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Metastatic Lymph Nodes

« Stage of the Cancer »

Determining the Stage of the Cancer

The final step before discussing treatment options is a determination of the stage of the cancer. As with all
cancers of the head and neck, doctors in the U.S. use the American Joint Committee on Cancer (AJCC) Cancer
Staging Manual (7th edition) to determine the stage based on three factors.

Factors that go into determining the stage of the cancer Introduction to Head and
Neck Cancer
T Characteristics of the main tumor mass
Oral Cancers
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
Salivary Gland Cancer
M Status of cancer spread to parts of the body outside of the head and neck

Throat Cancers
This staging applies to all forms of carcinoma. It does not apply to mucosal melanoma, lymphomas and
sarcomas. Neck Cancers

At first, you will be given a clinical stage based on all of the available information. Nose and Sinus Cancers
Clinical staging (cTNM) is determined from any information your doctor might have about how extensive
Orbital Tumors
the cancer is BEFORE starting any treatment. Stage is determined based on your doctor’s physical exam,
imaging studies, laboratory work and biopsies. Classification of clinical stage is described using the Skin Cancer
lowercase prefix c (e.g., cT, cN, cM).
Distant Metastasis
If there is surgical removal of the cancer as part of your treatment, a pathologist will analyze the tumor and any
lymph nodes that may have been removed. You will then be assigned a pathologic stage.
Head & Neck Cancer Glossary
Pathologic staging (pTNM) provides more data. Classification of pathology stage is described using the
lowercase prefix p (e.g., pT, pN, pM). This may or may not differ from the clinical stage.
Select Glossary

There are also a number of other lowercase prefixes that might be used in the staging of your cancer.

The subscript y (yTNM) is used to assign a cancer stage after some sort of medical, systemic or radiation The Visual
treatment is given (Posttherapy or Post-Neoadjuvant Stage). It is typically combined with either a clinical Selector
or pathologic stage. For example, ycT2N0M0 indicates that after some sort of non-surgical therapy, the new tool
clinical stage is T2N0M0.
The subscript r (rTNM) is used when the tumor has recurred after some period of time in which it was gone.
This is called Retreatment Classification Stage. Your doctor will use all the available information to assign
you a retreatment stage.
Find the right
T stage: the main tumor mass info for me >

Based on a physical examination and review of any imaging, your doctor should be able to give you a T stage of
the primary cancer. If a primary cancer cannot be found (cancer with an unknown primary, or CUP), your T stage
will be Tx. If a primary cancer site is known, your T stage will be assigned based on the site of the primary cancer.

N stage: spread of cancer to the lymph nodes in the neck

For most (but not all) cancers of the head and neck, the N stage of cancer is fairly consistent. This staging system
applies to oral carcinomas, salivary gland carcinomas and most throat carcinomas. It does not apply to thyroid
cancers, cancers of the skin, nasopharynx cancers, orbital cancers, esophageal cancer or sarcomas and some
other rare non-squamous cell cancers.

Nx The neck lymph nodes cannot be assessed.

N0 There is no evidence of any spread to the nodes.

N1 There is a single node, on the same side of the main tumor,

that is 3 centimeters or less in greatest size.

N2a Cancer has spread to a single lymph node, on the same

side as the main tumor, and it is more than 3 centimeters
but less than or equal to 6 centimeters in greatest
dimension.

N2b There are multiple lymph nodes that have cancer, on the
same side as the main tumor, but none are more than 6
centimeters.

N2c There are lymph nodes in the neck on either the opposite
side as the main cancer, or on both sides of the neck, but
none are more than 6 centimeters.

N3 There is spread to one or more neck lymph nodes, and the

size is greater than 6 centimeters.

M stage: spread of cancer outside the head and neck

Finally, based on an assessment on the entire body, you will be assigned an M stage.

M0 No evidence of distant (outside the head and neck) spread.

M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

Your clinical stage

Once the diagnostic tests are completed, before deciding what type of treatment you are going to receive, you
should be given a clinical stage that will look similar to the example below.

CLINICAL STAGE

Example

Site Cancer with an Unknown Primary (CUP)

Subsite Unknown

Type Squamous cell carcinoma

cT cTx

cN cN2b

cM cM0

cStage cIV

* The lowercase c indicates that this is a clinical stage, the stage assigned based on all information available to your
doctor before starting treatment.

After surgery, you should get a pathologic stage in regards to your tumor. It will look almost like the clinical stage
you received before starting treatment, but notice the “p” that indicates the stage group is based on an analysis of
the entire tumor, with or without lymph nodes, under a microscope by a pathologist. In many cases, the
pathologic stage will be the same as the clinical stage, but sometimes it will change. You should consider the
pathologic stage to be a more accurate assessment of your tumor at the time you start treatment.

After surgery, and after the pathologist has evaluated all of the tumor that was removed, you should be given a
pathologic stage that looks something like this:

PATHOLOGIC STAGE

Example

Site Unknown

Subsite Unknown

Type Squamous cell carcinoma

pT pTx

pN pN2b

cM cM0

pStage pIVa

* The lowercase p indicates that this is a pathologic stage, the stage assigned after tumor removal and confirmation
of cancer by a pathologist.

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