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TNM STAGING OF HEAD AND NECK CANCER AND NECK DISSECTION CLASSIFICATION
Edited by Daniel G. Deschler, MD Terry Day, MD
American Head and Neck Society
Pocket Guide to
NECK DISSECTION CLASSIFICATION AND TNM STAGING OF HEAD AND NECK CANCER
Committee for Head and Neck Surgery and Oncology American Academy of Otolaryngology– Head and Neck Surgery Neck Dissection Classification Committee American Head and Neck Society
Edited by Daniel G. Deschler, MD Terry Day, MD Primary Contributors Anand K. Sharma, MD Merrill S. Kies, MD __________ Published by American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. One Prince Street, Alexandria, VA 22314-3357
First Edition 1991 K. Thomas Robbins, MD; editor Second Edition 2001 K. Thomas Robbins, MD; editor Third Edition 2008 Library of Congress Cataloging-in-Publication Data Pocket guide to neck dissection classification and TNM staging of head and neck cancer. — 3rd ed. / Committee for Head and Neck Surgery and Oncology, American Academy of Otolaryngology—Head and Neck Surgery [and] Neck Dissection Classification Committee, American Head and Neck Society; edited by Daniel G. Deschler, Terry Day ; primary contributors, Anand K. Sharma, Merrill S. Kies. p. ; cm. Rev. ed. of: Pocket guide to neck dissection classification and TNM staging of head and neck cancer / Committee for Neck Dissection Classification, American Head and Neck Society [and] Committee for Head and Neck Surgery and Oncology, American Academy of Otolaryngology— Head and Neck Surgery ; edited by K. Thomas Robbins. 2nd ed. 2001. Includes bibliographical references. ISBN 978-1-56772-117-1 (pbk.) 1. Neck—Surgery—Classification—Handbooks, manuals, etc. 2. Neck— Tumors—Classification—Handbooks, manuals, etc. 3. Neck—Lymphatics— Handbooks, manuals, etc. 4. Head—Tumors—Classification—Handbooks, manuals, etc. I. Deschler, Daniel G. II. Day, Terry A. III. Sharma, Anand K. IV. Kies, Merrill S. V. American Academy of Otolaryngology—Head and Neck Surgery. Committee for Head and Neck Surgery and Oncology. VI. American Head and Neck Society. Neck Dissection Classification Committee. VII. American Academy of Otolaryngology—Head and Neck Surgery Foundation. [DNLM: 1. Neck Dissection—classification—Handbooks. 2. Head and Neck Neoplasms—surgery—Handbooks. 3. Neoplasm Staging—classification—Handbooks. WE 39 P739 2008] RC280.N35P63 2008 616.99'491—dc22 2008022331
NATHAN MD BRIAN NUSSENBAUM. MEYER.AMERICAN ACADEMY OF OTOLARYNGOLOGY– HEAD AND NECK SURGERY HEAD AND NECK SURGERY COMMITTEE FACULTY DEVRAJ BASU. EISELE. COUCH. TEKNOS. MD PATRICK JOSEPH GULLANE. SCHMALBACH. BECKEN. MD FRCS(C) STEPHEN Y. MD MARILENE B. MD PHD DANIEL G. MD PhD WILLIAM P. MD CHRISTINE G. MD JOSEPH BRENNAN. MD WENDELL G. MD MARION E. MD CECELIA E. WANG. MAGDYCZ. MD DAVID W. MD BEVAN YUEH. MD THEODOROS N. MD JAMES P. DESCHLER. MD KELLY MICHELE MALLOY. MALONE MD ABBY C. MD MPH With appreciation to all former committee members who contributed. YARBROUGH. MD CHERIE ANN O. GOURIN. 3 . LAI. MD URJEET PATEL. MD PhD ERIC T.
MD Alfio Ferlito. Califano. Som. Medina.NECK DISSECTION CLASSIFICATION COMMITTEE AMERICAN HEAD AND NECK SOCIETY K. MD Peter M. DDS Jesus E. MD Ashok R. Wolf. Clayman. Thomas Robbins. MD Gregory T. MD 4 . Shaha. MD (Chair) Joseph A. MD. MD Gary L.
Appreciation is also extended to Douglas Denys.ACKNOWLEDGMENTS The American Head and Neck Society Committee acknowledges the input from the Head and Neck Surgery and Oncology Committee and the Head and Neck Surgery Education Committee of the American Academy of Otolaryngology–Head and Neck Surgery. and the Council of the American Head and Neck Society. MD. for the illustrations and the AJCC for the use of staging information from the 6th edition of the AJCC Cancer Stating Manual. 6 . This monograph has been endorsed by the American Head and Neck Society and The American Academy of Otolaryngology– Head and Neck Surgery.
......................................................... Salivary Glands......... American Joint Committee on Cancer (AJCC) Tumor Staging by Site..... Nasal Cavity and Paranasal Sinuses .......................... Thyroid ............................................................................................................... Nasopharynx .........................16 B...... Larynx.............................. Hypopharynx......23 III..............25 IV.......................................24 A..................................... Oral Cavity.................................................................... Definition of Lymph Node Groups ...........................................9 2................................20 F........... Salivary Glands............................ Oropharynx ............... TNM Staging for the Larynx...................... Nasopharynx ..................... Oropharynx...........................................33 B..........11 5.....8 A........ Upper Aerodigestive Tract Sites ........ Oral Cavity ..................................... Oropharynx .................. Radiation Therapy and Chemotherapy.24 B..... Oral Cavity ..................9 3................22 H.................... Hypopharynx............... Conceptual Guidelines for Neck Dissection Classification ...........13 B..............29 V............. Nasal Cavity and Paranasal Sinuses ............. Larynx .................. Modified Radical Neck Dissection..37 7 .....8 1................................................................................17 D.............................21 G....... Hypopharynx............................. Extended Radical Neck Dissection..33 A........................................... and Paranasal Sinuses ...........16 C....... Selective Neck Dissection..........TABLE OF CONTENTS I................... Introduction ........14 II.......12 6..................... Radical Neck Dissection.................. Neck Staging Under the TNM Staging System for Head and Neck Tumors (excluding nasopharynx and thyroid)........... AJCC Tumor Staging—Nasopharynx and Thyroid ....................................34 C.............10 4............................................35 D.......................................19 E.......................................................................16 A...............................
A.I. The UADT begins where the skin meets the mucosa at the nasal vestibule and the vermillion borders of the lips and continues to the junction of the cricoid cartilage and the cervical trachea and at the level of the cricoid where the hypopharynx meets the cervical esophagus. II. The UADT is organized into several major sites that are subdivided to several anatomic subsites. and pathologic findings. Of importance is that any positive metastatic disease to the neck will classify the disease as advanced. b. metastasis (TNM) staging system allows clinicians to categorize tumors of the head and neck region in a specific manner to assist with the assessment of disease status. All available clinical information may be used in staging: physical exam. or c status. except in select nasopharynx and thyroid cancers. and advanced-stage disease as Stage III or IV disease. location. (2) the oropharynx. intraoperative. Other than histopathologic analysis. biomarkers and molecular studies are not yet included in the staging of head and neck cancers. The specific TNM status of each patient is then tabulated to give a numerical status of Stage I. and M— the absence or presence of distant metastases. radiographic. INTRODUCTION The tumor. and management. prognosis. Three categories comprise the system: T—the characteristics of the tumor at the primary site (this may be based on size. (3) the hypopharynx. The major sites include (1) the oral cavity. In general. node. or both). or IV. 8 . Upper Aerodigestive Tract Sites The majority of tumors arising in the head and neck (other than nonmelanoma skin cancers) arise from the squamous mucosa that lines the upper aerodigestive tract (UADT) and are predominately squamous cell carcinomas. N—the degree of regional lymph node involvement. early-stage disease is denoted as Stage I or II disease. III. Specific subdivisions may exist for each stage and may be denoted with an a.
relative to oropharyngeal or laryngeal cancers. where the hypopharynx begins. Oropharynx This structure begins where the oral cavity ends at the junction of the hard and soft palates superiorly and the circumvallate papillae inferiorly and extends from the level of the soft palate superiorly. upper and lower alveolar ridges. hard palate. Tumors of the oral cavity tend to spread regionally to lymph nodes of the submandibular region (Level I) and to the upper and middle jugular chain lymph nodes (Levels II and III). 1. The subsites of the 9 . primary treatment for most tumors is surgical. The anterior aspect of the oral cavity is the contact point of the skin with the vermilion of the lips extending posteriorly to the junction of the hard and soft palates. oral cavity squamous cell carcinomas may be less sensitive to chemotherapy and radiation. which separates it from the nasopharynx and to the level of the hyoid bone inferiorly. Positive surgical margins. anterior tongue. and retromolar trigone.(4) the larynx. and with the anterior tonsillar pillars and the circumvallate papillae forming the posterior limits. to improve local disease control. the nasopharynx. floor of mouth. Oral Cavity The oral cavity is a common site for squamous cell cancers of the UADT. Because of accessibility and the risk of involvement of bony structures. probably because it is the first entry point for many carcinogens. and/or extracapsular tumor extension call for consideration of postoperative chemoradiotherapy. Moreover. (5). treatment with radiotherapy can lead to radionecrosis of the mandible or maxilla. The trigone consists of the mucosa overlying the anterior aspect of the ascending ramus of the mandible. The major subsites of the oral cavity are the lips. buccal mucosa. Thus. 2. (6) and the nose and paranasal sinuses. multiple involved lymph nodes.
for patients with more advanced disease. and because of their location can impact swallowing and speech function adversely. Two other hallmarks of hypopharyngeal cancers are submucosal spread and skip areas of spread. and 7 has most often been studied and may be considered a standard. Induction chemotherapy before radiotherapy (or chemoradiotherapy) remains an investigational strategy. taxanes. However. 4. 10 . and pharyngeal walls. and lower jugular lymph nodes (Levels II–IV) and the retropharyngeal nodes is common in these cancers. soft palate. 3. Increasingly. which distinguishes them from oral cavity tumors and must be considered when treating oropharyngeal cancers. Spread to the upper. The major subsites of the hypopharynx are the pyriform sinuses.oropharynx are the tonsil. where it meets the cervical esophagus. T 3/4 or N 2 b/c/3 staging. but can also spread to retropharyngeal lymph nodes. chemoradiotherapy most often with a concomitant approach has become standard. especially in nonsmokers. carboplatin. Nonetheless. Cancers of the oropharynx often metastasize to upper and middle jugular chain lymph nodes (Levels II and III). base of tongue. middle. as a single modality for T 1/2 or N 0/1 stages. and drug combinations. such as cisplatin or carboplatin with fluorouracil. Tumors in this site are generally treated with radiotherapy. the postcricoid region. administered during weeks 1. but increasingly radiotherapy and chemoradiotherapy are used to treat cancers in this location with success. other regimens. some of these cancers are associated with human papilloma virus 16 infection. where it is contiguous with the oropharynx and it extends inferiorly to the cricopharyngeus muscle. Tumors often present here at advanced stages and can be difficult to cure. Surgery had been the mainstay of primary treatment for hypopharyngeal cancers for many years. and the pharyngeal walls. Hypopharynx The hypopharynx has its superior limit at the hyoid bone. Cisplatin. are also reported.
Between the thyroid cartilage and the vocal cord lies the paraglottic space. The glottic larynx extends from the ventricle to 1 cm below the level of the true cords. middle. which is known as transglottic spread. as well as where they meet the mobile laryngeal cartilages at the posterior commissure. This is a complex space with a rich lymphatic network that contributes to the early and bilateral spread of tumors that arise from supraglottic structures to upper. and subglottic subsites. Its important roles in speech. and the aryepiglottic folds. tumors arising in the supraglottic or glottic larynx commonly spread in a “transglottic” fashion to involve the 11 . and airway protection make the treatment considerations of cancers of this structure varied and controversial. While it is rare for tumors to arise initially in the subglottis. swallowing. The larynx is comprised of a cartilaginous framework. and lower jugular chain lymph nodes. the false vocal cords. which contrasts with the pseudostratified ciliated respiratory mucosa lining the remainder of the larynx. and where they come together anteriorly at the anterior commissure. or vice versa. This serves as a pathway for submucosal spread of tumors from the glottis to the supraglottis. glottic. The larynx is bordered by the oropharynx superiorly. the arytenoids cartilages. and is subdivided vertically by the vocal cords into the supraglottic. Larynx The larynx is the most complex of the mucosal lined structures of the UADT. The vocal cords are lined with stratified squamous epithelia. which has both lingual and laryngeal surfaces. The supraglottic larynx includes the epiglottis. and the hypopharynx laterally and posteriorly. The subglottic larynx starts 1 cm below the vocal folds and continues to the inferior aspect of the cricoid cartilage. which is continuous with the pre-epiglottic space. Anterior to the supraglottis is the pre-epiglottic space. Glottic laryngeal cancers tend to metastasize unilaterally and spread regionally less commonly than supraglottic tumors do. the trachea inferiorly. The glottic larynx describes the true vocal cords.4.
The roof and posterior walls of the nasopharynx are made up of the sphenoid bone and the upper cervical vertebrae. good long-term functional data are lacking. and unilateral neck treatment is considered for patients with advanced glottic tumors. 5. survival. but while total laryngectomy was long held as the gold standard for treating T3 and T4 larynx cancers. However. Subglottic tumors tend to metastasize to paratracheal (Level VI) as well as middle or lower jugular lymph (Levels III and IV) node groups. chemoradiotherapy has been shown to be quite effective in achieving local regional control. Concomitant chemoradiotherapy may be most appropriate for T3 primary lesions. therefore. and for early-stage lesions radiotherapy or transoral endoscopic excision are the most common treatment options.subglottic larynx. Both yield excellent tumor control. Thus. all adult patients with an unexplained unilateral middle-ear effusion. but proponents of each modality often disagree on the functional sequelae of the two types of treatment. and organ preservation. the nasopharynx meets the superior oropharynx. at the level of the soft palate. Treatment of both sides of the neck must be taken into consideration when treating supra. impingement of this opening by a nasopharyngeal tumor can lead to Eustachian dysfunction manifested by a middle-ear effusion and hearing loss. particularly in areas where nasopharyngeal carcinoma is endemic (such as southern China.and subglottic tumors. Treatment of more advanced tumors can be even more controversial. Nasopharynx The nasopharynx is a cuboidal structure bounded anteriorly by the choanae at the back of the nose where pseudostratified ciliated columnar cells are found. Inferiorly. northern 12 . covered with a stratified squamous epithelial lining. The opening of the Eustachian tube is found at the posterior-superior aspect of either lateral nasopharyngeal wall. Treatment of laryngeal cancers varies widely from center to center.
and in more advanced cases. the bilateral ethmoid system. Because of inherent bone involvement. as well as lymph nodes along the upper. Surgery is rarely used in salvage situations at the primary site or neck. especially in woodworkers.Africa. Sinonasal 13 . The adenoids. The EpsteinBarr virus is thought to play a pathogenic role in the development of Type II and III tumors. and WHO Type II is nonkeratinizing squamous cell carcinoma. with consideration for adjuvant radiation therapy based upon stage and pathologic findings. and the central spenoids. should have their nasopharynx examined. lower. also known as lymphoepithelioma. Nasopharyngeal carcinoma may also metastasize to retropharyngeal and parapharyngeal lymph nodes. Nasal Cavity and Paranasal Sinuses The paranasal sinuses consist of the paired maxillary sinuses. While minor salivary tumors can occur in the nasopharynx. 6. Reconstruction and rehabilitation. although adenocarcinomas are described. are found posteriorly and superiorly in the nasopharynx and are more prominent in children than adults. most nasopharyngeal cancers are derived from the mucosal lining and fit into one of the three histologic subtypes described by the World Health Organization (WHO). consisting of mucosa-covered lymphoid tissue. and Greenland). may be prosthetic or tissue based. This region includes the lining of the nasal cavity (medial maxillary walls) as well as the nasal septum. especially in cases with orbital involvement. initial treatment is usually surgical. WHO Type III is an undifferentiated tumor. the superior frontal sinuses. WHO Type I nasopharyngeal carcinoma (NPC) is keratinizing squamous carcinoma. Earlystage NPC is most often treated with radiotherapy alone. and middle jugular (Levels II–IV) chains and the posterior triangle of the neck (Level V). The majority of sinonasal carcinomas arise in the maxillary sinuses and are most commonly squamous cell carcinomas. T 3/4 N +/ concomitant chemotherapy is being increasingly utilized.
Such evaluation is also valuable in determining whether ipsilateral or bilateral neck disease needs to be addressed based on tumor location. ini- 14 . and size. scan magnetic resonance imaging. and delineation of postoperative tumor bed).g. while at the same time adequately covering the tumor volume. while adequately treating the tumor. Preoperative clinical and radiologic evaluation of disease is extremely important for postoperative radiotherapy planning. it is also very important for the clinician to be acutely aware of radiologic anatomy (levels of nodal disease. With the advent of IMRT. while utilizing computed tomography. as tissue planes may be obscured after surgery. B. pathways of loco-regional spread of tumor. Standard treatment is multidisciplinary. 3D conformal planning does not always result in optimal shielding of critical normal tissues (e. Intensity-modulated radiation therapy (IMRT) allows for better sparing of such critical normal tissues by modulating the radiation beam in multiple small beamlets. and positron emission tomography scan for treatment planning. Three-dimensional (3-D) conformal RT marked a significant improvement over the conventional two-dimensional 3-field setup in better delineation of tumor volume and nodal volume. due to current beam constraints. However. This improvement allows limited dosing to normal tissue. extent.. including craniofacial surgical intervention with adjuvant radiation and chemotherapy. salivary glands and visual apparatus). Radiation Therapy and Chemotherapy External beam radiation therapy (RT) alone or in conjunction with chemotherapy has a well-established role in the treatment of head and neck cancer as definitive therapy or as adjuvant to primary surgical treatment. The last two decades have seen tremendous technological developments in targeting and delivery of RT in a complex treatment site such as the head and neck.carcinomas of the anterior skull base include a variety of pathologies.
piriform sinus. and should be included in RT volumes. and perineural or lympho-vascular invasion at the primary site and size. unless postoperative complications significantly delay wound healing. In the contralateral elective neck irradiation. and likelihood of contralateral nodal involvement. Postoperative patients with ECE are at high risk for loco-regional recurrence. Certain primary tumor sites have a high risk of retropharyngeal nodal involvement (nasopharynx. Delaying adjuvant therapy has been shown to significantly decrease loco-regional control. Adjuvant RT should ideally begin within 4–6 weeks following primary surgical resection and neck dissection. and these nodal groups should be covered in RT target volumes for these tumors. the highest treated nodes are jugulodigastric nodes. Approximately 20% of anterior tongue and floor of mouth cancers may have skip nodal metastasis to Level IV nodal region. extension of the RT clinical target volume to include overlying skin. and the number and level of nodal involvement. and tongue base).tial nodal presentation. extra-capsular extension (ECE). The clinical target volume in radiation therapy of a clinically or pathologically involved neck typically extends up to the skull base to treat the highest neck nodes. Careful adjuvant treatment planning includes consideration of radiation dose (60–66 Gy). extension to soft tissue/bone. addition of concurrent chemotherapy (RTOG 95-01). and elective irradiation of contralateral neck nodes. Important considerations in RT planning following surgical resection include a thorough evaluation of the surgical pathology report with respect to resection margins. 15 .
hard palate. or skull base and/or encases the internal carotid artery. T4b Tumor invades masticator space. the circumvallate papillae inferiorly. chin or nose. and styloglossus]. hypoglossus. the inferior surface of the soft palate and uvula. Tumor is more than 2 cm but not greater than 4 cm in greatest dimension.e. Carcinoma is in situ.. through cavity) cortical bone. Oral Cavity Definition: The anterior border is the junction of the skin and vermilion border of the lip. AMERICAN JOINT COMMITTEE ON CANCER (AJCC) TUMOR STAGING BY SITE A. into deep [extrinsic] muscle of tongue [genioglossus. and retromolar trigone. floor of mouth. maxillary sinus. The posterior border is formed by the junction of the hard and soft palates superiorly.. Oropharynx Definition: The oropharynx includes the base of the tongue. palataglossus. or skin of face—i. inferior alveolar nerve. T3 Tumor is more than 4 cm in greatest dimension. There is no evidence of primary tumor. the anterior and posterior 16 . Tumor is 2 cm or less in greatest dimension. pterygoid plates. TX T0 Tis T1 T2 B. buccal mucosa. anterior 2/3 of tongue. T4 (lip) Tumor invades through cortical bone. skin of face). T4a (oral Tumor invades adjacent structures (e.g. Primary tumor cannot be assessed. The various sites within the oral cavity include the lip. gingival. and the anterior tonsillar pillars laterally. Note: Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify as T4. floor of mouth.II.
or skull base or encases the carotid artery. There is no evidence of primary tumor. deep/extrinsic muscle of the tongue. T3 Tumor is more than 4 cm in greatest dimension. pterygoid plates. Tumor is more than 2 cm but not more than 4 cm in greatest dimension. the glossotonsillar sulci. T1 T2 C. Larynx Site Subsite Supraglottis Suprahyoid epiglottis Infrahyoid epiglottis Aryepiglottic folds (laryngeal aspect) Arytenoids Ventricular bands (false cords) Glottis True vocal cords. Carcinoma is in situ. including anterior and posterior commisures. medial pterygoid. T4b Tumor invades the lateral pterygoid muscle.tonsillar pillars. or mandible. and the lateral and posterior pharyngeal walls. T4a Tumor invades the larynx. hard palate. the pharyngeal tonsils. lateral nasopharynx. including the region 1 cm below the plane of the true vocal folds Subglottis Region extending from 1 cm below the true vocal folds to the cervical trachea Primary Tumor (T) TX T0 Tis Primary tumor cannot be assessed. Tumor is 2 cm or less in greatest dimension. 17 .
T3 Tumor is limited to the larynx with vocal cord fixation and/or invades paraglottic space. or invades mediastinal structures. 18 . soft tissues of the neck. including deep extrinsic muscle of the tongue. T1a Tumor is limited to one vocal cord. medial wall of pyriform sinus). T2 Tumor extends to the supraglottis and/or subglottis. trachea. strap muscles.. inner cortex). or esophagus). and/or with impaired vocal cord mobility.. T4b Tumor invades prevertebral space.g. trachea.. with normal mobility. without fixation of the larynx. pre-epiglottic tissues. T2 Tumor invades mucosa of more than one adjacent subsite of the supraglottis or glottis or region outside the supraglottis (e. T1 Glottis T1 Tumor is limited to the vocal cords(s) (may involve anterior or posterior commissure). thyroid. mucosa of base of tongue. T4a Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.Supraglottis Tumor is limited to one subsite of the supraglottis. strap muscles. T4a Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e. soft tissues of neck.g. and/or minor thyroid cartilage erosion (e. vallecula.g. or esophagus). thyroid.g. inner cortex). and or minor thyroid cartilage erosion (e. paraglottic space.. including deep extrinsic muscle of the tongue. with normal vocal cord mobility.g. T3 Tumor is limited to the larynx with vocal cord fixation and/or invades any of the following: postcricoid area. T1b Tumor involves both vocal cords. encases the carotid artery..
T3 Tumor is more than 4 cm in greatest dimension or with fixation of the hemilarynx. D.g. or invades mediastinal structures. hyoid bone. T3 Tumor is limited to the larynx. or esophagus). including deep extrinsic muscles of the tongue. T4a Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e. the lateral and posterior hypopharyngeal walls. soft tissues of neck. or invades mediastinal structures. esophagus. T1 19 . thyroid. encases the carotid artery. Subglottis T1 T2 Tumor is limited to the subglottis.T4b Tumor invades prevertebral space. T2 Tumor invades more than one subsite of the hypopharynx or an adjacent site. encases the carotid artery. with vocal cord fixation. Tumor extends to the vocal cord(s). T4a Tumor invades thyroid/cricoid cartilage. T4b Tumor invades prevertebral fascia. encases the carotid artery. trachea. thyroid gland. or central compartment soft tissue. or measures more than 2 cm but not more than 4 cm in greatest dimension without fixation of the hemilarynx. or involves mediastinal structures. Hypopharynx Definition: The hypopharynx includes the pyriform sinuses.. Tumor is limited to one subsite of the hypopharynx and 2 cm or less in greatest dimension. T4b Tumor invades prevertebral space. with normal or impaired mobility. and the postcricoid region. strap muscles.
nasopharynx. The anterior wall is posterior to the facial skin and soft tissue. or medial wall of the orbit. floor. pterygoid fossa. the sinus abuts the orbital floor and contains the infraorbital canal. pterygoid plates. 20 . or ethmoid sinuses. infratemporal fossa. middle cranial fossa. sphenoid or frontal sinuses. The floor of the maxillary antrum extends below the nasal cavity floor and is in close proximity to the hard palate and maxillary tooth roots. The medial border is the lateral nasal wall. or clivus. Superiorly. cranial nerves other than maxillary division of trigeminal nerve (V2). sphenoid. The posterolateral wall is anterior to the infratemporal fossa and pterygopalatine fossa. Nasal Cavity and Paranasal Sinuses Definition: The paranasal sinuses include the ethmoid. T0 There is no evidence of primary tumor. T4b Tumor invades any of the following: orbital apex. T1 Tumor is limited to the maxillary sinus mucosa. except extension to the posterior wall of the maxillary sinus and pterygoid plates. Tis Carcinoma is in situ. subcutaneous tissues. maxillary. dura. cribriform plate. and frontal sinuses. TX Primary tumor cannot be assessed. including extension into the hard palate and/or middle nasal meatus. T2 Tumor is causing bone erosion or destruction. Maxillary Sinus Definition: The maxillary sinus is a pyramid-shaped cavity within the maxillary bone. skin of cheek.E. T4a Tumor invades anterior orbital contents. T3 Tumor invades any of the following: bone of the posterior wall of the maxillary sinus. with no erosion or destruction of bone. brain.
T2 Tumor invades two subsites in a single region or extends to involve an adjacent region within the nasoethmoidal complex. middle cranial fossa. middle. and inferior turbinates. maxillary sinus. superior. or clivus. T3 Tumor extends to invade the medial wall or floor of the orbit. The posterior border of the ethmoid sinus is close to the optic canal. T2 Tumor is greater than 2 cm but not more than 4 cm without extraparenchymal extension. T1 Tumor is 2 cm or less without extraparenchymal extension. brain. the ethmoid sinus is bound by a thin bone called the lamina papyracea. with or without bony invasion. or cribriform plate. The subsites within the nasal cavity include the septum. which separates it from the medial orbit. T4a Tumor invades any of the following: anterior orbital contents. dura. submandibular. nasopharynx. The perpendicular plate of the ethmoid bone separates the ethmoid cavity into left and right sides. cranial nerves other than (V2). and minor salivary glands. 21 . The ethmoid sinus is made up of several thin-walled air cells.Nasal Cavity and Ethmoid Sinus Definition: The nasal cavity includes the nasal antrum and the olfactory region. minimal extension to anterior cranial fossa. sphenoid or frontal sinuses. pterygoid plates. palate. and olfactory region of the cribriform plate. which separates it from the anterior cranial fossa. T1 Tumor is confined to the ethmoid sinus with or without bone erosion. The anterosuperior border or roof of the ethmoid is formed by the fovea ethmoidalis. Laterally. sublingual. skin of nose or cheek. Salivary Glands Definition: The salivary glands include the parotid. T4b Tumor invades any of the following: orbital apex. F.
none more than 6 cm in greatest dimension. T4b Tumor invades the skull base and/or pterygoid plates and/or encases the carotid artery. more than 3 cm but not more than 6 cm in greatest dimension. 3 cm or less in greatest dimension. none greater than 6 cm in greatest dimension. U. N2c Metastasis is in bilateral or contralateral lymph nodes. L A designation of “U” or “L” may be given in addition to indicate the level of metastasis above the lower border of the cricoid cartilage (U) or below the lower border of the cricoid cartilage (L). or metastasis is in multiple ipsilateral lymph nodes. N1 Metastasis is in a single ipsilateral lymph node. none more that 6 cm in greatest dimension. and/or facial nerve. N0 There is no regional nodes metastasis. N3 Metastasis is in a lymph node more than 6 cm in greatest dimension. 22 . or metastasis is in bilateral or contralateral lymph nodes. N2b Metastasis is in multiple ipsilateral lymph nodes. more than 3 cm but not more than 6 cm in greatest dimension.T3 Tumor is more than 4 cm and/or extraparenchymal extension. Neck Staging Under the TNM Staging System for Head and Neck Tumors (excluding nasopharynx and thyroid) NX Regional lymph nodes cannot be assessed. N2a Metastasis is in a single ipsilateral lymph node. ear canal. T4a Tumor invades the skin. mandible. N2 Metastasis is in a single ipsilateral lymph node. none more that 6 cm in greatest dimension. G.
TNM Staging for the Larynx. Oropharynx. H. Oral Cavity. Hypopharynx. and Paranasal Sinuses Stage Grouping Stage 0 Stage I Stage II Stage III Tis T1 T2 T3 T1 T2 T3 T4a T4a T1 T2 T3 T4a T4b Any T Any T N0 N0 N0 N0 N1 N1 N1 N0 N1 N2 N2 N2 N2 Any N N3 Amy N M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 Stage IVA Stage IVB Stage IVC Clinical Stage Grouping by T and N Status N0 N1 N2 N3 T1 I III IVa IVb T2 II III IVa IVb T3 III III IVa IVb T4a IVa IVa IVa IVb T4b IVb IVb IVb IVb 23 . Salivary Glands. M0 There is no distant metastasis. M1 There is distant metastasis.Distant Metastasis (M) MX Distant metastasis cannot be assessed.
hypopharynx. T3 Tumor involves bony structures and/or paranasal sinuses. N3a Tumor is greater than 6 cm in dimension. T4 Tumor has intracranial extension and/or involves cranial nerves. or masticator space. orbit. 24 . Regional Lymph Nodes (different from other head and neck sites) N0 There is no regional lymph node metastasis.III. T1 Tumor is confined to the nasopharynx. N3b Tumor extends to the supraclavicular fossa. above the supraclavicular fossa. T2 Tumor extends to soft tissues. without parapharyngeal extension. Nasopharynx Definition: The nasopharynx includes the vault. the posterior walls. N2 Bilateral metastasis in lymph nodes is 6 cm or less in greatest dimension. above the supraclavicular fossa. the lateral walls. N3 Metastasis in lymph node(s) is greater than 6 cm and/or to the supraclavicular fossa. N1 Unilateral metastasis in lymph node(s) is 6 cm or less in greatest dimension. infratemporal fossa. AJCC TUMOR STAGING—NASOPHARYNX AND THYROID A. T2a Tumor extends to the oropharynx and/or nasal cavity. and the superior surface of the soft palate. T2b Tumor extends into the parapharyngeal space.
and is limited to the thyroid. Primary Tumor (T) TX T0 T1 T2 Primary tumor cannot be assessed. 25 . Tumor is 2 cm or less in greatest dimension and is limited to the thyroid. There is no evidence of primary tumor. Tumor is more than 2 cm but not more than 4 cm in greatest dimension. with an isthmus connecting the two lobes.Stage Grouping (unique to site) Stage 0 Stage I Stage IIA Stage IIB Tis T1 T2a T1 T2 T2a T2b T2b T1 T2a T2b T3 T3 T3 T4 T4 T4 Any T Any T N0 N0 N0 N1 N1 N1 N0 N1 N2 N2 N2 N0 N1 N2 N0 N1 N2 N3 Any N M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 Stage III Stage IVA Stage IVB Stage IVC B. Thyroid Definition: The thyroid is composed of a right and left lobe.
bilateral. larynx. T4a Tumor of any size extends beyond the thyroid capsule to invade subcutaneous soft tissues. Distant Metastasis (M) MX Distant metastasis cannot be assessed. All anaplastic carcinomas are considered T4 tumors T4a Intrathyroidal anaplastic carcinoma—surgically resectable.. 26 .g. trachea. and is limited to the thyroid or any tumor with minimal extrathyroid extension (e. paratracheal. T3 Regional Lymph Nodes (N) Regional lymph nodes are the central compartment. M1 There is distant metastasis. or contralateral cervical or superior mediastinal lymph nodes. T4b Tumor invades prevertebral fascia or encases the carotid artery or mediastinal vessels. esophagus. and prelaryngeal/Delphian lymph nodes). N1a There is metastasis to Level VI (pretracheal. N1 There is regional lymph node metastasis. M0 There is no distant metastasis. T4b Extrathyroidal anaplastic carcinoma—surgically unresectable. or recurrent laryngeal nerve. N0 There is no regional lymph node metastasis. extension to sternothyroid muscle or perithyroid soft tissues). NX Regional lymph nodes cannot be assessed.Tumor is more than 4 cm in greatest dimension. N1b There is metastasis to unilateral. and upper mediastinal lymph nodes. lateral cervical.
Papillary or Follicular (Younger than 45 years) Stage I Any T Stage II Any T Papillary or Follicular (45 years and older) Stage I T1 Stage II T2 Stage III T3 T1 T2 T3 Stage IVA T4a T4a T1 T2 T3 T4a Stage IVB T4b Any T Stage IVC Any T Medullary Carcinoma Stage I T1 Stage II T2 Stage III T3 T1 T2 T3 Any N Any N M0 M1 N0 N0 N0 N1a N1a N1a N0 N1a N1b N1b N1b N1b Any N N3 Any N M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 N0 N0 N0 N1a N1a N1a M0 M0 M0 M0 M0 M0 27 . medullary.Stage Grouping Separate stage groupings are recommended for papillary or follicular. and anaplastic (undifferentiated) carcinoma.
Stage IVA Stage IVB Stage IVC T4a T4a T1 T2 T3 T4a T4b Any T Any T N0 N1a N1b N1b N1b N1b Any N N3 Any N M0 M0 M0 M0 M0 M0 M0 M0 M1 Anaplastic Carcinoma (All anaplastic carcinomas are considered Stage IV) Stage IVA T4a Any N M0 Stage IVB T4b Any N M0 Stage IVC Any T Any N M1 28 .
middle jugular group. submental and submandibular group. upper jugular group. DEFINITION OF LYMPH NODE GROUPS (FIGURE 1) Fig. anterior compartment. posterior triangle group.IV. Level III. Level V. and lower lip (Figure 2). Level VI. 29 . Level II. anterior mandibular alveolar ridge. 2—Dark lines depict the boundaries of the submental (IA) and anterior compartment (VI) lymph nodes. These nodes are at greatest risk for harboring metastases from cancers arising from the floor of the mouth. 1—The level system is used for describing the location of lymph nodes in the neck: Level I. anterior oral tongue. lower jugular group. Fig. Level IA: Submental Group Lymph nodes within the triangular boundary of the anterior belly of the digastric muscles and the hyoid bone. Level IV.
soft tissue structures of the midface. and V into sublevels A and B. Fig. and the body of the mandible. the vertical plane at the posterior aspect of the submandibular gland forms a use means of demarcating the posterior aspect of Level IB from IIA. and the posterior (lateral) boundary is the posterior border of the ster30 . Levels IIA & IIB: Upper Jugular Group Lymph nodes located around the upper third of the internal jugular vein and adjacent spinal accessory nerve extending from the level of the skull base (above) to the level of the inferior border of the hyoid bone (below). and submandibular gland (Figure 3). the stylohyoid muscle.The group includes the pre.Level IB: Submandibular Group Lymph nodes within the boundaries of the anterior and posterior bellies of the digastric muscles. anterior nasal cavity. The anterior (medial) boundary is the lateral border of the sternohyoid muscle and the stylohyoid muscle (or posterior aspect of the submandibular gland when assessed radiographically). See text for details. and the pre.and postglandular nodes. II. Radiographically. 3—The boundaries dividing levels I.and postvascular nodes. These nodes are at greatest risk for harboring metastases from the cancers arising from the oral cavity. The submandibular gland is included in the specimen when the lymph nodes within this triangle are removed.
oropharynx. nasopharynx. hypopharynx. and larynx (Figure 3). which lies immediately above the superior belly of the omohyoid muscle as it crosses the internal jugular vein. cervical esophagus. Level III: Middle Jugular Group Lymph nodes located around the middle third of the internal jugular vein extending from the inferior border of the hyoid bone (above) to the inferior border of the cricoid cartilage (below). and the posterior (lateral) boundary is the posterior border of the sternocleidomastoid muscle. larynx. Levels VA & VB: Posterior Triangle Group This group is comprised predominantly of the lymph nodes located along the lower half of the spinal accessory nerve and the transverse 31 . Level IV: Lower Jugular Group Lymph nodes located around the lower third of the internal jugular vein extending from the inferior border of the cricoid cartilage (above) to the clavicle (below). Sublevel IIB nodes are located posterior (lateral) to the vertical plane defined by the spinal accessory nerve. hypopharynx.* Sublevel IIA nodes are located anterior (medial) to the vertical plane defined by the spinal accessory nerve. oropharynx. The anterior (medial) boundary is the lateral border of the sternohyoid muscle.* These nodes are at greatest risk for harboring metastases from cancers arising from the hypopharynx. nasal cavity. The upper jugular nodes are at greatest risk for harboring metastases from cancers arising from the oral cavity. and parotid gland (Figure 3).* (Included in this group is the jugulo-omohyoid node.) These nodes are at greatest risk for harboring metastases from cancers arising from the oral cavity.nocleidomastoid muscle. and the posterior (lateral) boundary is the posterior border of the sternocleidomastoid muscle. nasopharynx. and larynx (Figure 3). The anterior (medial) boundary is the lateral border of the sternohyoid muscle.
The supraclavicular nodes are also included in the posterior triangle group. the anterior (medial) boundary is the posterior border of the sternocleidomastoid muscle. and cervical esophagus (Figure 2). apex of the piriform sinus. *The surgical landmark that defines the lateral boundary of Levels II. Sublevel VA includes the spinal accessory nodes. and the perithyroidal nodes.* and the posterior (lateral) boundary is the anterior border of the trapezius muscle.and paratracheal nodes. III. 32 . including the lymph nodes along the recurrent laryngeal nerves. and IV and the corresponding medial boundary of the posterior triangle (Level V) is the plane that parallels the sensory branches of the cervical plexus. and the thyroid gland (Sublevel VB) (Figure 3). the inferior boundary is the suprasternal notch. glottic and subglottic larynx.cervical artery. and the lateral boundaries are the common carotid arteries.) The posterior triangle nodes are at greatest risk for harboring metastases from cancers arising from the nasopharynx and oropharynx (Sublevel VA). (The Virchow is located in Level IV. Sublevel VA is separated from Sublevel VB by a horizontal plane marking the inferior border of the arch of the cricoid cartilage. and Sublevel VB includes the nodes following the transverse cervical vessels and the supraclavicular nodes. the precricoid (Delphian) node. Level VI: Anterior (Central) Compartment Group Lymph nodes in this compartment include the pre. the inferior boundary is the clavicle. The superior boundary is the hyoid bone. The superior boundary is the apex formed by a convergence of the sternocleidomastoid and the trapezius muscles. These nodes are at greatest risk for harboring metastases from cancers arising from the thyroid gland.
and sternocleidomastoid muscle are also removed. buccinator nodes. and contralateral anterior belly of the digastric muscle medially. and midline visceral (anterior compartment) nodes. hyoid bone. Radical Neck Dissection Radical neck dissection (Figure 4) is considered to be the standard basic procedure for cervical lymphadenectomy. internal jugular vein. 4—Radical neck dissection. from the lateral border of the sternohyoid muscle. retropharyngeal nodes. The spinal accessory nerve. Included are all lymph nodes from Levels I through V. Radical neck dissection refers to the removal of all ipsilateral cervical lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly. CONCEPTUAL GUIDELINES FOR NECK DISSECTION CLASSIFICATION A. Radical neck dissection does not include removal of the suboccipital nodes. All other procedures represent one or more alterations of this procedure. periparotid nodes (except infraparotid nodes located in the posterior aspect of the submandibular triangle).V. 33 . to the anterior border of the trapezius muscle laterally. Fig.
34 . Modified Radical Neck Dissection Modified radical neck dissection (Figure 5a–c) refers to the excision of all lymph nodes routinely removed by the radical neck dissection.” Fig.g.. spinal accessory nerve (SAN). Fig. 5c—Modified radical neck dissection with preservation of SAN. IJV. with preservation of one or more nonlymphatic structures: i. 5a—Modified radical neck dissection with preservation of SCM. internal jugular vein (IJV). “modified radical neck dissection with preservation of the spinal accessory nerve.B.e. and sternocleidomastoid muscle (SCM). and SAN. 5b—Modified radical neck dissection with preservation of IJV and SAN.. Fig. The structure(s) preserved should be specifically named—e.
For oral cavity cancers. the post-auricular nodes. 6—SND (Levels I–III) or supraomohyoid neck dissection. hypopharyngeal. II. and laryngeal cancers are located in Levels II. III. Level III. and IV. Lateral Neck Dissection—This includes Level IIA or Levels IIA & IIB. The lymph nodes at greatest risk for oropharyngeal. IV. Selective Neck Dissection Selective neck dissection (SND) refers to a cervical lymphadenectomy in which there is preservation of one or more of the lymph node groups that are routinely removed in the radical neck dissection. and the external jugular nodes (Figure 9). & V. Specific variations of the selective neck dissection include: Anterior Neck Dissection—This includes Level VI (Figure 6). Fig. Level III (Figure 7). Posterolateral Neck Dissection—This includes Levels II.C. and for thyroid cancer. 35 . Level IIA or Levels IIA & IIB. and III. and Level IV (Figure 8). are in Level VI. III. the lymph nodes at greatest risk are located in Levels I. Supraomohyoid Neck Dissection—This includes Levels IA & IB. The lymph nodes groups removed are based on the patterns of metastases that are predictable relative to the primary site of disease. suboccipital nodes.
suboccipital. 9—SND (Levels II–V). 7—SND (Levels II–IV) or lateral neck dissection. Fig. external jugular. 10—Extended radical neck dissection with removal of the common carotid artery or ERND (common carotid artery).Fig. postauricular. Fig. Fig. 8—SND (Level VI) or anterior neck dissection. 36 . or posterolateral neck dissection.
37 . IIA and III).” followed by the levels and/or sublevels removed—e. Examples of such lymph node groups include the parapharyngeal (retropharyngeal). The additional lymphatic or nonlymphatic structure(s). it is recommended to use the term “selective neck dissection” or “SND. should be identified. perifacial (buccinator). hypoglossal nerve.. not encompassed by the radical neck dissection (Figure 10). superior mediastinal. or both.g. Examples of the nonlymphatic structures include the carotid artery. and paraspinal muscles. Extended Radical Neck Dissection Extended radical neck dissection (ERND) refers to the removal of one or more additional lymph node groups or nonlymphatic structures.Since there is variation of levels and sublevels associated with the names given to the various types of SND. overlying skin. vagus nerve. and paratracheal lymph nodes. or both. D. SND (Levels IB.
NOTES 38 .
NOTES 39 .
MNGPH5206251 ISBN 978-1-56772-117-1 .Item No.