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Neck Cancers

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 AJCC Cancer Staging Manual (7th Ed) to determine the stage based on three factors.

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

At first, you will be given a clinical stage based on all of the available information.

  • Clinical staging (cTNM) is determined from any information your doctor might have about how extensive 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 lowercase prefix c (e.g., cT, cN, cM).

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 Maxillary Sinus
Type Squamous Cell Carcinoma
Grade Well-differentiated
cT cT2
cN cN1
cM cM0
cStage cIII

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

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.

  • 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.

Your pathologic stage may look something like this:

PATHOLOGIC STAGE
Example
Site Maxillary Sinus
Type Squamous Cell Carcinoma
Grade Moderately Differentiated
pT pT2
pN pN0
cM cM0
pStage pII

* The lowercase p indicates that this is a pathologic stage, the stage assigned after tumor removal and confirmation of cancer by a pathologist. Notice that the M stage remains cM; this is because no tissue was removed to give a pathologic M stage; the M stage remains clinical.

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 treatment is given (Posttherapy or Post-Neoadjuvant Stage). It is typically combined with either a clinical or pathologic stage. For example, ycT2N0M0 indicates that after some sort of non-surgical therapy, the new 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.

To learn more about staging for different types of cancer that spread to the neck, you should read those particular sections.

If your doctor looks everywhere and can’t find a primary cancer, you will be diagnosed with cancer with an unknown primary (CUP). It is not possible to properly stage CUP because the type of the original cancer is not known. However, since by definition CUP has already spread to other sites, all cases of CUP can be considered stage IV. See the staging section of Metastatic Lymph Nodes to learn more about CUP.

Sarcoma staging

The staging of sarcomas is for cancers of soft tissue origin. Typically, sarcomas just get larger and larger, but spread to lymph nodes is quite rare in adults.

T stage: main tumor mass

The T stage pertains to the main tumor mass. The main tumor, also called the primary tumor, is the first tumor that formed. Based on a physical examination and review of any imaging, your doctor should be able to give you a T stage that falls within one of the following categories:

Tx The main tumor cannot be assessed.
T0 There is no evidence of the main tumor.
T1a The main tumor is 5 centimeters or less at its largest point (and is superficial).
T1b The main tumor is 5 centimeters or less at its largest point (and is deep).
T2a The main tumor is more than 5 centimeters at its largest point (and is superficial).
T2b The main tumor is more than 5 centimeters at its largest point (and is deep).

*Superficial means that there is no involvement of the fascia overlying muscles.

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

Next, your doctor will use all the available information and assign you an N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

Nx The regional lymph nodes cannot be assessed.
N0 There is no spread into the regional lymph nodes.
N1 There are regional lymph nodes involved.

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 spread to distant sites.
M1 Spread to distant sites.

Your cancer stage

After TNM staging, your doctor can assign a cancer stage based on the following chart.

 

Stage IA T1a N0, NX M0 Low Grade
T1b N0, NX M0 Low Grade
Stage IB T2a N0, NX M0 Low Grade
T2b N0, NX M0 Low Grade
Stage IIA T1a N0, NX M0 High Grade
T1b N0, NX M0 High Grade
Stage IIB T2a N0, NX M0 High Grade
Stage III T2b N0, NX M0 High Grade
Stage IV Any T N1 M0 Any Grade
Any T Any N M1 Any Grade

Lymphoma staging

Lymphoma has its own staging system based on what parts of the body are involved.5 Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Page 611. With good imaging and diagnostic tests, the need for an abdominal surgery to get biopsies is rarely needed these days. Therefore, the staging is clinical, which means (based on all the information available) the doctor will decide how involved the cancer is before starting treatment.

This illustration is an easy way for you to understand staging in lymphoma. The dotted line represents the diaphragm, a sheet of muscle that separates the thorax from the abdomen. Whether cancerous lymph nodes are on both sides of the diaphragm or on just one side plays an important role in staging lymphoma. See the chart after the illustration for an explanation of how staging for lymphoma works.

73.1_lymphomastaging

Staging for Lymphoma
Stage I Only a single lymph node region or a single extralymphatic organ is involved.
Stage II Two or more lymph node groups are involved, but they are on the same side of the diaphragm.
Stage III Lymph node groups above and below the diaphragm are involved.
Stage IV More than one extralymphatic organ is involved.

Lymph node regions include a specific nodal region (such as the neck, armpit, etc.) as well as Waldeyer’s ring (tonsils/adenoids/and lingual tonsil complex), thymus and spleen.

Extralymphatic organs could include the liver, bone, brain, spinal cord or even bone marrow. Involvement of one of these organs is based on your doctor’s examination or some sort of imaging. Biopsies of different regions might be necessary if the diagnosis is not clear or if getting more tissue will change the treatment.

For lymphoma, in addition to a stage, you will also be given a class.

  • Class A is when there are no symptoms associated with the lymphoma.
  • Class B is when there are symptoms such as fevers, night sweats and weight loss.
References

1 Gurney JG, Young JL, Roffers SD, Smith MA, Bunin GR. SEER pediatric monograph – soft tissue sarcomas. National Cancer Institute. Page 111. http://seer.cancer.gov/publications/childhood/softtissue.pdf.

2 Fletcher CDM, Rydholm A, Singer S, Sundaram M, Coindre JM. Soft Tissue Tumours. In: Barnes EL, Eveson JW, Reichart P, Sidransky D, editors. World Health Organization classification of tumours: pathology & genetics WHO Classification. Lyon: IARCPress; 2005.

3 Zhang MQ, El-Mofty SK, Dávila RM. Detection of human papillomavirus-related squamous cell carcinoma cytologically and by in situ hybridization in fine-needle aspiration biopsies of cervical metastasis: a tool for identifying the site of an occult head and neck primary. Cancer. 2008;114(2):118-23.

4 Cunningham MJ, Myers EN, Bluestone CD. Malignant tumors of the head and neck in children – a 20 year review. International Journal of Pediatric Otorhinolaryngology. 1987;(13)3:279-292.

5 Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Page 611.

6 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2013. © National Comprehensive Cancer Network, Inc 2013. All rights reserved. Accessed June 20, 2013. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

7 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Soft Tissue Sarcoma V.1.2013. © National Comprehensive Cancer Network, Inc 2013. All rights reserved. Accessed July 17, 2013. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

8 Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.