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TNM classification of malignant tumours
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Tuberculosis of the Nasopharynx Following Radiotherapy remaining patients with progressive symptoms were confirmed as having recurrent NPC, based on CT scan evidence of tumour progression. These authors reported that recurrent NPC was not easily confirmed when based on rhinoscopy and biopsy alone. CT imaging was also used for diagnosis. The theory is that, in NPC relapse, the tumour grows submucosally, beyond the reach of the biopsy forceps, and thus presents at a more advanced stage. The patient we now report presented with symptoms similar to recurrence of NPC, with radiological evidence to support this diagnosis. The only missing supportive evidence was a positive tissue biopsy for malignancy. Based on the diagnostic criteria by Sham et al. [6], our patient would have been diagnosed as having recurrent NPC. At the time, it was difficult to decide whether the CT and MRI findings in our patient were due to tumour, postradiation changes or TB. However, she responded to the antituberculous treatment. A repeat CT scan did not show evidence of tumour recurrence or spread. W e believe that the bony changes and soft tissue enhancement seen radiologically were probably inflammatory changes. It was easy to miss the diagnosis of primary NPTB in this patient, due to the rarity of this disease. A negative
nasopharyngeal biopsy for malignancy should alert clinicians to the other differential diagnoses of a lesion in the nasopharynx. These are: midline granuloma, Wegeners's granuloma, sarcoid, TB, syphilis, lymphoma, fungal infections, leprosy and periarteritis nodosa [4].
References 1. Graft S. Die bedenturg des epipharynx fur die Menschlidie. Pathol Klin Wochenschr 1936;27:9535. 2. Sire T, Ong BH. Primary tuberculosis of the nasopharynx. Singapore Med J 1972;13:3943. 3. Waldron J, Van Hasselt AC, Skinner DW, et al. Tuberculosis of the nasopharynx: clinicopathological features. Clin Otolaryngol 1992;17:579. 4. Bath AP, O'Flynn P, Gibbin KP. Nasopharyngeal tuberculosis. J Laryngol Otol 1992;106:107980. 5. Warwick-Brown NP. Cranial nerve palsies following tuberculosis. J Laryngol Otol 1984;98:2179. 6. Sham JST, Choy D, Wei WI, et al. Value of clinical follow-up for local nasopharyngeal carcinoma relapse. Head Neck 1992;14:20817.
Received for publication April 1997 Accepted following revision September 1997
Book Review TNM Classification of Malignant Tumours, fifth edition. Edited by L H. Sobin and C. Wittekind. Wiley-Liss, for the UICC, New York, 1997. Pages: 227; Price £24.95; Paperback. ISBN 0-47118486-1. The last fully revised edition of the TNM was published in 1987. In this fifth edition, most sites are unchanged. The changes that have been introduced reflect new data on prognosis as well as new methods for assessment. There are major changes in the classification of nasopharyngeal carcinoma, testicular mmours and urological malignancies. The classifications of vulval and uterine/cervix tumours have been modified to keep the FIGO and TNM staging in line. Gestational tumours have now been included, while paediatric tumours have been excluded because of the variety of classification systems in use by different investigational groups. The classification of brain tumours has also been removed, as those previously proposed have not been found to be useful predictors. As before, this TNM classification of the International Union Against Cancer (UICC) is identical to that of the American Joint Committee on Cancer Classification (AJCC). The principles of the TNM classification are unchanged. An alphanumeric classification for sites of metastasis and optional descriptors for lymphatic and vascular invasion have been added. The major difference within the head and neck section relates to the nasopharynx, where the T-staging has been altered so that the subsites in the nasopharynx are no longer relevant. In addition, the N-staging is different to the rest of the head and neck, with nodal
metastases up to 6 cm included under N1. In the classification of vulval tumours, the depth of stromal invasion has been added as a prognostic feature and, for the uterine cervix, the degree of stromal invasion within the the various T stages has been altered. A classification for the fallopian tubes has been added. There are several changes within the classification for urological malignancies. The staging of prostatic cancer has been changed to reflect anatomical spread rather than precise measurements, and the staging of testicular tumours takes into account an additional classification (S category), which has been included to reflect the prognostic significance of tumour markers. The Tt classification of renal tumours includes tumours up to 7 cm in diameter, which is a considerable size change from the previous classification. In the section on soft tissue tumours, ICD-O codes have been given for a variety of histological types, although the list is by no means exhaustive. A welcome change is the recognition of the better prognostic significance of superficial soft tissue sarcomas. In summary, the TNM classification remains an extremely well researched publication and essential reading for all those involved in the diagnosis and management of malignant turnouts. There is continuing evolution to make the system more clinically relevant and to keep coherent the various classification systems in use worldwide. A. M. CASSOM Middlesex Hospital London, UK
Tuberculosis of the Nasopharynx Following Radiotherapy remaining patients with progressive symptoms were confirmed as having recurrent NPC, based on CT scan evidence of tumour progression. These authors reported that recurrent NPC was not easily confirmed when based on rhinoscopy and biopsy alone. CT imaging was also used for diagnosis. The theory is that, in NPC relapse, the tumour grows submucosally, beyond the reach of the biopsy forceps, and thus presents at a more advanced stage. The patient we now report presented with symptoms similar to recurrence of NPC, with radiological evidence to support this diagnosis. The only missing supportive evidence was a positive tissue biopsy for malignancy. Based on the diagnostic criteria by Sham et al. [6], our patient would have been diagnosed as having recurrent NPC. At the time, it was difficult to decide whether the CT and MRI findings in our patient were due to tumour, postradiation changes or TB. However, she responded to the antituberculous treatment. A repeat CT scan did not show evidence of tumour recurrence or spread. W e believe that the bony changes and soft tissue enhancement seen radiologically were probably inflammatory changes. It was easy to miss the diagnosis of primary NPTB in this patient, due to the rarity of this disease. A negative
nasopharyngeal biopsy for malignancy should alert clinicians to the other differential diagnoses of a lesion in the nasopharynx. These are: midline granuloma, Wegeners's granuloma, sarcoid, TB, syphilis, lymphoma, fungal infections, leprosy and periarteritis nodosa [4].
References 1. Graft S. Die bedenturg des epipharynx fur die Menschlidie. Pathol Klin Wochenschr 1936;27:9535. 2. Sire T, Ong BH. Primary tuberculosis of the nasopharynx. Singapore Med J 1972;13:3943. 3. Waldron J, Van Hasselt AC, Skinner DW, et al. Tuberculosis of the nasopharynx: clinicopathological features. Clin Otolaryngol 1992;17:579. 4. Bath AP, O'Flynn P, Gibbin KP. Nasopharyngeal tuberculosis. J Laryngol Otol 1992;106:107980. 5. Warwick-Brown NP. Cranial nerve palsies following tuberculosis. J Laryngol Otol 1984;98:2179. 6. Sham JST, Choy D, Wei WI, et al. Value of clinical follow-up for local nasopharyngeal carcinoma relapse. Head Neck 1992;14:20817.
Received for publication April 1997 Accepted following revision September 1997
Book Review TNM Classification of Malignant Tumours, fifth edition. Edited by L H. Sobin and C. Wittekind. Wiley-Liss, for the UICC, New York, 1997. Pages: 227; Price £24.95; Paperback. ISBN 0-47118486-1. The last fully revised edition of the TNM was published in 1987. In this fifth edition, most sites are unchanged. The changes that have been introduced reflect new data on prognosis as well as new methods for assessment. There are major changes in the classification of nasopharyngeal carcinoma, testicular mmours and urological malignancies. The classifications of vulval and uterine/cervix tumours have been modified to keep the FIGO and TNM staging in line. Gestational tumours have now been included, while paediatric tumours have been excluded because of the variety of classification systems in use by different investigational groups. The classification of brain tumours has also been removed, as those previously proposed have not been found to be useful predictors. As before, this TNM classification of the International Union Against Cancer (UICC) is identical to that of the American Joint Committee on Cancer Classification (AJCC). The principles of the TNM classification are unchanged. An alphanumeric classification for sites of metastasis and optional descriptors for lymphatic and vascular invasion have been added. The major difference within the head and neck section relates to the nasopharynx, where the T-staging has been altered so that the subsites in the nasopharynx are no longer relevant. In addition, the N-staging is different to the rest of the head and neck, with nodal
metastases up to 6 cm included under N1. In the classification of vulval tumours, the depth of stromal invasion has been added as a prognostic feature and, for the uterine cervix, the degree of stromal invasion within the the various T stages has been altered. A classification for the fallopian tubes has been added. There are several changes within the classification for urological malignancies. The staging of prostatic cancer has been changed to reflect anatomical spread rather than precise measurements, and the staging of testicular tumours takes into account an additional classification (S category), which has been included to reflect the prognostic significance of tumour markers. The Tt classification of renal tumours includes tumours up to 7 cm in diameter, which is a considerable size change from the previous classification. In the section on soft tissue tumours, ICD-O codes have been given for a variety of histological types, although the list is by no means exhaustive. A welcome change is the recognition of the better prognostic significance of superficial soft tissue sarcomas. In summary, the TNM classification remains an extremely well researched publication and essential reading for all those involved in the diagnosis and management of malignant turnouts. There is continuing evolution to make the system more clinically relevant and to keep coherent the various classification systems in use worldwide. A. M. CASSOM Middlesex Hospital London, UK