Site-Specific Recommendations for pT and pN

1. Head and Neck Tumours
2. Digestive System Tumours
3. Lung Tumours
4. Tumours of Bone and Soft Tissues
5. Skin Tumours
6. Breast Tumours
7. Gynaecological Tumours
8. Urological Tumours
9. Ophthalmic Tumours
10. 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, 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 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

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 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) 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 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 examination1 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 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 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 no gross tumour at the margins of resection (with or without microscopic involvement) pT4 Microscopic confirmation of multiple tumours in more than one lobe 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 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 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 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 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 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 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).

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 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 dimension1 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 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).

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 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 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 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).

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 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 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 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 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 [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).* 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 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

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