Update on TNM 8 Staging Modifications for Head and Neck Cancers
In the latest TNM 8 updates, significant modifications have been introduced for staging various head and neck cancers. Changes include new stage classifications, adjustments in T and N categories, and considerations for HPV status and other factors. The revisions aim to enhance accuracy in staging and treatment planning for better patient outcomes.
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Presentation Transcript
TNM 8 UPDATE TNM 8 UPDATE Head and Neck SSG March 2018 Head and Neck SSG March 2018
TNM 8 TNM 8 New stage classifications HPV +ve oropharyngeal Soft tissue sarcoma of head and Neck Modification of T+N for nasopharyngeal Modification of T for Oral SCC Modification of N category and sub-classification into non-viral and viral related head and neck cancers and CUP Modification to head and neck cutaneous carcinoma Modification of T for thyroid and age consideration
Oral SCC Oral SCC T stage T stage Clinical and Pathological T staging same TX T0 Tis CIS T1 T2 Primary cannot be assessed No evidence of primary 2cm or less and depth of 5mm or less 2cm or less and depth more than 5mm but no more than 10mm Or more than 2cm but not more than 4cm and depth no more than 10mm More than 4cm or depth more than 10mm (A+B) same as previous (bone invasion etc) T3 T4
Clinical N stage vs Pathological for Oral SCC Clinical N stage vs Pathological for Oral SCC (applies also to other non viral) (applies also to other non viral) NX, N0, N1, same N1 Single ipsilateral, 3cm or less ve ENE N2 N2a Single ipsilateral, more than 3cm, less than 6cm ve ENE Single ipsilateral, less than 3cm, ENE +ve Multiple ipsilateral, none more than 6cm - ve ENE Bilateral or contralateral, none more than 6cm ve ENE N2b N2c cN3 N3a N3b More than 6cm ENE Single or multiple with* clinical ENE+ve pN3 N3a N3b More than 6cm ve ENE More than 3cm, ENE +ve or, multiple ipsilateral, or any contralateral or bilateral with ENE *Clinical +ve ENE- skin involvement or soft tissue invasion with deep fixation/tethering to muscle or adjacent structures or clinical signs of nerve involvement
STAGING OROPHARYNGEAL STAGING OROPHARYNGEAL TNM8 mandates p16 IHC in decision making (ISH as an alternative)
T Staging OROPHARYNGEAL MALIGNANCY T Staging OROPHARYNGEAL MALIGNANCY Clinical and pathological T staging is essentially the same for HPV +ve and -ve Differences: No CIS (pTis) in p16 +ve pT4b category removed from p16+ve
T categories p16 + T categories p16 +ve ve vs vs - -ve ve Clinical and Pathological T category for p16-ve OPC (or when p16 has not been performed) Clinical and Pathological T category for p16+ve OPC T0 T1 T2 T3 No primary identified TX Tis T1 T2 T3 Primary tumour cannot be assessed Cis 2cm or smaller >2cm but not larger than 4cm >4cm or extension to lingual surface of epiglottis 2cm or smaller >2cm but not larger than 4cm >4cm or extension to lingual surface of epiglottis T4 Tumour invades larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible or beyond T4a Tumour invades larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible Tumour invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base or encases carotid artery T4b
Clinical vs pathological N stage for HPV + Clinical vs pathological N stage for HPV +ve ve Clinical N category for p16+ve OPC Pathological N category for p16+ve OPC cNx cN0 No regional LN cN1 Unilateral metastasis all 6cm or less cN2 Contralateral or bilateral LN, none larger than 6cm cN3 LN larger than 6cm pNx Regional LN cannot be assessed pN0 No regional LN pN1 Metastasis in 1-4 nodes pN2 Metastasis in 5 or more nodes Regional LN cannot be assessed
Clinical vs pathological TNM staging for Clinical vs pathological TNM staging for HPV+ve HPV+ve OPC OPC Clinical TNM Pathological TNM Stage 0 Stage I Stage II Stage 0 Stage I Stage II Tis N0 M0 Tis N0 M0 T1,T2 N0,N1 M0 T1,T2 N0,N1 M0 T1,T2, T3 N2 N0,N1,N2 M0 M0 T1,T2 T3 N2 N0,N1 M0 M0 Stage III Stage III Stage IV T1-3 T4 N3 Any M0 M0 T3,T4 N2 M0 Any T Any N M1 Stage IV Any T Any N M1 A patient that presents with a 2 cm p16+ tonsil cancer and 2 positive lymph nodes in the same side neck is stage IV in the 7th Edition Staging Manual but will become a stage I in the 8th Edition.
PUO/ CUP PUO/ CUP There should be histological confirmation of SCC in a LN without identification of primary carcinoma Histological methods should be used to identify EBV and HPV/p16 related tumours (EBV vs HPV CUP) If there is evidence of EBV use the nasopharyngeal classification If there is evidence of HPV and +ve p16 use the p16 positive oropharyngeal classification
Non viral CUP STAGING (EBV or HPV/p16 Non viral CUP STAGING (EBV or HPV/p16 ve ve) ) T0 category only cN and pN same as non viral neck Stage III Stage IVA Stage IVB Stage IVC T0 N1 M0 T0 N2 M0 T0 N3 M0 T0 N1,N2,N3 M1
HPV/p16 + HPV/p16 +ve ve CUP CUP Clinical TNM Pathological TNM All T0 N1 N2 Uilateral in cervical node(s), all 6cm or less There is no pT category pN1 Metastasis in 1-4 LN(s) pN2 Metastasis in 5 or more LN(s) Contralateral or bilateral in cervical LN all 6cm or less N3 Metastasis greater than 6cm Stage I Stage II Stage III Stage IV T0 N1 M0 Stage I Stage II Stage IV T0 N1 M0 T0 N2 M0 T0 N2 M0 T0 N3 M0 T0 N1,N2 M1 T0 N1-3 M1
EBV +VE CUP EBV +VE CUP Clinical and pathological the same TNM T0 N1 Unilateral in cervical node(s) and /or unilateral or bilateral in retropharyngeal, 6cm or less, above caudal border of cricoid cartilage N2 Bilateral in cervical node(s), 6cm or less above the caudal border of cricoid cartilage N3 Cervical nodes greater than 6cm and/or extension below the caudal border of cricoid No primary tumour Stage II Stage III Stage IVA T0 Stage IVB T0 T0 T0 N1 N2 N3 N1-3 M1 M0 M0 M0
