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