Schaefer, MD, FACS  Chair, Professor, Department of Otolaryngology, New York Eye and Ear Infirmary, New York Medical College

Steven D Schaefer, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Cancer Society, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, New York Academy of Medicine, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

M Abraham Kuriakose, MD, DDS, FRCS  Chairman, Head and Neck Institute, Amrita Institute of Medical Sciences

M Abraham Kuriakose, MD, DDS, FRCS is a member of the following medical societies: American Association for Cancer Research, American Head and Neck Society, British Association of Oral and Maxillofacial Surgeons, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Nader Sadeghi, MD, FRCSC  Professor, Otolaryngology-Head and Neck Surgery, Director of Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Thyroid Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

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A surgical specimen after laryngectomy. The arrow points to the vocal fold. Note the epiglottis, aryepiglottic fold, arytenoids, and false folds superior to the arrow.
Laryngoscopic view of the larynx. Note the following supraglottic structures: epiglottis, aryepiglottic folds, arytenoids, and false folds.
Histological specimen of squamous cell carcinoma (SCC).
Table. Staging of Supraglottic Cancer
StageTumor SpreadNode InvolvementDistant Metastases
Stage 0TisN0M0
Stage IT1N0M0
Stage IIT2N0M0
Stage IIIT3N0M0
T1N1M0
T2N1M0
T3N1M0
Stage IVAT4aN0M0
T4aN1M0
T1N2M0
T2N2M0
T3N2M0
T4aN2M0
Stage IVBT4bAny NM0
Any TN3M0
Stage IVCAny TAny NM1
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