Rapid Acquisition Of Key Concepts Head And Neck

Outline of the T category from the American Joint Committee on Cancer (AJCC) tumour- node-metastasis (TNM) staging manual, 8th edition

T category

T criteria

TX

Primary tumour cannot be assessed

Tis

Carcinoma in situ

T1

Tumour ≤ 2 cm, ≤5 mm DOI

T2

Tumour ≤ 2 cm, DOI >5 mm and ≤10 mm or tumour >2 cm but ≤4 cm, and ≤ 10 mm DOI

T3

Tumour > 4 cm or any tumour > 10 mm DOI 

T4

Moderately advanced or very advanced local disease

T4a

Moderately advanced local disease: (lip) tumour invades though cortical bone or involves the inferior alveolar nerve, floor of mouth or skin of face (i.e. chin or nose); (oral cavity) tumour invades adjacent structures only (e.g. through cortical bone of the mandible or maxilla. or involves the maxillary sinus or skin of the face): note that superficial erosion of bone/tooth socket (alone) by a gingival primary is not sufficient

N Category

Criteria

NX

Regional lymph cannot be assessed 

N0

No regional lymph node metastasis 

N1

Metastasis in a single ipsilateral lymph node, 3cm smaller in greatest dimension and ENE-negative

N2a

Metastasis in a single ipsilateral lymph node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE-negative

N2b

Metastasis in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE-negative 

N2c

Metastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension and ENE-negative 

N3a

Metastasis in a lymph none larger than 6 cm in greatest dimension and ENE-negative

N3b

ENE-positive

T staging of salivary gland tumours as per the American Joint Committee on Cancer system

T Category

T criteria 

TX

T0

Tis

T1

T2

T3

T4a

T4b

Primary tumour cannot be assessed

No evidence of primary tumour 

Carcinoma in situ

Tumour 2 cm or smaller in qreatest dimension without extraparenchymal extension 

Tumour larger than 2 cm but not larger than 4 cm in greatest dimension without extraparenchymal extension 

Tumour larger than 4 cm and/or tumour having extra parenchymal extension 

Moderately advanced disease

Tumour invades skin, mandible, ear canal and/or facial nerve

Very advanced disease 

Tumour invades skull base and/or pterygoid plates and/or encases carotid artery 

Commonly used regional flaps in head and neck reconstruction

Flap name

Vascular supply

Components

Pectoralis major

Pectoral branch of thoracoacromial artery

Muscle 

Musculocutaneous

Supraclavicular artery island

Supraclavicular branch of transverse cervical artery

Fasciocutaneous

Submental artery island

Submental branch of the facial artery

Fasciocutaneous

Temporalis

Deep temporal artery

Muscle

Temporoparietal fascia

Superficial temporal artery

Fasciocutaneous

Latissimus dorsi

Thoracodorsal artery

Muscle 

Musculocutaneous

Deltopectoral flap

Intercostal perforators of the internal mammary artery

Fasciocutaneous

Commonly used free flaps in head and neck reconstruction

Fascial and /or fasciocutaneous

Muscle and/or myocutaneous

Bone Containing Free FLAPS (Composite)

• Radial forearm (Workhouse free flap)
• Anterolateral thigh
• Lateral arm
• Ulnar forearm
• Temporoparietal fascia 
• Lateral thigh

• Rectus abdominis
• Latissimus dorsi (Also a pedicle flap)
• Gracilis
• Anterolateral thigh with vastus lateralis

• Fibula
• Scapula (lateral border or tip)
• Radial forearm
• Radial forearm
• Iliac crest/ external oblique flap

Composite (Bone containing) Free Flaps used for Reconstruction in Oral Cavity Cancers

• Fibula Osseocutaneous

• Peroneal artery

• Excellent bone stock and length, long pedicle, thin skin paddle

• Scapula osseocutaneous

• Circumflex scapular artery

• Less bone length compared to fibula, large scapular or parascapular skin paddles ideal for large composite defects

• Composite radial forearm osseocutaneous

• Radial artery

• Long pedicle, diminutive bone stock

• Perforator based iliac crest osseocutaneous free flap

• Deep circumflex iliac artery

• Up to 16 cm of bone available, limited soft tissue, significant donor site morbidity

Preferable method of flap for reconstruction based on the subsite of Oral Cavity Cancer

Anatomical site

Primary reconstructive options

Alternative reconstruction

Floor of mouth

RFFF

• Free flap- ALT, MSAP, Lateral arm
• Pedicled/ local flap- nasolabial flaps (bilateral), submental island flap

Lateral tongue

RFF/ ALT

• Free flap- MSAP
• Pedicled flap- pectoralis major, platysma skin flap

Total tongue/ glossectomy

ALT/rectus Abdominis

• Pedicled flap- pectoralis major

Buccal mucosa

RFFF

• Free flap- ALT/MSAP
• Pedicled/ local flap- pectoralis major

Mandible

Dentate

Iliac crest (DCIA)

• Free flap- fibula, composite radial, scapula or tip of scapula (angular branch of thoracodorsal artery)

Edentulous

Fibular free flap

• Free flap- composite radial, scapula or tip of scapula (angular branch of thoracodorsal artery)
• Pedicled/local flap- reconstruction plate and pectoralis major