CAP Approved Head and Neck • Pharynx 4.0.0.0 (AJCC 8th ed)

Note: The phrases in italics include clinical findings required for AJCC staging. This clinical information may not be available to the pathologist. However, if known, these findings should be incorporated into the pathologic staging.

TNM Descriptors (required only if applicable) (select all that apply)

___ m (multiple primary tumors)

___ r (recurrent)

___ y (posttreatment)

Primary Tumor (pT)

___ pTX: Cannot be assessed

___ pT0: No evidence of primary tumor

___ pTis: Carcinoma in situ

For All Carcinomas Excluding Mucosal Melanoma

For HPV-Mediated (Positive) Oropharynx

___ pT0:        No primary identified

___ pT1:        Tumor 2 cm or smaller in greatest dimension

___ pT2:        Tumor larger than 2 cm but not larger than 4 cm in greatest dimension 

___ pT3:        Tumor more than 4 cm in greatest dimension or extension to lingual surface of epiglottis

___ pT4:        Moderately advanced local disease. Tumor invades larynx, extrinsic muscle of tongue, medial pterygoid muscles, hard palate, or mandible or beyond #

# Note:  Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not constitute invasion of larynx.

For HPV-Unrelated (Negative) Oropharynx

___ pTX:        Primary tumor cannot be assessed

___ pTis:        Carcinoma in situ

___ pT1:        Tumor 2 cm or less in greatest dimension

___ pT2:        Tumor more than 2 cm but not more than 4 cm in greatest dimension

___ pT3:        Tumor more than 4 cm in greatest dimension or extension to lingual surface of epiglottis

___ pT4a:        Moderately advanced local disease. Tumor invades larynx, extrinsic muscle of tongue, medial pterygoid muscles, hard palate, or mandible#

___ pT4b:        Very advanced local disease. Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base, or encases carotid artery

For Nasopharynx

___ pTX:        Primary tumor cannot be assessed

___ pT0:        No tumor identified, but EBV-positive cervical node(s) involvement

___ pT1:        Tumor confined to nasopharynx, or tumor extends to oropharynx and/or nasal cavity without parapharyngeal extension#

___ pT2:        Tumor with extension to parapharyngeal space, and/or adjacent soft tissue involvement (medial pterygoid, lateral pterygoid, prevertebral muscles)

___ pT3:        Tumor with infiltration of bony structures at skull base, cervical vertebra, pterygoid structures, and/or paranasal sinuses

___ pT4:        Tumor with intracranial extension and/or involvement of cranial nerves, hypopharynx, orbit, parotid gland, and/ or extensive soft tissue infiltration beyond the lateral surface of the lateral pterygoid muscle

For Hypopharynx

___ pTX:        Primary tumor cannot be assessed

___ pTis:        Carcinoma in situ

___ pT1:        Tumor limited to one subsite of hypopharynx and/or 2 cm or less in greatest dimension

___ pT2:        Tumor invades more than one subsite of hypopharynx or an adjacent site, or measures more than 2 cm but not more than 4 cm in greatest dimension without fixation of hemilarynx

___ pT3:        Tumor measures more than 4 cm in greatest dimension or with fixation of hemilarynx or extension to esophagus

___ pT4a:        Moderately advanced local disease. Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible#

___ pT4b:        Very advanced local disease. Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases carotid artery

# Note: Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not constitute invasion of larynx.

Regional Lymph Nodes (pN)

___ pNX:          Cannot be assessed

___ pN0:          No regional lymph node metastasis

For HPV-Mediated (Positive) Oropharynx 

___ pNX:        Regional lymph nodes cannot be assessed

___ pN0:        No regional lymph node metastasis

___ pN1:        Metastasis in 4 or fewer lymph nodes

___ pN2:         Metastasis in more than 4 lymph nodes

For HPV-Unrelated (Negative) Oropharynx and Hypopharynx#

___ pN3a:        Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE(−)

___ pN3b:         Metastasis in a single ipsilateral node larger than 3 cm in greatest dimension and ENE(+);

               or multiple ipsilateral, contralateral or bilateral nodes any with ENE(+);

or a single contralateral node 3 cm or smaller and ENE(+)

# Midline nodes are considered ipsilateral nodes.

For Nasopharynx#

Distant Metastasis (pM)

___ Not applicable

___ pM1:  Distant metastasis

       Specify site(s), if known: ____________________________        

For Mucosal Melanoma

Primary Tumor (pT)

___ pT3:         Tumors limited to the mucosa and immediately underlying soft tissue, regardless of thickness or greatest dimension; for example, polypoid nasal disease, pigmented or nonpigmented lesions of the oral cavity, pharynx, or larynx

___ pT4a:         Moderately advanced disease. Tumor involving deep soft tissue,  cartilage, bone, or overlying skin

___ pT4b:  Very advanced disease. Tumor involving brain, dura, skull base, lower  cranial nerves (IX, X, XI, XII), masticator space, carotid artery,  prevertebral space, or mediastinal structures

Regional Lymph Nodes (pN)

___ pNX:         Regional lymph nodes cannot be assessed

___ pN0:         No regional lymph node metastases

___ pN1:         Regional lymph node metastases present

Distant Metastasis (pM)

___ Not applicable

___ pM1:  Distant metastasis present

Pharynx CAP 4.0.0.0 summary of pTNM changes AJCC 7th to 8th edition

• Create a specific staging pTNM for HPV+orophargeal carcinoma
• For HPV negative orophargeal carcinoma, extranodal extension (ENE) is an important part of pN1, pN2a, pN2b, pN2c, pN3a, and pN3b
• P16 stain interpretation: equivocal >50% and <70% diffuse strong nuclear and cytoplasmic staining; negative <50% diffuse strong staining nuclear and cytoplasmic staining; positive >70% diffuse strong nuclear and cytoplasmic staining

Head & Neck

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