Hypopharyngeal Cancer

Determining the Stage of the Cancer

The final step before discussing treatment options is a determination of the stage of the cancer. Like 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).

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 Postneoadjuvant 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 that falls within one of the following categories.


Tx The doctor is unable to assess the primary tumor.
T0 The doctor is unable to find the primary tumor.
Tis Carcinoma in situ (or severe dysplasia); this means there are cancer type cells, but they have not yet invaded deep into tissue. This is more of a pre-cancer lesion.
T1 The tumor is only in one subsite of the hypopharynx and/or it is 2 centimeters or less in greatest dimension.
T2 The tumor is in more than one subsite (specific anatomical structure) of the hypopharynx or a site next to the hypopharynx, or it is more than 2 centimeters but less than or equal to 4 centimeters in greatest dimension.
T3 The tumor is more than 4 centimeters in its largest measurement OR one of the vocal cords doesn’t move OR the tumor extends down to the upper part of the esophagus.
T4a This is moderately advanced local disease. The tumor invades the thyroid or cricoid cartilage, hyoid bone, thyroid gland or tissues in the central compartment of the neck (including the strap muscles and fat).
T4b This is very advanced local disease. The tumor invades the prevertebral fascia, encases the carotid artery or involves chest (mediastinal) structures.

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.

06_Nstages (1)

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 in size.
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 cancer stage

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

Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVB T4b Any N M0
Any T N3 M0
Stage IVC Any T Any N M1

Your clinical stage

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

Site Hypopharynx
Subsite Left Pyriform Sinus
Type Squamous Cell Carcinoma
cT cT3
cN cN1
cM cM0
cStage cIII

* The lowercase subscript 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 stageof your tumor. It will look almost like the clinical stageyou 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.

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 Hypopharynx
Subsite Left Pyriform Sinus
Type Squamous Cell Carcinoma
pT pT3
pN pN1
cM cM0
pStage pIII
  • The lowercase subscript p indicates that this is a PATHOLOGIC STAGE, the stage assigned after tumor removal and confirmation of cancer by a pathologist.
  • Note also that the M stage is usually clinical, based on all available data without actually analyzing any tissue.

1 Harrison DF. Pathology of hypopharyngeal cancer in relation to surgical management. The Journal of laryngology and otology. Apr 1970;84(4):349-367.

2 Shah JP, Shaha AR, Spiro RH, Strong EW. Carcinoma of the hypopharynx. Am J Surg. Oct 1976;132(4):439-443.

3 Menvielle G, Luce D, Goldberg P, Leclerc A. Smoking, alcohol drinking, occupational exposures and social inequalities in hypopharyngeal and laryngeal cancer. International journal of epidemiology. Aug 2004;33(4):799-806.

4 Larsson LG, Sandstrom A, Westling P. Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden. Cancer research. Nov 1975;35(11 Pt. 2):3308-3316.

5 Marchand JL, Luce D, Leclerc A, et al. Laryngeal and hypopharyngeal cancer and occupational exposure to asbestos and man-made vitreous fibers: results of a case-control study. Am J Ind Med. Jun 2000;37(6):581-589.

6 Dolan RW, Vaughan CW, Fuleihan N. Symptoms in early head and neck cancer: an inadequate indicator. Otolaryngology--head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery. Nov 1998;119(5):463-467.

7 Spiro RH, Thaler HT, Hicks WF, Kher UA, Huvos AH, Strong EW. The importance of clinical staging of minor salivary gland carcinoma. Am J Surg. 1991 Oct;162(4):330-6.

8 Krause CJ, Carey TE, Ott RW, Hurbis C, McClatchey KD, Regezi JA. Human squamous cell carcinoma. Establishment and characterization of new permanent cell lines. Arch Otolaryngol. Nov 1981;107(11):703-710.

9 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to

10 Piccirillo JF, Costas I, Reichman ME. Chapter 2: Cancers of the Head and Neck. 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.