Head and Neck Cancer: Stages

What does the stage of a cancer mean?

The stage of a cancer is how much and how far the cancer has spread in your body. Your healthcare provider uses exams and tests to find out the size of the cancer and where it is. He or she can also see if the cancer has spread to nearby areas or other parts of your body. The stage of a cancer is one of the most important things to know when deciding how to treat the cancer. 

The TNM system for head and neck cancers

The most commonly used system to stage head and neck cancers is the TNM system from the American Joint Committee on Cancer. Be sure to ask your healthcare provider to explain the stage of your cancer to you in a way you can understand.

The first step in staging is to find the value for each part of the TNM system. Here's what the letters stand for in the TNM system:

• T tells how far the main tumor has spread into nearby tissues.

• N tells if the lymph nodes in the area of the original tumor have cancer in them.

• M tells if the cancer has spread (metastasized) to organs in other parts of the body.

Numbers or letters after T, N, and M provide more details about each of these factors. There are also 2 two other values that can be assigned in certain types of head and neck cancer:

• X means the provider does not have enough information to tell the extent of the main tumor (TX), or if the lymph nodes have cancer cells in them (NX).

• 0 means no sign of cancer, such as no sign of the primary (main) tumor (T0).

What are the stage groupings of head and neck cancers?

Stage groupings are determined by combining the T, N, and M values from the TNM system. These groupings give an overall description of your cancer. A stage grouping can have a value of 0 or of Roman numerals of I through IV (1 through 4). The higher the number, the more advanced the cancer is. Letters and numbers can be used after the Roman numeral to give more details.

Different head and neck cancers are staged in different ways. Below is a list of stages for some of the more common types of head and neck cancer.

Cancer of the bottom of the throat (hypopharynx)

The hypopharynx is the lower part of the throat the attaches to the esophagus (the tube that connects the mouth to the stomach). It's behind the voice box (or larynx). The stages for cancer of the hypopharynx are:

Stage 0 (carcinoma in situ). The cancer is only in the top layer of cells lining the hypopharynx where it started. It has not spread to nearby lymph nodes or organs in other parts of the body.

Stage I. The cancer has grown into deeper layers of the hypopharynx, is only in one part of the hypopharynx and is smaller than 2 centimeters (cm) across. It has not spread to nearby lymph nodes or organs in other parts of the body.

Stage II. The cancer has not grown into the voice box (larynx), nearby lymph nodes, or organs in other parts of the body. And one of the following is also true:

• The cancer is in more than one part of the hypopharynx.

• The cancer is bigger than 2 cm but less than 4 cm across.

• The cancer has spread to nearby tissues.

Stage III. One of the following is true:

• The cancer is larger than 4 cm across, has grown into the esophagus, or it is affecting the vocal cords. It has not spread to nearby lymph nodes or organs in other parts of the body.

• The cancer is any size and may or may not have spread into nearby tissues. It may or may not be affecting a vocal cord. It has spread to one lymph node on the same side of the neck and that node is not bigger than 3 cm across. It has not spread to organs in other parts of the body.

Stage IV. This stage is divided into these 3 groups:

• Stage IVA. The cancer has not spread to organs in other parts of the body and one of the following is true:

• The cancer is growing into cartilage, bone, the thyroid gland, or nearby fat or muscle. It has not spread to nearby lymph nodes, or it has spread to one lymph node that's less than 3 cm across and on the same side of the neck as the tumor.

• The tumor can be any size and may or may not have grown into a vocal cord or nearby structures. It has spread to lymph nodes in one of three ways:

  • It has spread to one lymph node that's more than 3 cm but less than 6 cm across and on the same side of the neck as the tumor.

  • It has spread to more than one lymph node on the same side of the neck as the tumor and none of them are more than 6 cm across.

  • It has spread, to at least one lymph node on the other side of the neck and none of them are more than 6 cm across.

• Stage IVB. The cancer has not spread to organs in other parts of the body and one of the following is true:

  • The tumor is growing into the space between the lungs or into the area in front of the spine in the neck, or it wraps around a carotid artery. It may or may not have spread to nearby lymph nodes.

  • The tumor is any size and may or may not have spread into a vocal cord or nearby tissues. It has spread to at least one lymph node that's more than 6 cm across, or has spread to and grown outside of the lymph node.

• Stage IVC. The cancer is any size and may or may not have spread into a vocal cord or nearby tissues. It may or may not have spread to nearby lymph nodes. The cancer has spread to distant lymph nodes or organs in other parts of the body.

Cancer of the upper portion of the throat (nasopharynx)

The hypopharynx is the upper part of the throat behind the nose. The stages for cancer of the nasopharynx are:

Stage 0 (carcinoma in situ). The cancer is only in the top layer of cells of the tissure that lines the nasopharynx. It has not spread to nearby lymph nodes or organs in other parts of the body.

Stage I. The tumor is in the nasopharynx and may or may not have spread into the oropharynx (the part of the throat at the back of the mouth) or to the inside of the nose.  It has not spread to nearby lymph nodes or other parts of the body.

Stage II. One of the following is true:

• The tumor is in the nasopharynx and may or may not have spread into the oropharynx or to the inside of the nose, or no tumor can be seen in the nasopharynx, but cancer is found in lymph nodes in the neck and is Epstein-Barr virus positive (EBV+). It has spread to one or more lymph nodes on one side of the neck or to lymph nodes behind the throat, and none of the nodes are larger than 6 cm across. It has not spread to organs in other parts of the body.

• The tumor has spread to tissues on the left or right sides of the upper throat, but not into bone. It may or may not have spread to one or more lymph nodes on one side of the neck or to lymph nodes behind the throat, and none of the nodes are larger than 6 cm across. It has not spread to organs in other parts of the body.

Stage III. One of the following is true:

• The tumor is in the nasopharynx and may or may not have spread into the oropharynx or to the inside of the nose, or no tumor can be seen in the nasopharynx, but cancer is found in lymph nodes in the neck and is EBV+. It has spread to lymph nodes on both sides of the neck, and none of the nodes are larger than 6 cm across. It has not spread to organs in other parts of the body.

• The tumor has spread to tissues on the left or right sides of the upper throat, but not into bone. It has spread to lymph nodes on both sides of the neck, and none of the nodes are larger than 6 cm across. It has not spread to organs in other parts of the body.

• The tumor has grown into the sinuses and/or nearby bones. It may or may not have spread to lymph nodes in the neck or to lymph nodes behind the throat, and none of the nodes are larger than 6 cm across. It has not spread to organs in other parts of the body.

Stage IV. This stage is divided into two groups:

• Stage IVA. One of the following is true:

  • The cancer has spread to bones or nerves in the head, to the hypopharynx (the lower part of the throat), to the main salivary gland, or to the eye and its nearby structures. It may or may not have spread to lymph nodes in the neck or to lymph nodes behind the throat, and none of the nodes are larger than 6 cm across. It has not spread to organs in other parts of the body.

  • The cancer has spread to structures outside the nasopharynx and has spread to lymph nodes that are either more than 6 cm across or are above the collarbone. It has not spread to organs in other parts of the body.

• Stage IVB. The cancer may or may not have spread to structures outside the nasopharynx or to nearby lymph nodes. It has spread to distant lymph nodes or organs in other parts of the body.

Cancer of the middle part of the throat (oropharynx)

The oropharynx is the part of the throat that's in the back of the mouth. Oropharyngeal cancer is usually assigned a stage after surgery. Staging is based on the results of tests done on the tissue that was removed. A key factor in staging is whether the cancer cells have human papilloma virus (HPV) in them. People with HPV in their cancer cells (HPV positive) tend to do better than those without HPV (HPV negative). Staging is different based on this, and both are covered here.

The stages for HPV-positive cancer of the oropharynx are:

Stage I.  The cancer is not larger than 2 cm across. It has not spread to nearby lymph nodes. Or if it has spread to at least 1 lymph node on the same side as the primary (first) tumor, none of the nodes are more than 6 cm across. It has not spread to organs in other parts of the body.

Stage II. The cancer has not spread to organs in other parts of the body and one of the following is true: 

• The cancer is no bigger than 4 cm across. It has spread to at least 1 lymph node on the opposite side of the neck as the primary (first) tumor or to lymph nodes on both sides of the neck, but none of the nodes are more than 6 cm across.

• The cancer is more than 4 cm across, or it's growing into the base of the tongue (the epiglottis), the voice box (larynx), the tongue muscle, nearby bones, the jaw, or the hard palate. One of these is also true:

  • It has not spread to nearby lymph nodes.

  • It has spread to at least 1 lymph node on the same side as the primary (first) tumor, but none of the nodes are more than 6 cm across.

Stage III. The cancer has spread to at least one lymph node on the opposite side of the neck as the primary (first) tumor or to lymph nodes on both sides of the neck, but none of the nodes is more than 6 cm across. It has not spread to organs in other parts of the body. And one of the following is true:

• The cancer is more than 4 cm across.

• The cancer is growing into the base of the tongue (epiglottis).

• The cancer is growing into the voice box (larynx), tongue muscle, nearby bones, the jaw, or the hard palate.

Stage IV. The cancer is any size. It may or may not have grown into nearby tissues or lymph nodes, but it has spread to distant lymph nodes or organs in other parts of the body, like the bones or lungs.

The stages for HPV-negative cancer of the oropharynx are:

Stage 0 (carcinoma in situ). The cancer is only in the lining of the oropharyx where it first started. It has not spread to nearby lymph nodes or organs in other parts of the body.

Stage I.  The cancer is no more than 2 cm across and has not spread to nearby lymph nodes or organs in other parts of the body.

Stage II. The cancer is between 2 cm and 4 cm across and has not spread to nearby tissues, lymph nodes, or organs in other parts of the body.

Stage III. The cancer has not spread to organs in other parts of the body, and one of the following is true:

• The cancer is more than 4 cm across and may or may not be growing into the base of the tongue (epiglottis).

• The cancer is any size and may or may not have grown into nearby tissues. It has spread to one lymph node on the same side of the neck as the primary (first) tumor. The node is no more than 3 cm across and the cancer has not spread to the outside of it.

Stage IV. This stage is divided into 3 groups: 

• Stage IVA: The cancer is any size and has spread into nearby tissues, like the the voice box (larynx), tongue muscle, nearby bones, the jaw, or the hard palate. It has not spread to organs in other parts of the body and one of the following is true:

  • It has not spread to nearby lymph nodes, or it has spread to one lymph node on the same side of the neck as the primary (first) tumor. The node is no more than 3 cm across and the cancer has not spread to the outside of it.

  • The cancer has spread to one lymph node on the same side of the neck as the primary (first) tumor. The node is more than 3 cm but less than 6 cm across and the cancer has not spread to the outside of it.

  • It has spread to more than one lymph node on the same side of the neck as the primary (first) tumor. None of the nodes are more than 6 cm across and the cancer has not spread to the outside of any of them.

  • The cancer has spread to at least one lymph node on the opposite side of the neck as the primary (first) tumor or to lymph nodes on both sides of the neck, but none are more than 6 cm across.

• Stage IVB: The cancer is any size and may have spread into nearby tissues, like the the voice box (larynx), tongue muscle, nearby bones, the jaw, or the hard palate. It has not spread to organs in other parts of the body and one of the following is true:

  • There is spread to lymph nodes in one of these ways:

    • The cancer has spread to one lymph node that's more than 6 cm across, but the cancer has not spread to the outside of it.

    • It has spread to one lymph node that's more than 3 cm across, and the cancer has clearly spread outside the node.

    • It has spread to more than one lymph node on the same side of the neck as the primary (first) tumor, a node on the opposite side of the neck, or to nodes on both sides of the neck and has clearly spread outside of at least one node.

    • The cancer has spread to one lymph node on the same side of the neck as the primary (first) tumor. The node is no more than 3 cm across and the cancer has clearly spread outside the node.

  • The cancer is growing into the base of the skull or other nearby bones, or it's wrapped around the carotid artery. It may or may not have spread to nearby lymph nodes.

• Stage IVC:  The cancer is any size and may have spread into nearby tissues. It may or may not have spread to nearby lymph nodes, but it has spread to organs in other parts of the body, such as the lungs.

Cancer of the paranasal ethmoid sinus and nasal cavity

The ethmoid sinuses are bony cavities that sit above the nose between the eyes. The nose opens into the nasal cavity which is above the roof of the mouth and curves down to the throat at the back of the mouth. The stages for cancer of the paranasal ethmoid sinus and nasal cavity are:

Stage 0 (carcinoma in situ). The cancer is only in top layer of the tissue it started in. It has not spread to nearby lymph nodes or organs in other parts of the body.

Stage I. The cancer has grown deeper into only one part the sinus or nasal cavity. It may be growing into the bone. Cancer has not spread to nearby lymph nodes or organs in other parts of the body.

Stage II. The cancer has spread to more than one part of the sinus or nasal cavity or it's in both the sinus and nasal cavity.  It has not spread to nearby lymph nodes or organs in other parts of the body.

Stage III. The cancer has not spread to organs in other parts of the body and one of the following is true:

• The cancer has grown into at least one of these places: the side or bottom of the eye socket, the roof of the mouth, one of the maxillary sinuses (which are next to the nose and under the eyes), or the bone that's between the nose and the brain (the cribiform plate). It hasn't spread to nearby lymph nodes.

• The cancer may or may not have spread outside the sinus or nasal cavity and into nearby tissues. Its found in only one lymph node which is no bigger tahn 3 cm across and on the same side of the neck as the tumor.

Stage IV. This stage is divided into 3 groups:

• Stage IVA: The cancer has not spread to organs in other parts of the body and one of the following is true:

  • The cancer has spread to other structures, such as the front of the eye, the skin of the nose or cheek, other sinuses, or certain bones in the face. It may or may not have spread to nearby lymph nodes. If it has, it's only in one lymph node which is no bigger than 3 cm across and on the same side of the neck as the tumor.

  • The cancer may or may not have spread to other structures, but has spread to lymph nodes in one of these ways:

    • It has spread to one lymph node on the same side of the neck as the primary (first) tumor. The node is more than 3 cm but less than 6 cm across.

    • It has spread to more than one lymph node on the same side of the neck as the primary (first) tumor, and none of the nodes are more than 6 cm across.

    • It has spread to at least one lymph node on the opposite side of the neck as the primary (first) tumor, and none of the nodes are more than 6 cm across.

• Stage IVB: The cancer has not spread to organs in other parts of the body and one of the following is true:

  • The cancer is growing into at least one of these places: the back of the eye socket, certain parts of the skull, certain nerves in the face or head, the brain, the tissue covering the brain (the dura), or the upper part of the throat behind the nose (nasopharynx). It may or may not have spread to nearby lymph nodes.

  • The cancer may or may not have spread to nearby structures. It has spread to at least one lymph node that's more than 6 cm across, or it has spread to a lymph node and then grown outside that node.

• Stage IVC: The cancer may or may not have spread to nearby structures and lymph nodes. It has spread to distant lymph nodes or organs in other parts of the body.

Cancer of the salivary gland

 

The salivary glands make saliva which travels through tiny tubes (called ducts) to the mouth. There are many salivary glands in and around the mouth. The stages for cancer of the salivary gland are:

Stage 0 (carcinoma in situ). The cancer is only in the top layer of the cells lining the salivary duct. It has not spread to nearby lymph nodes or organs in other parts of the body.

Stage I. The cancer is no more than 2 cm across and has not spread into nearby lymph nodes or nearby tissue. It has not spread to organs in other parts of the body.

Stage II. The Ccancer is  more than 2 cm  but less than 6 cm across and has not spread into nearby lymph nodes or nearby tissue. It has not spread to organs in other parts of the body.

Stage III. The cancer has not spread to organs in other parts of the body and one of the following is true:

• The cancer is more than 4 cm across and has spread into nearby soft tissues. It has not spread to nearby lymph nodes or organs in other parts of the body.

• The cancer is any size and may or may not have spread into nearby soft tissues. It has spread to one lymph node on the same side of the head as the primary (first) tumor. The node is no more than 3 cm across, and the cancer has not spread to the outside of it. It has not spread to organs in other parts of the body.

Stage IV. This stage is divided into 3 groups:

• Stage IVA: The cancer has not spread to organs in other parts of the body and one of the following is true:

  • The cancer is any size and is growing into nearby tissues, like the jaw bone, ear, skin, or facial nerve. It may or may not have spread to nearby lymph nodes. If it has, it's only in one lymph node which is on the same side of the neck as the tumor. The node is no bigger than 3 cm across and the cancer has not spread to the outside of it.

  • The cancer is any size and may or may not be growing into nearby tissues. It has spread to lymph nodes in one of these ways:

    • It's only in one lymph node which is on the same side of the neck as the tumor. The node is bigger than 3 cm but less than 6 cm across and cancer has not spread to the outside of it.

    • It's in more than one lymph node on the same side of the neck as the tumor. None of the nodes are more than 6 cm across and cancer has not spread to the outside of any of them.

    • It's in more than one lymph node on the opposite side of the neck as the tumor or on both sides of the neck. None of the nodes are more than 6 cm across and the cancer has not spread to the outside of any of them.

• Stage IVB: The cancer has not spread to organs in other parts of the body and one of the following is true:

  • The cancer is any size and may or may not be growing into nearby tissues. It has spread to lymph nodes in one of these ways:

    • It's only in one lymph node that's more than 6 cm across and the cancer has not spread to the outside of it.

    • It has spread to one lymph node that's more than 3 cm across and the cancer has clearly spread outside the node.

    • It's in more than one lymph node in the neck and the cancer has clearly spread to the outside of them.

    • It has spread to one lymph node on the opposite side of the neck as the tumor. The node is no more than 3 cm across and the cancer has clearly spread outside the node.

  • The cancer is any size and is growing into nearby tissues, such as the base of the skull or other nearby bones, or it's wrapped around the carotid artery. It may or may not have spread to nearby lymph nodes.

• Stage IVC: The cancer is any size and may or may not have spread to nearby structures and lymph nodes. It has spread to distant lymph nodes or organs in other parts of the body, such as the lungs.

Talking with your healthcare provider

Once your cancer is staged, talk with your healthcare provider about what the stage means for you. Be sure to ask questions and talk about your concerns.