Head & Neck

What is the primary site? This can be difficult to determine with head and neck cases due to:

• Complex anatomy
  Lots of structures within head and neck which are located in close proximity to each other
• Laterality
  Some anatomy has laterality, such as left or right cheek mucosa
• Paired site
  Paired site or organ (tonsil, parotid) is a different concept than laterality
• Upper/lower
  The separateness of primary sites in the upper and lower lip and gum/gingiva is not addressed in existing rules
• Field effect
  The propensity of the epithelium in a region to develop multiple cancers is not recognized in the existing rules.
• Multiple tumors
  Definitions of single and multiple tumors in the head and neck do not fit neatly into the existing rules.
• Contiguous/overlapping sites
  Because the different primary sites in the head and neck are so close together, biopsies of tumors that overlap contiguous sites may end up being incorrectly counted as multiple primaries. Furthermore, physician may make statements that seem contrary in endoscopy, surgery, and/or pathology reports. Each report is provided from a slightly different perspective and the primary site may be called something different depending on the perspective.
• Site groupings
  This is a new concept: certain sites within the head and neck area should be grouped together for purposes of the new rules because the same rules apply to all sites within the group.
• Multiple reports
  Multiple reports cause considerable confusion during the abstracting and tumor consolidation processes. Priorities are needed for determining whether one or multiple primaries and a single or complex histology are present.
• Multiple biopsies
  The same concept of determining whether multiple biopsies represent multiple primaries needs clarification.
• Biopsy versus resection
  What determines the primary site, the biopsy(ies) or the resection?
• Multiple resections
  The same issues apply to determining site(s) and histology when multiple resections are performed.

Other issues

• In situ and invasive
  Head and neck tumors are prone to have invasive tumor surrounded by areas of in situ tumor. This issue affects both determination of primaries and histology coding.
• Time between diagnoses
  In the presence of field effect, should diagnosis of tumor in another head and neck site be affected by the existing two-month rule for multiple primaries?
• Histology group
  These are other new concepts: squamous cell carcinoma versus non-squamous carcinoma, and the hierarchy of multiple subgroups within the general term squamous cell carcinoma.