Nasal cavity, paranasal sinuses, nasopharynx

• Staging of definitive resections for carcinoma (squamous cell carcinoma, neuroendocrine carcinoma and minor salivary gland carcinoma) of the nasal cavity and paranasal sinuses should use this system (AJCC: Cancer Staging [Accessed 24 September 2018], CAP: Protocol for the Examination of Specimens from Patients with Cancers of the Nasal Cavity and Paranasal Sinuses [Accessed 24 September 2018])
• Cancer of the maxillary sinus is the most common of the sinonasal malignancies
  • Ethmoid sinus and nasal cavity cancers are equal in frequency but considerably less common than maxillary sinus cancers
  • Tumors of the sphenoid and frontal sinuses are rare
• Staging protocols such as those of CAP are to document procedure, tumor site, tumor laterality, tumor focality, tumor size, histologic type, histologic grade where applicable, margin status, lymphovascular invasion, perineural invasion, regional lymph node findings and summarize these pathologic findings using TNM system

• pNX: Regional lymph nodes cannot be assessed
• pN0: No regional lymph node metastasis
• pN1: Metastasis in a single ipsilateral lymph node, ≤ 3 cm in greatest dimension and extranodal extension negative (ENE-)
• pN2a: Metastasis in:
  • Single ipsilateral lymph node that is ≤ 3 cm and ENE+ or
  • Single ipsilateral lymph node that is > 3 cm but ≤ 6 cm in greatest dimension and ENE-
• pN2b: Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension and ENE-
• pN2c: Metastasis in bilateral or contralateral lymph node(s), none > 6 cm in greatest dimension and ENE-
• pN3a: Metastasis in a lymph node that is > 6 cm in greatest dimension and ENE-
• pN3b: Metastasis in:
  • Single ipsilateral lymph node, > 3 cm and ENE+ or
  • Multiple ipsilateral, contralateral or bilateral lymph nodes, any with ENE+ or
  • Single contralateral lymph node of any size and ENE+

Notes:

• Designation of "U" or "L" may be used for any N category to indicate metastasis above the lower border of the cricoid (U) or below the lower border of the cricoid (L)
• A selective neck dissection will ordinarily include 10+ lymph nodes and a comprehensive neck dissection (radical or modified radical neck dissection) will ordinarily include 15+ lymph nodes
• Negative pathologic examination of a smaller number of nodes still mandates a pN0 designation
• Midline nodes are considered ipsilateral nodes

• pM0: No distant metastasis
• pM1: Distant metastasis

Notes:

• Measurement of tumor metastasis (AJCC: Cancer Staging [Accessed 24 September 2018], CAP: Protocol for the Examination of Specimens from Patients with Cancers of the Nasal Cavity and Paranasal Sinuses [Accessed 24 September 2018]):
  • Cross sectional diameter of the largest lymph node metastasis (not the lymph node itself) is measured in the gross specimen at the time of macroscopic examination or if necessary, on the histologic slide at the time of microscopic examination
  • Measurement of the metastatic focus in the lymph nodes is based on the largest metastatic deposit size, which may include matted or fused lymph nodes

• GX: Cannot be assessed
• G1: Well differentiated
• G2: Moderately differentiated
• G3: Poorly differentiated

Notes:

• For histologic types of carcinomas that are amenable to grading, 3 histologic grades are suggested, as shown above
  • For conventional squamous cell carcinoma, histologic grading as a whole does not perform well as a prognosticator
  • Nonetheless, it should be recorded when applicable, as it is a basic tumor characteristic
  • Selecting either the most prevalent grade or the highest grade for this synoptic protocol is acceptable
  • Variants of squamous cell carcinoma (i.e. verrucous, basaloid, etc.) have an intrinsic biologic potential and currently do not appear to require grading
• Histologic (microscopic) grading of salivary gland carcinomas has been shown to be an independent predictor of behavior and plays a role in optimizing therapy
  • However, most salivary gland carcinoma types have an intrinsic biologic behavior and attempted application of a universal grading scheme is merely a crude surrogate
  • Thus a generic grading scheme is no longer recommended for salivary gland carcinomas
  • Carcinoma types for which grading systems exist and are relevant are incorporated into histologic type
  • 3 major categories that are amenable to grading include adenoid cystic carcinoma, mucoepidermoid carcinoma and adenocarcinoma, not otherwise specified
• In some carcinomas, histologic grading may be based on growth pattern, such as in adenoid cystic carcinoma, for which a histologic high grade variant has been recognized based on the percentage of solid growth
  • Those adenoid cystic carcinomas showing ≥ 30% of solid growth pattern are considered to be histologically high grade carcinomas
  • Histologic grading of mucoepidermoid carcinoma includes a combination of growth pattern characteristics (e.g. cystic, solid, neurotropism) and cytomorphologic findings (e.g. anaplasia, mitoses, necrosis)
  • Adenocarcinomas, not otherwise specified do not have a formalized grading scheme and are graded intuitively based on cytomorphologic features
• For nonsalivary sinonasal adenocarcinoma, intestinal type adenocarcinoma grading is based on growth pattern
  • Generally, papillary patterns correspond to low grade tumors, colonic to intermediate grade and solid to high grade
  • Mucinous and mixed types have variable behavior
  • Nonintestinal type adenocarcinomas are graded intuitively into low, intermediate and high grade tumors

Based on the gross and microscopic examination of the 2.2 cm nasal cavity adenosquamous carcinoma originating along the right nasal septum in the following images, which of the pT category criteria in the 8th edition AJCC staging guide is satisfied?

1. pT1 due to tumor size
2. pT2 due to tumor size
3. pT3 due to extension to overlying nasal skin
4. pT4 due to extension to overlying nasal skin

D. pT4 due to extension to overlying nasal skin

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Reference: Pathologic TNM staging of nasal cavity and paranasal sinuses (AJCC 8th edition)