# Radiation Oncology/Head & Neck/Larynx/Staging

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Laryngeal Cancer Staging

## AJCC 8th Edition

AJCC 8th Edition (2017): To be used for staging beginning Jan 1, 2018.
T-Stage
* unchanged from 7th edition
N-Stage
Clinical (cN)
* NX - Cannot be assessed
* N0 - No regional lymph nodes metastasis
* N1 - Single ipsilateral lymph node, <= 3 cm in greatest dimension, and ENE(-)
* N2
** N2a - Single ipsilateral lymph node, 3-6 cm in greatest dimension, and ENE(-)
** N2b - Multiple ipsilateral lymph nodes, <= 6 cm in greatest dimension, and ENE(-)
** N2c - Bilateral or contralateral lymph nodes, <= 6cm in greatest dimension, and ENE(-)
* N3
** N3a - Lymph node > 6 cm, and ENE(-)
** N3b - Clinically overt ENE(+) (ENE$_c$) (defined as invasion of skin, infiltration of muscle, dense tethering or fixation to adjacent structures, cranial nerve, brachial plexus, sympathetic trunk, or phrenic nerve invasion with dysfunction)
Pathological (pN)
* NX - Cannot be assessed
* N0 - No regional lymph nodes metastasis
* N1 - Single ipsilateral lymph node, <= 3cm in greatest dimension, and ENE(-)
* N2
** N2a - Single node (ipsi or contralateral), <= 3cm, and ENE(+); or single ipsilateral node, 3-6 cm, and ENE(-)
** N2b - Multiple ipsilateral nodes, <= 6 cm, and ENE(-)
** N2c - Bilateral or contralateral nodes, <= 6 cm, and ENE(-)
* N3
** N3a - Lymph node > 6 cm, and ENE(-)
** N3b - Single ipsilateral node, > 3 cm, and ECE(+); or multiple LNs and any with ENE(+)
Overall stage
* unchanged from 7th edition

## AJCC 7th Edition

AJCC 7th Edition (2009)

## Tumor Stage
### Supraglottis

* Anatomy: the inferior boundary of the supraglottis is a horizontal plane passing through the lateral margin of the ventricle at its junction with the superior surface of the vocal cord.
** Subsites: False cords, arytenoids, suprahyoid epiglottis, infrahyoid epiglottis, aryepiglotic folds
* T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility
* T2: Tumor invades mucosa of more than one adjacent subsite* of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, or medial wall of pyriform sinus) without fixation of the larynx
* T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex)
* T4a: Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
    Note: extrinsic muscles of the tongue are: genioglossus, hyoglossus, styloglossus, and palatoglossus
* T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

### Glottis

* Anatomy: The glottis is composed of the superior and inferior surfaces of the true vocal cords, including the anterior and posterior commissures. It occupies a horizontal plane 1 cm in thickness, extending inferiorly from the lateral margin of the ventricle.
* T1: Tumor limited to the vocal cord(s), which may involve anterior or posterior commissure, with normal mobility
** T1a: Tumor limited to one vocal cord
** T1b: Tumor involves both vocal cords
* T2: Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility
* T3: Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex)
* T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
    Note: extrinsic muscles of the tongue are: genioglossus, hyoglossus, styloglossus, and palatoglossus
* T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

### Subglottis

* Anatomy: The subglottis is the region extending from the lower boundary of the glottis to the lower margin of the cricoid cartilage.
* T1: Tumor limited to the subglottis
* T2: Tumor extends to vocal cord(s) with normal or impaired mobility
* T3: Tumor limited to larynx with vocal cord fixation
* T4a: Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus)
    Note: extrinsic muscles of the tongue are: genioglossus, hyoglossus, styloglossus, and palatoglossus
* T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

## Lymph Node Stage

* NX - Cannot be assessed
* N0 - No regional lymph nodes metastasis
* N1 - Single ipsilateral lymph node, <= 3cm in greatest dimension
* N2
** N2a - Single ipsilateral lymph node, 3-6 cm in greatest dimension
** N2b - Multiple ipsilateral lymph nodes, <= 6cm in greatest dimension
** N2c - Bilateral or contralateral lymph nodes, <= 6cm in greatest dimension
* N3 - Lymph node(s) >6 cm in greatest dimension

## Metastasis Stage

* MX: Distant metastasis cannot be assessed
* M0: No distant metastasis
* M1: Distant metastasis

## AJCC Overall Stage

* I - T1 N0
* II - T2 N0
* III - T3 N0, T1-3 N1
* IVA - T4a N0-2, T1-4a N2
* IVB - T4b any N, any T N3
* IVC - M1

## Older staging systems

AJCC 6th edition (2002)
* no changes compared to 7th edition
* new since 5th edition: subdivided T4 into T4a and T4b
AJCC 5th edition (1997)
* For all subsites, T4 is a single grouping, not divided into T4a and T4b
* Supraglottis:
** Unchanged compared to current edition (7th), except for T4 as noted above
* Glottis:
** Unchanged compared to current edition (7th), except for T4 as noted above
* Subglottis:
** Unchanged compared to current edition (7th), except for T4 as noted above
AJCC 3rd edition (1988)
* Supraglottis:
** no changes compared to 7th edition
* Glottis:
** T1 - no changes compared to current edition (7th)
** T2 - no changes compared to current edition (7th)
** T3 - tumor limited to larynx with vocal cord fixation (does not mention paraglottic space invasion or minor thyroid cartilage erosion)
* Subglottis:
** no changes compared to 7th edition
AJCC 2nd edition (1983)
* Glottis:
** T2a - normal mobility
** T2b - decreased mobility