Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
• TNM STAGING
• INTRODUCTION
• DISCUSSION
• RESULTS
• REFERENCE ARTICLES
• CONCLUSION
• REFERENCES
SQUAMOUS CELL CARCINOMA
It is the most common malignant
epithelial tissue neoplasm of the
oral cavity.
It is derived from the stratifi ed
squamous epithelium.
Since oral squamous cell
carcinomas constitute bulk of the
oral malignancies (above 90 %) it
is thus commonly referred to as
Oral Cancer.
Rajendran, Arya, and Shivapatha Sundaram. Shafer's Textbook of Oral Pathology. 2012.
PRIMARY TUMOR [T]
T CATEGORY T CRITERIA
TX Primary tumor cannot be assessed
Tis Carcinoma in situ
Tumor< 2 cm , < 5 mm depth of invasion (DOI)
T1
DOI is depth of invasion and not tumor thickness.
Tumor < 2 cm, DOI > 5 mm and < 10 mm
T2
or tumor > 2 cm but < 4 cm, and < 10 mm DOI
T3 Tumor > 4 cm or any tumor > 10 mm DOI
T4 Moderately advanced or very advanced local disease
Moderately advanced local disease
(lip) Tumor invades through cortical bone or involves the inferior alveolar nerve, floor of mouth, or
skin of face (i.e., chin or nose).
T4a (oral cavity) Tumor invades adjacent structures only (e.g., through cortical bone of the mandible or
maxilla, or involves the maxillary sinus or skin of the face)
Note: Superficial erosion of bone/tooth socket.
(alone) by a gingival primary is not sufficient to classify a tumor as T4.
Very advanced local disease
T4b Tumor invades masticator space, pterygoid plates, or skull base and/or encases the internal carotid
artery
Gress DM, Edge SB, Greene FL, et al. Principles of cancer staging. In: Amin MB, ed. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.
REGIONAL LYMPH NODE – CLINICAL [cN]
N CATEGORY N CRITERIA
Metastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension,
N2a
and ENE(-)
N2b Metastasis in multiple ipsilateral nodes, none larger than 6 cm in greatest dimension, and ENE(-)
Metastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension, and
N2c
ENE(-)
Gress DM, Edge SB, Greene FL, et al. Principles of cancer staging. In: Amin MB, ed. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.
REGIONAL LYMPH NODE – CLINICAL [cN]
N CATEGORY N CRITERIA
N3a Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-)
A designation of “U” or “L” may be used for any N category to indicate metastasis above the lower
NOTE border of the cricoid (U) or below the lower border of the cricoid (L).
Similarly, clinical and pathological ENE should be recorded as ENE(-) or ENE(+)
Gress DM, Edge SB, Greene FL, et al. Principles of cancer staging. In: Amin MB, ed. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.
REGIONAL LYMPH NODE – PATHOLOGICAL [pN]
N CATEGORY N CRITERIA
Metastasis in a single ipsilateral lymph node- 3 cm or smaller in greatest dimension and ENE(+);
or larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-);
N2 or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and
ENE(-);
or in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension, ENE(-)
Metastasis in single ipsilateral or contralateral node 3 cm or smaller in greatest dimension and ENE(+);
N2a
or single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-)
N2b Metastasis in multiple ipsilateral nodes, none larger than 6 cm in greatest dimension and ENE(-)
Metastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension and
N2c
ENE(-)
Gress DM, Edge SB, Greene FL, et al. Principles of cancer staging. In: Amin MB, ed. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.
REGIONAL LYMPH NODE – PATHOLOGICAL [pN]
N CATEGORY N CRITERIA
N3a Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-)
Metastasis in a single ipsilateral node larger than 3 cm in greatest dimension and ENE(+);
N3b
or multiple ipsilateral, contralateral or bilateral nodes any with ENE(+)
A designation o f “U” or “L” may be used for any N category to indicate metastasis above
NOTE the lower border o f the cricoid (U) or below the lower border of the cricoid (L) Similarly,
clinical and pathological ENE should be recorded as ENE(-) or ENE(+)
Gress DM, Edge SB, Greene FL, et al. Principles of cancer staging. In: Amin MB, ed. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.
DISTANT METASTASIS
M CATEGORY M CRITERIA
M0 No distant metastasis
M1 Distant metastasis
Gress DM, Edge SB, Greene FL, et al. Principles of cancer staging. In: Amin MB, ed. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.
PROGNOSTIC STAGE GROUPS
THEN THE STAGE
WHEN T is.. AND N is.. AND M is..
GROUP is..
T1 N0 M0 I
T2 N0 M0 II
T3 N0 M0 III
T4a N0, N1 M0 IV A
ANY T N3 M0 IV B
T4b ANY N M0 IV B
ANY T ANY N M1 IV C
Gress DM, Edge SB, Greene FL, et al. Principles of cancer staging. In: Amin MB, ed. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017.
CHARACTERISTICS OF LIP AND ORAL CAVITY TUMORS
• If the lesion is ulcerated, the ulcer base serves as the reference point.
• In those cases in which the tumor was exophytic, the most perpendicular
section was measured from the tip of the papilla to the maximal depth.
• Other authors likely used the same technique, but it is not clear whether
they excluded keratin, parakeratin, and infl ammatory exudates.
• All the histologic slides were blind reviewed by expert pathologists, who
examined maximum tumor thickness, grading, and infl ammatory
reaction.
• The authors evaluated three thickness ranges (<1.5 mm, from 1.6 to
3.5 mm, and >3.6 mm ) and found a metastases incidence of 2%, 35%,
and 60%, respectively.
• They had not been selected on the basis of tumor stage, but had been
followed up for at least 24 months.
• The lack of inclusion criteria regarding tumor stage meant that they
only included seven of 87 cases with tumor thickness measuring less
than 2 mm.
• In any case, none of Brown et al’s seven patients had regional
metastases or died of disease, thus the authors suggested elective
treatment of the neck when tumor thickness measured less than 2
mm.
• They also pointed out some of the problems related to measuring
tumor thickness, the main one being the diff erence in complexity
when measuring tumor thickness in melanoma lesions (as described
by Breslow) compared with measuring thickness in mucosal tumors,
where there is often no mucosal surface on the slide to use as a
reference point.
• Moreover, only prospective studies can avoid the problems related to
the lack of strict guidelines for processing the samples and measuring
tumor thickness.
• Close et al studied 43 patients with stage II or greater
oral /oropharyngeal carcinoma who underwent resection of the
primary tumor and simultaneous neck dissection as initial treatment.
• They adopted 5 mm and 10 mm as cut off values but failed to fi nd a
link between tumor thickness and regional involvement.
• It must be pointed out that they had a very small number of early-
stage lesions, with only nine of 43 stage II tumors, and only 12 of 43
lesions measuring less than 5 mm.
• This may have reduced the impact of the tumor thickness parameter
in predicting nodal metastases.
• Morton et al reviewed the data of 26 patients treated for early-stage
tongue carcinoma.
• None had nodal clinical evidence, and the maximum diameter of the
tumor was 30 mm (T1 and T2).
• This was based on data from mixed groups of tumors of diff erent
stages from both the oral cavity and the oropharynx.
2. G r e s s D M , E d g e S B , G r e e n e F L , e t a l . P r i n c i pl e s o f c a n c e r s t a g i n g . I n : A m i n M B , e d . A J C C
C a n c e r S t a g i n g M a n u a l . 8 t h e d. N e w Yo r k , N Y: S p r i n g e r ; 2 0 1 7 .
3. Ta n W J, C h i a C l a ra m a e , Ta n H K , S o o KC , Iy e r N G . P r o g n o s t i c S i g n i fi c a n c e o f I nva s i o n D e p t h i n
O ra l To n g u e S q u a m o u s C e l l C a r c i n o m a . O R L . 2 0 1 2 ; 7 4 : 2 6 4 – 2 7 0 .
4. B e r d u g o J, T h o m p s o n L DR , P u r g i n a B , e t a l . M e a s u r i n g D e p t h o f I nva s i o n i n E a r l y S q u a m o u s
C e l l C a r c i n o ma o f t h e O ra l To n g u e : Po s i t i v e D e e p M a r g i n, E x t ra t u m o ra l Pe r i n e u ra l I nva s i o n ,
a n d O t h e r C h a l l e n g e s . H e a d N e c k Pa t h o l . 2 0 1 9 ; 1 3 ( 2 ) : 1 5 4 – 1 6 1 .
5. G h a z i N , G h a z i A , S h a fi e e S, Fay ya z i M . I m p o r t a n c e o f de p t h o f i nva s i o n i n p a t i e n t s w i t h o ra l
squamous cell carcinoma: A review article. J Orofac Sci. 2018; 10:3-6
6. M o e J, M c H u g h J B , U d a g e r A M , B ra u n T M , H e l ma n J I , Wa r d B B . I n t ra o p e ra t i v e D e p t h o f
I nva s i o n Is A c c u ra t e i n Ea r l y-S t a g e O ra l C av i t y S qu a mo u s C e l l C a r c i n o m a . J O ra l M a x i l l o f a c
Surg. 2019; 77:1704-1712.
7. C h a n g W C , C h a n g C F, L i Y H , Ya n g G Y, S u R Y, L i n C K , C h e n Y W. A h i s t o p a t h o l o g i c a l e va l u a t i o n
a n d p o t e n t i a l p r o g n o s t i c i m pl i c a t i o n s o f o ra l s q u a m o u s c e l l c a r c i n o m a w i t h a d v e r s e f e a t u r e s .
O ra l O n c o l . 2 0 1 9 A u g ; 9 5 : 6 5 - 7 3 .