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Nasopharyngeal Cancers

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.

41_1_tonsil

T1 The tumor is just within the nasopharynx, or it has grown into the oropharynx and/or nasal cavity, but there is no extension into the parapharyngeal space (soft tissue space behind and to the side of the pharynx).
T2 The tumor extends into the parapharyngeal space (soft tissue space next to the pharynx).
T3 The tumor has grown into the bone of the head, including the skull base and/or the sinuses.
T4 The tumor has grown into the skull and/or involves the cranial nerves, hypopharynx, eye socket (orbit). Or it has extended to the infratemporal fossa or masticator space.

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.

40_larynx_Nstages

N0 There is no evidence of any spread to lymph nodes in the neck or retropharyngeal space.
N1 There are cancerous lymph nodes on just one side of the neck, where the largest is 6 centimeters or less, and all the lymph nodes are above the supraclavicular fossa. Also, the cancer is at this stage if the lymph nodes are found in the retropharyngeal space (6 centimeters or less in size, one side or both).
N2 There are lymph nodes with cancer on both sides of the neck (where the biggest lymph node is 6 centimeters or less in size, and all the lymph nodes are above the supraclavicular fossa).
N3a There is a lymph node with cancer that is bigger than 6 centimeters.
N3b There is a lymph node of any size that is far down in the neck, just above the clavicles (supraclavicular fossa).

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 0 Tis N0 M0
Stage 1 T1 N0 M0
Stage 2 T1 N1 M0
T2 N0 M0
T2 N1 M0
Stage 3 T1 N2 M0
T2 N2 M0
T3 N0 M0
T3 N1 M0
T3 N2 M0
Stage 4a T4 N0 M0
T4 N1 M0
T4 N2 M0
Stage 4b Any T N3 M0
Stage 4c 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.

CLINICAL STAGE
Example
Site Nasopharynx
Type Squamous Cell Carcinoma (WHO Type I)
cT cT2
cN cN1
cM cM0
cStage cII

* 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 stage of 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.

After surgery, and after the pathologist has evaluated all of the tumor that was removed,

you should be given a pathologic stagethat looks something like this:

PATHOLOGIC STAGE
Example
Site Nasopharynx
Type Squamous Cell Carcinoma (WHO Type I)
pT pT2
pN pN1
cM cM0
pStage pII
  • 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.
References

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18 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 www.nccn.org.

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