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TNM
Atlas
Illustrated Guide to the TNM Classification
of Malignant Tumours

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 Union for International Cancer Control

TNM
Atlas
Illustrated Guide to the TNM Classification
of Malignant Tumours

SEVENTH EDITION

EDITED BY

James D. Brierley
University of Toronto, Canada

Hisao Asamura
Tokyo, Japan

Elisabeth Van Eycken

Brussels, Belgium

Brian Rous
Cambridge, United Kingdom

ffirs.indd 3 2/24/2021 10:28:45 AM

 This edition first published 2021
© 2021 UICC. Published 2021 by John Wiley & Sons, Ltd This Work is a co‐publication between the UICC and
John Wiley & Sons, Ltd.
Edition History
UICC (6e, 2014). Published 2014 by John Wiley & Sons Ltd
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Library of Congress Cataloging‐in‐Publication Data
Names: Brierley, James, editor. | Asamura, H., editor. | Eycken, E. Van,
editor. | Rous, Brian Arthur, 1967– editor. | Union for International
Cancer Control.
Title: TNM atlas : illustrated guide to the TNM classification of malignant
tumours / edited by James D. Brierley, Hisao Asamura, Elisabeth
Jozefa Van Eycken, Brian Arthur Rous.
Description: Seventh edition. | Hoboken, NJ : Wiley-Blackwell, 2020.
Identifiers: LCCN 2020025431 (print) | LCCN 2020025432 (ebook) | ISBN
9781119263845 (paperback) | ISBN 9781119263913 (adobe pdf) | ISBN
9781119263838 (epub)
Subjects: MESH: Neoplasms–classification | Atlas
Classification: LCC RC258 (print) | LCC RC258 (ebook) | NLM QZ 17 | DDC
616.99/40012–dc23
LC record available at https://lccn.loc.gov/2020025431
LC ebook record available at https://lccn.loc.gov/2020025432
Cover Design: Wiley
Cover Images: (figures) Wiley, (flag) © UICC
Set in 9/12pt and Frutiger LT Std by SPi Global, Pondy, India

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 CONTENTS

Preface to the Seventh Edition, vii

Acknowledgements, ix
Contributors to the Seventh Edition, xi
Preliminary Note, xiii

HEAD AND NECK TUMOURS, 1

Section Editors Brian O’Sullivan and Shao Hui Huang
Regional Lymph Nodes, 1
Lip and Oral Cavity, 15
Pharynx, 26
Larynx, 47
Nasal Cavity and Paranasal Sinuses, 57
Unknown Primary – Cervical Nodes, 66
Malignant Melanoma of Upper Aerodigestive Tract, 70
Major Salivary Glands, 73
Thyroid Gland, 77

DIGESTIVE SYSTEM TUMOURS, 85

Section Editor James D. Brierley
Oesophagus Including Oesophagogastric Junction, 86
Stomach, 94
Small Intestine, 101
Appendix, 106
Colon and Rectum, 112
Anal Canal, 122
Liver – Hepatocellular Carcinoma, 129
Liver – Intrahepatic Bile Ducts, 135
Gallbladder, 139
Extrahepatic Bile Ducts – Perihilar, 145
Extrahepatic Bile Ducts – Distal, 149
Ampulla of Vater, 152
Pancreas, 159
Well-Differentiated Neuroendocrine Tumours of the Gastrointestinal Tract, 165
Well-Differentiated Neuroendocrine Tumours of the Pancreas, 177

LUNG, PLEURAL AND THYMIC TUMOURS, 181

Section Editor Hisao Asamura
Lung, 182
Pleural Mesothelioma, 193
Thymic Tumours, 200

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 vi   Contents

BONE AND SOFT TISSUE TUMOURS, 209

Section Editor Brian O’Sullivan
Bone, 210
Soft Tissues, 217
Gastrointestinal Stromal Tumours (GIST), 223

SKIN TUMOURS, 227

Section Editor Brian Rous
Carcinoma of the Skin, 233
Carcinoma of Skin of the Head and Neck, 237
Carcinoma of the Skin of the Eyelid, 248
Malignant Melanoma of Skin, 255
Merkel Cell Carcinoma of Skin, 263

BREAST TUMOURS, 267

Section Editor Elisabeth Van Eycken

GYNAECOLOGICAL TUMOURS, 287

Section Editor Brian Rous
Vulva, 288
Vagina, 293
Cervix Uteri, 300
Uterus Endometrium, 310
Uterus – Uterine Sarcomas, 315
Ovarian, Fallopian Tube and Primary Peritoneal Carcinoma, 323
Gestational Trophoblastic Tumours, 331

UROLOGICAL TUMOURS, 335

Section Editor Elisabeth Van Eycken
Penis, 336
Prostate, 345
Testis, 353
Kidney, 371
Renal Pelvis and Ureter, 380
Urinary Bladder, 387
Urethra, 394
Adrenal Cortex Tumours, 404

HODGKIN LYMPHOMA, 409

Section Editor James D. Brierley

NON‐HODGKIN LYMPHOMAS, 424

Section Editor James D. Brierley

Index, 425

ftoc.indd 6 2/26/2021 6:47:38 AM

 PREFACE TO THE SEVENTH EDITION

This new seventh edition of the TNM Atlas incorporates the changes in the TNM System
that are in the eighth edition of the TNM Classification of Malignant Tumours.1 In the
eighth edition of the TNM Classification staging at many of the tumour sites is unchanged
from the seventh edition. However, some tumour entities and anatomical sites have been
newly introduced and some tumours contain modifications; this follows the basic phi-
losophy of maintaining stability of the classification over time. The new additions are:
p16 oropharyngeal carcinomas, carcinomas of the thymus, neuroendocrine carcinomas
of the pancreas and sarcomas of the spine, pelvis, head and neck, retroperitoneum and
thoracic and abdominal viscera. In addition, many tumour sites have important updates.
The Atlas’s content follows the approach of depicting the Ts, Ns and Ms in graphic
terms. The full‐colour artwork is augmented with an increased number of clinical imag-
ing studies illustrating many of the changes between the seventh and eighth editions of
the TNM Classification of Malignant Tumours.

1
Brierley, J.D., Gospodarowicz, M.K., Wittekind, C. (eds.) (2017) TNM Classification of Malignant
Tumours, 8th edn. Chichester: Wiley-Blackwell.

vii

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fpref.indd 8 01/27/2021 8.48.50 PM
 ACKNOWLEDGEMENTS

The editors wish to express their thanks to all who contributed to this seventh edition by
comments, questions and their critical interest. In particular we would like to thank Professor
Ch. Wittekind, Leipzig, Germany for his enormous contributions as co‐editor of the 4th, 5th
and 6th editions of the TNM Atlas, the 5th, 6th, 7th and 8th editions of the TNM Classification
of Malignant Tumours and the 2nd, 3rd, 4th and 5th editions of the TNM Supplement.
He was the driving force behind many of these editions.
The Editors have much pleasure in acknowledging the great help received from the
members of the TNM Prognostic Factors Project Committee and the National Staging
Committees Global Representatives and International Organizations listed on pages xv–
xvi of the TNM Classification of Malignant Tumours, 8th edition. In addition, we would
like to thank, Dr Brian O’Sullivan and Dr Shao Hui Huang for providing clinical images
for the Head and Neck Tumours chapter, Mr Anthony Griffin, Dr Peter Chung and Dr
Ali Hosni for providing clinical images for the Tumours of the Bone and Soft tissues chap-
ter and Dr Richard Tsang for clinical Images in the Lymphoma chapter.
This edition builds on the work by contributors to all previous editions. In particular we
would like to thank Dr Leslie Sobin and Dr Christian Wittekind, who along with Dr Hisao
Asamura edited the 6th edition. Contributors to all previous editions are listed in the 6th
edition pp. x–xiv.

ix

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flast.indd 10 02-15-2021 19:22:13
 CONTRIBUTORS TO THE SEVENTH
EDITION
Asamura, H. Tokyo, Japan
Brierley, J. Toronto, Canada
Huang, Shao Hui. Toronto, Canada
O‘Sullivan, B. Toronto, Canada
Rous, B. Cambridge, UK
Ruffino, E. Torino. Italy
Van Eycken, E, Brussels, Belgium
flast.indd 11
Lung
Digestive System, Thyroid, Lymphoma
Head and Neck Tumours
Head and Neck Tumours
Tumours of the Bone and Soft Tissue
Gynaecological Tumours, Skin Tumours
Thymic Tumours
Breast, Urological, Adrenal Cortex Tumours
xi
02-15-2021 19:22:13
flast.indd 12 02-15-2021 19:22:13
 PRELIMINARY NOTE

Digestive
The TNM System for describing the anatomical extent of disease is based on assessment
of three components:

T – The extent of the primary tumour

N – The absence or presence and extent of regional lymph node metastasis
M – The absence or presence of distant metastasis

The addition of numbers to these three components indicates the extent of the malig-
nant disease, thus:

T0, T1, T2, T3, T4 N0, N1, N2, N3 M0, M1

In effect, the system is a “short‐hand notation“ for describing the extent of a particular
malignant tumour.

Each site is described under the following headings:

1)  Anatomy
Drawings of the anatomical sites and subsites are presented with the appropriate
ICD‐O‐3 topography numbers.1
2) Regional Lymph Nodes
The regional lymph nodes are listed and shown in drawings.
3) T/pT Clinical and Pathological Classification of the Primary Tumour
The definitions for T and pT categories are presented. In the eighth edition (2017) of
the TNM Classification the clinical and pathological classifications (T and pT) generally
coincide, therefore the same illustrations are valid for the T and pT classifications for
most sites.
4) N/pN Clinical and Pathological Classification of Regional Lymph Nodes
The N and pN categories are presented in a fashion similar to the T and pT categories.
Differences between N and pN definitions in the seventh edition arise in the case of
carcinomas of the breast and penis and germ cell tumours of the testis.
5) M/pM Clinical and Pathological Classification of Distant Metastasis
M localization is given only in selected cases because of its many possible variables.

Please visit the UICC https://www.uicc.org/resources/tnm/publications-resources or Wiley websites

for any errata or updates.
1
ICD-O International Classification of Diseases for Oncology, 3rd edn (2000), WHO, Geneva.

xiii

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flast.indd 14 02-15-2021 19:22:13
 HEAD AND NECK TUMOURS

Head and Neck

Introductory Notes

The following sites are included:

•• Lip, oral cavity
•• Pharynx: oropharynx, nasopharynx, hypopharynx
•• Larynx: supraglottis, glottis, subglottis
•• Nasal cavity and paranasal sinuses
•• Malignant melanoma of upper aerodigestive tract
•• Major salivary glands
•• Thyroid gland

Carcinomas arising in the minor salivary glands of the upper aerodigestive tract are classi-
fied according to the rules for tumours of their anatomical site of origin, e.g., oral cavity.

Regional Lymph Nodes (Figs. 1, 2, 3)

The definitions of the N categories for all head and neck sites except p‐16 positive
­oropharynx, nasopharynx, mucosal malignant melanoma of the upper aerodigestive
tract and thyroid are the same.
Midline nodes are considered ipsilateral nodes except in the thyroid.
The status of the regional lymph nodes in head and neck cancer is of considerable
prognostic importance. In addition, it is helpful to subdivide the lymph nodes and
­possible metastasis into specific anatomical subsites and to group these lymph nodes
into levels. A consensus guideline from DAHANCA, EORTC, HKNPCSG, NCIC CTG, NCRI,
RTOG and TROG has been published and the nodal groups are listed below. However, a
number of different classifications exist that use variable level numbers and therefore we
recommend the levels be named rather than referred to by number to limit any confu-
sion, although the levels used in the consensus document are given.1 In the consensus
classification, the retropharyngeal nodes are classified as Level VII, but in the classifica-
tion used by the AJCC, Level VII described the upper mediastinal nodes.

1
Grégoire, V., Ang., K., Budach, W., et al. (2013) Delineation of the neck node levels for head and
neck tumors: a 2013 update. DAHANCA, EORTC, HKNPCSG, NCIC CTG, NCRI, RTOG, TROG
consensus guidelines. Radiother Oncol 2014 110(1):172–181.

TNM Atlas: Illustrated Guide to the TNM Classification of Malignant Tumours, Seventh Edition.
Edited by James D. Brierley, Hisao Asamura, Elisabeth Van Eycken, and Brian Rous.
© 2021 by UICC. Published 2021 by John Wiley & Sons Ltd.

0004972361.INDD 1 10-13-2021 17:05:17

 2    Head and Neck Tumours

Fig. 1 Source: Modified from Lengele B et al., Radiothor Oncol, 2007; 85(1): 146–155.

0004972361.INDD 2 10-13-2021 17:05:17

 Head and Neck Tumours    3

Head and Neck

Right sided level II
lymph node

Fig. 2 Axial CT scan showing enlarged right upper jugular (deep cervical) Level II lymph node
measuring 2.5 cm in greatest dimension.

Horizontal plane
(dotted line) defined
by the hyoid bone

Fig. 3 Coronal CT scan showing the same enlarged right upper jugular (deep cervical) Level II
lymph node measuring 2.5 cm in greatest dimension, but also an enlarged right medial jugular
(deep cervical) Level III lymph node measuring 1.5 cm in greatest dimension. Horizontal plane
(dotted line) delineated by the hyoid bone that defines Level II nodes superiorly from Level III nodes
inferiorly is marked. This is classified as cN2b: metastasis in multiple ipsilateral lymph nodes, none
more than 6 cm in greatest dimension without extranodal extension.

0004972361.INDD 3 10-13-2021 17:05:19

 4    Head and Neck Tumours

1. Submental nodes
2. Submandibular
3. Cranial jugular (deep cervical) nodes
4. Medial jugular (deep cervical) nodes
5. Caudal jugular (deep cervical) nodes
6. Dorsal cervical (superficial cervical) nodes along the spinal accessory nerve
7. Supraclavicular nodes
8. Prelaryngeal and paratracheal (syn. anterior cervical) nodes
9. Retropharyngeal nodes
10. Parotid nodes
11. Buccal nodes (syn. facial nodes)
12. Retroauricular (syn. mastoid, posterior auricular) and occipital nodes

The lymph node groups are defined as follows

1. Submental group
Lymph nodes within the triangular boundary of the anterior belly of the digastric
muscle and the hyoid bone.
2. Submandibular group
Lymph nodes within the boundaries of the anterior and posterior bellies of the digas-
tric muscle and the body of the mandible.
3. Upper (cranial) jugular group
Lymph nodes located around the upper third of the internal jugular vein and adjacent
spinal accessory nerve, extending from the hyoid bone (clinical landmark) to the skull
base. The posterior boundary is the posterior border of the sternocleidomastoid mus-
cle, and the anterior boundary is the lateral border of the sternohyoid muscle. This
group includes the jugulodigastric node, which is the most cranial jugular node.
4. Middle (medial) jugular group
Lymph nodes located around the middle third of the internal jugular vein, extending
from the carotid bifurcation superiorly to the omohyoid muscle (surgical landmark) or
cricothyroid notch (clinical landmark) inferiorly. The posterior boundary is the poste-
rior border of the sternocleidomastoid muscle, and the anterior boundary is the lat-
eral border of the sternohyoid muscle. This group includes the jugulo‐omohyoid
lymph node located between the omohyoid muscle and the internal jugular vein.
5. Lower (caudal) jugular group
Lymph nodes located around the lower third of the internal jugular vein, extending
from the omohyoid muscle superiorly to the clavicle inferiorly. The posterior bound-
ary is the posterior border of the sternocleidomastoid muscle, and the anterior
boundary is the lateral border of the sternohyoid muscle.
6. Dorsal cervical nodes along the spinal accessory chain
This forms the “posterior triangle group”. This comprises predominantly the lymph
nodes located along the spinal accessory nerve and the transverse cervical artery.
7. Supraclavicular nodes
The posterior boundary is the anterior border of the trapezius muscle, the anterior
boundary is the posterior border of the sternocleidomastoid muscle, and the inferior
border is the clavicle.
8. Anterior cervical nodes
Lymph nodes surrounding the midline visceral structures of the neck, extending from
the level of the hyoid bone superiorly to the suprasternal notch inferiorly. On each
side, the lateral boundary is the medial border of the carotid sheath. Located within

0004972361.INDD 4 10-13-2021 17:05:19

 Head and Neck Tumours    5

this compartment are the perithyroidal lymph nodes, paratracheal lymph nodes,
lymph nodes along the recurrent laryngeal nerves and precricoid lymph nodes.

Head and Neck

Node group 8 (prelaryngeal and paratracheal nodes) may be further subdivided as
follows:
8a: cranial paratracheal (suprathyroidal)
8b: thyroidal (perithyroidal)
8c: caudal paratracheal (infrathyroidal, lateral tracheal)
8d: prelaryngeal
8e: pretracheal near the thyroid isthmus (Delphian)
9. Retropharyngeal nodes
These lie in the buccopharyngeal fascia, behind the upper part of the pharynx and
in front of the arch of the atlas.
10. Parotid nodes
These may be subdivided into superficial (in front of the tragus on top of the parotid
fascia) and deep parotid nodes. The latter are located underneath the parotid fascia
and include intraglandular nodes directly in the parotid gland. The preauricular and
infra‐auricular (infra‐ or subparotid) nodes are assigned to the parotid nodes.
11. Buccal (facial) nodes
These include the buccinator nodes located deep on the buccinator muscle, the
nasolabial nodes located underneath the nasolabial groove, the molar nodes
located in the surface of the cheek and the mandibular nodes located outside the
lower jaw.
12. Retroauricular (syn. mastoid, posterior auricular) and occipital nodes
The regional lymph nodes for thyroid include the upper (superior) mediastinal lymph
nodes, which may be subdivided into tracheo‐oesophageal (posterior mediastinal)
and upper anterior mediastinal nodes. Cervical and mediastinal lymph nodes are not
divided by a fascia; the left brachiocephalic vein is considered as the boundary.
For the tumour entities listed below, a clinical and a pathological N classification have
been introduced in the 8th edition of the UICC TNM Classification of Malignant Tumours:
•• Lip and oral cavity
•• Oropharynx (p‐16‐negative or oropharyngeal without p‐16‐IH performed)
•• Hypopharynx
•• Pharynx
•• Nasal cavity and paranasal sinuses
•• Unknown primary – cervical nodes
•• Major salivary glands
•• Skin carcinoma of head and neck

N Classification – Regional Lymph Nodes

N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension

without extranodal extension (Fig. 4)
N2a Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than
6 cm in greatest dimension without extranodal extension (Fig. 5)
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest
dimension without extranodal extension (Fig. 6)

0004972361.INDD 5 10-13-2021 17:05:19

 6    Head and Neck Tumours

Any head or neck primary except p16-positive

oropharynx, nasopharynx, malignant melanoma
of upper aerodigestive tract and thyroid gland

N1

Ipsilateral

≤ 3 cm

Fig. 4

N2a

> 3 to 6 cm

Ipsilateral

Fig. 5

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 Head and Neck Tumours    7

N2b

Head and Neck

Ipsilateral

≤ 6 cm

Fig. 6

N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in

greatest dimension without extranodal extension (Fig. 7)

N2c

≤ 6 cm

Fig. 7

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 8    Head and Neck Tumours

N3a Metastasis in a lymph node more than 6 cm in greatest dimension without

extranodal extension (Fig. 8)

N3a

> 6 cm
Without extranodal
extension

Fig. 8

N3b Metastasis in a single or multiple lymph node(s) with extranodal extension

(Figs. 9, 10)

Note
Midline nodes are considered ipsilateral nodes.

0004972361.INDD 8 10-13-2021 17:05:21

 Head and Neck Tumours    9

N3b

Head and Neck

Ipsilateral

Any size
with extranodal
extension

Fig. 9

Encasement of
carotid artery

Normal Level II lymph node

sternomastoid with subcutaneous
muscle tissue invasion (arrow)
and engulfment of
sternomastoid muscle

Fig. 10 Axial CT scan showing clinically fixed right upper jugular (deep cervical) Level II lymph
node with subcutaneous tissue invasion, engulfment of sternomastoid muscle and encasement of
the carotid artery. This is classified as cN3b.

0004972361.INDD 9 10-13-2021 17:05:22

 10    Head and Neck Tumours

pN Classification – Regional Lymph Nodes

pN0 Histological examination of a selective neck dissection specimen will ordinarily

include 6 or more lymph nodes. Histological examination of a radical or modified
radical neck dissection specimen will ordinarily include 10 or more lymph nodes. If
the lymph nodes are negative, but the number ordinarily examined is not met,
classify as pN0. When size is a criterion for pN classification, measurement is made
of the metastasis, not of the entire lymph node.
pN1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
without extranodal extension (Fig. 11)

pN1

Ipsilateral

≤ 3 cm

Fig. 11

pN2 Metastasis as described below:

pN2a Metastasis in a single ipsilateral lymph node, 3cm or less in greatest
dimension with extranodal extension (Fig. 12), or more than 3 cm but
not more than 6 cm in greatest dimension without extranodal extension
(Fig. 13)

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 Head and Neck Tumours    11

pN2a

Head and Neck

Ipsilateral

≤ 3 cm
with extranodal extension

Fig. 12

pN2a

> 3 to 6 cm

Ipsilateral

Fig. 13

0004972361.INDD 11 10-13-2021 17:05:23

 12    Head and Neck Tumours

pN2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in

greatest dimension without extranodal extension (Fig. 14)

pN2b

Ipsilateral

≤ 6 cm

Fig. 14

pN2c Metastasis in bilateral or contralateral lymph nodes, none more than 6

cm in greatest dimension without extranodal extension (Fig. 15)

pN2c

≤ 6 cm

Fig. 15

0004972361.INDD 12 10-13-2021 17:05:24

 Head and Neck Tumours    13

pN3a Metastasis in a lymph node more than 6 cm in greatest dimension

without extranodal extension (Fig. 16)

Head and Neck

pN3a

> 6 cm
Without extranodal
extension

Fig. 16

0004972361.INDD 13 10-13-2021 17:05:24

 14    Head and Neck Tumours

pN3b Metastasis in a lymph node more than 3 cm in greatest dimension with

extranodal extension, or multiple ipsilateral, contralateral or bilateral
with extranodal extension (Figs. 17, 18)

pN3b

>3
Extra nodal
extension

Fig. 17

pN3b

Extra nodal
extension

Fig. 18

0004972361.INDD 14 10-13-2021 17:05:25

 LIP AND ORAL CAVITY (ICD‐O C00, C02–06)

Head and Neck

Rules for Classification

The classification applies only to carcinomas of the vermilion surfaces of the lips and of
the oral cavity, including those of minor salivary glands. There should be histological
confirmation of the disease.

Anatomical Sites and Subsites

Lip* (Fig. 19)

1. External upper lip (vermilion border) (C00.0)

2. External lower lip (vermilion border) (C00.1)
3. Commissures (C00.6)

* In the 9th edition TNM external upper and lower lip C00.0 and C00.1) and
commissure (C00.6) will be classified with carcinoma of the skin.

C00.0
C00.6
C00.1

Fig. 19

15

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 16    Head and Neck Tumours

Oral Cavity (Figs. 20, 21, 22)

1. Buccal mucosa
(i) Mucosa of upper and lower lips (C00.3, 4)
(ii) Cheek mucosa (C06.0)
(iii) Retromolar areas (C06.2)
(iv) Bucco‐alveolar sulci, upper and lower (vestibule of mouth) (C06.1)
2. Upper alveolus and gingiva (upper gum) (C03.0)
3. Lower alveolus and gingiva (lower gum) (C03.1)
4. Hard palate (C05.0)
5. Tongue*
(i) Dorsal surface and lateral borders anterior to vallate papillae (anterior two‐thirds)
(C02.0, 1)
(ii) Inferior (ventral) surface (C02.2)
* Note lingual tonsil,C02.4, is classified in the oropharynx

C05.0
C06.2

C06.1
C00.3 C05.1
Oropharynx
C03.0 C05.2

C00.4 C06.2
C03.1 C03.1

C06.1 C06.0
Fig. 20

0004972361.INDD 16 10-13-2021 17:05:26

 Lip and Oral Cavity    17

Head and Neck

C00.3

C02.1 C02.0
C02.1

C00.4

Fig. 21

C02.2

C04.0

Fig. 22

0004972361.INDD 17 10-13-2021 17:05:27

 18    Head and Neck Tumours

TN Clinical Classification

T – Primary Tumour

TX Primary tumour cannot be assessed

T0 No evidence of primary tumour
Tis Carcinoma in situ
T1 Tumour 2 cm or less in greatest dimension and 5 mm or less depth of invasion
(Figs. 23, 24, 25, 26, 27)

T1 pT1

≤ 2 cm

≤ 5 mm depth of
invasion Fig. 23

T1 pT1

≤ 2 cm ≤ 5 mm depth of Fig. 24
invasion

0004972361.INDD 18 10-13-2021 17:05:28

 Lip and Oral Cavity    19

Head and Neck

DOI

Interpreted mucosal plane

Fig. 25 Example of measuring depth of invasion on a T1 MRI sequence from the mucosal surface
to the deepest point of invasion, perpendicular to the interpreted mucosal plane (in blue), a plane
just beneath the closest intact surface of normal mucosa for clinical T category.

“Flat” Tumour Exophytic Tumour Ulcerated Tumour

DOI = TT DOI < TT DOI > TT

DOI TT DOI TT
DOI TT

Tumour Closest mucosal surface Deepest point of invasion Interpreted submucosal plane

• Black dotted line: IMP (“Interpreted Mucosal Plane”): a plane just beneath the closest intact surface of normal mucosa
• Red solid arrow: DOI (“Depth of Invastion”): measured from IMP to deepest point of invasion
• Black dotted arrow: TT (Tumour thickness): measured from centre of tumour surface to the deepest point of invasion

Fig. 26 Schematic Fig.ure depicting the difference between radiologic depth of invasion (DOI)
and tumour thickness (TT) for clinical T category.

T2 Tumour 2 cm or less in greatest dimension and more than 5 mm depth of

invasion (Figs 28, 29), or
Tumour more than 2 cm but not more than 4 cm in greatest dimension and
depth of invasion not more than 10 mm (Figs. 30, 31)
T3 Tumour more than 2 cm but not more than 4 cm in greatest dimension and
depth of invasion more than 10 mm (Figs. 32, 33) or
Tumour more than 4 cm in greatest dimension and not more than 10 mm depth
of invasion
(Figs. 34, 35)
T4a (lip and oral cavity)
Tumour more than 4 cm in greatest dimension and more than 10 mm depth of
invasion (Fig. 36), or
(Lip) – Tumour invades through cortical bone, inferior alveolar nerve, floor of
mouth or skin (of the chin or the nose) (Figs. 37, 38)

0004972361.INDD 19 10-13-2021 17:05:28

 20    Head and Neck Tumours

Fig. 27 Measurement of depth of invasion in carcinomas of the oral cavity to assess the pT
category. The horizon is established at the level of the basement membrane relative to the closest
intact squamous mucosa. The greatest depth of invasion is measured by dropping a plumb line
from the horizon. Source: From AJCC Cancer Staging Manual, 2017. © Springer Nature.

≤ 2 cm

> 5 mm depth of invasion Fig. 28

0004972361.INDD 20 10-13-2021 17:05:29

 Lip and Oral Cavity    21

Head and Neck

≤ 2 cm
Fig. 29 > 5 mm depth of invasion

T2 pT2

> 2 to 4 cm

Fig. 30 Depth of invasion ≤ 10 mm

T2 pT2

> 2 to 4 cm
Fig. 31 depth of invasion ≤ 10 mm

0004972361.INDD 21 10-13-2021 17:05:30

 22    Head and Neck Tumours

T3 pT3

> 2 to 4 cm

Depth of invasion >10 mm Fig. 32

T3 pT3

> 2 to 4 cm
depth of invasion >10 mm Fig. 33

T3 pT3

> 4 cm

≤ 10 mm depth of invasion Fig. 34

0004972361.INDD 22 10-13-2021 17:05:31

 Lip and Oral Cavity    23

T3 pT3

Head and Neck

> 4 cm
≤ 10 mm depth of invasion
Fig. 35

T4a pT4a

> 4 cm
> 10 mm depth of invasion
Fig. 36

T4a pT4a

Fig. 37

0004972361.INDD 23 10-13-2021 17:05:33

 24    Head and Neck Tumours

T4a pT4a

Fig. 38

T4a Continued
(Oral Cavity) – Tumour invades through the cortical bone of the mandible or
maxilla or involves the maxillary sinus, or invades the skin of the face (Fig. 39)

T4a pT4a

Fig. 39

0004972361.INDD 24 10-13-2021 17:05:34

 Lip and Oral Cavity    25

T4b (lip and oral cavity) Tumour invades masticator space, pterygoid plates or skull
base, or encases internal carotid artery (Fig. 40)

Head and Neck

Internal carotid artery

Fig. 40

0004972361.INDD 25 10-13-2021 17:05:34

 PHARYNX (ICD‐O C01, C05.1, 2, C09, C10.0, 2, 3,
Head and Neck

C11–13)

Rules for Classification

The classification applies only to carcinomas. There should be histological confirmation

of the disease.

Anatomical Sites and Subsites

Oropharynx (C01, C05.1, 2, C09.0, 1, 9, C10.0, 2, 3) (Figs. 41, 42)

1. Anterior wall (glosso‐epiglottic area)

(i) Base of tongue (posterior to the vallate papillae or posterior third) (C01)
(ii) Vallecula (C10.0)
2. Lateral wall (C10.2)
(i) Tonsil (C09.9)
(ii) Tonsillar fossa (C09.0) and tonsillar (faucial) pillars (C09.1)
(iii) Glossotonsillar sulci (tonsillar pillars) (C09.1)
3. Posterior wall (C10.3)
4. Superior wall
(i) Inferior surface of soft palate (C05.1)
(ii) Uvula (C05.2)

C05.1
C09.0
C09.9
C01 C10.2
C10.2
C10.1

Fig. 41

26

0004972361.INDD 26 10-13-2021 17:05:34

 Pharynx   27

C10.3 C10.3

Head and Neck

C10.0 C10.1
C10.2
C09.0
C09.9 C01.9
C09.1
C09.0

Fig. 42

Note
The lingual (anterior) surface of the epiglottis (C10.1) is included with the larynx, suprahyoid
epiglottis (see pages 35–36).

Nasopharynx (Fig. 43)

1. Postero‐superior wall: extends from the level of the junction of the hard and soft
­palates to the base of the skull (C11.0, 1)
2. Lateral wall: including the fossa of Rosenmüller (C11.2)
3. Inferior wall: consists of the superior surface of the soft palate (C11.3)

Note
The margin of the choanal orifices, including the posterior margin of the nasal septum, is included
with the nasal fossa.

Hypopharynx (C12, C13) (Fig. 43)

1. Pharyngo‐oesophageal junction (postcricoid area) (C13.0): extends from the level of

the arytenoid cartilages and connecting folds to the inferior border of the cricoid
cartilage, thus forming the anterior wall of the hypopharynx
2. Piriform sinus (C12.9): extends from the pharyngoepiglottic fold to the upper end of
the oesophagus. It is bounded laterally by the thyroid cartilage and medially by the
hypopharyngeal surface of the aryepiglottic fold (C13.1) and the arytenoid and cri-
coid cartilages
3. Posterior pharyngeal wall (C13.2): extends from the superior level of the hyoid bone
(or floor of the vallecula) to the level of the inferior border of the cricoid cartilage and
from the apex of one piriform sinus to the other

0004972361.INDD 27 10-13-2021 17:05:35

 28    Head and Neck Tumours

C11.0 C11.1

C11.2

Nasopharynx
C11

C11.2
C11.3

Oropharynx C10.3
C10

C13.1

Hypopharynx C12.9
C13
C13.2
C13.0

C15.0

Oesophagus
C15

Fig. 43

Regional Lymph Nodes

The regional lymph nodes are the cervical nodes.

The supraclavicular fossa (relevant to classifying nasopharyngeal carcinoma) is the tri-
angular region defined by three points:
1. the superior margin of the sternal end of the clavicle;
2. the superior margin of the lateral end of the clavicle;
3. the point where the neck meets the shoulder. This includes caudal portions of Levels
IV and V (classification according to Robbins et al.2).

2
Robbins KT, Median JE, Wolfe GT, Levine PA, Sesions RB, Pruet CW (1991) Standardizing neck
dissection terminology. Official report of the Academy’s Committee for Head and Neck Surgery and
Oncology. Arch Otolaryngol Head Neck Surg 117:601–605.

0004972361.INDD 28 10-13-2021 17:05:35

 Pharynx   29

TN Clinical Classification

Head and Neck

T – Primary Tumour

TX Primary tumour cannot be assessed

T0 No evidence of primary tumour
Tis Carcinoma in situ

Oropharynx

p16 negative cancers of the oropharynx, or oropharyngeal cancers without a p16 immu-
nohistochemistry performed

T1 Tumour 2 cm or less in greatest dimension (Fig. 44)

T2 Tumour more than 2 cm but not more than 4 cm in greatest dimension (Fig. 45)

T1 pT1

≤ 2 cm

Fig. 44

T2 pT2

> 2 to 4 cm

Fig. 45

0004972361.INDD 29 10-13-2021 17:05:36

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184 Oct
11560 Irwin W
A 27
May
831 Ingersoll Sam 3D
1
Mar
233 Johnson Jno J 45 I
29
April
463 Johnson Chas 90 C
9
April
565 Johnson Jno Cav 2G
15
April
576 Jacobs Jacob “ 2M
9
145 May
1303 Jones Wm
A 23
147 June
1595 Jones J
C 3
June
1840 Jones Wm 26 C
11
June
2108 Jones O Cav 4D
17
June
2312 Johnston Wm Art 3A
22
2593 Jones R 103 June