Pocket Guide To

TNM STAGING OF HEAD AND NECK CANCER AND NECK DISSECTION CLASSIFICATION
Edited by Daniel G. Deschler, MD Terry Day, MD

AAO–HNS/F

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

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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

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MD JOSEPH BRENNAN. MD FRCS(C) STEPHEN Y. MD BEVAN YUEH. NATHAN MD BRIAN NUSSENBAUM. BECKEN. MD MPH With appreciation to all former committee members who contributed. TEKNOS. MD MARION E. MD DAVID W. MD PATRICK JOSEPH GULLANE. MD CECELIA E. MD THEODOROS N. MEYER. DESCHLER. MAGDYCZ. COUCH. MD PHD DANIEL G. MD PhD WILLIAM P. SCHMALBACH. LAI. EISELE. MD PhD ERIC T. MD URJEET PATEL. WANG. MD CHRISTINE G. MD KELLY MICHELE MALLOY. MD CHERIE ANN O. MALONE MD ABBY C. MD MARILENE B.AMERICAN ACADEMY OF OTOLARYNGOLOGY– HEAD AND NECK SURGERY HEAD AND NECK SURGERY COMMITTEE FACULTY DEVRAJ BASU. MD WENDELL G. YARBROUGH. GOURIN. 3 . MD JAMES P.

Clayman. Califano. MD Alfio Ferlito. MD 4 . Shaha. Som. Thomas Robbins. MD Gary L. MD (Chair) Joseph A. Wolf. MD Peter M. Medina. MD Ashok R. DDS Jesus E.NECK DISSECTION CLASSIFICATION COMMITTEE AMERICAN HEAD AND NECK SOCIETY K. MD. MD Gregory T.

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for the illustrations and the AJCC for the use of staging information from the 6th edition of the AJCC Cancer Stating Manual. MD. and the Council of the American Head and Neck Society. Appreciation is also extended to Douglas Denys. This monograph has been endorsed by the American Head and Neck Society and The American Academy of Otolaryngology– Head and Neck Surgery. 6 .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.

.................. Selective Neck Dissection............................... Oropharynx ........... Introduction ..... Oropharynx....................................... Nasopharynx ...........25 IV.13 B.......... Hypopharynx.................. Hypopharynx.......................19 E.............................................. Larynx..... Thyroid . Oropharynx ........11 5.............14 II...TABLE OF CONTENTS I............................. Oral Cavity ......24 A............................. Larynx .............................................................................34 C.....21 G..............10 4............................................... Radical Neck Dissection............................... Upper Aerodigestive Tract Sites ............................................................37 7 ............................................................. Definition of Lymph Node Groups ............22 H............................................................. Nasopharynx ...................................................................9 2.............. Oral Cavity.......... Nasal Cavity and Paranasal Sinuses ........................16 C.........29 V.........17 D.................. Extended Radical Neck Dissection........................16 B....................................... Oral Cavity ................................. TNM Staging for the Larynx....12 6.....33 A......16 A.......................... American Joint Committee on Cancer (AJCC) Tumor Staging by Site...... Hypopharynx........................ AJCC Tumor Staging—Nasopharynx and Thyroid .35 D.......... Neck Staging Under the TNM Staging System for Head and Neck Tumors (excluding nasopharynx and thyroid)....................... Salivary Glands....................... Nasal Cavity and Paranasal Sinuses ................................................................ Salivary Glands.................. Conceptual Guidelines for Neck Dissection Classification ................................. and Paranasal Sinuses ..........................................8 A............................................. Modified Radical Neck Dissection.9 3...........................24 B........................................................8 1...........33 B..23 III.............. Radiation Therapy and Chemotherapy..................20 F........................................

Three categories comprise the system: T—the characteristics of the tumor at the primary site (this may be based on size. Other than histopathologic analysis.I. or c status. or IV. 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. INTRODUCTION The tumor. 8 . or both). and M— the absence or presence of distant metastases. Of importance is that any positive metastatic disease to the neck will classify the disease as advanced. The specific TNM status of each patient is then tabulated to give a numerical status of Stage I. prognosis. radiographic. (3) the hypopharynx. location. 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. node. The major sites include (1) the oral cavity. and advanced-stage disease as Stage III or IV disease. III. N—the degree of regional lymph node involvement. and pathologic findings. and management. early-stage disease is denoted as Stage I or II disease. biomarkers and molecular studies are not yet included in the staging of head and neck cancers. A. intraoperative. (2) the oropharynx. All available clinical information may be used in staging: physical exam. except in select nasopharynx and thyroid cancers. In general. 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. The UADT is organized into several major sites that are subdivided to several anatomic subsites. II. Specific subdivisions may exist for each stage and may be denoted with an a. b.

where the hypopharynx begins. hard palate. and with the anterior tonsillar pillars and the circumvallate papillae forming the posterior limits. treatment with radiotherapy can lead to radionecrosis of the mandible or maxilla. oral cavity squamous cell carcinomas may be less sensitive to chemotherapy and radiation. (6) and the nose and paranasal sinuses. 1. and retromolar trigone. 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). upper and lower alveolar ridges. 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. to improve local disease control. the nasopharynx. relative to oropharyngeal or laryngeal cancers. Positive surgical margins. Oral Cavity The oral cavity is a common site for squamous cell cancers of the UADT. The major subsites of the oral cavity are the lips. multiple involved lymph nodes. The subsites of the 9 . Moreover. floor of mouth.(4) the larynx. The trigone consists of the mucosa overlying the anterior aspect of the ascending ramus of the mandible. (5). and/or extracapsular tumor extension call for consideration of postoperative chemoradiotherapy. buccal mucosa. primary treatment for most tumors is surgical. 2. which separates it from the nasopharynx and to the level of the hyoid bone inferiorly. Thus. 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. anterior tongue. probably because it is the first entry point for many carcinogens. Because of accessibility and the risk of involvement of bony structures.

especially in nonsmokers. other regimens. Cancers of the oropharynx often metastasize to upper and middle jugular chain lymph nodes (Levels II and III). Surgery had been the mainstay of primary treatment for hypopharyngeal cancers for many years. chemoradiotherapy most often with a concomitant approach has become standard. T 3/4 or N 2 b/c/3 staging. some of these cancers are associated with human papilloma virus 16 infection. which distinguishes them from oral cavity tumors and must be considered when treating oropharyngeal cancers. and because of their location can impact swallowing and speech function adversely. and pharyngeal walls. and drug combinations. Two other hallmarks of hypopharyngeal cancers are submucosal spread and skip areas of spread. Spread to the upper. where it meets the cervical esophagus. 4. the postcricoid region. where it is contiguous with the oropharynx and it extends inferiorly to the cricopharyngeus muscle. Induction chemotherapy before radiotherapy (or chemoradiotherapy) remains an investigational strategy. carboplatin. taxanes. administered during weeks 1. but increasingly radiotherapy and chemoradiotherapy are used to treat cancers in this location with success. Cisplatin. 10 . base of tongue. Increasingly. Tumors often present here at advanced stages and can be difficult to cure. middle. 3. and the pharyngeal walls. Nonetheless. for patients with more advanced disease. Tumors in this site are generally treated with radiotherapy. Hypopharynx The hypopharynx has its superior limit at the hyoid bone. and lower jugular lymph nodes (Levels II–IV) and the retropharyngeal nodes is common in these cancers. However. soft palate. are also reported. but can also spread to retropharyngeal lymph nodes. and 7 has most often been studied and may be considered a standard. as a single modality for T 1/2 or N 0/1 stages. The major subsites of the hypopharynx are the pyriform sinuses. such as cisplatin or carboplatin with fluorouracil.oropharynx are the tonsil.

Anterior to the supraglottis is the pre-epiglottic space. The larynx is comprised of a cartilaginous framework. The supraglottic larynx includes the epiglottis. which has both lingual and laryngeal surfaces. 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. glottic. which contrasts with the pseudostratified ciliated respiratory mucosa lining the remainder of the larynx. which is known as transglottic spread. swallowing. 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. the false vocal cords. While it is rare for tumors to arise initially in the subglottis. or vice versa. and where they come together anteriorly at the anterior commissure. Between the thyroid cartilage and the vocal cord lies the paraglottic space. Glottic laryngeal cancers tend to metastasize unilaterally and spread regionally less commonly than supraglottic tumors do. The vocal cords are lined with stratified squamous epithelia. which is continuous with the pre-epiglottic space. middle. The glottic larynx extends from the ventricle to 1 cm below the level of the true cords. and the aryepiglottic folds. Its important roles in speech. as well as where they meet the mobile laryngeal cartilages at the posterior commissure. the trachea inferiorly. The larynx is bordered by the oropharynx superiorly. Larynx The larynx is the most complex of the mucosal lined structures of the UADT. tumors arising in the supraglottic or glottic larynx commonly spread in a “transglottic” fashion to involve the 11 . The glottic larynx describes the true vocal cords. and airway protection make the treatment considerations of cancers of this structure varied and controversial. This serves as a pathway for submucosal spread of tumors from the glottis to the supraglottis. and subglottic subsites.4. and lower jugular chain lymph nodes. and is subdivided vertically by the vocal cords into the supraglottic. the arytenoids cartilages.

the nasopharynx meets the superior oropharynx. particularly in areas where nasopharyngeal carcinoma is endemic (such as southern China. but while total laryngectomy was long held as the gold standard for treating T3 and T4 larynx cancers.and subglottic tumors. chemoradiotherapy has been shown to be quite effective in achieving local regional control. Thus. and unilateral neck treatment is considered for patients with advanced glottic tumors.subglottic larynx. impingement of this opening by a nasopharyngeal tumor can lead to Eustachian dysfunction manifested by a middle-ear effusion and hearing loss. Treatment of laryngeal cancers varies widely from center to center. therefore. Inferiorly. Subglottic tumors tend to metastasize to paratracheal (Level VI) as well as middle or lower jugular lymph (Levels III and IV) node groups. 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. and organ preservation. but proponents of each modality often disagree on the functional sequelae of the two types of treatment. at the level of the soft palate. and for early-stage lesions radiotherapy or transoral endoscopic excision are the most common treatment options. The roof and posterior walls of the nasopharynx are made up of the sphenoid bone and the upper cervical vertebrae. Treatment of both sides of the neck must be taken into consideration when treating supra. However. The opening of the Eustachian tube is found at the posterior-superior aspect of either lateral nasopharyngeal wall. covered with a stratified squamous epithelial lining. survival. Both yield excellent tumor control. all adult patients with an unexplained unilateral middle-ear effusion. Treatment of more advanced tumors can be even more controversial. Concomitant chemoradiotherapy may be most appropriate for T3 primary lesions. northern 12 . good long-term functional data are lacking. 5.

Because of inherent bone involvement. especially in cases with orbital involvement. Sinonasal 13 . although adenocarcinomas are described.Africa. and Greenland). Surgery is rarely used in salvage situations at the primary site or neck. consisting of mucosa-covered lymphoid tissue. Nasal Cavity and Paranasal Sinuses The paranasal sinuses consist of the paired maxillary sinuses. The adenoids. Nasopharyngeal carcinoma may also metastasize to retropharyngeal and parapharyngeal lymph nodes. While minor salivary tumors can occur in the nasopharynx. 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). The EpsteinBarr virus is thought to play a pathogenic role in the development of Type II and III tumors. WHO Type I nasopharyngeal carcinoma (NPC) is keratinizing squamous carcinoma. Reconstruction and rehabilitation. T 3/4 N +/ concomitant chemotherapy is being increasingly utilized. should have their nasopharynx examined. Earlystage NPC is most often treated with radiotherapy alone. and in more advanced cases. and WHO Type II is nonkeratinizing squamous cell carcinoma. as well as lymph nodes along the upper. and the central spenoids. are found posteriorly and superiorly in the nasopharynx and are more prominent in children than adults. WHO Type III is an undifferentiated tumor. The majority of sinonasal carcinomas arise in the maxillary sinuses and are most commonly squamous cell carcinomas. with consideration for adjuvant radiation therapy based upon stage and pathologic findings. This region includes the lining of the nasal cavity (medial maxillary walls) as well as the nasal septum. may be prosthetic or tissue based. the bilateral ethmoid system. also known as lymphoepithelioma. lower. the superior frontal sinuses. 6. initial treatment is usually surgical. especially in woodworkers. and middle jugular (Levels II–IV) chains and the posterior triangle of the neck (Level V).

salivary glands and visual apparatus). 3D conformal planning does not always result in optimal shielding of critical normal tissues (e. and size. it is also very important for the clinician to be acutely aware of radiologic anatomy (levels of nodal disease. while adequately treating the tumor.g. including craniofacial surgical intervention with adjuvant radiation and chemotherapy. and delineation of postoperative tumor bed). B. while at the same time adequately covering the tumor volume. extent. 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. This improvement allows limited dosing to normal tissue. However. pathways of loco-regional spread of tumor.. ini- 14 . Preoperative clinical and radiologic evaluation of disease is extremely important for postoperative radiotherapy planning. Such evaluation is also valuable in determining whether ipsilateral or bilateral neck disease needs to be addressed based on tumor location. Intensity-modulated radiation therapy (IMRT) allows for better sparing of such critical normal tissues by modulating the radiation beam in multiple small beamlets. due to current beam constraints. and positron emission tomography scan for treatment planning. scan magnetic resonance imaging. With the advent of IMRT. 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. 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. while utilizing computed tomography. Standard treatment is multidisciplinary. as tissue planes may be obscured after surgery.carcinomas of the anterior skull base include a variety of pathologies.

extension of the RT clinical target volume to include overlying skin. and should be included in RT volumes. extension to soft tissue/bone. Approximately 20% of anterior tongue and floor of mouth cancers may have skip nodal metastasis to Level IV nodal region. Delaying adjuvant therapy has been shown to significantly decrease loco-regional control. and the number and level of nodal involvement. unless postoperative complications significantly delay wound healing. Postoperative patients with ECE are at high risk for loco-regional recurrence. extra-capsular extension (ECE). addition of concurrent chemotherapy (RTOG 95-01). 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. and likelihood of contralateral nodal involvement. Careful adjuvant treatment planning includes consideration of radiation dose (60–66 Gy). Certain primary tumor sites have a high risk of retropharyngeal nodal involvement (nasopharynx. the highest treated nodes are jugulodigastric nodes. and perineural or lympho-vascular invasion at the primary site and size. piriform sinus. 15 . and these nodal groups should be covered in RT target volumes for these tumors.tial nodal presentation. and tongue base). Important considerations in RT planning following surgical resection include a thorough evaluation of the surgical pathology report with respect to resection margins. In the contralateral elective neck irradiation. and elective irradiation of contralateral neck nodes. Adjuvant RT should ideally begin within 4–6 weeks following primary surgical resection and neck dissection.

AMERICAN JOINT COMMITTEE ON CANCER (AJCC) TUMOR STAGING BY SITE A. TX T0 Tis T1 T2 B. T3 Tumor is more than 4 cm in greatest dimension. Carcinoma is in situ. T4 (lip) Tumor invades through cortical bone. chin or nose. or skull base and/or encases the internal carotid artery.. The posterior border is formed by the junction of the hard and soft palates superiorly. and retromolar trigone. the inferior surface of the soft palate and uvula. Oropharynx Definition: The oropharynx includes the base of the tongue. hard palate.g.e. Tumor is more than 2 cm but not greater than 4 cm in greatest dimension. T4a (oral Tumor invades adjacent structures (e. anterior 2/3 of tongue. through cavity) cortical bone. hypoglossus. The various sites within the oral cavity include the lip. floor of mouth. pterygoid plates. and styloglossus]. Tumor is 2 cm or less in greatest dimension. or skin of face—i. T4b Tumor invades masticator space. the anterior and posterior 16 . maxillary sinus. inferior alveolar nerve.. the circumvallate papillae inferiorly. Note: Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify as T4. into deep [extrinsic] muscle of tongue [genioglossus. Primary tumor cannot be assessed. floor of mouth. palataglossus. Oral Cavity Definition: The anterior border is the junction of the skin and vermilion border of the lip. gingival.II. buccal mucosa. There is no evidence of primary tumor. and the anterior tonsillar pillars laterally. skin of face).

lateral nasopharynx. deep/extrinsic muscle of the tongue. T3 Tumor is more than 4 cm in greatest dimension. medial pterygoid. and the lateral and posterior pharyngeal walls. pterygoid plates. hard palate. 17 . Tumor is more than 2 cm but not more than 4 cm in greatest dimension. Tumor is 2 cm or less in greatest dimension. 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. T4b Tumor invades the lateral pterygoid muscle. including anterior and posterior commisures. or skull base or encases the carotid artery. or mandible. T1 T2 C. 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. the glossotonsillar sulci.tonsillar pillars. There is no evidence of primary tumor. Carcinoma is in situ. the pharyngeal tonsils.

T2 Tumor extends to the supraglottis and/or subglottis. vallecula.. paraglottic space.g. with normal mobility.. strap muscles. T1 Glottis T1 Tumor is limited to the vocal cords(s) (may involve anterior or posterior commissure). T4a Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e. and/or minor thyroid cartilage erosion (e..g.g. including deep extrinsic muscle of the tongue.. T3 Tumor is limited to the larynx with vocal cord fixation and/or invades paraglottic space. encases the carotid artery. T2 Tumor invades mucosa of more than one adjacent subsite of the supraglottis or glottis or region outside the supraglottis (e. and/or with impaired vocal cord mobility. with normal vocal cord mobility. trachea. 18 . T4b Tumor invades prevertebral space. T4a Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e. and or minor thyroid cartilage erosion (e. soft tissues of neck.. or esophagus). strap muscles. medial wall of pyriform sinus). inner cortex). T3 Tumor is limited to the larynx with vocal cord fixation and/or invades any of the following: postcricoid area.g. or esophagus). thyroid. mucosa of base of tongue. without fixation of the larynx. inner cortex). pre-epiglottic tissues. T1a Tumor is limited to one vocal cord. soft tissues of the neck. including deep extrinsic muscle of the tongue.Supraglottis Tumor is limited to one subsite of the supraglottis. trachea. T1b Tumor involves both vocal cords.g. or invades mediastinal structures. thyroid.

g. the lateral and posterior hypopharyngeal walls. or measures more than 2 cm but not more than 4 cm in greatest dimension without fixation of the hemilarynx. or invades mediastinal structures.. T4b Tumor invades prevertebral fascia. T2 Tumor invades more than one subsite of the hypopharynx or an adjacent site. esophagus. encases the carotid artery. or central compartment soft tissue. and the postcricoid region. T4a Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e. strap muscles. encases the carotid artery. with vocal cord fixation. Subglottis T1 T2 Tumor is limited to the subglottis. T3 Tumor is more than 4 cm in greatest dimension or with fixation of the hemilarynx. D. thyroid gland. or involves mediastinal structures. soft tissues of neck. or invades mediastinal structures.T4b Tumor invades prevertebral space. including deep extrinsic muscles of the tongue. or esophagus). thyroid. encases the carotid artery. trachea. Tumor is limited to one subsite of the hypopharynx and 2 cm or less in greatest dimension. T3 Tumor is limited to the larynx. T1 19 . Tumor extends to the vocal cord(s). T4a Tumor invades thyroid/cricoid cartilage. Hypopharynx Definition: The hypopharynx includes the pyriform sinuses. with normal or impaired mobility. T4b Tumor invades prevertebral space. hyoid bone.

brain. The medial border is the lateral nasal wall. infratemporal fossa. TX Primary tumor cannot be assessed. The posterolateral wall is anterior to the infratemporal fossa and pterygopalatine fossa. including extension into the hard palate and/or middle nasal meatus. Nasal Cavity and Paranasal Sinuses Definition: The paranasal sinuses include the ethmoid. except extension to the posterior wall of the maxillary sinus and pterygoid plates. T4b Tumor invades any of the following: orbital apex. T3 Tumor invades any of the following: bone of the posterior wall of the maxillary sinus. sphenoid. sphenoid or frontal sinuses. Tis Carcinoma is in situ. the sinus abuts the orbital floor and contains the infraorbital canal. middle cranial fossa. maxillary. 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. pterygoid plates. Maxillary Sinus Definition: The maxillary sinus is a pyramid-shaped cavity within the maxillary bone. or clivus. cribriform plate. 20 . The anterior wall is posterior to the facial skin and soft tissue. T1 Tumor is limited to the maxillary sinus mucosa. skin of cheek. T0 There is no evidence of primary tumor. Superiorly.E. cranial nerves other than maxillary division of trigeminal nerve (V2). or ethmoid sinuses. pterygoid fossa. T2 Tumor is causing bone erosion or destruction. with no erosion or destruction of bone. dura. floor. or medial wall of the orbit. nasopharynx. subcutaneous tissues. T4a Tumor invades anterior orbital contents. and frontal sinuses.

T2 Tumor is greater than 2 cm but not more than 4 cm without extraparenchymal extension. middle cranial fossa.Nasal Cavity and Ethmoid Sinus Definition: The nasal cavity includes the nasal antrum and the olfactory region. T1 Tumor is 2 cm or less without extraparenchymal extension. or clivus. minimal extension to anterior cranial fossa. sphenoid or frontal sinuses. The anterosuperior border or roof of the ethmoid is formed by the fovea ethmoidalis. T2 Tumor invades two subsites in a single region or extends to involve an adjacent region within the nasoethmoidal complex. which separates it from the anterior cranial fossa. the ethmoid sinus is bound by a thin bone called the lamina papyracea. dura. T4a Tumor invades any of the following: anterior orbital contents. palate. pterygoid plates. The ethmoid sinus is made up of several thin-walled air cells. 21 . middle. The perpendicular plate of the ethmoid bone separates the ethmoid cavity into left and right sides. and olfactory region of the cribriform plate. maxillary sinus. submandibular. brain. superior. cranial nerves other than (V2). skin of nose or cheek. The subsites within the nasal cavity include the septum. T1 Tumor is confined to the ethmoid sinus with or without bone erosion. Salivary Glands Definition: The salivary glands include the parotid. sublingual. The posterior border of the ethmoid sinus is close to the optic canal. Laterally. T4b Tumor invades any of the following: orbital apex. nasopharynx. with or without bony invasion. which separates it from the medial orbit. F. and inferior turbinates. or cribriform plate. T3 Tumor extends to invade the medial wall or floor of the orbit. and minor salivary glands.

N2b Metastasis is in multiple ipsilateral lymph nodes. N2a Metastasis is in a single ipsilateral lymph node. N2c Metastasis is in bilateral or contralateral lymph nodes. none greater than 6 cm in greatest dimension. Neck Staging Under the TNM Staging System for Head and Neck Tumors (excluding nasopharynx and thyroid) NX Regional lymph nodes cannot be assessed. none more that 6 cm in greatest dimension. more than 3 cm but not more than 6 cm in greatest dimension. none more than 6 cm in greatest dimension. or metastasis is in multiple ipsilateral lymph nodes. N3 Metastasis is in a lymph node more than 6 cm in greatest dimension.T3 Tumor is more than 4 cm and/or extraparenchymal extension. 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). N2 Metastasis is in a single ipsilateral lymph node. T4a Tumor invades the skin. and/or facial nerve. mandible. N1 Metastasis is in a single ipsilateral lymph node. or metastasis is in bilateral or contralateral lymph nodes. none more that 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. N0 There is no regional nodes metastasis. U. G. 22 . ear canal.

Distant Metastasis (M) MX Distant metastasis cannot be assessed. TNM Staging for the Larynx. Salivary Glands. M1 There is distant metastasis. M0 There is no distant metastasis. 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 . Oral Cavity. Oropharynx. H. Hypopharynx.

T2a Tumor extends to the oropharynx and/or nasal cavity. N3b Tumor extends to the supraclavicular fossa. T1 Tumor is confined to the nasopharynx. AJCC TUMOR STAGING—NASOPHARYNX AND THYROID A. infratemporal fossa. the posterior walls. hypopharynx. N2 Bilateral metastasis in lymph nodes is 6 cm or less in greatest dimension. above the supraclavicular fossa. T4 Tumor has intracranial extension and/or involves cranial nerves. T2 Tumor extends to soft tissues. 24 . N1 Unilateral metastasis in lymph node(s) is 6 cm or less in greatest dimension. N3 Metastasis in lymph node(s) is greater than 6 cm and/or to the supraclavicular fossa. Nasopharynx Definition: The nasopharynx includes the vault. and the superior surface of the soft palate. above the supraclavicular fossa. orbit. the lateral walls. or masticator space. T3 Tumor involves bony structures and/or paranasal sinuses.III. without parapharyngeal extension. T2b Tumor extends into the parapharyngeal space. N3a Tumor is greater than 6 cm in dimension. Regional Lymph Nodes (different from other head and neck sites) N0 There is no regional lymph node metastasis.

Primary Tumor (T) TX T0 T1 T2 Primary tumor cannot be assessed. 25 . Tumor is more than 2 cm but not more than 4 cm in greatest dimension.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. with an isthmus connecting the two lobes. and is limited to the thyroid. Thyroid Definition: The thyroid is composed of a right and left lobe. Tumor is 2 cm or less in greatest dimension and is limited to the thyroid. There is no evidence of primary tumor.

and is limited to the thyroid or any tumor with minimal extrathyroid extension (e. N0 There is no regional lymph node metastasis. All anaplastic carcinomas are considered T4 tumors T4a Intrathyroidal anaplastic carcinoma—surgically resectable. N1b There is metastasis to unilateral. bilateral. N1 There is regional lymph node metastasis. M1 There is distant metastasis. and prelaryngeal/Delphian lymph nodes).. T3 Regional Lymph Nodes (N) Regional lymph nodes are the central compartment. 26 . or contralateral cervical or superior mediastinal lymph nodes. NX Regional lymph nodes cannot be assessed. trachea. and upper mediastinal lymph nodes. T4b Tumor invades prevertebral fascia or encases the carotid artery or mediastinal vessels. M0 There is no distant metastasis. esophagus. T4b Extrathyroidal anaplastic carcinoma—surgically unresectable. or recurrent laryngeal nerve.Tumor is more than 4 cm in greatest dimension. Distant Metastasis (M) MX Distant metastasis cannot be assessed.g. lateral cervical. T4a Tumor of any size extends beyond the thyroid capsule to invade subcutaneous soft tissues. extension to sternothyroid muscle or perithyroid soft tissues). paratracheal. larynx. N1a There is metastasis to Level VI (pretracheal.

and anaplastic (undifferentiated) carcinoma. medullary. 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 .Stage Grouping Separate stage groupings are recommended for papillary or follicular.

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 .

2—Dark lines depict the boundaries of the submental (IA) and anterior compartment (VI) lymph nodes. middle jugular group. Fig. Level III. and lower lip (Figure 2). DEFINITION OF LYMPH NODE GROUPS (FIGURE 1) Fig. Level V. 1—The level system is used for describing the location of lymph nodes in the neck: Level I. Level IV. lower jugular group. anterior mandibular alveolar ridge. submental and submandibular group. anterior oral tongue. Level VI. 29 . Level IA: Submental Group Lymph nodes within the triangular boundary of the anterior belly of the digastric muscles and the hyoid bone.IV. upper jugular group. These nodes are at greatest risk for harboring metastases from cancers arising from the floor of the mouth. anterior compartment. posterior triangle group. Level II.

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). soft tissue structures of the midface.and postglandular nodes. Radiographically. and the pre. These nodes are at greatest risk for harboring metastases from the cancers arising from the oral 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. The submandibular gland is included in the specimen when the lymph nodes within this triangle are removed. anterior nasal cavity. 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). II.Level IB: Submandibular Group Lymph nodes within the boundaries of the anterior and posterior bellies of the digastric muscles. See text for details. and the posterior (lateral) boundary is the posterior border of the ster30 . and the body of the mandible. the stylohyoid muscle.and postvascular nodes.The group includes the pre. Fig. 3—The boundaries dividing levels I. and submandibular gland (Figure 3).

hypopharynx.* Sublevel IIA nodes are located anterior (medial) to the vertical plane defined by the spinal accessory nerve. and larynx (Figure 3). nasal cavity. and parotid gland (Figure 3). The anterior (medial) boundary is the lateral border of the sternohyoid muscle. The anterior (medial) boundary is the lateral border of the sternohyoid muscle. larynx. which lies immediately above the superior belly of the omohyoid muscle as it crosses the internal jugular vein.nocleidomastoid muscle. hypopharynx.* (Included in this group is the jugulo-omohyoid node. The upper jugular nodes are at greatest risk for harboring metastases from cancers arising from the oral cavity. Sublevel IIB nodes are located posterior (lateral) to the vertical plane defined by the spinal accessory nerve. and larynx (Figure 3). and the posterior (lateral) boundary is the posterior border of the sternocleidomastoid muscle. 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). cervical esophagus. nasopharynx. 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.) These nodes are at greatest risk for harboring metastases from cancers arising from the oral cavity. oropharynx. 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 . and the posterior (lateral) boundary is the posterior border of the sternocleidomastoid muscle. oropharynx.

Level VI: Anterior (Central) Compartment Group Lymph nodes in this compartment include the pre. 32 . and the perithyroidal nodes. and cervical esophagus (Figure 2). III.* and the posterior (lateral) boundary is the anterior border of the trapezius muscle.and paratracheal nodes. the anterior (medial) boundary is the posterior border of the sternocleidomastoid muscle. apex of the piriform sinus. These nodes are at greatest risk for harboring metastases from cancers arising from the thyroid gland. 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. *The surgical landmark that defines the lateral boundary of Levels II. The superior boundary is the hyoid bone. including the lymph nodes along the recurrent laryngeal nerves. The superior boundary is the apex formed by a convergence of the sternocleidomastoid and the trapezius muscles. Sublevel VA is separated from Sublevel VB by a horizontal plane marking the inferior border of the arch of the cricoid cartilage. The supraclavicular nodes are also included in the posterior triangle group. and the lateral boundaries are the common carotid arteries. the precricoid (Delphian) node. the inferior boundary is the clavicle. glottic and subglottic larynx. and the thyroid gland (Sublevel VB) (Figure 3).) The posterior triangle nodes are at greatest risk for harboring metastases from cancers arising from the nasopharynx and oropharynx (Sublevel VA).cervical artery. and Sublevel VB includes the nodes following the transverse cervical vessels and the supraclavicular nodes. Sublevel VA includes the spinal accessory nodes. (The Virchow is located in Level IV. the inferior boundary is the suprasternal notch.

retropharyngeal nodes. periparotid nodes (except infraparotid nodes located in the posterior aspect of the submandibular triangle). 33 . Included are all lymph nodes from Levels I through V. to the anterior border of the trapezius muscle laterally. from the lateral border of the sternohyoid muscle. 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. The spinal accessory nerve. CONCEPTUAL GUIDELINES FOR NECK DISSECTION CLASSIFICATION A. and sternocleidomastoid muscle are also removed. 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. All other procedures represent one or more alterations of this procedure. 4—Radical neck dissection. buccinator nodes. Radical neck dissection does not include removal of the suboccipital nodes. and contralateral anterior belly of the digastric muscle medially.V. internal jugular vein. Fig.

B. Fig. 5a—Modified radical neck dissection with preservation of SCM. “modified radical neck dissection with preservation of the spinal accessory nerve. 5b—Modified radical neck dissection with preservation of IJV and SAN. 5c—Modified radical neck dissection with preservation of SAN. 34 .. internal jugular vein (IJV).” Fig. IJV.g. with preservation of one or more nonlymphatic structures: i.e. Fig. The structure(s) preserved should be specifically named—e. and SAN. and sternocleidomastoid muscle (SCM). spinal accessory nerve (SAN). 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..

Supraomohyoid Neck Dissection—This includes Levels IA & IB. the lymph nodes at greatest risk are located in Levels I.C. are in Level VI. and IV. & V. Specific variations of the selective neck dissection include: Anterior Neck Dissection—This includes Level VI (Figure 6). 6—SND (Levels I–III) or supraomohyoid neck dissection. IV. and Level IV (Figure 8). the post-auricular nodes. and for thyroid cancer. 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). hypopharyngeal. 35 . and laryngeal cancers are located in Levels II. Level III (Figure 7). Posterolateral Neck Dissection—This includes Levels II. Fig. Level IIA or Levels IIA & IIB. Level III. II. For oral cavity cancers. suboccipital nodes. and III. The lymph nodes at greatest risk for oropharyngeal. Lateral Neck Dissection—This includes Level IIA or Levels IIA & IIB. III. The lymph nodes groups removed are based on the patterns of metastases that are predictable relative to the primary site of disease. III.

suboccipital. 10—Extended radical neck dissection with removal of the common carotid artery or ERND (common carotid artery). 8—SND (Level VI) or anterior neck dissection. 36 . Fig. 7—SND (Levels II–IV) or lateral neck dissection. 9—SND (Levels II–V). postauricular. Fig. external jugular. or posterolateral neck dissection. Fig.Fig.

not encompassed by the radical neck dissection (Figure 10). and paratracheal lymph nodes. perifacial (buccinator). and paraspinal muscles.. The additional lymphatic or nonlymphatic structure(s). superior mediastinal. should be identified. Examples of such lymph node groups include the parapharyngeal (retropharyngeal). hypoglossal nerve. Extended Radical Neck Dissection Extended radical neck dissection (ERND) refers to the removal of one or more additional lymph node groups or nonlymphatic structures. IIA and III). SND (Levels IB.Since there is variation of levels and sublevels associated with the names given to the various types of SND. Examples of the nonlymphatic structures include the carotid artery. D. overlying skin.g. or both. 37 . or both.” followed by the levels and/or sublevels removed—e. it is recommended to use the term “selective neck dissection” or “SND. vagus nerve.

NOTES 38 .

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MNGPH5206251 ISBN 978-1-56772-117-1 .Item No.

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