1. TNM 8 UPDATE Head and Neck SSG March 2018

2. 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

3. 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)

4. 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

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

6. 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

7. 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

8. 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

9. Clinical vs pathological TNM staging for HPV+ve OPC
Clinical TNM
Stage 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.

10. 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

11. 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

12. 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

13. 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