Elsevier

Oral Oncology

Volume 45, Issues 4–5, April–May 2009, Pages 356-360
Oral Oncology

Review
Staging and prognosis in head and neck cancer

https://doi.org/10.1016/j.oraloncology.2008.05.022Get rights and content

Summary

Head and neck malignant tumors are classified according to the TNM staging system. The TNM system is a universally accepted, widely used, staging method. Its goals are to help clinicians and researchers to choose from treatment options, to give patients an estimate of their prognosis and to compare results of treatment. In this paper we discuss the history and daily usage of the TNM system and some pros and cons. In the field of prognostic estimations, particularly for the individual patient, the TNM system could be upgraded with other prognostic indicators. We discuss insights into enhanced usage of the TNM system and the possibilities of comprehensive and dynamic staging models.

Section snippets

TNM history

The first attempt to categorize malignant tumors into different stages was made in the early years of the 20th century. Steinthal (1905) and later Paterson (1940) created a staging system for breast cancer. Between 1943 and 1952, Pierre Denoix, a Parisian oncologic surgeon, chairman of the ‘Institute Gustave-Roussy’ and the International Union Against Cancer (UICC), introduced the well-known TNM-system.1 Both the American Joint Committee on Cancer (AJCC) and the UICC used this system, but with

Tumor staging in head and neck cancer

Head and neck malignant tumors are classified according to the TNM system too (Figure 1a, Figure 1b, Figure 1c, Figure 1d); the most recent (sixth) edition of the UICC TNM classification4 is identical to that published by the AJCC.5

Tumors are stratified into at least 32 (4 × 4 × 2) possible combinations of local tumor spread (T1-4), regional lymph node involvement (N0-3) and presence of distant metastases (M0-1). Tumors, within a particular head and neck site and of specific histology, who share

Pros and cons of the TNM system

The purpose of the TNM system is to facilitate treatment planning, prognosis, uniform evaluation of treatment results and research. Especially in the field of inter-physician communication and research, the purpose is well served. The TNM staging system is an anatomically based, user-friendly, universally applicable, indicator of tumor burden. The TNM system therefore is a major contribution to cancer care and research. However, important limitations do exist:

  • (a)

    The TNM stage groupings were

Enhanced TNM

Besides the AJCC/UICC TNM staging system there are alternative systems based on the TNM: e.g. TANIS, and systems developed by Hall et al., Hart et al., Berg, and Kiricuta.8, 9, 10, 11, 12, 13 These alternative systems were extensively discussed by Lydiatt et al.14 and Groome et al.15 e.g. TANIS transforms the TNM-score into different staging groups by adding the T and N integer values to produce a score from 1 to 7. TANIS is based on the assumption that T and N are equally important and

Comprehensive models

The present TNM system of head and neck cancer classification (as well as the alternative staging systems mentioned) lacks biological and molecular markers and general patient-based prognostic factors, such as co-morbidity. In recent years more and more multivariate analyses are done, yielding unbiased relative risks of prognostic factors, including non-tumor characteristics (e.g., Ribeiro et al.16). These studies could lead to a more comprehensive staging system using all relevant patient and

Conclusion

The TNM system is simple and therefore easy to use and adhere to. More importantly, it is universally accepted. The introduction of prefixes (e.g. c, p, r, R, C, G) to the TNM-score is a step forward in more detailed description of tumor characteristics and yields transparency as to how the information was gathered. We would strongly recommend adding this detailed information to the TNM. New improvements of the TNM should include the possibility to include other relevant factors, such as age

Conflict of interest statement

None declared.

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