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5 TNM STAGING .pptx
1. TNM STAGING
DR DAVIS NADAKKAVUKARAN
M.D.S.
ORAL AND MAXILLOFACIAL SUEGEON
MALABAR DENTAL COLLEGE MANOOR
2. • TNM staging system was first reported by Pierre
Dernoix in 1940’s
• The international union against cancer eventually
adapted the system and compiled first edition of
the TNM staging system in 1968 for 23 body sites
• Simply an anatomical staging system that
describes the anatomic extend of the primary
tumor as well as the involvement of regional
lymph nodes and distant metastasis
3. • Tumor size and extend of spread are
considered to be the best indicators of the
patient’s prognosis
• This system has three basic clinical features:
– Size of primary lesion
– Presence, number, size, and spread to the local
lymph nodes
– Presence or absence of distant metastasis
4. T- staging
SIZE OF PRIMARY TUMOUR
Tx - primary lesion cannot be assessed
T0 – no evidence of primary lesion
Tis – carcinoma in situ
T1 – lesion 2cm or less in greatest diameter
T2 – lesion >2cm but <4cm in the greatest dia
T3 – lesion >4cm in greatest diameter
T4 – divided into
– T4 A – lesion invades through cortical bone, into deep/extrinsic
muscles of tongue, maxillary sinus or skin of face
– T4 B – lesion invades masticatory space, pterygoid plates, or skull base
and/or encase internal carotid artery
5.
6. N – staging
REGIONAL LYMPH NODES
Nx – regional LN cannot be assessed
No – no regional LN metastasis
N1 – metastasis to a single ipsilateral LN >3cm in diameter
N2 A – metastasis to a single ipsilateral node, >3cm but not
more than 6cm in greatest dia
N2 B – metastasis in multiple ipsilateral nodes none more
than 6cm in dia
N2 C – metastasis in bilateral or contralateral nodes, none
more than 6cm in greatest dia
N3 – metastasis in lymph node more than 6cm in greatest dia
Midline nodes are considered ipsilateral nodes
10. MANAGMENT
• Treatment depends on the stage of cancer at
diagnosis:
Early stage oral cancer: stage I and II - single
modality treatment
Locally advanced and operable cancers : stage III
and IV A – treated with combined modality
treatment
11. Early stage:
• Radiotherapy : brachytherapy or external
beam radiotherapy
– In brachytherapy, radiation is administered
interstitially through catheters surgically placed
across the lesion
– spares normal tissue such as bone , salivary
gland, and spinal cord
– ideal lesion should be less than 3 cm, superficial
invasion not close to the bone
12. • Surgical technique of early lesion:
1. Margins : all lesions should be excised with a
margin of atleast 1cm in all dimension.
2. Modality used : excision can be done using
the cautery, laser or knife
13. • Approaches to oral cavity:
1. Peroral – restricted to anteriorly placed lesion
2. Lipsplit – to raise a cheek flap for posteriorly
based gingivobuccal complex lesions and for
performing marginal mandibulectomy
3. Pull through approach : tongue and floor of
mouth lesion
4. Mandibulotomy - tongue and floor of mouth
close to mandible
14. • Marginal mandibulectomy :
– involves removal of rim of mandible
– Lesion reaching close to mandible
– Lesion superficially eroding bone
– A margin of .5 to 1cm of the mandible should be
preserved
17. Node
negative
Early
cancer
T1, T2
Elective neck dissection: observe
Elective neck dissection preferred if :
T2 cancer
Poor follow up
Poor prognostic variables
Thick tumor >4mm
If removal of primary tumor need to
raise a check flap
Locally
advanced
T3, T4
Treatment of neck
mandatory
High chance of
metastasis
Surgery for neck
•Selective neck
dissection(I to III)
•Modified neck
dissection(I to V)
•Never perform
