Nasal cavity, paranasal sinuses, nasopharynx
General
Staging terminology
Author: Kelly Magliocca, D.D.S., M.P.H.
Last author update: 1 September 2018
Last staff update: 31 March 2021
Copyright: 2004-2024, PathologyOutlines.com, Inc.
PubMed Search: Staging[TIAB] nasal cavity paranasal sinuses
Cite this page: Magliocca, KR. Staging terminology. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/Nasalcavitystagingterminology.html. Accessed May 6th, 2024.
Anatomy
- Anatomic sites and subsites for the nasal cavity and paranasal sinuses
- Nasal cavity is divided in the midline to right and left halves by the septum; each half opens on the face via the nares or nostrils and communicates behind with the nasopharynx through the posterior nasal apertures or the choanae
- Nasal cavity is divided into 4 subsites including the septum, floor, lateral wall and vestibule
- Paranasal sinuses represent a grouping of 4 paired sinuses including the maxillary sinuses, ethmoid sinuses, frontal sinuses and sphenoid sinuses
- Nasoethmoidal complex is divided into 2 sites including the nasal cavity and the ethmoid sinuses
- Nasal cavity is divided in the midline to right and left halves by the septum; each half opens on the face via the nares or nostrils and communicates behind with the nasopharynx through the posterior nasal apertures or the choanae
Surgical margins
- Surgical margins (AJCC: Cancer Staging [Accessed 3 December 2018], CAP: Protocol for the Examination of Specimens from Patients with Cancers of the Nasal Cavity and Paranasal Sinuses [Accessed 3 December 2018]):
- Definition of a positive margin is somewhat controversial given the varied results from prior studies
- This is made even more challenging and nebulous for sinonasal tumors, which are often received piecemeal with margins submitted separately
- But for squamous cell carcinoma, data is essentially extrapolated from other sites
- Here, overall, several studies support the definition of a positive margin to be invasive carcinoma or carcinoma in situ / high grade dysplasia present at margins (microscopic cut through of tumor)
- Furthermore, reporting of surgical margins should also include information regarding the distance of invasive carcinoma, carcinoma in situ or high grade dysplasia (moderate to severe) from the surgical margin
- Tumors with "close" margins also carry an increased risk for local recurrence
- Definition of a "close" margin is not standardized as the effective cutoff varies between studies and between anatomic subsites
- Commonly used cutpoints to define close margins are 5 mm in general and 2 mm with respect to glottic larynx
- However, values ranging from 3 to 7 mm have been used with success and for glottic tumors as low as 1 mm
- Thus, distance of tumor from the nearest margin should be recorded
- Reporting of surgical margins for carcinomas of the minor salivary glands should follow those used for squamous cell carcinoma of oral cavity
- While there is no standard recommendation for the other histologic types of carcinoma encountered, adherence to the recommendations for squamous cell carcinoma is acceptable
- Definition of a positive margin is somewhat controversial given the varied results from prior studies
Extranodal extension (ENE)
- Extranodal extension (ENE) (AJCC: Cancer Staging [Accessed 3 December 2018], CAP: Protocol for the Examination of Specimens from Patients with Cancers of the Nasal Cavity and Paranasal Sinuses [Accessed 3 December 2018]):
- 8th edition introduces the use of extranodal extension in categorizing the "N" category for metastatic cancer to neck nodes
- Effect of ENE on prognosis in head and neck cancers is profound, except for those tumors associated with HR HPV
- Pathological ENE also must be clearly defined as extension of metastatic tumor (tumor present within the confines of the lymph node and extending through the lymph node capsule into the surrounding connective tissue, with or without associated stromal reaction)
- Histopathologic designations for ENE are as follows (Amin: AJCC Cancer Staging Manual, 8th Edition, 2018):
- ENEn (none)
- ENEmi (microscopic ENE ≤ 2 mm)
- ENEma (ENE > 2 mm or gross ENE)
- ENEmi and ENEma are used to define pathological ENE nodal status
- ENEmi versus ENEn will affect current nodal staging but data collection is recommended to allow standardization of data collection and future analysis (AJCC: Cancer Staging [Accessed 3 December 2018])
TNM descriptors
- TNM descriptors:
- By AJCC / UICC convention, the designation "T" refers to a primary tumor that has not been previously treated
- "p" symbol refers to the pathologic classification of the TNM, as opposed to the clinical classification and based on clinical stage information supplemented / modified by operative findings and gross and microscopic evaluation of the resected specimens
- pT entails a resection of the primary tumor or biopsy adequate to evaluate the highest pT category, pN entails removal of nodes adequate to validate lymph node metastasis and pM entails microscopic examination of distant lesions
- Clinical classification (cTNM) is usually carried out by the referring physician before treatment during initial evaluation of the patient or when pathologic classification is not possible
- Pathologic staging is usually performed after surgical resection of the primary tumor
- Pathologic staging depends on pathologic documentation of the anatomic extent of disease, whether or not the primary tumor has been completely removed
- If a biopsied tumor is not resected for any reason (e.g. when technically unfeasible) and if the highest T and N categories or the M1 category of the tumor can be confirmed microscopically, the criteria for pathologic classification and staging have been satisfied without total removal of the primary cancer
- Use of pT0:
- Additional change in AJCC 8th edition is the elimination of the T0 category for all oral cavity, skin, larynx, HPV- oropharynx, hypopharynx and sinus
- This change affects cases where a cervical lymph node has metastatic squamous cell carcinoma but no primary tumor is identified despite thorough history, examination and available imaging studies
- Assigning these cases to a specific head and neck site is not possible
- Previous editions of TNM staging included a T0 category in each of these disease sites
- However, it is seldom used and if it is, the cancer could not be assigned to a stage group
- Therefore, for the 8th edition, the expert panel eliminated the T0 category from the head and neck staging systems
- Additional TNM descriptors:
- For identification of special cases of TNM or pTNM classifications, the "m" suffix and "y" and "r" prefixes are used; although they do not affect the stage grouping, they indicate cases needing separate analysis
- "m" suffix indicates the presence of multiple primary tumors in a single site and is recorded in parentheses: pT(m)NM
- "y" prefix indicates those cases in which classification is performed during or following initial multimodality therapy (i.e. neoadjuvant chemotherapy, radiation therapy or both chemotherapy and radiation therapy)
- cTNM or pTNM category is identified by a "y" prefix
- ycTNM or ypTNM categorize the extent of tumor actually present at the time of that examination
- "y" categorization is not an estimate of tumor prior to multimodality therapy (i.e. before initiation of neoadjuvant therapy)
- "r" prefix indicates a recurrent tumor when staged after a documented disease free interval and is identified by the "r" prefix: rTNM
