New staging for ENT Cancers

Assessment consists of clinical examination, chest X-ray or CT scan, an endoscopy of the upper aerodigestive tract (usually under general anesthetic) and CT examination (scan) of the ENT sphere.
Magnetic resonance imaging (MRI) is often indicated (oropharynx and oral cavity, in particular). FDG PET imaging is often performed as an additional investigation.

TNM staging groups squamous cell cancers of the upper aerodigestive tract into four stages, such as :

Carcinomas of the vermilion surfaces of the lips and of the oral cavity

Carcinomas of the pharynx

Oropharynx - p16 negative

Oropharynx - p16 positive

Clinical

Pathological

Hypopharynx

Larynx

Carcinomas of the nasal cavity and paranasal sinuses

Unknown Primary - Cervical Nodes - EBV or HPV/p16 negative or unknown

Unknown Primary - Cervical Nodes - HPV/p16 positive

Clinical

Pathological

Unknown Primary - Cervical Nodes - EBV/p16 positive

Carcinomas of the salivary glands

Carcinomas of the thyroid gland

* including papillary, follicular, poorly differentiated, and Hurthle cell carcinomas.

Malignant melanoma of upper aerodigestive Tract

T4 cancers are divided into 2 categories:
T4a : resectable
T4b unresectable
This leads to subdivision of stage IV cancers into stages IVa and IVb depending on resectability.
Finally, stage IVc corresponds to metastatic disease.

Main treatments :

In all cases, treatment decisions are reached by a multidisciplinary team during the course of multidisciplinary consultation meetings.
Re-nutrition of the patient may be necessary, along with appropriate dental care, particularly in preparation for radiotherapy.
Treatment will be administered on the basis of the primary tumor site, lymph node involvement, the general condition and comorbidities of patients, as well as the level of evidence that may have been obtained via randomized clinical studies.

For stages I and II, the reference treatments are either conservative surgery or radiotherapy (external or brachytherapy). These two approaches generally result in comparable locoregional control rates.
However, there are no randomized studies comparing surgery and radiotherapy in these early stages.
Modern radiotherapy consists of 3D conformal radiotherapy and/or intensity-modulated conformal radiotherapy (IMRT).

Standard options for locally advanced forms (stages III and IV) are :
Surgery, including reconstruction if necessary and, usually, postoperative radiotherapy.
For patients at high risk of recurrence after surgery (extracapsular lymph node rupture and/or positive margin), radiotherapy may be delivered with concomitant chemotherapy with cisplatin (level of evidence I,A).
However, in patients presenting a resectable tumor, when the foreseeable outcome of surgery is liable to result in a significant functional deficit, it is preferable to immediately envisage a concomitant radio-chemotherapy combination, which is one of the standard treatments (level of evidence I,A).

In addition, radiotherapy given concurrently with cetuximab (erbitux) demonstrates higher response rates, a longer relapse-free survival and a longer overall survival than radiotherapy alone (level of evidence I,A).

With respect to cervical lymph nodes, if surgery is performed on the primary tumor, surgery is also generally performed for cervical lymphadenopathies (lymphadenectomy).
Postoperative radiotherapy depends on the risk factors (size and number of lymphadenopathies) and histological observations (size and number of lymphadenopathies and capsule rupture).
When radiotherapy is the main treatment, it generally includes the primary tumor, as well as the cervical lymph nodes.
In the event of residual lymph node disease persisting 2 to 4 months after radiotherapy, the performance of cervical lymphadenectomy may be proposed.

In locally advanced forms (stages III and IV), the role of induction chemotherapy is currently being assessed, since the introduction of new treatment combinations with taxotere, cisplatin, and 5FU (TPF).

Several randomized trials are ongoing to evaluate its benefit before concurrent radio-chemotherapy and before combination of radiotherapy and erbitux (Gortec trial 2007-02, 2007-01 and Gortec/Gettec Tremplin trial).

For locally advanced carcinomas of the larynx (T2 or T3 requiring total laryngectomy), induction chemotherapy with taxotere, cisplatin and 5FU may be used.
Depending on the response to induction chemotherapy, local treatment will either be radiotherapy, enabling preservation of the larynx if it is successful, or surgery with total laryngectomy in non responders (level of evidence I,A). This larynx preservation approach may also be proposed for carcinomas of the hypopharynx and has no negative effects on patient survival (level of evidence I,A)
Other larynx preservation approaches have been proposed using concurrent radio-chemotherapy (RTOG study, level I,A).

For initially metastatic carcinomas, treatment with cisplatin, 5FU and erbitux is the reference treatment. (EXTREME randomized trial conducted by EORTC, level of evidence I,A).
This is also the reference treatment in inoperable local recurrences, which cannot be treated by localized re-irradiation.
For patients who cannot receive this 5FU-cisplatin-erbitux treatment, weekly intramuscular or intravenous methotrexate (30 to 40 mg/m²) may be offered.