The document summarizes key changes in the 8th edition of the American Joint Committee on Cancer (AJCC) head and neck cancer staging manual. It notes changes to the T categories for nasopharynx, oral cavity and skin cancers to incorporate depth of invasion. It also includes the addition of extra-nodal extension to the N category for lymph node metastases. The summary highlights limitations of the TNM system and discusses the future of incorporating additional prognostic factors into cancer staging to improve accuracy and predictive ability.

1. Good morning

4. Union for International Cancer
Control

5. INTRODUCTION
 Assigning the proper clinical and pathological stage is one of the
key activities for clinicians caring for those afflicted with cancer.
 Staging is based on anatomic and non-anatomic criteria to assist
in estimating prognosis and planning treatment.

6. Background on the AJCC Head and Neck Task Force
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balance between
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high predictive
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7. OVERVIEW
1. Changes to the T categories in nasopharynx, oral cavity and
skin(DOI & PNI)
2. Alterations in N category in nasopharynx
3. Addition of extra-nodal extension (ENE) by tumor in a
metastatic lymph node (N category)

8. Changes to the T category
 The T category acknowledges the different biological behavior
of deeply invasive but small tumors and incorporates depth of
invasion (DOI)
 Recent data: DOI >>> tumor thickness
 6th edition – DOI has been recorded and available for analysis.
 DOI is distinct from tumor thickness.

9. Assessing DOI by clinical examination
 Clinicians will need to distinguish a thick, exophytic, but less
invasive tumor from one that is ulcerated and deeply invasive
through careful palpation, supplemented by radiographic
assessment.

10. ….change
 Staging will no longer depend solely upon the greatest surface
dimension.
 For every 5mm increase in DOI, both cT and pT categories
will increase one level.

11. Pathologically, DOI is measured from the level of the basement
membrane of the closest adjacent normal mucosa. A ‘PLUMB
LINE’ is dropped from this plane to the deepest point of tumor
invasion.

13. Key point
• Tumor thickness underestimates aggressive potential
• DOI is superior to tumor thickness

16. ENE in N categorization
 ENE has been added as a prognostic variable for regional
lymph node metastases in addition to the number and size
of metastatic lymph nodes.

17. ….problem with stage migration
 Current imaging modalities have significant limitations
and lack sensitivity and specificity in their ability to
identify early or minor ENE.
What is Stage migration…..??

21. ….cENE positive status?
 Clinical staging of ENE is determined by physical examination:
e.g.
1. invasion of skin,
2. infiltration of musculature/dense tethering to adjacent
structures, or
3. Dysfunction of cranial nerve, the brachial plexus, the
sympathetic trunk, or phrenic nerve
 and supported by radiological evidence, should be present to
assign a status of ENE-positive

22. ….pENE positive status?
 Pathological ENE is defined as extension of metastatic carcinoma
from within a lymph node through the fibrous capsule and into
the surrounding connective tissue, regardless of the presence of
stromal reaction.
 Pathological ENE can be minor or major extension.
 Metastatic carcinoma that stretches the capsule but does not breach
it does not constitute ENE
Minor ENE (ENEmi)
defined as extension of
≤2mm from the capsule
Major ENE (ENEma)
defined as either extension apparent to
pathologist naked eye or
>2mm beyond the capsule microscopically.

23. Conclusion……..
 The 8th edition head and neck AJCC cancer staging manual
incorporates significant changes which include:
1. A separate staging algorithm for HPV-assosiated cancer of the
oropharynx.
2. Changes to the tumor T categories in the nasopharynx, oral
cavity, and skin.
3. And addition of tumor ENE to the lymph node category for
most sites.

24. How good is this update?
1. Inherent drawbacks of the TNM staging
2. Future of cancer staging
3. When applied to Indian scenario ….!!

25. Drawbacks of TNM system
 Is it workable ?????– YES
1. But the TNM system takes into consideration only
the anatomic factors of the tumor, and not patient
related factors such as smoking, alcohol, pulmonary
status, general medical condition (life style and
comorbidities)
2. It is a static system and stages patients only at the
time of initial diagnosis
3. The TNM system does not include ‘response to
therapy’ and thus is not dynamic.

26. Future directions
Incorporation of TNM and other tumor parameters such as
 histo-morphological features,
 molecular markers,
 Non-anatomic prognostic factors,
 life style and comorbidities
 response to therapy.
 Dynamic Personalized Prognostic Nomograms

32. Staging
 It is a continuously evolving and dynamic process
incorporating new and valid information to improve
accuracy and predictive power.
 Frequency of revision: previous update -2010
 Too frequent revisions: Not be able to generate
comparative data, to show outcomes of the disease and
therapy
 On the other hand new discoveries and new knowledge
must be incorporated to continually improve
 Compromise between ‘ideal’ and ‘practical’

33. References
 Lydiatt, W., Patel, S., O'Sullivan, B., Brandwein, M., Ridge, J.,
Migliacci, J., Loomis, A. and Shah, J. (2017). Head and neck
cancers-major changes in the American Joint Committee on
cancer eighth edition cancer staging manual. CA: A Cancer
Journal for Clinicians, 67(2), pp.122-137.
 Groome P, Schulze K, Boysen M, Hall S, Mackillop W. A
comparison of published head and neck stage groupings in
carcinomas of the oral cavity. Head & Neck. 2001;23(8):613-624.
 Pai P, Tuljapurkar V, Dhar H, Mishra A, Chakraborti S,
Chaturvedi P. The Indian scenario of head and neck oncology -
Challenging the dogmas. South Asian Journal of Cancer.
2016;5(3):105.

34. Thank you …………