TNM 8 UPDATE Head and Neck SSG March 2018

TNM 8 New stage classifications Modification of T+N for nasopharyngeal HPV +ve oropharyngeal Soft tissue sarcoma of head and Neck Modification of T+N for nasopharyngeal Modification of T for Oral SCC Modification of N category and sub-classification into ‘non-viral’ and viral related head and neck cancers and CUP Modification to head and neck cutaneous carcinoma Modification of T for thyroid and age consideration

Oral SCC – T stage Clinical and Pathological T staging same TX Primary cannot be assessed T0 No evidence of primary Tis CIS T1 2cm or less and depth of 5mm or less T2 2cm or less and depth more than 5mm but no more than 10mm Or more than 2cm but not more than 4cm and depth no more than 10mm T3 More than 4cm or depth more than 10mm T4 (A+B) same as previous (bone invasion etc)

Clinical N stage vs Pathological for Oral SCC (applies also to other non viral) NX, N0, N1, same N1 Single ipsilateral, 3cm or less – ve ENE N2 N2a Single ipsilateral, more than 3cm, less than 6cm –ve ENE Single ipsilateral, less than 3cm, ENE +ve N2b Multiple ipsilateral, none more than 6cm - ve ENE N2c Bilateral or contralateral, none more than 6cm – ve ENE cN3 N3a More than 6cm –ENE N3b Single or multiple with* clinical ENE+ve pN3 N3a More than 6cm –ve ENE N3b More than 3cm, ENE +ve or, multiple ipsilateral, or any contralateral or bilateral with ENE *Clinical +ve ENE- skin involvement or soft tissue invasion with deep fixation/tethering to muscle or adjacent structures or clinical signs of nerve involvement

STAGING OROPHARYNGEAL TNM8 mandates p16 IHC in decision making (ISH as an alternative)

T Staging OROPHARYNGEAL MALIGNANCY Clinical and pathological T staging is essentially the same for HPV +ve and -ve Differences: No CIS (pTis) in p16 +ve pT4b category removed from p16+ve

T categories p16 +ve vs -ve Clinical and Pathological T category for p16-ve OPC (or when p16 has not been performed) TX Primary tumour cannot be assessed Tis Cis T1 2cm or smaller T2 >2cm but not larger than 4cm T3 >4cm or extension to lingual surface of epiglottis T4a Tumour invades larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible T4b Tumour invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base or encases carotid artery Clinical and Pathological T category for p16+ve OPC T0 No primary identified T1 2cm or smaller T2 >2cm but not larger than 4cm T3 >4cm or extension to lingual surface of epiglottis T4 Tumour invades larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible or beyond

Clinical vs pathological N stage for HPV +ve Clinical N category for p16+ve OPC cNx Regional LN cannot be assessed cN0 No regional LN cN1 Unilateral metastasis all 6cm or less cN2 Contralateral or bilateral LN, none larger than 6cm cN3 LN larger than 6cm Pathological N category for p16+ve OPC pNx Regional LN cannot be assessed pN0 No regional LN pN1 Metastasis in 1-4 nodes pN2 Metastasis in 5 or more nodes

Clinical vs pathological TNM staging for HPV+ve OPC Clinical TNM 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 T1-3 N3 M0 T4 Any M0 Stage IV Any T Any N M1 Pathological TNM Stage 0 Tis N0 M0 Stage I T1,T2 N0,N1 M0 Stage II T1,T2 N2 M0 T3 N0,N1 M0 Stage III T3,T4 N2 M0 Stage IV Any T Any N M1 A patient that presents with a 2 cm p16+ tonsil cancer and 2 positive lymph nodes in the same side neck is stage IV in the 7th Edition Staging Manual but will become a stage I in the 8th Edition.

PUO/ CUP There should be histological confirmation of SCC in a LN without identification of primary carcinoma Histological methods should be used to identify EBV and HPV/p16 related tumours (EBV vs HPV CUP) If there is evidence of EBV use the nasopharyngeal classification If there is evidence of HPV and +ve p16 use the p16 positive oropharyngeal classification

Non viral CUP STAGING (EBV or HPV/p16 –ve) T0 category only cN and pN same as ‘non viral’ neck Stage III T0 N1 M0 Stage IVA T0 N2 M0 Stage IVB T0 N3 M0 Stage IVC T0 N1,N2,N3 M1

HPV/p16 +ve CUP Pathological TNM There is no pT category Clinical TNM All T0 N1 Uilateral in cervical node(s), all 6cm or less N2 Contralateral or bilateral in cervical LN all 6cm or less N3 Metastasis greater than 6cm Stage I T0 N1 M0 Stage II T0 N2 M0 Stage III T0 N3 M0 Stage IV T0 N1-3 M1 Pathological TNM There is no pT category pN1 Metastasis in 1-4 LN(s) pN2 Metastasis in 5 or more LN(s) Stage I T0 N1 M0 Stage II T0 N2 M0 Stage IV T0 N1,N2 M1

EBV +VE CUP TNM Clinical and pathological the same Stage II T0 N1 M0 T0 No primary tumour N1 Unilateral in cervical node(s) and /or unilateral or bilateral in retropharyngeal, 6cm or less, above caudal border of cricoid cartilage N2 Bilateral in cervical node(s), 6cm or less above the caudal border of cricoid cartilage N3 Cervical nodes greater than 6cm and/or extension below the caudal border of cricoid TNM Stage II T0 N1 M0 Stage III T0 N2 M0 Stage IVA T0 N3 M0 Stage IVB T0 N1-3 M1