1. The document discusses changes to the TNM staging system for head and neck cancers, including nasopharynx, oropharynx, and oral cavity cancers. 2. Key changes include incorporating depth of invasion instead of tumor thickness for oral cavity cancers, and adding extra-nodal extension as a prognostic variable for nodal metastases. 3. For oropharynx cancers, HPV-positive and HPV-negative cancers now have different N category classifications, with HPV-positive cancers not including N3a/N3b categories.

1. ddr
SEMINAR - Dr. Abhijeet Singh, AIIMS

4. Union for International Cancer
Control

5. Overview:
Changes to the T categories in nasopharynx, oropharynx and
oral cavity (DOI & PNI)
Alterations in N category in oropharynx/nasopharynx
Addition of extra-nodal extension (ENE) by tumor in a
metastatic lymph node (N category)

6. th
Oral cavity: 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
6 edition – DOI has been recorded and available for analysis.
 DOI is distinct from tumor thickness.

7. 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.

8. ….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.

9. 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.

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

13. 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.

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

18. ….cENE positive status?
 Clinical staging of ENE is determined by physical examination:
e.g.
1 invasion of skin,
1 infiltration of musculature/dense tethering to adjacent
structures, or
1 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

19. 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.
….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

20. OROPHARYNX

21. • T Classification:
HPV positive Ca Oropharynx
Largely unchanged except:
– Carcinoma in situ (Tis) removed
– T4b removed
• N Classification:
Difference between clinical and pathologic staging
– Clinical staging based on laterality and size of nodes
– Pathologic staging based on number of nodes
ENE NOT INCLUDED
•M Classification: Unchanged
•Overall Stage: Drastic Change
– Stage IV reserved for M1 disease

22. Unique characteristic of HPV +ve / -ve

23. (no N3a/N3b in HPV
positive)

26. HPV negative Ca Oropharynx
• TClassification:
• -Unchanged except T0removed
• NClassification:
• -Unchanged with the exception of Extra Nodal Extension(ENE)
• -N3 divided into N3aandN3b
• -N3a, lymph node >6cmin dimension, noENE
• -N3b, anyENE
• M Classification:Unchanged
• Overall Stage:Unchanged
• –ENEnow N3b sohigher proportion of patients in stageIVbgroup

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

29. 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)
1 It is a static system and stages patients only at the
time of initial diagnosis
1 The TNM system does not include ‘response to
therapy’and thus is not dynamic.

30. 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

31. TAKE HOME..

35. Thank you …………