TNM 8 UPDATE Head and Neck SSG March

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TNM 8 UPDATE Head and Neck SSG March 2018

TNM 8 UPDATE Head and Neck SSG March 2018

TNM 8 • New stage classifications • HPV +ve oropharyngeal • Soft tissue sarcoma

TNM 8 • New stage classifications • HPV +ve oropharyngeal • Soft tissue sarcoma of head and Neck • Modification of T+N for nasopharyngeal • Modification of T for Oral SCC • Modification of N category and sub-classification into ‘non-viral’ and viral related head and neck cancers and CUP • Modification to head and neck cutaneous carcinoma • Modification of T for thyroid and age consideration

Oral SCC – T stage • Clinical and Pathological T staging same • •

Oral SCC – T stage • Clinical and Pathological T staging same • • • TX T 0 Tis T 1 T 2 • T 3 • T 4 Primary cannot be assessed No evidence of primary CIS 2 cm or less and depth of 5 mm or less 2 cm or less and depth more than 5 mm but no more than 10 mm Or more than 2 cm but not more than 4 cm and depth no more than 10 mm More than 4 cm or depth more than 10 mm (A+B) same as previous (bone invasion etc)

Clinical N stage vs Pathological for Oral SCC (applies also to other non viral)

Clinical N stage vs Pathological for Oral SCC (applies also to other non viral) • NX, N 0, N 1, same • N 1 Single ipsilateral, 3 cm or less – ve ENE • N 2 a • N 2 b • N 2 c Single ipsilateral, more than 3 cm, less than 6 cm –ve ENE Single ipsilateral, less than 3 cm, ENE +ve Multiple ipsilateral, none more than 6 cm - ve ENE Bilateral or contralateral, none more than 6 cm – ve ENE • c. N 3 • N 3 a • N 3 b More than 6 cm –ENE Single or multiple with* clinical ENE+ve • p. N 3 • N 3 a • N 3 b More than 6 cm –ve ENE More than 3 cm, ENE +ve or, multiple ipsilateral, or any contralateral or bilateral with ENE *Clinical +ve ENE- skin involvement or soft tissue invasion with deep fixation/tethering to muscle or adjacent structures or clinical signs of nerve involvement

STAGING OROPHARYNGEAL TNM 8 mandates p 16 IHC in decision making (ISH as an

STAGING OROPHARYNGEAL TNM 8 mandates p 16 IHC in decision making (ISH as an alternative)

T Staging OROPHARYNGEAL MALIGNANCY • Clinical and pathological T staging is essentially the same

T Staging OROPHARYNGEAL MALIGNANCY • Clinical and pathological T staging is essentially the same for HPV +ve and -ve • Differences: No CIS (p. Tis) in p 16 +ve p. T 4 b category removed from p 16+ve

T categories p 16 +ve vs -ve Clinical and Pathological T category for p

T categories p 16 +ve vs -ve Clinical and Pathological T category for p 16 -ve OPC (or when p 16 has not been performed) • • • TX Tis T 1 T 2 T 3 • T 4 a • T 4 b Primary tumour cannot be assessed Cis 2 cm or smaller >2 cm but not larger than 4 cm >4 cm or extension to lingual surface of epiglottis Tumour invades larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible Tumour invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base or encases carotid artery Clinical and Pathological T category for p 16+ve OPC • T 0 No primary identified • T 1 2 cm or smaller • T 2 >2 cm but not larger than 4 cm • T 3 >4 cm or extension to lingual surface of epiglottis • T 4 Tumour invades larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible or beyond

Clinical vs pathological N stage for HPV +ve Clinical N category for p 16+ve

Clinical vs pathological N stage for HPV +ve Clinical N category for p 16+ve OPC Pathological N category for p 16+ve OPC • c. Nx Regional LN cannot be assessed • p. Nx Regional LN cannot be assessed • c. N 0 No regional LN • p. N 0 No regional LN • c. N 1 Unilateral metastasis all 6 cm or less • p. N 1 Metastasis in 1 -4 nodes • c. N 2 Contralateral or bilateral LN, none larger than 6 cm • p. N 2 Metastasis in 5 or more nodes • c. N 3 LN larger than 6 cm

Clinical vs pathological TNM staging for HPV+ve OPC Clinical TNM Pathological TNM • Stage

Clinical vs pathological TNM staging for HPV+ve OPC Clinical TNM Pathological TNM • Stage 0 Tis N 0 M 0 • Stage I T 1, T 2 N 0, N 1 M 0 • Stage II T 1, T 2, N 2 M 0 • Stage II T 3 N 0, N 1, N 2 M 0 T 1, T 2 T 3 N 2 N 0, N 1 M 0 T 1 -3 N 3 M 0 T 4 Any M 0 • Stage III T 3, T 4 N 2 M 0 Any T Any N M 1 • Stage IV Any T Any N M 1 • Stage III • Stage IV A patient that presents with a 2 cm p 16+ tonsil cancer and 2 positive lymph nodes in the same side neck is stage IV in the 7 th Edition Staging Manual but will become a stage I in the 8 th Edition.

PUO/ CUP • There should be histological confirmation of SCC in a LN without

PUO/ CUP • There should be histological confirmation of SCC in a LN without identification of primary carcinoma • Histological methods should be used to identify EBV and HPV/p 16 related tumours (EBV vs HPV CUP) • If there is evidence of EBV use the nasopharyngeal classification • If there is evidence of HPV and +ve p 16 use the p 16 positive oropharyngeal classification

Non viral CUP STAGING (EBV or HPV/p 16 –ve) • T 0 category only

Non viral CUP STAGING (EBV or HPV/p 16 –ve) • T 0 category only • c. N and p. N same as ‘non viral’ neck • Stage III T 0 N 1 M 0 • Stage IVA T 0 N 2 M 0 • Stage IVB T 0 N 3 M 0 • Stage IVC T 0 N 1, N 2, N 3 M 1

HPV/p 16 +ve CUP Clinical TNM • All T 0 • N 1 Uilateral

HPV/p 16 +ve CUP Clinical TNM • All T 0 • N 1 Uilateral in cervical node(s), all 6 cm or less • N 2 Contralateral or bilateral in cervical LN all 6 cm or less • N 3 Metastasis greater than 6 cm • • Stage I T 0 N 1 M 0 Stage II T 0 N 2 M 0 Stage III T 0 N 3 Stage IV T 0 N 1 -3 Pathological TNM • There is no p. T category • p. N 1 Metastasis in 1 -4 LN(s) • p. N 2 Metastasis in 5 or more LN(s) • Stage I T 0 N 1 M 0 • Stage II T 0 N 2 M 0 M 1 • Stage IV T 0 N 1, N 2 M 1

EBV +VE CUP Clinical and pathological the same • T 0 • N 1

EBV +VE CUP Clinical and pathological the same • T 0 • N 1 • N 2 • N 3 No primary tumour Unilateral in cervical node(s) and /or unilateral or bilateral in retropharyngeal, 6 cm or less, above caudal border of cricoid cartilage Bilateral in cervical node(s), 6 cm or less above the caudal border of cricoid cartilage Cervical nodes greater than 6 cm and/or extension below the caudal border of cricoid TNM • • Stage III Stage IVA Stage IVB T 0 T 0 N 1 N 2 N 3 N 1 -3 M 0 M 0 M 1