The Anatomy of Collaborative Staging:Head and Neck Presentation developed by Collaborative Staging Steering Committee email@example.com 2005 update
Head and Neck Cancer • Collaborative Stage fields (in general) • Tumor Size--standard • Extension • TS/Ext Eval--standard • Lymph Nodes • LN Eval--standard • LN Pos--standard • LN Exam--standard • Mets at Dx • Mets Eval--standard • Site-Specific Factors • SSF1 Size of LN • SSF2 Extracapsular exten. • SSF3 Levels I-III • SSF4 Levels IV-V, Retrophar • SSF5 Levels VI-VII, Facial • SSF6 Other H&N nodes
Head and Neck Schemes TNM Chapters: 6 Summary Stage Sites: 22 Collaborative Staging: 30 • Determining the correct primary site is important! • Site-specific factors are the same for all head and neck sites.
Head and Neck -- CS Tumor Size • Lip • Upper • Lower • Other • Tongue • Base • Anterior • Gum • Upper • Lower • Other • Floor of Mouth • Palate • Hard • Soft • Other Mouth • Buccal Mucosa • Salivary Glands • Parotid • Submandibular • Other Salivary • Pharynx • Oropharynx • Anterior Epiglottis • Nasopharynx • Hypopharynx • Other Pharynx * • Nasal Cavity • Middle Ear • Sinus • Maxillary • Ethmoid • Other * • Larynx • Glottic • Supraglottic • Subglottic • Other • Thyroid is NOT included • * no TNM staging • ABC requires Tumor Size for TNM • XYZTumor Size not a factor in TNM
Head and Neck -- CS Extension • General format • 00 In situ • 10 Lamina propria/submucosa • 30 Localized, NOS • 40-59 Adjacent structures (T3) • 60-69 Mixed T3-T4 (site specific) • 70-80 Adjacent structures (T4) • 95 No evidence of primary tumor
Head and Neck -- CS Extension • Muscles of the tongue • Used in shaping the mouth for speech, chewing and swallowing • Intrinsic musculature • Muscles within the tongue (no bony attachment) • Also called lingual • Used to curl sides of tongue upward • When mentioned as involved, code in CS Extension 20 range • NOT part of T4 category in TNM • Extrinsic musculature • Muscles anchoring the tongue in the mouth • Attached to mandible, hyoid bone, styloid process of temporal bone, or palate • When mentioned as involved, code in CS Extension 70-75 range (except sites: floor of mouth and submandibular gland) • When involved, map to T4 in TNM
C H J A B B C H E E F G G H D Head and Neck Lymph NodesOverview Level I (* = not shown) A Submental B Submandibular (submaxillary) Level II C Upper deep cervical (upper jugular) * Jugulodigastric (subdigastric) Level III D Middle deep cervical (mid-jugular) Level IV E Lower deep cervical (lower jugular) * Jugulo-omohyoid (supraomohyoid) Level V F Posterior cervical G Posterior triangle * Supraclavicular, NOS Level VI H Pre/paralaryngeal and pre/paratracheal (anterior deep cervical) Level VII J Upper mediastinal Adapted from: TNM Interactive (CD-ROM), Wiley-Liss
Head and Neck Lymph NodesOverview • Regional lymph node information is coded in several fields. • CS Lymph Nodes field • nodes involved, their number and laterality • Site-Specific Factors 1 and 2 • size of involved lymph nodes • presence of extracapsular extension • Site-Specific Factors 3-6 • presence or absence of lymph node involvement in each of 7 different levels and other groups defined by AJCC.
Lymph Nodes--Specific Fields • CS LN: which nodes, number and laterality • SSF1: size of involved node • SSF2: extracapsular extension • SSF3: levels I-III • SSF4: levels IV-V • SSF5: levels VI-VII and face • SSF6: other LN groups Image source: AJCC Cancer Staging Manual, 5th edition
Head and Neck Lymph NodesCS Lymph Nodes • Contains information about the nodes involved, their general number and laterality. • Code ranges vary by primary site. • Major categories: Single positive ipsilateral node involved Multiple positive ipsilateral nodes Bilateral or contralateral positive nodes Positive regional nodes, NOS
Head and Neck Lymph NodesCS Lymph Nodes • New note March 2005 • Supraclavicular lymph nodes can be either Level IV or Level V. • Level IV: deep to sternocleidomastoid muscle or in lower jugular chain • Level V: posterior triangle, inferior to transverse cervical artery • Try to determine whether Level IV or Level V. • If cannot be determined, code as Level V. • Excludes Nasopharynx and Thyroid • March 2005 revision: Add “Supraclavicular, NOS” to code 12 • Excludes Nasopharynx and Thyroid
Head and Neck Lymph NodesCS Lymph Nodes • Example--Parotid Gland 00 None 10-19 Single positive ipsilateral node involved 20-29 Multiple positive ipsilateral nodes 30-32 Positive ipsilateral nodes, unk. if 1 or > 1 40-49 Bilateral or contralateral positive nodes 50-52 Regional nodes, NOS, unk. number and laterality 80 Lymph nodes, NOS
Head and Neck Lymph NodesCS Lymph Nodes--N Categories • Example--Parotid Gland 00 N0 18 N1, no other information 19 N2a, no other information 29 N2b, no other information 49 N2c, no other information 60 N2, NOS 70 N3, no other information
Site-Specific Factor 1Size of Involved Node • Code size of NODE, not size of metastasis • Code largest diameter measured clinically or pathologically • Code regional nodes only • Size format same as tumor size with extra choices • 996 Described as less than 6 cm • 997 Described as more than 6 cm
Site-Specific Factor 2Extracapsular Extension • Code extracapsular extension identified clinically or pathologically • Pathologic confirmation takes precedence • Imaging studies may show • amorphous spiculated margins on nodes • involvement of internodal fat • loss of normal oval to round shape • Code regional nodes only • Code 888 if nodes are negative
Site-Specific Factor 2Extracapsular Extension • Codes 000 No extracapsular extension 001 Extracapsular extension clinically, no path; Nodes described as “fixed,” no path 005 Extracapsular extension on path exam 888 Not applicable: no node involvement 999 Unknown; not documented; not assessed Pathologic Lymph Nodes 000 No extracapsular extension 005 Extracapsular extension Image source: TNM Interactive (CD-ROM), Wiley-Liss
Site-Specific Factors 3-6 Definitions of levels are the same for all applicable head and neck sites. SSF 3 Levels I-III SSF 4 Levels IV and V and the retropharyngeal nodes SSF 5 Levels VI and VII and the facial nodes SSF 6 Other groups as defined by AJCC
Lymph Node Levels I Submental and submandibular II Upper jugular III Middle jugular IV Lower jugular and supraclavicular V Superficial cervical (along spinal accessory nerve) VI Anterior compartment (prelaryngeal and paratracheal) VII Upper mediastinal VII Image source: voice-center.com (The Voice Center, Norfolk, VA)
Coding Site-Specific Factors 3-6 SSF 3 Levels I-III ___ ___ ___ I II III SSF 4 Levels IV-V, ___ ___ ___ retropharyngeal (RP) IV V RP SSF 5 Levels VI-VII, ___ ___ ___ Facial (F) VI VII F SSF 6 Other groups ___ ___ ___ Parapharyngeal (PP), PP PA S Parotid (PA), Suboccipital (S) • Default is 0, not involved. • If any level/chain is involved, code as 1, involved.
Coding Site-Specific Factors 3-6Example: Buccal Mucosa LRND: 2 positive parotid nodes (< 3 cm with extracapsular exten.), 1 positive buccal (facial) node (2 cm), and 1 positive 2 cm submandibular (Level I) node. SSF 3 Levels I-III _1__0__0_ I II III SSF 4 Levels IV-V, _0__0__0_Retropharyngeal (RP) IV V RP SSF 5 Levels VI-VII, _0__0__1_ Facial (F) VI VII F SSF 6 Other groups _0__1__0_ Parapharyngeal (PP), PP PA S Parotid (PA), Suboccipital (S)
Coding Site-Specific Factors 1-6Example -- Full Coding of Nodes--Buccal Mucosa LRND: 2 positive parotid nodes (< 3 cm with extracapsular exten.), 1 positive buccal (facial) node (2 cm), and 1 positive 2 cm submandibular node. CS Lymph Nodes 20 Multiple ipsilateral LN positive CS Reg Nodes Eval 3 Based on dissection Reg LN Pos 04 2+1+1 = 4 positive nodes Reg LN Exam 97 Dissection, number not stated SSF 1 Size of node 993 Described as < 3 cm SSF 2 Extracaps. exten 005 Pathologic extension SSF 3 Levels I-III 100 Level 1 only SSF 4 Levels IV-V, RP 000 All nodes neg SSF 5 Levels VI-VII, F 001 Facial nodes only SSF 6 Other groups 010 Parotid nodes only Computer derived N: pN2b
Head and Neck -- CS Mets at Dx • Code 10 revision March 2005 • DeleteSupraclavicular (transverse cervical) • Supraclavicular nodes are REGIONAL--code in CS Lymph Nodes and SSF4. • Review and recode any cases coded 10 or 50 (should be very few)
Classification of Neck Dissections (1) • Standardized terminology of American Academy of Otolaryngology/Head and Neck Surgery • Radical Neck Dissection • Standard basic procedure for cervical lymphadenectomy • En bloc clearance of all fibrofatty tissue from one side of neck • Includes lymph nodes from Levels I-V plus those around tail of parotid • Removes spinal accessory nerve (SAN), internal jugular vein (IJV), and sternocleidomastoid muscle (SCM)
Classification of Neck Dissections (2) • Modified Radical Neck Dissection • Removal of same lymph node groups (I-V) but with preservation of 1 or more of non-lymphatic structures: • spinal accessory nerve (SAN) • internal jugular vein (IJV) • sternocleidomastoid muscle (SCM) • Comprehensive Neck Dissection • Non-standard term referring to any dissection removing node Levels I-V, i.e., radical or modified radical
Classification of Neck Dissections (3) • Selective Neck Dissection • Removal of certain lymph node groups and preservation of other groups • Supraomohyoid • selective removal of Levels I, II, and III • preservation of SAN, SCM, and IJV • sometimes includes Level IV • Lateral • selective removal of Levels II, III, and IV • preservation of SAN, SCM, and IJV
Classification of Neck Dissections (4) • Selective Neck Dissections, continued • Anterior Compartment • selective removal of Level VI • usually bilateral, may be unilateral • Posterolateral • used for cutaneous scalp malignancies • removal of suboccipital, postauricular, and upper, middle, and lower jugular nodes, and posterior triangle nodes
Classification of Neck Dissections (5) • Extended Neck Dissection • Refers to any type of above types of dissection, but involving the removal of additional lymph node groups or nonlymphatic structures beyond what is normally included. Examples: • Extended modified radical neck dissection • Extended selective anterior compartment neck dissection
TNM Supplement Guidelines • Tumor involving two sites • Classify to site in which greater part of tumor is located • Consider only invasive component if tumor has associated carcinoma in situ • Extension • Superficial • spread limited to mucosa • not sufficient for T4 • Deep • muscles, bones or other deep structures (vertical or horizontal invasion)
Head and Neck CancerCase Study 1: “Accessible site” • 1.5 cm tumor, confined to lateral hard palate; negative nodes clinically; no nodes removed. Remainder of exam negative. Referred for chemo. • Tumor size 015 1.5 cm • Extension 30 Localized, NOS • TS/Ext Eval 0 Physical exam • Lymph nodes 00 Negative • Reg LN Eval 0 Physical exam • Reg LN Pos 98 None examined • Reg LN Exam 00 None removed • Mets at Dx 00 None • Mets Eval 0 Clinical only • SSF1 (LN size) 000 No nodes involved • SSF2 888 No LN involvement • SSF3 = 000 SSF4 = 000 All levels of lymph • SSF5 = 000 SSF6 = 000 nodes negative
Head and Neck CancerCase Study 2: Positive nodes • Mobile tongue primary 2.5 cm; firm submental node palpable. Excision and node dissection: tumor in deep (extrinsic) muscle and 1 of 2 submental nodes positive, no extracapsular extension. PE: WNL • Tumor size 025 2.5 cm • Extension 75 Deep muscle • TS/Ext Eval 3 Based on excision • Lymph nodes 10 Single level I node involved • Reg LN Eval 3 Based on node dissection • Reg LN Pos 01 One node positive • Reg LN Exam 02 Two nodes removed • Mets at Dx 00 Physical exam normal • Mets Eval 0 Based on physical exam • SSF1 999 Size not stated • SSF2 000 No extracapsular extension • SSF3 100 Level I node involved • SSF4 = 000 SSF5 = 000 SSF6 = 000 All other LN neg.
Head and Neck CancerCase Study 3: Preoperative therapy • Hard mass in floor of mouth 3 cm size attached to mandible. Rest of exam neg. Pt given chemo. prior to wide excision and radical neck dissection. At surgery, 1 level IV and 2 level V nodes positive (largest size < 3 cm). TS 1.3 cm. • Tumor size 030 3 cm • Extension 70 Mandible involved • TS/Ext Eval 5 Clinical info pre-Rx • Lymph nodes 22 Multiple nodes listed in code 12 • Reg LN Eval 6 Residual positive nodes post-Rx • Reg LN Pos 03 1 + 2 = 3 nodes involved • Reg LN Exam 97 Dissection, number of nodes unknown • Mets at Dx 00 “Rest of exam neg.” • Mets Eval 0 Based on physical exam • SSF1 = 993 SSF2 = 999 Size < 3 cm; unknown exten. • SSF3 = 000 SSF4 = 110 Level IV and V nodes positive • SSF5 = 000 SSF6 = 000 All other nodes negative
Head and Neck CancerCase Study 4: Inaccessible site • Pt hoarse. ENT exam (endoscopy): 1.5 cm supraglottic mass extending into pyriform sinus; cords fixed. Modified radical neck dissection: 8/20 paralaryngeal and retropharyngeal nodes pos. • Tumor size 015 1.5 cm mass • Extension 62 Pyriform sinus + fixation • TS/Ext Eval 1 Based on endoscopy • Lymph nodes 21 Multiple positive ipsilateral nodes • Reg LN Eval 3 Based on dissection • Reg LN Pos 08 Eight nodes positive • Reg LN Exam 20 Twenty nodes examined • Mets at Dx 00 Inaccessible sites rule--presumed neg. • Mets Eval 0 Based on non-invasive clinical evidence • SSF1 999 Size not stated • SSF2 999 Extracaps. exten not documented • SSF3 = 000 SSF4 = 001 Retropharyngeal LN pos. • SSF5 = 100 SSF6 = 000 Level VI (paralaryngeal) LN pos.