Staging of Oral Cancer

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Oral Cancer Diagnosis and Treatment
Its what you learn after you know it all that
counts. John Wooden
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Staging of Oral Cancer

• Squamous cell carcinoma minor salivary gland
  malignancies
• Major salivary gland malignancies

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american joint committee on cancer
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Biologic Progression of Tumor

• Tumor first grows locally
• Metastasizes to regional lymph nodes
• Finally, metastasizes systemically

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Application of Prognostic Factors in Clinical
Practice

• Select appropriate diagnostic tests
• Select optimal treatment plan
• Predict the outcome for an individual patient
• Select appropriate follow-up monitoring
• Patient and caregiver education

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Staging

• Provides a framework for discussion
• Helps stratify patients into groups that are
  prognostically and therapeutically similar
• Facilitates comparison across large populations

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AJCC staging is hosted by the
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Age-specific incidence rates for intraoral
squamous cell carcinoma (number of new cases per
100,000 persons each year). Separate rates are
provided for white and black males and females in
the United States.

Neville. Oral and Maxillofacial Pathology, 2nd
Edition. Elsevier, 2002.
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Oral Squamous Cell CarcinomaRegional Spread
Neville. Oral and Maxillofacial Pathology, 2nd
Edition. Elsevier, 2002.
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The oncologic lymph node levels of the neck.
Level I submental/submandibular nodes level II
upper jugular nodes level III middle jugular
nodes level IV lower jugular nodes level V
posterior triangle nodes. Regezi. Oral
Pathology Clinical Pathologic Correlations, 4th
Edition. Elsevier, 2002.
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Definitions of Levels for Head and Neck (nodal)
Sites

• The definitions of the levels and the lymph node
  chains included in each level are as follows
• Level I contains the submental and submandibular
  triangles bounded by the anterior and posterior
  bellies of the digastric muscle, and the hyoid
  bone inferiorly, and the body of the mandible
  superiorly. Submandibular, submaxillary,
  submental.
• Level II contains the upper jugular lymph nodes
  and extends from the level of the skull base
  superiorly to the hyoid bone inferiorly.
  Jugulodigastric, upper deep cervical, upper
  jugular
• (subdigastric).
• Level III contains the middle jugular lymph nodes
  from the hyoid bone superiorly to the level of
  the lower border of the cricoid cartilage
  inferiorly. Middle deep cervical, mid-jugular.

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Definitions of Levels for Head and Neck (nodal)
Sites

• Level IV contains the lower jugular lymph nodes
  from the level of the cricoid cartilage
  superiorly to the clavicle inferiorly.
  Jugulo-omohyoid, lower deep cervical, lower
  jugular (supraomohyoid).
• Level V contains the lymph nodes in the posterior
  triangle bounded by the anterior border of the
  trapezius muscle posteriorly, the posterior
  border of the sternocleidomastoid muscle
  anteriorly, and the clavicle inferiorly. For
  descriptive purposes, Level V may be further
  subdivided into upper, middle, and lower levels
  corresponding to the superior and inferior planes
  that define Levels II, III, and IV. Posterior
  cervical posterior triangle (spinal accessory and
  transverse cervical) (upper, middle, and lower,
  corresponding to the levels that define upper,
  middle, and lower jugular nodes).

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Definitions of Levels for Head and Neck (nodal)
Sites

• Level VI contains the lymph nodes of the anterior
  central compartment from the hyoid bone
  superiorly to the suprasternal notch inferiorly.
  On each side, the lateral boundary is formed by
  the medial border of the carotid sheath. Anterior
  deep cervical, paratracheal, pretracheal,
  laterotracheal, prelaryngeal , recurrent
  laryngeal, paralaryngeal.
• Level VII contains the lymph nodes inferior to
  the suprasternal notch in the superior
  mediastinum. Upper mediastinal.
• Other groups buccinator (facial) periparotid,
  retropharyngeal, nasolabial, intraparotid,
  sub-occipital , parapharyngeal, preauricular.

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Lymph nodes in TNM staging
Neville. Oral and Maxillofacial Pathology, 2nd
Edition. Elsevier, 2002.
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Grading of Squamous Cell Carcinoma (modified
Broders classification)?

• G1 Well differentiated
• G2 Moderately well differentiated
• G3 Poorly differentiated
• G4 Undifferentiated

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TNM Clinical Staging System for Oral Squamous
Cell Carcinoma

• TTUMOR
• T1 tumor lt 2cm
• T2 tumor 2 to 4 cm
• T3 tumor gt 4 cm
• T4 tumor invades deep subjacent structures
• NNODES
• N0 no palpable nodes
• N1 single ipsilateral node 3cm
• N2A single ipsilateral node 3 to 6 cm
• N2B multiple ipsilateral nodes 6cm
• N2C contralateral or bilateral nodes 6cm
• N3 node gt 6cm
• MMETASTASIS
• M0 no distant metastasis
• M1 distant metastasis

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Staging of Oral Squamous Cell Carcinoma and Minor
Salivary GlandsPrimary tumor (T)?

• T1 Tumor 2 cm or less in greatest dimension
• T2 Tumor more than 2 cm but not more than 4 cm
  in greatest dimension
• T3 Tumor more than 4 cm in greatest dimension
• T4 (oral cavity) Tumor invades adjacent
  structures (e.g., through cortical bone, into
  deep (extrinsic) muscles of tongue, maxillary
  sinus, skin. Superficial erosion alone of
  bone/tooth socket by gingival primary is not
  sufficient to classify as T4)
• T4 (lip) Tumor invades adjacent structures
  (e.g., through cortical bone, inferior alveolar
  nerve, floor of mouth, skin of face ).

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Staging of Salivary Gland Malignancies (Major
Glands only)Primary tumor (T)?

• T1 Tumor 2 cm in greatest dimension without
  extraparenchymal extension
• T2 Tumor gt2 cm but 4 cm in greatest dimension
  without extraparenchymal extension
• T3 Tumor gt4 cm and/or tumor having
  extraparenchymal extension
• T4a Tumor invades skin, mandible, ear canal,
  and/or facial nerve
• T4b Tumor invades skull base and/or pterygoid
  plates and/or encases carotid artery

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Proposed modification of T4 designation

• For all head and neck sites, a uniform
  description of advanced tumors has been
  recommended whereby T4 lesions are divided into
• T4a (resectable)?
• T4b (unresectable).
• This will allow description of patients with
  advanced stage disease into three categories
• Stage IVA, advanced resectable disease
• Stage IVB, advanced unresectable disease
• Stage IVC, advanced distant metastatic disease.

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Staging of Oral Squamous Cell Carcinoma and Minor
Salivary Glands Regional lymph nodes (N)?

• N0 No regional lymph node metastasis
• N1 Metastasis in a single ipsilateral lymph
  node, 3 cm or less in greatest dimension
• N2 Metastasis in a single ipsilateral lymph
  node, more than 3 cm but not more than 6 cm in
  greatest dimension or in multiple ipsilateral
  lymph nodes, none more than 6 cm in greatest
  dimension or in bilateral or contralateral
  lymph nodes, none more than 6 cm in greatest
  dimension
• N2a Metastasis in a single ipsilateral lymph
  node more than 3 cm but not more than 6 cm in
  dimension
• N2b Metastasis in multiple ipsilateral lymph
  nodes, none more than 6 cm in greatest dimension
• N2c Metastasis in bilateral or contralateral
  lymph nodes, none more than 6 cm in greatest
  dimension
• N3 Metastasis in a lymph node more than 6 cm in
  greatest dimension

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Staging of Oral Squamous Cell Carcinoma and Minor
Salivary Glands Distant metastasis (M)?

• M0 No distant metastasis
• M1 Distant metastasis

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Staging of Oral Squamous Cell Carcinoma, Minor
Salivary Glands AJCC stage groupings

• Stage I
• T1, N0, M0
• Stage II
• T2, N0, M0
• Stage III
• T3, N0, M0
• T1, N1, M0
• T2, N1, M0
• T3, N1, M0

• Stage IVA
• T4, N0, M0
• T4, N1, M0
• Any T, N2, M0
• Stage IVB
• Any T, N3, M0
• Stage IVC
• Any T, Any N, M1

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NCDB Clinical Surveillance

• (National Cancer Data Base)?
• Patient Demographics
• Diagnosis / AJCC Stage
• Treatment by AJCC Stage
• Survival by Treatment Stage

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Five-year Survival for Lip Cancer (AJCC)?

• Stage I  83
• Stage II 73
• Stage III 62
• Stage IV 47

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TNM Clinical Staging Categories for Oral Squamous
Cell Carcinoma
Neville. Oral and Maxillofacial Pathology, 2nd
Edition. Elsevier, 2002.
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Five-year Relative Survival Rate for Salivary
Gland Cancers (AJCC)?

• Stage I 86
• Stage II 66
• Stage III 53
• Stage IV 32

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Distribution of Salivary Gland Malignancies
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Probability Malignancy in a Salivary Gland
Neoplasm based on its Location (AFIP data)?

• Parotid 32
• Submandibular 41
• Sublingual 70
• Minor gland collectivelygt50
• 23 upper lip
• 60 lower lip
• 47 palate
• 86 tongue
• 50 check
• 90 retromolar
• 88 floor of mouth

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Metastatic Cancers to the Oral Cavity

• Metastatic tumors to the oral cavity, either to
  soft tissues or bone, are not classified as oral
  cancers.
• Therefore
• Cancer metastatic to the oral region, originating
  from a remote site, are staged according to the
  rules for the primary site (e.g., breast, lung,
  prostate, etc.)?

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Medicine is a science of uncertainty and an art
of probability. Sir William Osler, 1904