To remember TNM staging is important for residents engaged in multidisciplinary tumour clinics. This slide provides a brief insight into the TNM staging of some common head & neck cancer. I have tried to make the staging concise and easy to remember for you guys. Hope it helps you all.

1. HEAD & NECK
CANCER STAGING
Dr Utkal Mishra

2. Lets start with some Q&A…
• Head, and Neck Cancer Awareness Month
Ans: April
• Thyroid Cancer Awareness Month
Ans: September
• World No-Tobacco Day
Ans: May 31st
• World cancer day
Ans: February 4th
• How common is Head and Neck Squamous Cell Carcinoma (HNSCC) worldwide
Ans: 16th

3. Q&A
• What is Stage 0 ?
Ans: TisN0M0
• Occult primary is T0 or Tx ?
Ans: T0
• Midline nodes are ipsilateral or contralateral ?
Ans: Ipsilateral (except for thyroid)
• What are sentinel nodes ?
Ans: First nodes directly draining lymph from the primary tumor.

4. Q&A
• Case of MDSCC of left lateral border of tongue [cT1N1M0] underwent WLE + MRND. Final HPE report revealed tumor
size of 2 x 2 cm with ipsilateral positive lvl II node of size 2 cm with ENE. Mention p staging.
Ans: p T1N2aM0
• Micro metastases ?
Ans: ≤ 2 mm deposits in HPE. Labelled as pN1(mi), pN2b(mi), or pN2c(mi)
• For assessment of pN, minimum lymph node yield for Selective ND & Comprehensive ND is ?
Ans: 15, 22
• Tumour Margins ?
Ans: >5mm is clear, 1–5mm is close and <1mm is positive.

5. William Stewart Halsted
First to theorize that cancer progression followed an
orderly stepwise process beginning from the
primary tumor formation to distant metastases,
passing through regional lymph nodes, using breast
cancer as an example.

6. Pierre Denoix
Originator of TNM classification

7. HISTORY OF TNM
 To study the validity of the TNM system, the International Union Against Cancer (UICC) appointed a TNM Committee in
1954.
 Similarly, in the USA, the American Joint Committee for Cancer Staging and End Results Reporting (AJCC) was appointed.
 Both the UICC and the AJCC met on January 9, 1959, to initiate a cancer staging system.
 First edition of the TNM cancer staging manual was published in 1977 which included only some sites of cancer.
 The second edition of the cancer staging manual was published in 1983, where several other sites of cancer were added.
 The most recently published 8th Edition is a single staging system approved and accepted by both UICC and AJCC.

8. Why to stage ?
• Extent of disease
• Prognosis
• Appropriate selection of treatment
• Comparison of outcomes of therapy

9. Extent of tumour
T1: Tumor confined to site
T2: Early local spread
T3: Locally invasive tumour
T4a: Regional spread
T4b: Involvement of skull base, pterygoids, ICA, prevertebral fascia, mediastinum.

10. ORAL CAVITY
&
LIP

11. Subsites
Lip
1. External upper lip (vermilion border)
2. External lower lip (vermilion border)
3. Commissures
Oral Cavity
1. Buccal mucosa
a. Mucosa of upper and lower lips
b. Cheek mucosa
c. Retromolar trigone
d. Bucco alveolar sulci, upper and lower (vestibule of mouth)
2. Upper alveolus and gingiva (upper gum)
3. Lower alveolus and gingiva (lower gum)
4. Hard palate
5. Tongue
a. Dorsal surface and lateral borders anterior to vallate papillae (anterior two thirds)
b. Inferior (ventral) surface
6. Floor of mouth

12. Definitions
• Oral Cavity:
Extends from the portion of the lip that contacts the opposed lip (wet mucosa) to the junction of the hard
and soft palate above, to the line of circumvallate papillae below, and to the anterior tonsillar pillars laterally.
• Mucosal Lip:
It begins at the junction of the wet and dry mucosa of the lip and extends posteriorly into the oral cavity to
the attached gingiva of the alveolar ridge.
• Buccal Mucosa:
Junction of wet & dry mucosa of lip to the line of attachment of mucosa of the alveolar ridge (upper and
lower) and pterygomandibular raphe.
• Retromolar Trigone:
Attached mucosa overlying the ascending ramus of the mandible from the level of the posterior surface of
the last lower molar tooth to the apex superiorly, adjacent to the tuberosity of the maxilla.

13. • Floor of the Mouth:
Extends from the inner surface of the lower alveolar ridge to the undersurface of the tongue. Its
posterior boundary is the base of the anterior pillar of the tonsil.
• Anterior Two-Thirds of the Tongue:
Extends anteriorly from the line of circumvallate papillae to the undersurface of the tongue at the
junction with the floor of the mouth. It is composed of four areas: the tip, the lateral borders, the
dorsum, and the under surface of tongue.
• DOI:

14. T Staging
T1 - Tumor ≤ 2 cm and DOI ≤ 5 mm
T2 - Tumor ≤ 2 cm and DOI 5 mm - 10 mm or Tumor 2 - 4 cm and DOI < 10 mm
T3 - Tumor > 4 cm or DOI > 10 mm
T4a (Lip) - Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth,
or skin (of the chin or the nose)
T4a (Oral cavity) Tumor invades through the cortical bone of the mandible or
maxillary sinus, or invades the skin of the face
T4b (Lip and oral cavity) Tumor invades masticator space / pterygoid plates / skull base/ encases ICA.

15. T4a

16. T4b

17. N Staging
N1 : Metastasis in a single ipsilateral lymph node, ≤ 3 cm
N2 :
N2a - Metastasis in a single ipsilateral lymph node, 3 cm - 6 cm
N2b - Metastasis in multiple ipsilateral lymph nodes, < 6 cm
N2c - Metastasis in bilateral or contralateral lymph nodes, < 6 cm
N3 :
N3a - Metastasis in a lymph node > 6 cm without extra nodal extension
N3b - Metastasis in a single or multiple lymph nodes with clinical extra nodal extension
 skin involvement
 nerve involvement
 deep fixation

18. Pathological N staging
N1 : Metastasis in a single ipsilateral lymph node, ≤ 3 cm, no ENE
N2 :
N2a - Metastasis in a single ipsilateral lymph node ≤ 3 cm with ENE
Metastasis in a single ipsilateral lymph node, 3 cm - 6 cm, no ENE
N2b - Metastasis in multiple ipsilateral lymph nodes, < 6 cm , no ENE
N2c - Metastasis in bilateral or contralateral lymph nodes, < 6 cm , no ENE
N3 :
N3a - Metastasis in a lymph node > 6 cm without extra nodal extension
N3b - Metastasis in a single node > 3 cm with ENE or multiple ipsilateral/Bilateral/contralateral nodes with ENE

19. Staging
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1, T2, T3 N1 M0
Stage IVA T4a N0, N1 M0
T1, T2, T3, T4a N2 M0
Stage IVB Any T N3 M0
T4b Any N M0
Stage IVC Any T Any N M1

20. Follow-up schedule for Head & Neck Ca

21. 5 year survival rates

22. Limitations of T staging
• Larynx
• Alveolus
• Maxillary ca with palate erosion vs oral ca

23. Limitations of N staging
• Clinical examination: Interobserver variations
• Level of node involvement
• Bilateral or contralateral disease are labelled as N2

24. PHARYNX

25. Sites & Subsites
Oropharynx
1. Anterior wall (glosso epiglottic area)
a. Base of tongue (posterior to the vallate
papillae or posterior third)
b. Vallecula
2. Lateral wall
a. Tonsil
b. Tonsillar fossa and tonsillar (faucial) pillars
c. Gloss tonsillar sulci (tonsillar pillars)
3. Posterior wall
4. Superior wall
a. Inferior surface of soft palate
b. Uvula
Nasopharynx
1. Posterosuperior wall: extends from the
level of the junction of the hard and soft
palate to the base of the skull
2. Lateral wall: including the fossa of
Rosenmüller
3. Inferior wall: consists of the superior
surface of the soft palate
Hypopharynx
1. Pharyngo oesophageal junction
(postcricoid area)
2. Piriform sinus
3. Posterior pharyngeal wall

26. T staging OROPHARYNX
T1: Tumor ≤ 2 cm
T2: Tumor 2 cm - 4 cm
T3: Tumor > 4 cm or extension to lingual surface of epiglottis
T4a: Tumor invades any of the following: larynx,
deep/extrinsic muscle of tongue, medial pterygoid, hard
palate, or mandible
T4b: Tumor invades any of the following: lateral pterygoid
muscle, pterygoid plates, lateral nasopharynx, skull base; or
encases carotid artery
T1: Tumor ≤ 2 cm
T2: Tumor 2 cm - 4 cm
T3: Tumor > 4 cm or extension to lingual surface of epiglottis
T4: Tumor invades any of the following: larynx, deep/extrinsic
muscle of tongue, medial pterygoid, hard palate, mandible,
lateral pterygoid muscle, pterygoid plates, lateral
nasopharynx, skull base; or encases carotid artery
P16 negative P16 positive

27. N staging
N1: Ipsilateral lymph node(s) ≤ 6 cm
N2: Contralateral or bilateral lymph node(s) ≤ 6 cm
N3: Metastasis in lymph node(s) > 6 cm
N1 : Metastasis in a single ipsilateral lymph node, ≤ 3 cm
N2 :
N2a - Metastasis in a single ipsilateral lymph node, 3 cm - 6
cm
N2b - Metastasis in multiple ipsilateral lymph nodes, < 6 cm
N2c - Metastasis in bilateral or contralateral lymph nodes, < 6
cm
N3 :
N3a - Metastasis in a lymph node > 6 cm without extra nodal
extension
N3b - Metastasis in a single or multiple lymph nodes with
clinical extra nodal extension
 skin involvement
 nerve involvement
 deep fixation
P16 negative P16 positive
pN1: Metastasis in 1 to 4 lymph node(s)
pN2: Metastasis in 5 or more lymph node(s)
pN staging P16 positive

28. TNM Staging
Clinical
Stage 0 Tis N0 M0
Stage I T1, T2 N0, N1 M0
Stage II T1, T2 N2 M0
T3 N0, N1, N2 M0
Stage III T1, T2, T3 N3 M0
T4 Any N M0
Stage IV Any T Any N M1
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1, T2, T3 N1 M0
Stage IVA T4a N0, N1 M0
T1, T2, T3, T4a N2 M0
Stage IVB Any T N3 M0
T4b Any N M0
Stage IVC Any T Any N M1
Pathological
Stage 0 Tis N0 M0
Stage I T1, T2 N0, 1 M0
Stage II T1, T2 N2 M0
T3 N0, N1 M0
Stage III T3, T4 N2 M0
Stage IV Any T Any N M1
P16 negative P16 positive

29. Nasopharynx
T1: Tumor confined to nasopharynx, or extends to oropharynx
and/or nasal cavity without parapharyngeal involvement
T2: Tumor with extension to parapharyngeal space and/or
infiltration of the medial pterygoid, lateral pterygoid, and/or
prevertebral muscles
T3: Tumour invades bony structures of skull base cervical
vertebra, pterygoid structures, and/or paranasal sinuses
T4: Tumor with intracranial extension and/or involvement of
cranial nerves, hypopharynx, orbit, parotid gland and/or
infiltration beyond the lateral surface of the lateral pterygoid
muscle
N1: Unilateral metastasis, in cervical lymph node(s),
and/or unilateral or bilateral metastasis in
retropharyngeal lymph nodes, ≤ 6 cm above the caudal
border of cricoid cartilage
N2 Bilateral metastasis in cervical lymph node(s), ≤ 6
cm above the caudal border of cricoid cartilage
N3 Metastasis in cervical lymph node(s) > 6 cm
and/or extension below the caudal border of cricoid
cartilage

30. TNM Staging Nasopharynx
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T1 N1 M0
T2 N0, N1 M0
Stage III T1, T2 N2 M0
T3 N0, N1, N2 M0
Stage IVA T4 N0, N1, N2 M0
Any T N3 M0
Stage IVB Any T Any N M1

31. Hypopharynx
T1 Tumor limited to one subsite of hypopharynx and/or ≤ 2 cm
T2 Tumor invades more than one subsite of hypopharynx or an adjacent site, or measures 2 cm - 4 cm, without
fixation of hemi larynx
T3 Tumor > 4 cm, or with fixation of hemi larynx or extension to oesophagus
T4a Tumor invades any of the following: thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, central
compartment soft tissue
T4b Tumour invades prevertebral fascia, encases carotid artery, or invades mediastinal
structures

32. LARYNX

33. Sites & Subsites
A. Supraglottis
• Suprahyoid epiglottis (tip, lingual and laryngeal surfaces)
• Infrahyoid epiglottis
• Aryepiglottic folds (laryngeal aspect only)
• Arytenoids
• Ventricular bands (or false cords)
B. Glottis
• Vocal cords
• Anterior commissure
• Posterior commissure
C. Subglottis - extends from the lower limit of the glottis to the lower border of the cricoid cartilage.

34. LARYNX
Supraglottis Glottis Subglottis
T1 Tumor limited to one subsite of supraglottis with normal vocal
cord mobility
Tumour limited to vocal cord(s) (may involve anterior or posterior
commissures) with normal mobility.
Tumour limited to the subglottis.
T2 Tumor invades mucosa of more than one adjacent subsites of
supraglottis or glottis or region outside the supraglottis (e.g.,
mucosa of base of tongue, vallecula, medial wall of pyriform sinus)
without fixation of the larynx.
Tumour extends to supraglottis and/or sub glottis, and/or with
impaired vocal cord mobility.
Tumour extends to vocal cord(s) with normal or
impaired mobility.
T3 Tumor limited to larynx with vocal cord fixation and/or invades
any of the following: post cricoid area, pre-epiglottic tissues,
paraglottic space and/or minor thyroid cartilage invasion.
Tumour limited to the larynx with vocal cord fixation and/or
invades paraglottic space and/or minor thyroid cartilage erosion.
Tumour limited to larynx with vocal cord fixation.
T4a Tumor invades through the thyroid cartilage and/or invades
tissues beyond the larynx (e.g., trachea, soft tissues of neck
including deep extrinsic muscle of tongue, strap muscles, thyroid
or esophagus).
Tumour invades through thyroid cartilage and/or invades tissues
beyond the larynx (e.g., trachea, soft tissues of neck including deep
extrinsic muscles of the tongue, strap muscles, thyroid, or
oesophagus).
Tumour invades cricoid or thyroid cartilage and/or
invades tissues beyond the larynx (e.g., trachea,
soft tissues of neck including deep extrinsic muscle
of tongue, strap muscles, thyroid or oesophagus).
T4b Tumor invades prevertebral space, encases carotid artery or
invades mediastinal structures.
Tumour invades prevertebral space, encases carotid artery or
invades mediastinal structures.
Tumour invades prevertebral space, encases
carotid artery or invades mediastinal structures.

35. THANK YOU