Staging for Head & Neck Cancer

The TNM classifications and anatomic staging for cancers of the head and neck. World Health Organization (WHO) criteria are supplied for the nasopharynx.

Primary Tumor (T)
Oral Cavity:
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor 2 cm or less in greatest dimension
T2 Tumor > 2 cm but not more than 4 cm in greatest dimension
T3 Tumor > 4 cm in greatest dimension
T4a Moderately advanced local disease
  • Lip - Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face
  • Oral cavity - Tumor invades adjacent structures (eg, through cortical bone into deep extrinsic muscle of the tongue, maxillary sinus, or skin of face)
T4b Very advanced local disease
  • Tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery
Glottis:
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility
T1a Tumor limited to 1 vocal cord
T1b Tumor involves both vocal cords
T2 Tumor extends to the supraglottis and/or subglottis, and/or with impaired vocal cord mobility
T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of the paraglottic space, and/or inner cortex of the thyroid cartilage
T4a Moderately advanced local disease
  • Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of the neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
T4b Very advanced local disease
  • Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Supraglottis:
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor limited to 1 subsite of the supraglottis with normal vocal cord mobility
T2 Tumor invades mucosa of more than 1 adjacent subsite of the supraglottis or glottis or region outside the supraglottis (eg, mucosa of base of the tongue, vallecula, medial wall of piriform sinus) without fixation of the larynx
T3 Tumor limited to the larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of the thyroid cartilage
T4a Moderately advanced local disease
  • Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of the neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
T4b Very advanced local disease
  • Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Subglottis:
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor limited to the subglottis
T2 Tumor extends to vocal cord(s) with normal or impaired mobility
T3 Tumor limited to the larynx with vocal cord fixation
T4a Moderately advanced local disease
  • Tumor invades cricoids or thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of the neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
T4b Very advanced local disease
  • Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Regional Lymph Nodes (N)
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node 3 cm or less in greatest dimension
N2 Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
N3 Metastasis in a lymph node > 6 cm in greatest dimension
Distant Metastasis (M)
M0 No Distant Metastasis
M1 Distant Metastasis

Histologic Grade (G)
GX Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated

Anatomic Stage/Prognostic Groups
Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
III T1
T2
T3		 N1 M0
IVA T4a N0
N1
N2		 M0
IVA T1
T2
T3		 N2 M0
IVB T Any N3 M0
IVB T4b N Any M0
IVC T Any N Any M1
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WHO Criteria
Type 1 Differentiated squamous cell carcinoma
Type 2 Nonkeratinizing carcinoma
Type 3 Undifferentiated carcinoma

Primary Tumor (T)
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor confined to the nasopharynx, or tumor extends to oropharynx and/or nasal cavity without parapharyngeal extension (eg, without posterolateral infiltration of tumor)
T2 Tumor with parapharyngeal extension (posterolateral infiltration of tumor)
T3 Tumor involves bony structures of skull base and/or paranasal sinuses
T4 Tumor with intracranial extension and/or involvement of cranial nerves, hypopharynx, or orbit, or with extension to the infratemporal fossa/masticator space
Regional Lymph Nodes (N)
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Unilateral metastasis in cervical lymph nodes ≤ 6 cm in greatest dimension, above the supraclavicular fossa, and/or unilateral or bilateral retropharyngeal lymph nodes ≤ 6 cm in greatest dimension (midline nodes are considered ipsilateral nodes)
N2 Bilateral metastasis in cervical lymph nodes  ≤ 6 cm in greatest dimension, above the supraclavicular fossa (midline nodes are considered ipsilateral nodes)
N3 Metastasis in a lymph node > 6 cm and/or to the supraclavicular fossa (midline nodes are considered ipsilateral nodes)
N3a > 6 cm in dimension
N3b Extension to the supraclavicular fossa
Distant Metastasis (M)
M0 No Distant Metastasis
M1 Distant Metastasis

Histologic Grade (G)
GX Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated

Anatomic Stage/Prognostic Groups
Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T1 N1 M0
II T2 N0
N1		 M0
III T1
T2		 N2 M0
III T3 N0
N1
N2		 M0
IVA T4 N0
N1
N2		 M0
IVB T Any N3 M0
IVC T Any N Any M1
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Primary Tumor (T)
Oropharynx:
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor ≤ 2 cm in greatest dimension
T2 Tumor > 2 cm but not more than 4 cm in greatest dimension
T3 Tumor > 4 cm in greatest dimension or extension to lingual surface of the epiglottis
T4a Moderately advanced local disease
  • Tumor invades the larynx, deep/extrinsic muscle of the tongue, medial pterygoid, hard palate, or mandible
T4b Very advanced local disease
  • Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases the carotid artery
Hypopharynx:
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor limited to 1 subsite of the hypopharynx and/or ≤ 2 cm in greatest dimension
T2 Tumor invades more than 1 subsite of the hypopharynx or an adjacent site or measures > 2 cm but not more than 4 cm in greatest dimension without fixation of the hemilarynx
T3 Tumor > 4 cm in greatest dimension or with fixation of the hemilarynx or extension to the esophagus
T4a Moderately advanced local disease
  • Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central compartment soft tissue (including prelaryngeal strap muscles and subcutaneous fat)
T4b Very advanced local disease
  • Tumor invades prevertebral fascia, encases carotid artery, or involves mediastinal structures
Regional Lymph Nodes (N)
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node ≤ 3 cm in greatest dimension
N2 Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
N3 Metastasis in a lymph node > 6 cm in greatest dimension
Distant Metastasis (M)
M0 No Distant Metastasis
M1 Distant Metastasis

Histologic Grade (G)
GX Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated

Anatomic Stage/Prognostic Groups
Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
III T1
T2
T3		 N1 M0
IVA T4a N0
N1
N2		 M0
IVA T1
T2
T3		 N2 M0
IVB T Any N3 M0
IVB T4b N Any M0
IVC T Any N Any M1
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Primary Tumor (T)
Maxillary sinus:
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone
T2 Tumor causing bone erosion or destruction, including extension into the hard palate and/or middle nasal meatus, except extension to posterior wall of the maxillary sinus and pterygoid plates
T3 Tumor invades any of the following: bone of the posterior wall of the maxillary sinus, subcutaneous tissues, floor or medial wall of the orbit, pterygoid fossa, ethmoid sinuses
T4a Moderately advanced local disease
  • Tumor invades the anterior orbital contents, skin of the cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses
T4b Very advanced local disease
  • Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus
Nasal cavity and ethmoid sinus:
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor restricted to any 1 subsite, with or without bony invasion
T2 Tumor invading 2 subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion
T3 Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate
T4a Moderately advanced local disease
  • Tumor invades any of the following: anterior orbital contents, skin of the nose or cheek, minimal extension to the anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses
T4b Very advanced local disease
  • Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus
Regional Lymph Nodes (N)
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node ≤ 3 cm in greatest dimension
N2 Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
N3 Metastasis in a lymph node > 6 cm in greatest dimension
Distant Metastasis (M)
M0 No Distant Metastasis
M1 Distant Metastasis

Histologic Grade (G)
GX Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated

Anatomic Stage/Prognostic Groups
Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
III T1
T2
T3		 N1 M0
IVA T4a N0
N1
N2		 M0
IVA T1
T2
T3		 N2 M0
IVB T Any N3 M0
IVB T4b N Any M0
IVC T Any N Any M1
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Primary Tumor (T)
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
Tis Carcinoma in situ
T1 Tumor ≤ 2 cm in greatest dimension without extraparenchymal extension (clinical or macroscopic evidence of invasion of the soft tissues, not microscopic evidence)
T2 Tumor > 2 cm but not more than 4 cm in greatest dimension without extraparenchymal extension
T3 Tumor > 4 cm and/or tumor having extraparenchymal extension
T4a Moderately advanced disease
  • Tumor invades the skin, mandible, ear canal, and/or facial nerve
T4b Very advanced disease
  • Tumor invades skull base and/or pterygoid plates and/or encases carotid artery
Regional Lymph Nodes (N)
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node ≤ 3 cm in greatest dimension
N2 Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension
N3 Metastasis in a lymph node > 6 cm in greatest dimension
Distant Metastasis (M)
M0 No Distant Metastasis
M1 Distant Metastasis

Anatomic Stage/Prognostic Groups
Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
III T1
T2
T3		 N1 M0
IVA T4a N0
N1
N2		 M0
IVA T1
T2
T3		 N2 M0
IVB T Any N3 M0
IVB T4b N Any M0
IVC T Any N Any M1
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Primary Tumor (T)
TX Primary Tumor cannot be assessed
T0 No evidence of Primary Tumor
T1 Tumor ≤2cm in greatest dimension and is limited to the thyroid
  • T1a: Tumor ≤1cm in greatest dimension, limited to the thyroid
  • T1b: Tumor >1cm but ≤2cm in greatest dimension, limited to the thyroid
T2 Tumor >2cm but not more than 4 cm in greatest dimension, limited to the thyroid
T3 Tumor >4cm, limited to the thyroid or any tumor with minimal extrathyroidal extension (eg, extension to sternothyroid muscle or perithyroid soft tissues)
T4 Advanced disease
  • T4a: Moderately advanced disease; tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve
  • T4b: Very advanced disease; tumor invades prevertebral fascia or encases carotid artery or mediastinal vessel
  • * All anaplastic carcinomas are considered stage IV
  • T4a: Intrathyroidal anaplastic carcinoma
  • T4b: Anaplastic carcinoma with gross extrathyroid extension
Regional Lymph Nodes (N)
Regional lymph nodes are: central compartment, lateral cervical, and upper mediastinal lymph nodes
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
  • N1a: Metastases to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes)
  • N1b: Metastases to unilateral, bilateral, or contralateral cervical (levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (level VII)
Distant Metastasis (M)
M0 No Distant Metastasis
M1 Distant Metastasis is present

Anatomic Stage/Prognostic Groups
Papillary and follicular thyroid cancer (age < 45y):
Stage T N M
I ant T any N M0
II ant T any N M1
Papillary and follicular; differentiated (age ≥ 45y):
Stage T N M
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
IVA T1
T2
T3		 N1a M0
IVA T4a N1b M0
IVB T4b any N M0
IVC ant T any N M1
Anaplastic carcinoma (all anaplastic carcinomas are considered stage IV):
Stage T N M
IVA T4a any N M0
IVB T4b any N M0
IVC ant T any N M1
Medullary carcinoma (all age groups):
Stage T N M
I T1 N0 M0
II T2
T3		 N0 M0
III T1
T2
T3		 N1a M0
IVA T4a N0
N1a		 M0
IVA T1
T2
T3
T4a		 N1b M0
IVB T4b N Any M0
IVC T Any N Any M1
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Primary Tumor (T)
TX Primary Tumor cannot be assessed
T3 Mucosal disease
T4a Moderately advanced disease
  • Tumor involving deep soft tissue, cartilage, bone, or overlying skin
T4b Very advanced disease
  • Tumor involving brain, dura, skull base, lower cranial nerves (IX, X, XI, XII), masticator space, carotid artery, prevertebral space, or mediastinal structures
Regional Lymph Nodes (N)
NX Regional Lymph Nodes cannot be assessed
N0 No regional lymph node metastases
N1 Regional lymph node metastases present
Distant Metastasis (M)
M0 No Distant Metastasis
M1 Distant Metastasis

Anatomic Stage/Prognostic Groups
Stage T N M
III T3 N0 M0
IVA T4a N0
N1		 M0
IVA T3 N1 M0
IVB T4b N Any M0
IVC T Any N Any M1
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