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Patterns of Lymph Node Metastasis

The regional lymphatic drainage of the neck is divided into seven
levels. These levels allow for a standardized format for radiologists,
surgeons, pathologists, and radiation oncologists to communicate
concerning specific sites within the neck and does not represent
regions isolated by fascial planes. The levels are defined as the
following:

Level Ithe submental and submandibular nodes

Level Iathe submental nodes; medial to the anterior
belly of the digastric muscle bilaterally, symphysis of
mandible superiorly, and hyoid inferiorly
Level Ibthe submandibular nodes and gland; posterior to
the anterior belly of digastric, anterior to the posterior
belly of digastric and inferior to the body of the mandible
Level IIupper jugular chain nodes
 Level IIajugulodigastric nodes; deep to
sternocleidomastoid (SCM) muscle, anterior to the
posterior border of the muscle, posterior to the
posterior aspect of the posterior belly of
digastric, superior to the level of the hyoid,
inferior to spinal accessory nerve (CN XI)
Level IIbsubmuscular recess; superior to spinal
accessory nerve to the level of the skull base
Level IIImiddle jugular chain nodes; inferior to the
hyoid, superior to the level of the hyoid, deep to
SCM from posterior border of the muscle to the
strap muscles medially
Level IVlower jugular chain nodes; inferior to the
level of the cricoid, superior to the clavicle,
deep to SCM from posterior border of the muscle to
the strap muscles medially
 Level Vposterior triangle nodes
Level Valateral to the posterior aspect of the
SCM, inferior and medial to splenius
capitis and trapezius, superior to the spinal
accessory nerve
Level Vblateral to the posterior aspect of SCM,
medial to trapezius, inferior to the spinal
accessory nerve, superior to the clavicle
Level VIanterior compartment nodes; inferior to
the hyoid, superior to suprasternal
notch, medial to the lateral extent of the
strap muscles bilaterally
Level VIIparatracheal nodes; inferior to the
suprasternal notch in the upper
mediastinum
 Table 17-3 TNM Staging for Oral Cavity Carcinoma

Primary tumor
TX Unable to assess primary tumor
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor is <2 cm in greatest dimension
T2 Tumor >2 cm and <4 cm in greatest dimension
T3 Tumor >4 cm in greatest dimension
T4 (lip) Primary tumor invading cortical bone, inferior alveolar
nerve, floor of mouth, or skin of face (e.g., nose or chin)
T4a (oral) Tumor invades adjacent structures (e.g., cortical
bone, into deep tongue musculature, maxillary sinus) or
skin of face
T4b (oral) Tumor invades masticator space, pterygoid plates, or
skull base and/or encases the internal carotid artery
Regional lymphadenopathy

NX Unable to assess regional lymph nodes

N0 No evidence of regional metastasis
N1 Metastasis in a single ipsilateral lymph node,
3 cm or less in greatest dimension
N2a Metastasis in single ipsilateral lymph node, >3
cm and <6 cm
N2b Metastasis in multiple ipsilateral lymph
nodes, all nodes <6 cm
N2c Metastasis in bilateral or contralateral lymph
nodes, all nodes <6 cm
N3 Metastasis in a lymph node >6 cm in greatest
dimension
Distant metastases
MX Unable to assess for distant metastases
M0 No distant metastases
M1 Distant metastases

TMN staging
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0 T1-3 N1 M0
Stage IVa T4a N0 M0 T4a N1 M0 T1-4a N2 M0
Stage IVb Any T N3 M0 T4b Any N M0
Stage IVc Any T Any N M1