The cornerstone of oncology literature and therefore medical practice is the ability to compare outcomes of treatment modalities for different stages of cancer

A Eryilmaz

B Charlin

Callum Faris

F Wallner

J Gamboa

Nimesh Narendra Patel

P Zbaren

T Ferri

Tahwinder Upile

English

PubMed

Nimesh Patel

Springer - Publisher Connector

Getting the basics right-staging in head and neck cancer

BioMed CentralHead & Neck Oncology
ssOpen AcceCommentary
Getting the basics right-staging in head and neck cancer
Nimesh Narendra Patel*, Callum Faris and Tahwinder Upile
Address: ENT Department, Southampton University Hospitals, Southampton, Hampshire, UK
Email: Nimesh Narendra Patel* - nnpatel2000@hotmail.com; Callum Faris - callumfaris@gmail.com; Tahwinder Upile - mrtupile@yahoo.com
* Corresponding author    
Abstract
The cornerstone of oncology literature and therefore medical practice is the ability to compare
outcomes of treatment modalities for different stages of cancer.
The head and neck represents a complicated anatomical region with multiple tumour sites and sub-
sites. Modern management necessitates accurate staging to allow meaningful discussion between all
members of the multidisciplinary team. Variations in techniques utilized for staging laryngeal cancer
may lead to inconsistencies in staging and result in inaccuracies in interpreting comparative
interventional studies.
We call for standardisation in assessment of head and neck cancers in order to maximize the
accuracy of clinical staging. We suggest a schema that we currently use in our institution for staging
of all head and neck cancers and a schema for upper aero-digestive tract endoscopy.
Introduction
The cornerstone of oncology literature and therefore med-
ical practice is the ability to compare outcomes of treat-
ment modalities for different stages of cancer.
The head and neck represents a complicated anatomical
region with multiple tumour sites and subsites. Modern
management necessitates accurate staging to allow mean-
ingful discussion between all members of the multidisci-
plinary team. Organ preservation treatments (especially
surgery) demand accurate tumour mapping to determine
feasibility.
Discussion
Most published papers now adhere to the International
Union Against Cancer (UICC) or the American Joint
Committee on Cancer (AJCC) in staging method and
result reporting. However, the literature rarely details the
techniques used to stage the tumour. Surgical en bloc
resection would be expected to provide definitive tumour
staging; however, surgical specimens are subject to shrink-
age artefact and errors of orientation. Recent trans-oral
laser microsurgical techniques can also provide difficul-
ties with pathological staging due to the piecemeal resec-
tion procedure and resultant multiple specimens
generated. Staging of tumours treated with non-surgical
techniques; do not have the benefit of cross-referencing
clinical staging with pathological staging.
Staging by imaging is subject to inaccuracies, being rela-
tively insensitive to superficially spreading upper aerodi-
gestive tract mucosal tumours [1]. CT scanning is also
thought to under-stage diseases in some subsites and MRI
over-stage tumours in some subsites [2]. The traditional
panendoscopy provided detailed visual and palpation evi-
dence of tumour extent. When coupled with awake fibre-
optic laryngopharyngosopy, dynamic assessment was
added – essential in staging laryngeal disease. There is
Published: 9 June 2009
Head & Neck Oncology 2009, 1:16 doi:10.1186/1758-3284-1-16
Received: 18 May 2009
Accepted: 9 June 2009
This article is available from: http://www.headandneckoncology.org/content/1/1/16
© 2009 Patel et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 2
(page number not for citation purposes)
Head & Neck Oncology 2009, 1:16 http://www.headandneckoncology.org/content/1/1/16even evidence to suggest that videostroboscopy has a role
to play in tumour staging [3]. The recent move towards
fibre-optic evaluation only, might risk losing some of the
detailed information gained by a full panendoscopy
under general anaesthesia [4], although detailed compar-
ative studied have not been performed to answer this
question. Two modern additions to the panenedoscopy-
use of the operating microscope and the Hopkin's rod
rigid telescope system (with straight and angled lenses)
have been shown to change staging [5,6].
In our institution we use the schema in Appendix 1 for
staging head and neck cancers. The panendoscopy has the
elements described in Appendix 2. Imaging and patholog-
ical reporting is performed to the recommendations of the
Scottish Intercollegiate Guidelines Network (SIGN)
guidelines on the diagnosis and management of head and
neck cancer [7].
Conclusion
We call for standardisation in assessment of head and
neck cancers in order to maximize the accuracy of clinical
staging, a key recommendation in the UK National Head
and Neck Cancer Audit [8]. Only once this most funda-
mental part of head and neck cancer management is
achieved can we meaningfully interpret patient outcomes
from different treatment modalities and undertake
informative comparative interventional studies.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
NNP and TU contributed to conception and design and
were involved in drafting the manuscript. CF revised the
manuscript critically for important intellectual content.
All authors read and approved the final manuscript.
Appendix 1
Schema for diagnostic work up of a head and neck cancer 
patient
Full ENT history and Exam
Outpatient naso-laryngoscopy with photo/video docu-
mentation
Videostroboscopy (larynx) with photo/video documenta-
tion
CT scanning – head/neck/chest
MRI scanning/PET-CT/USS/FNAC, as indicated, pre-
biopsy (if possible)
Laryngopharyngoscopy and direct bronchoscopy and
oesphagoscopy with 0° and 30/90° endoscopes with
photo/video documentation
Appendix 2
Schema for panendoscopy
Palpation of neck
Examination of oral cavity
Pharyngoscopy of all subsites
Laryngoscopy (with Pilling's Laryngoscope), bimanual
palpation
Suspension Laryngoscopy (Pilling's Laryngoscope), exam-
ination of larynx with microscope and 0° Hopkins rod,
then re-examine laryngeal ventricles, anterior commissure
and sub-glottis with ridged 30° Hopkins rod (including
photo documentation). Palpation of larynx with microin-
struments
Oesphagoscopy-rigid/flexible and Rigid Bronchoscopy
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Crossref

Head & Neck Oncology

C: Assessment of laryngeal cancer: CT scan versus endoscopy.

Cobeta I: Stroboscopic assessment of chronic laryngitis. Acta Otorrinolaringol Esp

D: The value of CT scans in improving laryngoscopy in patients with laryngeal cancer. Eur Arch Otorhinolaryngol

Korkmaz H: The role of 70-degree telescopic examination during direct laryngoscopic evaluation of laryngeal cancers. Eur Arch Otorhinolaryngol

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Scottish Intercollegiate Guidelines Network.

Staging of laryngeal cancer: endoscopy, computed tomography and magnetic resonance versus histopathology. Eur Arch Otorhinolaryngol

The potential uses and limitations of the flexible laryngoscopy under local anesthesia in clinical practice. HNO

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Getting the basics right-staging in head and neck cancer

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