AJCC Staging of Head & Neck Cancer (7 th edition, 2010) -LIP & ORAL CAVITY-

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1 TX: primary tumor cannot be assessed T0: no evidence of primary tumor Tis: carcinoma in situ. T1: tumor is 2 cm or smaller AJCC Staging of Head & Neck Cancer (7 th edition, 2010) -LIP & ORAL CAVITY- T2: tumor is larger than 2 cm across, but smaller than 4 cm T3: tumor is larger than 4 cm across T4a: The tumor is growing into nearby structures. ( Moderately advanced local disease ) -Lip: tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face -Oral cavity Tumor invades adjacent structures only (e.g., through cortical bone [mandible or maxilla] into deep [extrinsic] muscle of tongue [genioglossus, hyoglossus, palatoglossus, and styloglossus], maxillary sinus, or skin of face). T4b: Tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery. T1: Tumor 2 cm in greatest dimension. T2: Tumor >2 cm but 4 cm in greatest dimension. -OROPHARYNX- T3: Tumor >4 cm in greatest dimension or extension to lingual surface of epiglottis. T4a: Moderately advanced local disease. Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible T4b: Very advanced local disease. Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base, or encases carotid artery. -HYPOPHARYNX- T1: Tumor limited to 1 subsite of hypopharynx and/or 2 cm in greatest dimension. T2: Tumor invades >1 subsite of hypopharynx or an adjacent site, or measures >2 cm but not >4 cm in greatest dimension without fixation of hemilarynx. T3: Tumor >4 cm in greatest dimension or with fixation of hemilarynx or extension to esophagus. T4a: Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central compartment soft tissue. T4b: Tumor invades prevertebral fascia, encases carotid artery, or involves mediastinal structures.

2 -NASOPHARYNX- T1: Tumor confined to the nasopharynx, or tumor extends to oropharynx and/or nasal cavity without parapharyngeal extension. T2: Tumor with parapharyngeal extension. T3: Tumor involves bony structures of skull base and/or paranasal sinuses. T4: Tumor with intracranial extension and/or involvement of cranial nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space. -SUPRAGLOTTIC LARYNX- T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility. T2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx. T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage. T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus). T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures. -GLOTTIC LARYNX- T1: Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility. -T1a: Tumor limited to one vocal cord. -T1b: Tumor involves both vocal cords. T2: Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility. T3: Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage. T4a: Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus). T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.

3 T1: Tumor limited to the subglottis. -SUBGLOTTIC LARYNX- T2: Tumor extends to vocal cord(s) with normal or impaired mobility. T3: Tumor limited to larynx with vocal cord fixation. T4a: Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus). T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures. -MAXILLARY SINUS- T1: Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone. T2: Tumor causing bone erosion or destruction including extension into the hard palate and/or middle nasal meatus, except extension to posterior wall of maxillary sinus and pterygoid plates. T3: Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, or ethmoid sinuses. T4a: Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, or sphenoid or frontal sinuses. T4b: Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus. -NASAL CAVITY & ETHMOID SINUS- T1: Tumor restricted to any one subsite, with or without bony invasion. T2: Tumor invading two subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion. T3: Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate. T4a: Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, or sphenoid or frontal sinuses. T4b: Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than (V2), nasopharynx, or clivus.

4 -SALIVARY GLAND- T1: Tumor 2 cm in greatest dimension without extraparenchymal extension (macroscopic). T2: Tumor >2 cm but 4 cm in greatest dimension without extraparenchymal extension (macroscopic). T3: Tumor >4 cm and/or tumor having extraparenchymal extension (macroscopic). 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. N Stage (Lip & Oral Cavity; Oropharynx, Hypopharynx, Larynx, Nasal cavity, Sinuses, Salivary): Nx: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis. N1: Metastasis in a single ipsilateral lymph node, 3 cm in greatest dimension. -N2a: Metastasis in single ipsilateral lymph node, >3 cm but 6 cm in greatest dimension. -N2b: Metastases in multiple ipsilateral lymph nodes, none >6 cm in greatest dimension. -N2c: Metastases in bilateral or contralateral lymph nodes, none >6 cm in greatest dimension. N3: Metastasis in a lymph node >6 cm in greatest dimension. N Stage (Nasopharynx): Nx: Regional lymph nodes cannot be assessed. N0: No regional lymph node metastasis. N1: Unilateral metastasis in cervical lymph node(s), 6 cm in greatest dimension, above the supraclavicular fossa, and/or unilateral or bilateral, retropharyngeal lymph nodes, 6 cm in greatest dimension. N2: Bilateral metastasis in cervical lymph node(s), 6 cm in greatest dimension, above the supraclavicular fossa. N3: Metastasis in a lymph node(s)c >6 cm and/or to supraclavicular fossa -N3a: >6 cm in dimension. -N3b: Extension to the supraclavicular fossa M Stage (Lip & Oral Cavity; Nasopharynx, Oropharynx, Hypopharynx, Larynx, Nasal cavity, Sinuses, Salivary): M0: no distant metastases M1: distant metastases

5 STAGE GROUPING (Lip & Oral Cavity; Oropharynx, Hypopharynx, Larynx, Nasal Cavity, Sinuses, Salivary): Stage T N M 0 Tis N0 M0 I T1 N0 M0 II T2 N0 M0 III T3 N0 M0 T1 N1 M0 T2 N1 M0 T3 N1 M0 IVA T4a N0-N2 M0 T1-T3 N2 M0 IVB T4b Any N M0 Any T N3 M0 IVC Any T Any N M1 STAGE GROUPING (Nasopharynx): Stage T N M 0 Tis N0 M0 I T1 N0 M0 II T1 N1 M0 T2 N0 M0 III T1-T2 N0 M0 T3 N0-N2 M0 IVA T4 N0-N2 M0 IVB Any T N3 M0 IVC Any T Any N M1

6 -NONMELANOMA SKIN- Tis: Carcinoma in situ T1: Tumor 2 cm in greatest dimension with 0-1 high-risk features* T2: Tumor >2 cm in greatest dimension; OR tumor any size with 2 high-risk features* T3: Tumor with invasion of maxilla, mandible, orbit, or temporal bone T4: Tumor with invasion of skeleton (axial or appendicular) or perineural invasion of skull base *High-risk features: These features are used to distinguish between some T1 and T2 tumors. -Depth/Invasion: >2 mm thickness (Breslow thickness); Clark level IV; or perineural invasion. -Anatomic site: Primary site ear OR non-hair-bearing lip. -Differentiation: Poorly differentiated or undifferentiated. N Stage: Nx: Nearby lymph nodes cannot be assessed. N0: No spread to nearby lymph nodes. N1: Spread to 1 ipsilateral lymph node, 3 cm or less. N2a: Spread to 1 ipsilateral lymph node, 3-6 cm. N2b: Spread to multiple ipsilateral nodes, all < 6 cm. N2c: Spread to contralateral node(s), all < 6 cm. N3: Any nodal disease >6 cm. M Stage: M0: No spread to distant organs. M1: Spread to distant organs. Stage 0 Stage I Stage II Stage III Stage IV Tis, N0, M0 T1, N0, M0 T2, N0, M0 T3, N0, M0 T1- T3, N1, M0 T1- T3, N2, M0 Any T, N3, M0 T4, any N, M0 Any T, any N, M1

7 -MELANOMA- (e.g., curettaged or severely regressed melanoma). Tis: Melanoma in situ (The tumor remains in the epidermis). T1: Melanomas 1.0 mm in thickness. -T1a without ulceration and with a mitotic rate of less than 1/mm2. -T1b: with ulceration and/or the mitotic rate is equal to or greater than 1/mm2. T2a: Melanomas mm thick without ulceration. T2b: Melanomas mm thick with ulceration. T3a: Melanomas mm thick without ulceration. T3b: Melanomas mm thick with ulceration. T4a: Melanomas >4.0 mm without ulceration. T4b: Melanomas >4.0 mm with ulceration. N Stage: Nx: Regional lymph nodes cannot be assessed (e.g., previously removed for another reason). N0: No regional metastases detected. N1: Spread to 1 regional lymph node. N2: Spread to 2 or 3 regional lymph nodes, OR in transit met(s)/satellites(s) without metastatic nodes. N3: 4 metastatic nodes, or matted nodes, or in transit met(s)/satellite(s) with metastatic node(s). *N1 and N2 disease may be further subclassified based upon the findings of sentinel node biopsy: a: micrometastasis b: macrometastasis c: in transit met(s)/satellites(s) without metastatic nodes. M Stage: M0: No distant metastasis. M1a: Metastases to skin, subcutaneous, or distant lymph nodes; with a normal serum HDL level. M1b: Metastasis to the lungs; with a normal serum HDL level. M1c: Any visceral mets, OR any distant mets along with an elevated blood LDH level.

8 STAGE GROUPING (Melanoma): Stage 0: Tis, N0, M0: Melanoma in situ Stage IA: T1a, N0, M0: Melanoma is < 1.0 mm thick, not ulcerated and has a mitotic rate <1/mm2. Stage IB: T1b or T2a, N0, M0: Melanoma is < 1.0 mm thick and ulcerated or has a mitotic rate of 1/mm2; OR it is between mm and not ulcerated. Stage IIA: T2b or T3a, N0, M0: Melanoma is between mm in thickness and is ulcerated, OR it is between mm and not ulcerated. Stage IIB: T3b or T4a, N0, M0: Melanoma is between mm in thickness and is ulcerated, OR it is thicker than 4.0 mm and not ulcerated. Stage IIC: T4b, N0, M0: The melanoma is 4.0 mm thick and is ulcerated. Stage IIIA: T1a to T4a, N1a or N2a, M0: The melanoma can be of any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread. Stage IIIB: One of the following applies: -T1b to T4b, N1a or N2a, M0: The melanoma can be of any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread. -T1a to T4a, N1b or N2b, M0: The melanoma can be of any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread. -T1a to T4a, N2c, M0: The melanoma can be of any thickness, but it is not ulcerated. It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma. There is no distant spread. Stage IIIC: One of the following applies: -T1b to T4b, N1b or N2b, M0: The melanoma can be of any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread. -T1b to T4b, N2c, M0: The melanoma can be of any thickness and is ulcerated. It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma. There is no distant spread. -Any T, N3, M0: The melanoma can be of any thickness and may or may not be ulcerated. It has spread to 4 or more nearby lymph nodes, OR to nearby lymph nodes that are clumped together, OR it has spread to nearby skin or lymphatic channels around the original tumor and to nearby lymph nodes. The nodes are enlarged because of the melanoma. There is no distant spread. Stage IV: Any T, any N, M1(a, b, or c): The melanoma has spread beyond the original area of skin and nearby lymph nodes to other organs such as the lung, liver, or brain, or to distant areas of the skin, subcutaneous tissue, or distant lymph nodes. Neither spread to nearby lymph nodes nor thickness is considered in this stage, but typically the melanoma is thick and has also spread to the lymph nodes.

9 -THYROID- T1: Tumor 2 cm in greatest dimension limited to the thyroid. -T1a: Tumor 1 cm, limited to the thyroid. -T1b: Tumor >1 cm but 2 cm in greatest dimension, limited to the thyroid. T2: Tumor >2 cm but 4 cm in greatest dimension, limited to the thyroid. T3: Tumor >4 cm in greatest dimension limited to the thyroid or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues). T4a: Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve; OR intrathyroidal anaplastic carcinoma T4b: Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels: OR anaplastic carcinoma with gross extrathyroid extension N Stage: Nx: Regional lymph nodes cannot be assessed. N0: No regional lymph node metastasis. N1: Regional lymph node metastasis. -N1a: Metastases to Level VI (pretracheal, paratracheal, and prelaryngeal/delphian lymph nodes). -N1b: Metastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII). M Stage: M0: no distant metastases M1: distant metastases STAGE GROUPING (Papillary or Follicular carcinoma): Stage T N M *Age younger than 45 years* I Any T Any N M0 II Any T Any N M1 *Age 45 years and older* I T1 N0 M0 II T2 N0 M0 III T3 N0 M0 T1-T3 N1a M0 IVA T4a N0-N1b M0 T1-T3 N1b M0 IVB T4b Any N M0 IVC Any T Any N M1

10 STAGE GROUPING (Medullary carcinoma): Stage T N M I T1 N0 M0 II T2-T3 N0 M0 III T1-T3 N1a M0 IVA T4a N0-N1b M0 T1-T3 N1b M0 IVB T4b Any N M0 IVC Any T Any N M1 STAGE GROUPING (Anaplastic carcinoma): Stage T N M IVA T4a Any N M0 IVB T4b Any N M0 IVC Any T Any N M1