40
Head and Neck Tumours
Unknown Primary – Cervical Nodes Rules for Classification There should be histological confirmation of squamous cell carcinoma with lymph node metastases but without an identified primary carcinoma. Histological methods should be used to identify EBV and HPV/p16‐related tumours. If there is evidence of EBV, the nasopharyngeal classification is applied. If there is evidence of HPV and positive immunohistochemistry p16 overexpression, the p16‐positive oropharyngeal classification is applied.
TNM Clinical Classification EBV or HPV/p16 negative or unknown
T – Primary Tumour T0
No evidence of primary tumour
N – Regional Lymph Nodes N1
Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension without extranodal extension N2 Metastasis described as: N2a Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension without extranodal extension N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, without extranodal extension N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension, without extranodal extension N3a Metastasis in a lymph node more than 6 cm in greatest dimension without extranodal extension N3b Metastasis in a single or multiple lymph nodes with clinical extranodal extension* Notes * The presence of skin involvement or soft tissue invasion with deep fixation/ tethering to underlying muscle or adjacent structures or clinical signs of nerve involvement is classified as clinical extra nodal extension. Midline nodes are considered ipsilateral nodes.
Unknown Primary – Cervical Nodes
41
M – Distant Metastasis M0 No distant metastasis M1 Distant metastasis
pTNM Pathological Classification The pT category corresponds to the clinical T category. For pM see page 8.
Histological examination of a selective neck dissection specimen will ordinarily include 10 or more lymph nodes. Histological examination of a radical or modified radical neck dissection specimen will ordinarily include 15 or more lymph nodes. pN1
Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension without extranodal extension pN2 Metastasis described as: pN2a Metastasis in a single ipsilateral lymph node, less than 3 cm in greatest dimension with extranodal extension or more than 3 cm but not more than 6 cm in greatest dimension without extranodal extension pN2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, without extranodal extension pN2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension, without extranodal extension pN3a Metastasis in a lymph node more than 6 cm in greatest dimension without extranodal extension pN3b Metastasis in a lymph node more than 3 cm in greatest dimension with extranodal extension or multiple ipsilateral, or any contralateral, or bilateral node(s) with extranodal extension
Stage Stage III Stage IVA Stage IVB Stage IVC
T0 T0 T0 T0
N1 N2 N3 N1, N2, N3
M0 M0 M0 M1
Head & Neck
pN – Regional Lymph Nodes
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Head and Neck Tumours
TNM Clinical Classification HPV/p16 positive
T – Primary Tumour T0
No evidence of primary tumour
N – Regional Lymph Nodes N1 Unilateral metastasis, in cervical lymph node(s), all 6 cm or less in greatest dimension N2 Contralateral or bilateral metastasis in cervical lymph node(s), all 6 cm or less in greatest dimension N3 Metastasis in cervical lymph node(s) greater than 6 cm in dimension
pTNM Pathological Classification There is no pT category.
pN – Regional Lymph Nodes Histological examination of a selective neck dissection specimen will ordinarily include 10 or more lymph nodes. Histological examination of a radical or modified radical neck dissection specimen will ordinarily include 15 or more lymph nodes. pN1 Metastasis in 1 to 4 lymph node(s) pN2 Metastasis in 5 or more lymph node(s)
Stage Clinical Stage I Stage II Stage III Stage IV
T0 T0 T0 T0
N1 N2 N3 N1, N2, N3
M0 M0 M0 M1
Pathological Stage I Stage II Stage IV
T0 T0 T0
N1 N2 N1, N2
M0 M0 M1
Unknown Primary – Cervical Nodes
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TNM Clinical Classification EBV positive
T – Primary Tumour T0
No evidence of primary tumour
N1 Unilateral metastasis, in cervical lymph node(s), and/or unilateral or bilateral metastasis in retropharyngeal lymph nodes, 6 cm or less in greatest dimension, above the caudal border of cricoid cartilage N2 Bilateral metastasis in cervical lymph node(s), 6 cm or less in greatest dimension, above the caudal border of cricoid cartilage N3 Metastasis in cervical lymph node(s) greater than 6 cm in dimension and/or extension below the caudal border of cricoid cartilage Note Midline nodes are considered ipsilateral nodes.
pTNM Pathological Classification The pT and pN categories correspond to the T and N categories. For pM see page 8. pN0 Histological examination of a selective neck dissection specimen will ordinarily include 10 or more lymph nodes. Histological examination of a radical or modified radical neck dissection specimen will ordinarily include 15 or more lymph nodes.
M – Distant Metastasis M0 No distant metastasis
Stage Stage II Stage III Stage IVA Stage IVB
T0 T0 T0 T0
N1 N2 N3 N1, N2, N3
M0 M0 M0 M1
Head & Neck
N – Regional Lymph Nodes (Nasopharynx)
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Head and Neck Tumours
Prognostic Factors Grid – Cervical Nodes Unknown Primary Prognostic factors for head and neck unknown primary Prognostic factors
Tumour related
Host related
Essential
Histology N category and number of nodes Extracapsular extension Presence or absence of metastatic disease p16INK4A/HPV status, or EBV DNA status
Immunosuppression (especially skin cancer)
Additional
Tumour differentiation Location of nodal disease (above vs below clavicle)
Gender Haemoglobin level Smoking history
New and Promising
TP53 Surviving nuclear expression
Environment related
Subsequent discovery of primary Overall treatment time
Source: UICC Manual of Clinical Oncology, Ninth Edition. Edited by Brian O’Sullivan, James D. Brierley, Anil K. D’Cruz, Martin F. Fey, Raphael Pollock, Jan B. Vermorken and Shao Hui Huang. © 2015 UICC. Published 2015 by John Wiley & Sons, Ltd.