Page 42 - Revista SPORL - Vol 59. Nº2

larynx cancer have been reported in the literature, but some neck staging and the mucosal extent and vocal cord (VC)
controversies remain. mobility, imaging studies are essential to determine
Material and methods: a retrospective analysis of the patients adjacent structures invasion and to evaluate metastasis
who underwent surgery for larynx cancer (LC) in Hospital de (neck and distant). Nevertheless, there are some well-
5
Braga between January of 2013 and December of 2017 was described limitations in cTNM assessment.
performed. Patients who underwent total laryngectomy (TL) Neck palpation has a sensitivity of only 64% for N+
and partial laryngectomy (PL) associated with neck dissection.
The following data were retrieved: age, gender, location, (with positive SCC metastasis, in contrast with N0,
cTNM, and pTNM, time between first histopathological term which refers to a neck without SCC metastasis)
diagnosis and surgery, 5-year overall survival (OS), relapse, considering histopathology examination the standard. 6
and death. For analysis purposes, the staging was performed Complementing the patient study with ultrasonography
according to American Joint Committee on Cancer 8th Edition, or CT can improve neck staging accuracy, given the
2017. higher sensitivity of these exams.
Results: of the 72 patients diagnosed with LC, 47 were included Also regarding imaging studies, one of the most
in the analysis. 17% (n=8) underwent PL, while 83% (n=39) discussed controversies is CT and MRI capacity
underwent TL. There was a discrepancy between cTNM and to determine cartilage involvement. CT has a low
pTNM in 66% of the patients: a different T in 44,7%, with a low sensitivity for cartilage invasion and can miss early/
Cohen Kappa coefficient of 0,310 (p = 0,01), and a different N minor involvement, being difficult to distinguish
in 29,8%, with a substantial Cohen Kappa coefficient of 0,688
(p < 0,001). The most common reason for upstaging T was the between normal irregular calcification of the cartilage
3,7
invasion of the outer cortex of the thyroid cartilage, and the or its involvement by tumor growth. MRI, on the other
most frequent reason for downstaging was apparent vocal hand, has proven more sensitive, with a sensitivity that
cord fixation in the preoperative examination. The median of can go as high as 93% for inner lamina involvement and
the days between histopathological diagnosis and surgery in 85% for outer lamina involvement. 7
the patients whose T was upstaged was significantly different After proper patient investigation, diagnosis, and cTNM
(superior) than other patients. Tumors located in the glottis establishment, treatment is programmed. There is
were associated with a T downstaging (p = 0,020). There was usually a time gap between the diagnosis confirmation
no statistically significant difference in survival curves between and treatment (either surgery of systemic treatment
patients with and without discrepancies in cTNM and pTNM. initiation). Some authors have questioned the influence
Discussion and conclusions: our results show higher rates of the delay in potential discrepancies between cTNM
of re-staging than the ones described in the literature, that
vary between 20 and 55%. New evaluation methods, such as and pTNM and in prognosis itself, although the results
imaging studies with better diagnostic accuracy, and, on the are quite conflicting. 4
other hand, reducing the time between first diagnosis and The objective of this study is to assess the differences
surgical treatment may be important to reduce the rates of in cTNM and pTNM staging between patients in whom
discrepancy between cTNM and pTNM. Despite re-staging surgery including neck dissection was performed
being frequent, according to our data, it is not associated with to treat SCC of the larynx, investigate the potential
worse OS. reasons for the differences, and the impact of the
Keywords: larynx cancer; TNM staging time gap between diagnosis and treatment in these
discrepancies. Another objective of this study is to
INTRODUCTION evaluate the influence of these differences in prognosis,
Cancer staging plays a major role in the treatment of namely the outcome 5-year overall survival (OS).
a patient with cancer. Standardizing patients by their
stage ease prognosis establishment, contributing to the MATERIAL AND METHODS
treatment choosing decision. 1 After Ethics Committee approval, a retrospective
Clinical TNM (cTNM), the pretherapeutic staging, in analysis of the patients who underwent surgery for
squamous cell carcinoma (SCC) of the larynx depends SCC of the larynx treatment between January 2013 and
on a myriad of procedures: physical examination, December 2017 was performed.
endoscopic exams, and imaging studies. The latter can Patients who underwent partial laryngectomy (PL) or
be further subdivided in computed tomography (CT) total laryngectomy (TL) associated with neck dissection
scan, magnetic resonance imaging (MRI) and positron- were selected. Patients who underwent surgery as
emission tomography (PET). On the other hand, after salvage treatment and follow-up losses were excluded.
2
the surgical approach and histopathological analysis, The following data were retrieved: demographic
the pathological TNM (pTNM) is determined. features; cTNM based on clinical examination and
Many authors found important differences between imaging (CT and/or MRI), and pTNM, based in
cTNM and pTNM in larynx cancers. As treatment histopathologic analysis; the time gap between first
2-4
choice depends on the cTNM, the search for the most histopathologic diagnosis confirmation and surgery; the
accurate diagnosis has been discussed thoroughly in the outcomes death, relapse, 5-years overall survival. For
literature. analysis purposes, we subdivided the staging process in
While physical exam and endoscopy are useful to assess T (cT or pT) and N (cN and pN); patients without neck

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