Metastatic Lymph Nodes

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
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

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

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).

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.

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.

T stage: the main tumor mass

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.06_Nstages

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.

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:

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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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 NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

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