The document discusses TNM staging for oral cancer. TNM staging classifies tumors based on the size of the primary tumor (T stage), presence of lymph node metastasis (N stage), and distant metastasis (M stage). Treatment depends on the cancer stage - early stage cancers are generally treated with single modality like surgery or radiation, while locally advanced or operable stage III/IV cancers receive combined modality treatment like surgery followed by radiation and/or chemotherapy. Management of neck lymph nodes also depends on whether they are clinically positive or negative.

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

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

8. M- staging
DISTANT METASTASIS
Mx – distant metastasis cannot be assessed
M0 – no distant metastasis
M1 – distant metastasis present

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

15. Locally
advanced
Operable
III/IV A
Surgery followed
by radiotherapy
with or without
chemotherapy
Inoperable
IV B/ IV C
Palliative CT/RT
Palliative RT/CT
Symptomatic care

16. Management of neck lymph nodes

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

18. Node positive
Modified neck
dissection
Radical neck
dissection

19. Stage III and IV
High risk lesions:
T4 lesion
Multiple node positive
Perinodal extension
Cut margins positive
Concurrent chemotherapy
Cisplatin-100mg/m2 3weekly or
30-40mg/m2 weekly
Low risk lesions
Radiotherapy alone
57/60 gy 30 fractions
/6 week