Site-Specific Recommendations for pT and pN

Head and Neck Tumours

Digestive System Tumours

Lung Tumours

Tumours of Bone and Soft Tissues

Skin Tumours

Breast Tumours

Gynaecological Tumours

Urological Tumours

Ophthalmic Tumours

References

Abstract

This new edition of TNM Supplement: A Commentary on Uniform Use, Second Edition, promotes the uniform application of the
TNM
classification in cancer practice. The text of the second edition of TNM Supplement provides explanations and examples to
answer many questions that might arise during the daily use of TNM, particularly in unusual cases.

This chapter provides additional explanatory information for application of TNM to specific anatomical sites by providing
more precise definitions for anatomical sites/subsites, regional lymph nodes and T, N, and M categories that are generic
or
ambiguous.

1. Introduction

This chapter is an expansion of the
following general rules of the TNM system (TNM Classification 1997 [13], pp. 7, 8):

2b. Pathological assessment of the primary tumour (pT) entails a resection of the primary tumour or biopsy
adequate to evaluate
the highest pT category. The pathological assessment of the regional lymph nodes (pN) entails removal of nodes
adequate to
validate the absence of regional lymph node metastasis (pN0) and sufficient to evaluate the highest pN
category.

4. If there is doubt concerning the correct T, N or M category to which a particular case
should be allotted, then the lower
(i.e., less advanced) category should be chosen.

In the TNM Classification of 1997 [13] these general rules have been specified for
breast cancer only. Analogous definitions for the pN0 category of other tumour
sites are given in the 1997 TNM Classification, except for bone, soft tissues, urological, and ophthalmic
tumours.

The numbers of lymph nodes given in the different tumour sites are considered adequate for staging. If the
examined lymph
nodes are negative but the number ordinarily resected is not met, classify as pN0. The number of nodes examined and the
number
involved by tumour should be recorded in the pathology report [1, 2, href="#ref4">4, 6, 7, 9]. This information may also be
added in parentheses, e.g., for colorectal carcinoma pN0 (0/11) or pN1 (3/10).

In many tumour sites, the number of
involved regional lymph nodes indicates differences in prognosis. For details, see
pN-Regional Lymph Nodes. A correlation exists between the number of
examined lymph nodes and the pN classification. With increasing number of examined
lymph nodes a higher frequency of lymph node-positive cases is found and-in tumour sites where more than one positive pN
category
is provided-a greater proportion of higher pN categories can be observed [3, 11].
Therefore, the number of examined lymph nodes reflects the reliability of the pN classification.

2. Head and Neck Tumours

2.1. pT-Primary Tumour

*Site*	*pT3 or less*	*pT4*

	Recommendation for all sites	Microscopic confirmation of:

Lip	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)	Invasion of adjacent structures, e.g., spongious bone, tongue or skin of neck
Oral Cavity		Invasion of adjacent structures, e.g., spongious bone, deep (extrinsic) muscle of tongue, maxillary sinus or skin.
Oropharynx		Invasion of adjacent structures, e.g., plerygoid muscle(s), mandible, hard palate or deep (extrinsic) muscle of tongue.
Nasopharynx		Invasion of cranial nerves, infratemporal fossa, orbit, hypopharynx or intracranial extension.
Hypopharynx		Invasion of adjacent structures, e.g., thyroid/cricoid cartilage, carotid artery, soft tissues of neck, prevertebral fascia/muscles, thyroid,and/or oesophagus.
Larynx		Invasion of tissue beyond the larynx, e.g., on the outer side of thyroid or cricoid cartilage, oesophagus or soft tissues of neck.
Maxillary Sinus		Invasion of the orbital contents beyond the floor or medial wall including any of the following: the orbital apex, cribriform plate, base of skull, nasopharynx, sphenoid, frontal sinuses.
Ethmoid sinus		Intracranial extension, orbital extension including apex, involvement of sphenoid and/or frontal sinus, and/or skin of nose.
Salivary Glands		Invasion of base of the skull, seventh cranial nerve, and/or size > 6 cm in greatest dimension.
Thyroid Gland		Invasion of tissue beyond the thyroid capsule.

2.2. pN-Regional Lymph Nodes

The site-specific recommendations regarding number of nodes for diagnosis of pN0 for all sites of head and neck
tumours have
been incorporated in the 5th edition [13] (see Table 3).

Site	Recommendations
All sites except thyroid gland and nasopharynx	pN1

	Microscopic confirmation of metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension

	pN2

	Microscopic confirmation of a regional lymph node metastasis more than 3 cm but not more than 6 cm in greatest dimension or microscopic confirmation of at least two regional lymph node metastases, none more than 6 cm in greatest dimension

	pN3

	Microscopic confirmation of a regional lymph node metastasis more than 6 cm in greatest dimension

Notes. 1. Terminology of neck dissection [8]: A radical neck
dissection includes the removal of all ipsilateral cervical lymph node groups, i.e., lymph nodes from levels
I through V and removal of the spinal accessory nerve, internal jugular
vein and sternocleidomastoid muscle.

In a modified radical neck dissection the same lymph nodes are removed as in a radical neck dissection;
however, one or more
nonlymphatic structures are preserved.

A selective neck dissection is a neck dissection with preservation of one or more lymph node groups
routinely removed in radical
neck dissection.

The most often performed types of selective neck dissections are: (a) supraomohyoid dissection, levels
I-III; (b) posterolateral
neck dissection, levels II-V and the retroauricular and occipital (suboccipital) nodes; (c) lateral neck
dissection, levels
II-IV, (d) anterior compartment neck dissection, level VI.

2. If the size of a biopsied lymph node is not indicated by the submitting surgeon,
classify pN1 if the positive biopsy is from one node and pN2 if positive
biopsies are from two or more lymph nodes.

Table 3. Number of lymph nodes usually examined in lymph node dissection specimens to classify
pN0

Site	Number of lymph nodes usually examined in lymph node dissection specimens to classify pN0

Lip and oral cavity	6	Selective neck dissection specimen
	10	Radical or modified radical neck dissection specimen
Pharynx	6	Selective neck dissection specimen
	10	Radical or modified radical neck dissection specimen
Larynx	6	Selective neck dissection specimen
	10	Radical or modified radical neck dissection specimen
Paranasal sinuses	6	Selective neck dissection specimen
	10	Radical or modified radical neck dissection specimen
Salivary glands	6	Selective neck dissection specimen
	10	Radical or modified radical neck dissection specimen
Thyroid gland	6
Oesophagus	6
Stomach	15
Small intestine	6
Colon and rectum	12
Anal canal	12	Perirectal-pelvic lymphadenectomy specimen
	6	Inguinal lymphadenectomy specimen
Liver	3
Gallbladder	3
Extrahepatic bile ducts	3
Ampulla of Vater	10
Pancreas	10
Lung	6
Bone and soft tissues	-
Carcinoma of the skin	6
Malignant melanoma of skin	6
Breast	6
Vulva	6
Vagina	6	Inguinal lymphadenectomy specimen
	10	Pelvic lymphadenectomy specimen
Cervix uteri	10
Corpus uteri	10
Ovary	10
Fallopian tube	10
Penis	6
Prostate	8
Testis	8
Kidney	8
Renal pelvis and ureter	8
Urinary bladder	8
Urethra	8
Ophthalmic tumours	6
All sites and types

2.3. Nasopharynx

2.3.1. pN1

Microscopic confirmation of unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above
supraclavicular
fossa

2.3.2. pN2

Microscopic confirmation of bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above
supraclavicular
fossa

2.3.3. pN3

Microscopic confirmation of metastasis in lymph node(s)

a.	greater than 6 cm in dimension
b.	in the supraclavicular fossa

2.4. Thyroid Gland

2.4.1. pN1a

Microscopic confirmation of a metastasis in an ipsilateral cervical lymph node

class="sect3">2.4.2. pN1b

Microscopic confirmation of a midline or contralateral cervical or mediastinal lymph node
metastasis

3. Digestive System Tumours

3.1. pT-Primary Tumour

Site	Recommendations
Oesophagus	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the deep (radial, lateral), proximal and distal margins of the resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of adjacent structures
Stomach	pT3 or less

	Pathological examination of the primary carcinoma removed by total or partial gastrectomy with no gross tumour at the deep (radial, lateral), proximal and distal margins of resection (with or without microscopic involvement) or Pathological examination of the primary carcinoma removed by endoscopic polypectomy or local excision with histologically tumour-free margins of resection

	pT4

	Microscopic confirmation of invasion of adjacent structures such as spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine and/or retroperitoneum
Small Intestine	pT3 or less

	Pathological examination of the primary carcinoma removed by short segment (limited) or radical resection with no gross tumour at the deep (radial, lateral), proximal and distal margins of resection (with or without microscopic involvement) class="emph">or Pathological examination of the primary carcinoma removed by endoscopic polypectomy or local excision with histologically tumour-free margins of resection

	pT4

	Pathological confirmation of perforation of the visceral peritoneum class="emph">or Microscopic confirmation of invasion of other organs or structures (including other loops of small intestine, mesentery or retroperitoneum more than 2 cm and abdominal wall via serosa; for duodenum only, invasion of pancreas)
Colon and Rectum	pT3 or less

	Pathological examination^{href="#tnms03-note-0002">1} of the primary carcinoma removed by short segment (limited) or radical resection with no gross tumour at the deep (radial, lateral, circumferential), proximal and distal margins of resection (with or without microscopic involvement) or Pathological examination of the primary carcinoma removed by endoscopic polypectomy or local excision with histologically tumour-free margins of resection

	pT4

	Pathological confirmation of perforation of the visceral peritoneum class="emph">or Microscopic confirmation of invasion of adjacent organs or structures (including invasion of levator muscles) and invasion of other segments of the colorectum by way of the sorosa
Anal Canal	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of adjacent organs (e.g. vagina, urethra, bladder) [invasion of the sphincter muscle(s) alone is not sufficient for pT4]
Liver	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of multiple tumours in more than one lobe class="emph">or Microscopic confirmation of invasion of a major branch of the portal or hepatic vein(s) or tumour(s) with direct invasion of adjacent organ(s) other than gallbladder, or tumour(s) with perforation of the visceral peritoneum
Gallbladder	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of tumour in the liver more than 2 cm from the gallbladder or invasion of at least two adjacent organs (stomach, duodenum, colon, pancreas, omentum, extrahepatic bile ducts, liver)
Extrahepatic Bile Ducts	pT2 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT3

	Microscopic confirmation of invasion of adjacent structures (liver, pancreas, duodenum, gallbladder, colon, stomach)
Ampulla of Vater	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of tumour in the pancreas more than 2 cm from the ampulla or invasion of other adjacent organs
Pancreas	pT2 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT3

	Microscopic confirmation of invasion of any of the following adjacent tissues: duodenum, bile duct, splenic vessels, peripancreatic tissues

	pT4

	Microscopic confirmation of invasion of stomach, spleen, colon and/or adjacent large vessels

¹
Note. Pathological confirmation may be achieved from biopsies or resection specimens
or by cytology of specimens obtained from
the serosa overlying the primary tumour [14].

3.2. pN-Regional Lymph Nodes
The site-specific recommendations regarding number of nodes for diagnosis of pN0 for all sites of Digestive System
Tumours
have been incorporated in the 5th edition [13] (see Table href="#tnms03-tbl-0019">3).

Site	Recommendations
Oesophagus	pN1

	Microscopic confirmation of at least one regional lymph node metastasis
Stomach	pN1

	Microscopic confirmation of one to six regional lymph node metastasis

	pN2

	Microscopic confirmation of seven to fifteen regional lymph node metastasis

	pN3

	Microscopic confirmation of more than fifteen regional lymph node metastasis
Small intestine	pN1

	Microscopic confirmation of at least one regional lymph node metastasis
Colon and rectum	pN1

	Microscopic confirmation of one to three regional lymph node metastasis

	pN2

	Microscopic confirmation of more than three regional lymph node metastasis

	pN1/2

	If the pathology report does not indicate the number of involved nodes, classify pN1
Anal Canal	pN1

	Microscopic confirmation of metastasis in perirectal lymph node(s)

	pN2

	Microscopic confirmation of metastasis in unilateral internal iliac and/or inguinal lymph node(s)

	pN3

	Microscopic confirmation of metastasis in perirectal and/or inguinal lymph nodes and/or bilateral internal iliac lymph nodes and/or bilateral inguinal lymph nodes
Liver	pN1

	Microscopic confirmation of at least one regional lymph node metastasis
Gallbladder, Extrahepatic Bile Ducts	pN1

	Microscopic confirmation of metastasis in lymph node(s) of the hepatoduodenal ligament (cystic duct, pericholedochal, hilar lymph nodes)

	pN2

	Microscopic confirmation of metastasis in peripancreatic (head only), periduodenal, periportal, coeliac and/or superior mesenteric lymph node(s)
Ampulla of Vater, Pancreas	pN1

	Microscopic confirmation of at least one regional lymph node metastasis

4. Lung and Pleural Tumours

4.1. pT-Primary Tumour

Site	Recommendations
Lung Tumours	pT3 or less Pathological examination of the primary carcinoma with no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of any of the following: mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina or microscopic confirmation of separate tumour nodule(s) in the same lobe or malignant cells in pleural effusion confirmed by cytology
Pleural Mesothelioma	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of any of the following: contralateral pleura, contralateral lung, peritoneum, intra-abdominal organs, cervical tissues

4.2. pN-Regional Lymph Nodes
The site-specific recommendations regarding number of nodes for diagnosis of pN0 for lung tumours have been
incorporated in
the 5th edition [13] (see Table 3).

align="center">

Site	Recommendations
Lung Tumours and Pleural Mesothelioma	pN1

	Microscopic confirmation of metastasis in ipsilateral peribronchial lymph node(s) or ipsilateral hilar lymph node(s) [including intrapulmonary lymph nodes for lung]

	pN2

	Microscopic confirmation of metastasis in ipsilateral mediastinal lymph node(s) or subcarinal lymph node(s)

	pN3

	Microscopic confirmation of metastasis in contralateral mediastinal lymph node(s) or contralateral hilar lymph node(s) or scalene or supraclavicular lymph node(s) (ipsilateral or contralateral)

5. Tumours of Bone and Soft Tissues

5.1. pT-Primary Tumour

Site	Recommendations
Bone	pT1

	Pathological examination of the primary tumour with no gross tumour at the margins of resection (with or without microscopic involvement)

	pT2

	Microscopic confirmation of invasion beyond the cortex
Soft Tissues	pTl and pT2

	Pathological examination of the primary tumour with no gross tumour at the margins of resection (with or without microscopic involvement)

5.2. pN-Regional Lymph Nodes

Site	Recommendations
Bone and Soft Tissues	pN0

	Histological examination of a regional lymphadenectomy specimen which will ordinarily include six or more lymph nodes

	pN1

	Microscopic confirmation of at least one regional lymph node metastasis

6. Skin Tumours

6.1. pT-Primary Tumour

Tumour type	Recommendations
Carcinoma	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of deep extradermal structures, i.e., cartilage, skeletal muscle or bone
Malignant Melanoma	pT3 or less

	Pathological examination of the primary melanoma with no gross tumour at the lateral margins of resection and with no histological tumour at the deep margins of resection

	pT4

	Pathological examination of the primary melanoma incompletely removed but more than 4 mm in thickness and/or with invasion of the subcutaneous tissue or Microscopic confirmation of satellites (pT4b)

6.2. pN-Regional Lymph Nodes
The site-specific recommendations regarding number of nodes for diagnosis of pN0 for all sites of skin tumours have
been incorporated
in the 5th edition (see Table 3).

Tumour type	Recommendations
Carcinoma	pN1

	Microscopic confirmation of at least one regional lymph node metastasis
Malignant Melanoma	pN1

	Histological examination of or positive biopsy from a regional lymph node metastasis 3 cm or less in greatest dimension^{href="#tnms03-note-0003">1}

	pN2a

	Histological examination of or positive biopsy from a regional lymph node metastasis more than 3 cm in greatest dimension

	pN2b

	Microscopic confirmation of an in-transit metastasis

	pN2c

	Metastasis more than 3 cm in greatest dimension in any regional lymph node(s) and microscopic confirmation of in-transit metastasis

¹
Note. If the size of the biopsied lymph node(s) is not indicated by the submitting
surgeon, classify a positive biopsy from a lymph
node as pN1.

7. Breast Tumours

7.1. pT-Primary Tumour

Tumour type	Recommendations
All pT	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

7.2. pN-Regional Lymph Nodes

7.2.1. Recommendations

The site-specific recommendations regarding number of nodes for diagnosis of pN0 for Breast tumours have been
incorporated
in the 5th edition of TNM [13] (see Table 3).

class="sect3">7.2.2. pN1

Histological examination of at least the low axillary lymph nodes (level I), which will ordinarily include six or
more lymph
nodes

7.2.3. pN2

Microscopic confirmation of a metastasis to ipsilateral axillary lymph nodes fixed to one another or to other
structures

7.2.4. pN3

Microscopic confirmation of a metastasis to ipsilateral internal mammary lymph node(s)

Note. Based on the results of histological examination of 1446 patients with
complete axillary dissection [10], a mathematical model was developed by Kiricuta and Tausch
[5] to determine the sample size from level I necessary for 90% certainty of N0 axillary
status. According to this model the
examination of 10 lymph nodes from level I is needed.

8. Gynaecological Tumours

8.1. pT-Primary Tumours

Site	Recommendations
Vulva	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of any of the following: bladder mucosa, rectal mucosa, upper-urethral mucosa, pelvic bone
Vagina	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of the mucosa of bladder or rectum or of extension beyond the true pelvis
Cervix Uteri and Corpus Uteri	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of mucosa of bladder or bowel or (for cervix uteri) beyond the true pelvis
Ovary	pT1

	Pathological examination of both ovaries

	pT2

	Microscopic confirmation of tumour outside the ovary within the pelvis or cytologically proven malignant cells in ascites or peritoneal washing

	pT3

	Microscopic confirmation of peritoneal metastasis outside the pelvis
Fallopian Tube	pT1

	Pathological examination of both tubes

	pT2

	Microscopic confirmation of tumour outside the tube within the pelvis or cytologically proven malignant cells in ascites or peritoneal washing

	pT3

	Microscopic confirmation of peritoneal metastasis outside the pelvis

Note. (Ovary and Fallopian tube). In the case of histologically proven tumour on
pelvic peritoneum only but macroscopic finding of peritoneal metastasis outside
the pelvis by the surgeon, the tumour is classified (c)T3 pT2

8.2. pN-Regional Lymph Nodes
The site-specific recommendations regarding number of nodes for diagnosis of pN0 for all gynaecological tumours have
been
incorporated in the 5th edition [13] (see Table 3).

align="center">

Site	Recommendations
Vulva	pN1

	Microscopic confirmation of a unilateral regional lymph node metastasis

	pN2

	Microscopic confirmation of bilateral regional lymph node metastasis
Vagina, Cervix Uteri, Corpus Uteri, Ovary, Fallopian tube	pN1

	Microscopic confirmation of at least one regional lymph node metastasis

9. Urological Tumours

9.1. pT-Primary Tumour

Site	Recommendations
Penis	pT3 or less

	Pathological examination of the primary carcinoma removed by partial or total penis amputation with no gross tumour at the margins of resection (with or without microscopic involvement) or Pathological examination of the primary tumour removed by local excision with histologically tumour-free margins of resection

	pT4

	Microscopic confirmation of invasion of adjacent structures other than urethra or prostate
Prostate	pT1

	A pT1 category is not defined, because there is insufficient tissue to assess the highest T category

	pT2 or pT3

	Pathological examination of a radical prostatectomy specimen with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement) or Pathological examination of a simple prostatectomy specimen with histologically tumour-free margins of resection

	pT4

	Microscopic confirmation of invasion of adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall
Testis	All pT

	Pathological examination of a radical orchiectomy specimen.
Kidney	pT3 or less

	Pathological examination of a partial or total nephrectomy specimen with no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion beyond Gerota fascia
Renal Pelvis and Ureter	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of perinephric fat or adjacent organs
Urinary Bladder	pT3 or less

	Pathological examination of partial or total cystectomy specimen with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of any of the following: prostate, uterus, vagina, pelvic wall, abdominal wall, intestine, seminal vesicles, or microscopic confirmation of perforation of visceral peritoneum
Note. There is a problem in the classification of bladder tumours after transurethral resection. The precondition for pT can only be met in cases of complete tumour resection, i.e., resection of all grossly visible tumour tissue from the remaining grossly tumour-free adjacent bladder wall (deep and laterally). If these additionally and separately submitted tissues are histologically negative, a complete tumour resection can be assumed. Only in such patients can pTaNXMX, pTisNXMX, pT1MXM0, pT2aNXM0 be considered as pathologic stages.
Urethra	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of adjacent organs other than prostate, anterior vagina and bladder neck

9.2. pN-Regional Lymph Nodes
The definitions of the following N categories for urological tumours changed between the 4th [ href="#ref12">12] and 5th [13] editions of TNM.

Site	N Categories (except NX and N0)

Penis	N1, N2, N3
Prostate	N1
Testis	N1, N2, N3, pN1, pN2, pN3
Kidney	N1, N2
Renal pelvis and ureter	N1, N2, N3
Urinary bladder	N1, N2, N3
Urethra	N1, N2

Site	Recommendations
All sites except penis	pN0

	Histological examination of a regional lymphadenectomy specimen which will ordinarily include eight or more lymph nodes (see Table 3).^{href="#tnms03-note-0005">*}
Note. Measurements are made of the metastasis, not of the entire lymph node. If the size of biopsied lymph node(s) is not indicated by the submitting surgeon, classify as pN1 if there is a positive biopsy from one lymph node and as pN2 (except prostate) if there are positive biopsies from two or more lymph nodes.
Penis	pN0

	Histological examination of an inguinal lymphadenectomy specimen which will ordinarily include six or more lymph nodes

	pN1

	Microscopic confirmation of metastasis in a single superficial inguinal lymph node

	pN2

	Microscopic confirmation of metastasis in multiple or bilateral superficial inguinal lymph nodes

	pN3

	Microscopic confirmation of metastasis in deep inguinal or pelvic lymph node(s)
Prostate	pN1

	Microscopic confirmation of at least one regional lymph node metastasis
Testis	pN1

	Microscopic confirmation of a lymph node metastasis (lymph node mass) 2 cm or less in greatest dimension or at least one/not more than 5 positive lymph nodes, none more than 2 cm in greatest dimension

	pN2

	Microscopic confirmation of a lymph node metastasis (lymph node mass) more than 2 cm in greatest dimension but not more than 5 cm in greatest dimension; or more than 5 nodes positive, none more than 5 cm; or evidence of extranodal extension of tumour

	pN3

	Microscopic confirmation of a lymph node metastasis (lymph node mass) more than 5 cm in greatest dimension
Kidney	pN1

	Microscopic confirmation of a single regional lymph node metastasis

	pN2

	Microscopic confirmation of metastasis in more than one regional lymph node
Renal pelvis, Ureter, Urinary bladder	pN1

	Microscopic confirmation of a single lymph node metastasis not more than 2 cm in diameter

	pN2

	Microscopic confirmation of a single lymph node metastasis more than 2 cm but not more than 5 cm in greatest dimension or Microscopic confirmation of at least two lymph node metastasis, none more than 5 cm in greatest dimension

	pN3

	Microscopic confirmation of a lymph node metastasis more than 5 cm in greatest dimension
Urethra	pN1

	Microscopic confirmation of a single lymph node metastasis 2 cm or less in greatest dimension

	pN2

	Microscopic confirmation of a single lymph node metastasis more than 2 cm in greatest dimension, or Microscopic confirmation of multiple lymph node metastasis

^*
These recommendations are not included in the 5th TNM edition but are
new.

10. Ophthalmic Tumours

10.1. pT-Primary Tumour

Site/Type	Recommendations
Carcinoma of Eyelid	pT3 or less

	Pathological examination of the primary carcinoma with histologically tumour-free margins of resection

	pT4

	Microscopic confirmation of invasion of adjacent structures
Carcinoma of Conjunctiva	pT3 or less

	Pathological examination of the primary carcinoma with histologically tumour-free margins of resection

	pT4

	Microscopic confirmation of invasion of the orbit
Malignant Melanoma of Conjunctiva	pT3 or less

	Pathological examination of the primary melanoma with histologically tumour-free margins of resection

	pT4

	Microscopic confirmation of invasion of the eyelid, cornea and/or orbit
Malignant Melanoma of Uvea	pT3 or less

	Pathological examination of the primary melanoma with histologically tumour-free margins of resection

	pT4

	Microscopic confirmation of extraocular extension
Retinoblastoma	pT3 or less

	Pathological examination of the primary retinoblastoma with histologically tumour-free margins of resection

	pT4

	Microscopic confirmation of intraneural tumour beyond lamina cribrosa but not at the line of resection (pT4a)

	Microscopic confirmation of tumour at the line of resection or other extraocular extension (pT4b)
Sarcoma of Orbit	pT3 or less

	Pathological examination of the primary sarcoma with histologically tumour-free margins of resection

	pT4

	Microscopic confirmation of tumour beyond the orbit (adjacent sinuses and/or cranium)
Carcinoma of Lacrimal Gland	pT3 or less

	Pathological examination of the primary carcinoma with class="emph">no gross tumour at the margins of resection (with or without microscopic involvement)

	pT4

	Microscopic confirmation of invasion of orbital tissues, optic nerve, or globe, without (pT4a) or with (pT4b) bone invasion

10.2. pN-Regional Lymph Nodes

Site	Recommendations
All Sites and Types	pN0

	Histological examination of a regional lymphadenectomy specimen which will ordinarily include six or more lymph nodes

	pN1

	Microscopic confirmation of atleast one regional lymph node metastasis

10.3. Hodgkin Disease and Non-Hodgkin Lymphomas
Pathological staging requires the histological examination of:

·	Liver biopsies
·	At least four abdominal lymph nodes
·	Bone marrow biopsies from clinically or radiologically non-involved area of bone
·	Spleen or spleen biopsies

References

1.	Fielding LP, Arsenault PA, Chapuis PH, et al. Clinicopathological staging for colorectal cancer: an International Documentation System (IDS) and an International Comprehensive Anatomical Terminology (ICAT). J Gastroenterol Hepatol 1991; 6: 325-344
2.	Hermanek P, Giedl J, Dworak O. Two programmes for examination of regional lymph nodes in colorectal carcinoma with regard to the new pN classification. Pathol Res Pract 1989; 185: 867-873
3.	Hermanek P. Onkologische Chirurgie/Pathologisch-anatomische Sicht. Langenbecks Arch Chir Suppl 1991; 277-281
4.	Honthoff MJ. "Surgical pathology of hepatobiliary and pancreatic tumours". In Hepatobiliary and Pancreatic Malignancies, Lygidakis NJ, Tytgat GNJ (eds). Thieme: Stuttgart, 1989
5.	Kiricuta CI, Tausch J. A mathematical model of axillary lymph node involvement based on 1446 complete axillary dissections in patients with breast carcinoma. Cancer 1992; 69: 2496-2501
6.	Qizilbash AH. Pathologic studies in colorectal cancer. Pathol Annu 1982; 17: 1-46
7.	Remmele W. Staging, typing and grading of colorectal cancer: a critical review of current classification systems. Prog Surg Pathol 1984; 5: 7-36
8.	Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB, Pruet CW. Standardizing neck dissection terminology. Official report of the Academy's Committee for Head and Neck Surgery and Oncology. Arch Otolaryngol Head Neck Surg 1991; 117: 601-605
9.	Rosai J. Ackerman's Surgical Pathology (8th ed). Mosby: St. Louis, MO, 1996
10.	Veronesi U, Luini A, Galimberti V, Marchini S, Sacchini V, Rilke F. Extent of metastatic axillary involvement in 1446 cases of breast cancer. Eur J Surg Oncol 1990; 16: 127-133
11.	UICC: TNM Supplement 1993. A commentary on uniform use. Hermanek P, Henson DE, Hutter RVP, Sobin LH (eds) Springer: Berlin Heidelberg New York Tokyo, 1993
12.	UICC. TNM Classification of Malignant Tumours. Hermanek P, Sobin LH (eds) Springer: Berlin Heidelberg New York, 1987, 2nd revision, 1992
13.	UICC. TNM Classification of Malignant Tumours. Sobin LH, Wittekind Ch (eds) Wiley-Liss: New York, 1997
14.	Zeng Z, Cohen AM, Hajdu S, et al. Serosal cytologic study to determine free mesothelial penetration by intraperitoneal colon cancer. Cancer 1992; 70: 737-740

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Site-Specific Recommendations for pT and pN

Abstract

1. Introduction

2. Head and Neck Tumours

3. Digestive System Tumours

4. Lung and Pleural Tumours

5. Tumours of Bone and Soft Tissues

6. Skin Tumours

7. Breast Tumours

8. Gynaecological Tumours

9. Urological Tumours

10. Ophthalmic Tumours

References

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Site-Specific Recommendations for pT and pN

Abstract

1. Introduction

2. Head and Neck Tumours

3. Digestive System Tumours

4. Lung and Pleural Tumours

5. Tumours of Bone and Soft Tissues

6. Skin Tumours

7. Breast Tumours

8. Gynaecological Tumours

9. Urological Tumours

10. Ophthalmic Tumours

References

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