Pocket Guide To TNM STAGING OF HEAD AND NECK CANCER AND NECK DISSECTION CLASSIFICATION pdf

Pocket Guide ToTNM STAGING OF HEAD AND NECK CANCER AND NECK DISSECTION CLASSIFICATION Edited by Daniel G.. Pocket Guide toNECK DISSECTION CLASSIFICATION AND TNM STAGING OF HEAD AND NECK

Pocket Guide To

TNM STAGING OF HEAD AND NECK CANCER AND NECK DISSECTION

CLASSIFICATION

Edited by Daniel G Deschler, MD Terry Day, MD

Pocket Guide to

NECK DISSECTION

CLASSIFICATION AND TNM STAGING OF HEAD AND NECK CANCER

Committee for Head and Neck Surgery

and Oncology American Academy of Otolaryngology–

Head and Neck Surgery

Neck Dissection Classification Committee American Head and Neck Society

Edited by Daniel G Deschler, MD

Terry Day, MD Primary Contributors

Library of Congress Cataloging-in-Publication Data

Pocket guide to neck dissection classification and TNM staging of head and neck cancer — 3rd ed / Committee for Head and Neck Surgery and Oncol- ogy, American Academy of Otolaryngology—Head and Neck Surgery [and] Neck Dissection Classification Committee, American Head and Neck Soci- ety; edited by Daniel G Deschler, Terry Day ; primary contributors, Anand

K Sharma, Merrill S Kies.

ISBN 978-1-56772-117-1 (pbk.)

1 Neck—Surgery—Classification—Handbooks, manuals, etc 2 Neck— Tumors—Classification—Handbooks, manuals, etc 3 Neck—Lymphatics— Handbooks, manuals, etc 4 Head—Tumors—Classification—Handbooks, manuals, etc I Deschler, Daniel G II Day, Terry A III Sharma, Anand K.

IV Kies, Merrill S V American Academy of Otolaryngology—Head and Neck Surgery Committee for Head and Neck Surgery and Oncology VI American Head and Neck Society Neck Dissection Classification Commit- tee VII American Academy of Otolaryngology—Head and Neck Surgery Foundation.

[DNLM: 1 Neck Dissection—classification—Handbooks 2 Head and Neck Neoplasms—surgery—Handbooks 3 Neoplasm Staging—classifica- tion—Handbooks WE 39 P739 2008]

RC280.N35P63 2008

616.99'491—dc22

2008022331

AMERICAN ACADEMY OF OTOLARYNGOLOGY–

HEAD AND NECK SURGERY

HEAD AND NECK SURGERY COMMITTEE

FACULTY

DEVRAJ BASU, MD PhDERIC T BECKEN, MDJOSEPH BRENNAN, MDMARION E COUCH, MD PHD

DANIEL G DESCHLER, MD

DAVID W EISELE, MDCHRISTINE G GOURIN, MD

PATRICK JOSEPH GULLANE, MD FRCS(C)

STEPHEN Y LAI, MD PhD

WILLIAM P MAGDYCZ, MD

KELLY MICHELE MALLOY, MD

JAMES P MALONE MDABBY C MEYER, MDCHERIE ANN O NATHAN MD

BRIAN NUSSENBAUM, MD

URJEET PATEL, MDCECELIA E SCHMALBACH, MD

Jesus E Medina, MDAshok R Shaha, MDPeter M Som, MDGregory T Wolf, MDAlfio Ferlito, MD

The American Head and Neck Society Committee acknowledgesthe input from the Head and Neck Surgery and Oncology Commit-tee and the Head and Neck Surgery Education Committee of theAmerican Academy of Otolaryngology–Head and Neck Surgery,and the Council of the American Head and Neck Society Appre-ciation is also extended to Douglas Denys, MD, for the illustrationsand the AJCC for the use of staging information from the 6th edi-

tion of the AJCC Cancer Stating Manual.

This monograph has been endorsed by the American Head andNeck Society and The American Academy of Otolaryngology–Head and Neck Surgery

TABLE OF CONTENTS

I Introduction 8

A Upper Aerodigestive Tract Sites 8

1 Oral Cavity 9

2 Oropharynx 9

3 Hypopharynx 10

4 Larynx 11

5 Nasopharynx 12

6 Nasal Cavity and Paranasal Sinuses 13

B Radiation Therapy and Chemotherapy 14

II American Joint Committee on Cancer (AJCC) Tumor Staging by Site 16

A Oral Cavity 16

B Oropharynx 16

C Larynx 17

D Hypopharynx 19

E Nasal Cavity and Paranasal Sinuses 20

F Salivary Glands 21

G Neck Staging Under the TNM Staging System for Head and Neck Tumors (excluding nasopharynx and thyroid) 22

H TNM Staging for the Larynx, Oropharynx, Hypopharynx, Oral Cavity, Salivary Glands, and Paranasal Sinuses 23

III AJCC Tumor Staging—Nasopharynx and Thyroid 24

A Nasopharynx 24

B Thyroid 25

IV Definition of Lymph Node Groups 29

V Conceptual Guidelines for Neck Dissection Classification 33

A Radical Neck Dissection 33

B Modified Radical Neck Dissection 34

C Selective Neck Dissection 35

D Extended Radical Neck Dissection 37

I INTRODUCTION

The tumor, node, metastasis (TNM) staging system allows clinicians

to categorize tumors of the head and neck region in a specific ner to assist with the assessment of disease status, prognosis, andmanagement All available clinical information may be used in stag-ing: physical exam, radiographic, intraoperative, and pathologicfindings, Other than histopathologic analysis, biomarkers and molec-ular studies are not yet included in the staging of head and neck can-cers

man-Three categories comprise the system: T—the characteristics of thetumor at the primary site (this may be based on size, location, orboth); N—the degree of regional lymph node involvement; and M—the absence or presence of distant metastases The specific TNM sta-tus of each patient is then tabulated to give a numerical status ofStage I, II, III, or IV Specific subdivisions may exist for each stageand may be denoted with an a, b, or c status In general, early-stagedisease is denoted as Stage I or II disease, and advanced-stage dis-ease as Stage III or IV disease Of importance is that any positivemetastatic disease to the neck will classify the disease as advanced,except in select nasopharynx and thyroid cancers

A Upper Aerodigestive Tract Sites

The majority of tumors arising in the head and neck (other than melanoma skin cancers) arise from the squamous mucosa that linesthe upper aerodigestive tract (UADT) and are predominately squa-mous cell carcinomas The UADT begins where the skin meets themucosa at the nasal vestibule and the vermillion borders of the lipsand continues to the junction of the cricoid cartilage and the cervicaltrachea and at the level of the cricoid where the hypopharynx meetsthe cervical esophagus The UADT is organized into several majorsites that are subdivided to several anatomic subsites The major sitesinclude (1) the oral cavity, (2) the oropharynx, (3) the hypopharynx,

non-(4) the larynx, (5), the nasopharynx, (6) and the nose and paranasalsinuses.

1 Oral Cavity

The oral cavity is a common site for squamous cell cancers of theUADT, probably because it is the first entry point for many carcino-gens The anterior aspect of the oral cavity is the contact point of theskin with the vermilion of the lips extending posteriorly to the junc-tion of the hard and soft palates, and with the anterior tonsillar pillarsand the circumvallate papillae forming the posterior limits Themajor subsites of the oral cavity are the lips, anterior tongue, floor ofmouth, buccal mucosa, upper and lower alveolar ridges, hard palate,and retromolar trigone The trigone consists of the mucosa overlyingthe anterior aspect of the ascending ramus of the mandible Tumors

of the oral cavity tend to spread regionally to lymph nodes of thesubmandibular region (Level I) and to the upper and middle jugularchain lymph nodes (Levels II and III)

Because of accessibility and the risk of involvement of bony tures, treatment with radiotherapy can lead to radionecrosis of themandible or maxilla Moreover, oral cavity squamous cell carcino-mas may be less sensitive to chemotherapy and radiation, relative tooropharyngeal or laryngeal cancers Thus, primary treatment formost tumors is surgical Positive surgical margins, multiple involvedlymph nodes, and/or extracapsular tumor extension call for consid-eration of postoperative chemoradiotherapy, to improve local dis-ease control

struc-2 Oropharynx

This structure begins where the oral cavity ends at the junction ofthe hard and soft palates superiorly and the circumvallate papillae in-feriorly and extends from the level of the soft palate superiorly, whichseparates it from the nasopharynx and to the level of the hyoid bone

oropharynx are the tonsil, base of tongue, soft palate, and pharyngealwalls Cancers of the oropharynx often metastasize to upper andmiddle jugular chain lymph nodes (Levels II and III), but can alsospread to retropharyngeal lymph nodes, which distinguishes themfrom oral cavity tumors and must be considered when treatingoropharyngeal cancers Tumors in this site are generally treated withradiotherapy, as a single modality for T 1/2 or N 0/1 stages Increas-ingly, some of these cancers are associated with human papillomavirus 16 infection, especially in nonsmokers However, for patientswith more advanced disease, T 3/4 or N 2 b/c/3 staging, chemora-diotherapy most often with a concomitant approach has becomestandard Cisplatin, administered during weeks 1, 4, and 7 has mostoften been studied and may be considered a standard Nonetheless,other regimens, carboplatin, taxanes, and drug combinations, such

as cisplatin or carboplatin with fluorouracil, are also reported duction chemotherapy before radiotherapy (or chemoradiotherapy)remains an investigational strategy

In-3 Hypopharynx

The hypopharynx has its superior limit at the hyoid bone, where it iscontiguous with the oropharynx and it extends inferiorly to thecricopharyngeus muscle, where it meets the cervical esophagus Themajor subsites of the hypopharynx are the pyriform sinuses, the post-cricoid region, and the pharyngeal walls Tumors often present here atadvanced stages and can be difficult to cure, and because of their lo-cation can impact swallowing and speech function adversely Spread

to the upper, middle, and lower jugular lymph nodes (Levels II–IV) andthe retropharyngeal nodes is common in these cancers Two other hall-marks of hypopharyngeal cancers are submucosal spread and skipareas of spread Surgery had been the mainstay of primary treatment forhypopharyngeal cancers for many years, but increasingly radiotherapyand chemoradiotherapy are used to treat cancers in this location withsuccess

4 Larynx

The larynx is the most complex of the mucosal lined structures ofthe UADT Its important roles in speech, swallowing, and airwayprotection make the treatment considerations of cancers of this struc-ture varied and controversial The larynx is bordered by the orophar-ynx superiorly, the trachea inferiorly, and the hypopharynx laterallyand posteriorly The larynx is comprised of a cartilaginous frame-work, and is subdivided vertically by the vocal cords into the supra-glottic, glottic, and subglottic subsites The supraglottic larynxincludes the epiglottis, which has both lingual and laryngeal sur-faces, the false vocal cords, the arytenoids cartilages, and thearyepiglottic folds Anterior to the supraglottis is the pre-epiglotticspace This is a complex space with a rich lymphatic network thatcontributes to the early and bilateral spread of tumors that arise fromsupraglottic structures to upper, middle, and lower jugular chainlymph nodes

The glottic larynx describes the true vocal cords, and where theycome together anteriorly at the anterior commissure, as well aswhere they meet the mobile laryngeal cartilages at the posteriorcommissure The glottic larynx extends from the ventricle to 1 cmbelow the level of the true cords The vocal cords are lined with strat-ified squamous epithelia, which contrasts with the pseudostratifiedciliated respiratory mucosa lining the remainder of the larynx Glotticlaryngeal cancers tend to metastasize unilaterally and spread region-ally less commonly than supraglottic tumors do Between the thyroidcartilage and the vocal cord lies the paraglottic space, which is con-tinuous with the pre-epiglottic space This serves as a pathway forsubmucosal spread of tumors from the glottis to the supraglottis, orvice versa, which is known as transglottic spread The subglottic lar-ynx starts 1 cm below the vocal folds and continues to the inferioraspect of the cricoid cartilage While it is rare for tumors to arise ini-tially in the subglottis, tumors arising in the supraglottic or glotticlarynx commonly spread in a “transglottic” fashion to involve the

subglottic larynx Subglottic tumors tend to metastasize to cheal (Level VI) as well as middle or lower jugular lymph (Levels IIIand IV) node groups

paratra-Treatment of laryngeal cancers varies widely from center to center,and for early-stage lesions radiotherapy or transoral endoscopic ex-cision are the most common treatment options Both yield excellenttumor control, but proponents of each modality often disagree onthe functional sequelae of the two types of treatment However, goodlong-term functional data are lacking Treatment of more advancedtumors can be even more controversial, but while total laryngectomywas long held as the gold standard for treating T3 and T4 larynx can-cers, chemoradiotherapy has been shown to be quite effective inachieving local regional control, survival, and organ preservation.Concomitant chemoradiotherapy may be most appropriate for T3primary lesions Treatment of both sides of the neck must be takeninto consideration when treating supra- and subglottic tumors, andunilateral neck treatment is considered for patients with advancedglottic tumors

5 Nasopharynx

The nasopharynx is a cuboidal structure bounded anteriorly by thechoanae at the back of the nose where pseudostratified ciliatedcolumnar cells are found The roof and posterior walls of the na-sopharynx are made up of the sphenoid bone and the upper cervicalvertebrae, covered with a stratified squamous epithelial lining Infe-riorly, at the level of the soft palate, the nasopharynx meets the su-perior oropharynx The opening of the Eustachian tube is found atthe posterior-superior aspect of either lateral nasopharyngeal wall;therefore, impingement of this opening by a nasopharyngeal tumorcan lead to Eustachian dysfunction manifested by a middle-ear effu-sion and hearing loss Thus, all adult patients with an unexplainedunilateral middle-ear effusion, particularly in areas where nasopha-ryngeal carcinoma is endemic (such as southern China, northern

Africa, and Greenland), should have their nasopharynx examined.The adenoids, consisting of mucosa-covered lymphoid tissue, arefound posteriorly and superiorly in the nasopharynx and are moreprominent in children than adults.

While minor salivary tumors can occur in the nasopharynx, most sopharyngeal cancers are derived from the mucosal lining and fitinto one of the three histologic subtypes described by the WorldHealth Organization (WHO) WHO Type I nasopharyngeal carci-noma (NPC) is keratinizing squamous carcinoma, and WHO Type II

na-is nonkeratinizing squamous cell carcinoma WHO Type III na-is an differentiated tumor, also known as lymphoepithelioma The Epstein-Barr virus is thought to play a pathogenic role in the development ofType II and III tumors Nasopharyngeal carcinoma may also metas-tasize to retropharyngeal and parapharyngeal lymph nodes, as well

un-as lymph nodes along the upper, lower, and middle jugular (LevelsII–IV) chains and the posterior triangle of the neck (Level V) Early-stage NPC is most often treated with radiotherapy alone, and in moreadvanced cases, T 3/4 N +/ concomitant chemotherapy is being in-creasingly utilized Surgery is rarely used in salvage situations at theprimary site or neck

6 Nasal Cavity and Paranasal Sinuses

The paranasal sinuses consist of the paired maxillary sinuses, the perior frontal sinuses, the bilateral ethmoid system, and the centralspenoids This region includes the lining of the nasal cavity (medialmaxillary walls) as well as the nasal septum The majority ofsinonasal carcinomas arise in the maxillary sinuses and are mostcommonly squamous cell carcinomas, although adenocarcinomasare described, especially in woodworkers Because of inherent boneinvolvement, initial treatment is usually surgical, with considerationfor adjuvant radiation therapy based upon stage and pathologic find-ings Reconstruction and rehabilitation, especially in cases with or-bital involvement, may be prosthetic or tissue based Sinonasal