TNM STAGING

 TNM staging has been developed by the American Joint Committee on

Cancer (AJCC) in cooperation with the TNM Committee of the
International Union Against Cancer (UICC). The two organization have
worked together at every level to create a staging schema that remains
uniform throughout.
 Classification and staging of cancer enable the physician and cancer
registrar to stratify patients, which leads to better treatment decisions
and the development of a common language that aids in the creation of
clinical trials for the future testing of cancer treatment strategies.
 The first clinical classification of the cancer led by the League of
Nations Health Organization in 1929 and later by the UICC and its TNM
Committee.
 The AJCC was first organized on January 9, 1959 as the American Joint
Committee for Cancer Sating and End Results Reporting (AJC).the
diving force behind the organization of this body was a desire to develop
a system of clinical sating for cancer that was acceptable to the
American medical profession.
 AJCC embraced the TNM system in order to describe the anatomic
extent of cancer at the time of initial diagnosis and before the application
of definitive treatment.
 The most clinically useful staging system is the tumor node metastasis
(TNM) system.
 The TNM system classifies cancer by the size and extent of the primary
tumor (T), involvement of regional lymph node (N), and the presence or
absence of distant metastasis (M).
 The criteria for defining anatomic extent of disease are specific for
tumors at different anatomic sites and of different histologic types.
 TNM system classifies cancers primarily by the anatomic extent of the
primary tumor, the status of regional draining lymph nodes, and the
presence or absence of distant metastases.
T – The T component defined by the size or contiguous extension of the
primary tumor.
N - The N component is defined by the absence or presence and extent
of cancer in the regional draining lymph nodes.
M – The M component is defined by the absence or presence of distant
spread or metastases, generally spread by the vascular channels or by
lymphatics beyond the nodes defined as “regional”.
 T,N,M are grouped into stage groups. Group are classified by Roman
numerals from I to IV with increasing severity of disease.
Stage I generally denotes cancer that are smaller or less deeply invasive
with negative nodes.
Stage II and III defines case with increasing tumor or nodal extent
Stage IV defines those who present with distant metastases (M1) at time
of diagnosis.
Stage 0 is used to denote carcinoma in situ with no metastatic spread and
is almost always determined by pathologic examination.

 TYPES OF SATING
1.Clinical stage (pretreatment stage ) (cTNM) is the extent of disease
defines by diagnostic study before information is available from surgical
resection or initiation of neoadjuvant therapy, within 4 months after the
date of diagnosis.
2. Pathologic stage (postsurgical stage ) (pTNM) is defined by the same
diagnostic studies used for clinical staging supplemented by findings
from surgical resection and histologic examination of the surgically
removed tissues.
3. Posttherapy stage (yTNM) documents the extent of the disease for
patients whose first course of therapy includes systemic or radiation
treatment prior to surgical resection (yc TNM or yp TNM).
4. Retreatment stage (r TNM) documents extent of disease defined
clinically may be prognostic for patients with recurrent cancer after
disease free interval.
5. Autopsy classification (aTNM) used to stage of cancer not identified
during life and only identified postmortem.
6. Multiple primary tumors (m suffix) documents multiple tumor in one
organ. Suffix m indicates “number”- e.g. T2(m) or T2(5).

CLASSIFICATION
Primary tumor (T)
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1, T2, T3, T4 Increasing size and /or local extension of the primary
Tumor
TX Primary tumor cannot be assessed

Regional Lymph Nodes (N)

N0 No regional lymph node metastases
N1, N2, N3 Increasing number or extent of regional lymph node
Involvement
NX Regional lymph node cannot be assessed

Distant Metastases (M)

M0 no distant metastases
M1 Distant metastases present
 The M1 category may be further specified according to the following
notation signifying the location of metastases
Pulmonary PUL
Osseous OSS
Hepatic HEP
Brain BRA
Lymph nodes LYM
Bone marrow MAR
Pleura PLE
Peritoneum PER
Adrenal ADR
Skin SKI
Other OTH

 UTILIZATION OF TNM SATING :

- Guide for treatment
- Guide for prognosis
- Comparison of end results of cancer management
- Defines critical element in determining appropriate treatment
based on the experience and outcomes of groups of prior patients
with similar stage.
- Improved understanding of cancer biology and factors affecting
prognosis.

TNM STAGING OF HEAD AND NECK CANCER

Primary Tumor (T)

TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor 2 c.m. or less in greatest dimension
T2 Tumor more than 2 c.m. but not more than 4 c.m. in greatest
Dimension
T3 Tumor more than 4 c.m. in greatest dimension
T4a Moderately advanced local disease ( Tumor involves bone, skin,
Nerve, or adjacent tissues)
T4b Very advanced local disease (Tumor involves skull base, skull
Space

Regional Lymph Nodes (N)

Nx Regional lymph node cannot be assessed
N0 No regional lymh node metastases
N1 Metastases in a single ipsilateral lymph nodes, 3 c.m. or less in
Greatest dimension
N2a Metastases in a single ipsilateral lymph node, more than 3 c.m.but
Not more than 6 c.m. in greatest dimension
N2b Metastases in multiple ipsilateral lymph nodes, none more than
6 c.m. in greatest dimension
N2c Metastases in bilateral or contralateral lymph nodes, none more
than 6 c.m. in greatest dimension
N3 Metastases in a lymph node more than 6 c.m. in greatest
Dimension

Distant Metastases (M)

M0 No distant metastasis
M1 Distant metastasis

STAGES
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVB Any T N3 M0
T4b Any N M0
Stage IVC Any T Any N M1