Head and Neck Cancer Stage III

Stage III head and neck cancer represents a significant turning point in the disease, where the tumor has grown larger or begun to involve nearby lymph nodes, requiring more complex treatment approaches that often combine multiple therapies.

Table of contents

• Understanding Stage III Head and Neck Cancer
• The TNM Staging System
• Characteristics of Stage III Disease
• Treatment Approaches for Stage III

Understanding Stage III Head and Neck Cancer

The stage of a cancer tells you how much cancer there is in your body and how far it has spread. Your healthcare provider uses examinations and tests to find out the size of the tumor (an abnormal mass of tissue) and where it is located^[1]. Scans can also show if the cancer has grown into nearby areas, and if it has spread to other parts of your body. The stage is one of the most important things to know when deciding how to treat the cancer^[2].

Head and neck cancers affect several areas including the mouth, throat, voice box, sinuses, and related structures^[6]. Most head and neck cancers start in squamous cells (thin, flat cells that make up the moist tissue lining your mouth and throat)^[6].

The TNM Staging System

The most commonly used system to stage head and neck cancers is the TNM system from the American Joint Committee on Cancer. This system helps doctors communicate clearly about the extent of your cancer^[2][4].

The letters in the TNM system stand for specific aspects of the cancer. T tells how far the main tumor has spread into nearby tissues. N tells if the lymph nodes (small bean-shaped organs that help fight infection) near the tumor have cancer in them. M tells if the cancer has spread, or metastasized, to distant organs like the brain, bones, or lungs^[2].

Numbers or letters after T, N, and M provide more details about each of these factors. There are also two other values that can be assigned: X means the healthcare provider does not have enough information to tell the extent of the main tumor or if the lymph nodes have cancer cells in them. The number 0 means no sign of cancer, such as no sign of cancer in the lymph nodes^[2].

Characteristics of Stage III Disease

Stage III head and neck cancer is considered locally advanced disease. The specific definition of Stage III varies depending on the exact location of the cancer in the head and neck region^[2].

For cancer of the bottom of the throat, called the hypopharynx (the lower part of the throat that connects to the food pipe), Stage III means the cancer has not spread to organs in other parts of the body, and one of these conditions is true: The tumor is more than 4 centimeters across, or it has grown into the food pipe, or it is affecting the vocal cords, but it has not spread to nearby lymph nodes. Alternatively, the tumor may be any size and may or may not have spread into nearby tissues or be affecting a vocal cord, but it has spread to one lymph node on the same side of the neck as the tumor, and that node is not more than 3 centimeters across^[2].

Traditionally, Stage III head and neck cancer has been defined as a tumor that is larger than 4 centimeters, or it is any size and has spread to one nearby lymph node and is smaller than 3 centimeters^[4]. Recently, staging systems have been adjusted according to advances in understanding of head and neck cancer. The latest staging systems are specific to the cause of cancer, such as cancers related to HPV (human papillomavirus, a type of sexually transmitted infection), and the location of the cancer^[4].

Treatment Approaches for Stage III

Stage III head and neck cancer requires more aggressive treatment than earlier stages. The decision to treat the patient should be made by a team of specialists including a medical oncologist, a radiation therapist, and an ear, nose, and throat surgeon^[14].

Surgery should be considered for locally advanced disease. However, definitive radiation therapy (treatment that uses high-energy rays to kill cancer cells), concurrent chemoradiation (chemotherapy given at the same time as radiation therapy) alone or after surgery, and induction therapy (chemotherapy given before other treatments) followed by concurrent chemoradiation are alternative options for patients who are not candidates for surgery alone^[14].

For Stage III hypopharyngeal cancer, treatment options include surgery or chemoradiation (a combination of chemotherapy and radiation therapy). Surgery is one of the main treatments and is used to remove the tumor along with a margin of healthy tissue around it. Surgery is the main treatment option when the cancer has made it difficult to swallow or breathe^[10].

The most common surgery used is a laryngopharyngectomy (removal of part or all of the voice box and throat) with a neck dissection (removal of lymph nodes in the neck). Other procedures may be done to help with breathing and nutrition, including placement of a breathing tube to help you breathe and placement of a feeding tube to make sure you get enough nutrients^[10].

Chemoradiation is one of the main treatments for Stage III hypopharyngeal cancer. In chemoradiation, chemotherapy is given during the same time period as radiation therapy. The chemotherapy makes the radiation more effective. For Stage III hypopharyngeal cancer, cisplatin is the chemotherapy drug (medicine that kills cancer cells) given along with radiation to the tumor and lymph nodes on both sides of the neck^[10].

Radiation therapy or chemoradiation is given after surgery for Stage III hypopharyngeal cancer. A specialized type of external radiation therapy called intensity-modulated radiation therapy (IMRT) may be used to lessen the damage to tissues around the tumor^[10].

Chemotherapy may be given to shrink the tumor before surgery or radiation therapy for Stage III hypopharyngeal cancer. The most common chemotherapy drug combination used to treat hypopharyngeal cancer is cisplatin and fluorouracil^[10].

Immunotherapy (treatment that helps your body’s immune system fight cancer) may be offered for Stage III locally advanced hypopharyngeal cancer. Pembrolizumab may be given before surgery to remove the tumor. It is then given with radiation therapy, with or without cisplatin, and then continued by itself after radiation therapy is finished^[10].