Head and Neck Cancer: Stages

What does the stage of a cancer mean?

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

The TNM system for head and neck cancer

The most commonly used system to stage head and neck cancers is the TNM system from the American Joint Committee on Cancer (AJCC). 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 near the tumor have cancer in them.

• M tells if the cancer has spread ( metastasized) to distant organs, like the brain, bones, or lungs.

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

• X means the healthcare provider does not have enough information to assess 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 cancer in the lymph nodes (N0).

What are the stage groupings of head and neck cancers?

The T, N, and M values from the TNM system are used to put these cancers into stage groupings. These groupings give an overall description of your cancer. A stage grouping is listed as a Roman numeral and can have a value of 0, I (1), II (2), III (3), or IV (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 are the stage groupings 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 that attaches to the esophagus (the tube that connects the mouth to the stomach). It's a hollow tube, about 5 inches long, that's around the voice box (larynx).

The stage groupings for cancer of the hypopharynx are:

Stage 0 (carcinoma in situ). The cancer is only where it started, in the top layer of cells lining the hypopharynx. It has not grown into deeper layers of the hypopharynx. 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, but it's in only one part of the hypopharynx. The tumor is no more 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 these is also true:

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

• The tumor is between 2 cm and 4 cm across.

• The cancer has spread to nearby tissues.

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

• The tumor is more than 4 cm across, or it has grown into the esophagus, or it's affecting the vocal cords. It has not spread to nearby lymph nodes.

• The tumor is any size. It may or may not have spread into nearby tissues. It may or may not be affecting a vocal cord. It has spread to 1 lymph node on the same side of the neck as the tumor, and that node is not more than 3 cm across.

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

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

  • The cancer is growing into cartilage, bone, the thyroid gland, or nearby fat or muscle. It either has not spread to nearby lymph nodes, or it has spread to 1 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. It may or may not have grown into a vocal cord or nearby structures. It has spread to lymph nodes in one of these ways:

    • It has spread to 1 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 1 lymph node on the same side of the neck as the tumor, and none of the lymph nodes are more than 6 cm across.

    • It has spread to at least 1 lymph node on the other side of the neck, and none of the lymph 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 these is true:

  • The tumor is growing into the space between the lungs, 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. It may or may not have spread into a vocal cord or nearby tissues. It has spread to at least 1 lymph node that's more than 6 cm across, or it has spread to and grown outside of the lymph node.

• Stage IVC. The tumor is any size. It 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, like the lung, liver, or bone.

Cancer of the upper portion of the throat (nasopharynx)

The nasopharynx is the upper part of the throat behind the nose. The nostrils lead into the nasopharynx.

The stage groupings for cancer of the nasopharynx are:

Stage 0 (carcinoma in situ). The cancer is in only the top layer of cells in the tissue 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. It may or may not have spread into the oropharynx (the part of the throat at the back of the mouth) or to the nasal cavity (inside of the nose). It has not spread to nearby lymph nodes or 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 these is true:

• The tumor is in the nasopharynx and may or may not have spread into the oropharynx and/or the nasal cavity. 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+). In either case, 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 more than 6 cm across.

• 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 1 or more lymph nodes on one side of the neck or to lymph nodes behind the throat, and none of the nodes are more than 6 cm across.

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

• The tumor is in the nasopharynx. It may or may not have spread into the oropharynx and/or the nasal cavity. Or, no tumor can be seen in the nasopharynx, but cancer is found in lymph nodes in the neck and is EBV+. In either case, it has spread to lymph nodes on both sides of the neck, and none of the nodes are more than 6 cm across.

• 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 more than 6 cm across.

• 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 more than 6 cm across.

Stage IV. This stage is divided into two groups:

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

  • The cancer has spread to the skull and/or nerves in the head, the hypopharynx (the lower part of the throat), the main salivary gland, or 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 more than 6 cm across.

  • The cancer has spread to structures outside the nasopharynx and to lymph nodes that are either more than 6 cm across or are above the collarbone.

• 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, like the bone, liver, or lung.

Cancer of the middle part of the throat (oropharynx)

The oropharynx is the middle part of the throat that's in the back of the mouth. It includes the soft palate, the back and sides of the throat, the back of the tongue, and the tonsils.

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 signs of HPV (human papillomavirus) 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 tumor is no more than 4 cm across. It has not spread to nearby lymph nodes, or it has spread to 1 or more lymph nodes on the same side as the main tumor and none of them 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 these is true:

• The tumor 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 tumor, or to lymph nodes on both sides of the neck. None of the lymph nodes are more than 6 cm across.

• The tumor 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 tumor, but none of the nodes are more than 6 cm across.

Stage III. The cancer has not spread to organs in other parts of the body. It has spread to at least 1 lymph node on the opposite side of the neck as the tumor or to lymph nodes on both sides of the neck, but none are more than 6 cm across. One of these is also true:

• The tumor 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 tumor is any size. It may or may not have grown into nearby tissues or lymph nodes. It has spread to 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 oropharynx where it first started. It has not spread to nearby lymph nodes or organs in other parts of the body.

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

Stage II. The tumor is between 2 cm and 4 cm. It 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 these is true:

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

• The tumor is any size and may or may not have grown into nearby tissues. It has spread to 1 lymph node on the same side of the neck as the 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 three groups:

• Stage IVA. The cancer is any size and has spread into nearby tissues, like 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 these is true:

  • It has not spread to nearby lymph nodes, or it has spread to 1 lymph node on the same side of the neck as the 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 1 lymph node on the same side of the neck as the tumor. The node is between 3 cm to 6 cm across, and the cancer has not spread to the outside of it.

  • It has spread to more than 1 lymph node on the same side of the neck as the 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 1 lymph node on the opposite side of the neck as the tumor or to lymph nodes on both sides of the neck. None of the nodes are more than 6 cm across.

• Stage IVB. The cancer is any size and may have spread into nearby tissues, like 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 these is true:

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

    • The cancer has spread to 1 lymph node that's more than 6 cm across, but the cancer has not spread to the outside of it.

    • It has spread to 1 lymph node that's more than 3 cm across, and the cancer has clearly spread outside the node.

    • It has spread to more than 1 lymph node on the same side of the neck as the tumor, a node on the opposite side of the neck, or to nodes on both sides of the neck. The cancer has clearly spread outside at least 1 node.

    • The cancer has spread to 1 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 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 or may not 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 or liver.

Cancer of the paranasal ethmoid sinus or nasal cavity

The ethmoid sinuses are air-filled, hollow spaces in the bone 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 or nasal cavity are:

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

Stage I. The cancer has grown deeper into one part of the sinus or nasal cavity. It may be growing into the bone. It 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 cavities. 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 these 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 cribriform plate). It has not spread to nearby lymph nodes.

• The cancer may or may not have spread outside the sinus or nasal cavity and into nearby tissues. It's found in only 1 lymph node that is no more than 3 cm across and is on the same side of the neck as the tumor.

Stage IV. This stage is divided into three groups:

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

  • The cancer has spread to other structures, such as the front of the eye socket, the skin on the nose or cheek, other sinuses, or certain bones in the face or skull. It may or may not have spread to 1 lymph node that's no more 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 1 lymph node on the same side of the neck as the tumor. The node is between 3 cm and 6 cm across.

    • It has spread to more than 1 lymph node on the same side of the neck as the tumor, and none of the nodes are more than 6 cm across.

    • It has spread to at least 1 lymph node on the opposite side of the neck as the tumor, and none of the nodes are more than 6 cm across.

    • It has spread to 1 lymph node on the same side as the tumor. The node is no more than 3 cm across. The cancer is growing outside of the lymph node.

• Stage IVB. The cancer has not spread to organs in other parts of the body, and one of these 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. But it has spread in 1 of these ways:

    • It has spread to at least 1 lymph node that's more than 6 cm across.

    • It has spread to 1 lymph node on the same side as the tumor. The node is larger than 3 cm across. The cancer has then grown outside that node.

    • The cancer has spread to many lymph nodes on the same or opposite side as the tumor.

• 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, like the lungs.

Cancer of the salivary gland

The salivary glands make saliva that 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 tumor is no more than 2 cm across. It has not spread into nearby lymph nodes or nearby tissues. It has not spread to organs in other parts of the body.

Stage II. The tumor is between 2 cm and 4 cm across. It 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 these is true:

• The tumor is more than 4 cm across and/or has spread into nearby soft tissues. It has not spread to nearby lymph nodes.

• The tumor is any size and may or may not have spread into nearby soft tissues. It has spread to 1 lymph node on the same side of the head as the 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 three groups:

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

  • The tumor is any size and is growing into nearby tissues, like the jawbone, ear, skin, and/or facial nerve. It may or may not have spread to nearby lymph nodes. If it has, it's in only 1 lymph node on the same side of the head or neck as the tumor. The node is no more 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 in only 1 lymph node on the same side of the head or neck as the tumor. The node is between 3 cm and 6 cm across, and cancer has not spread to the outside of it.

    • It's spread to 1 lymph node. The node is no more than 3 cm across, and the cancer has grown outside the lymph node.

    • It's in more than 1 lymph node on the same side of the head or 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 1 lymph node on the opposite side of the head or neck as the tumor, or it's in nodes on both sides of the head or 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 these is true:

  • The tumor 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 in only 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 tumor 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 tumor 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. Ask your healthcare provider to explain the stage of your cancer to you in a way you can understand. Ask any questions and talk about your concerns.