Head and Neck Cancer Staging 

Updated: Feb 29, 2016
  • Author: Marvaretta M Stevenson, MD; Chief Editor: Guy J Petruzzelli, MD, PhD, MBA, FACS  more...
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TNM Classification for Head and Neck Cancer

The TNM classifications for cancers of the head and neck (with the exception of thyroid cancer, which is addressed separately) are provided below, along with anatomic staging. [1] World Health Organization (WHO) criteria are supplied for the nasopharynx.

Oral cavity and larynx

Table. Oral cavity and larynx (Open Table in a new window)

Primary tumor (T)

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

Table. Histologic grade (Open Table in a new window)

Histologic grade (G)

GX

Grade cannot be assessed

G1

Well differentiated

G2

Moderately differentiated

G3

Poorly differentiated

G4

Undifferentiated

Table. Anatomic stage/prognostic groups (Open Table in a new window)

Stage

T

N

M

0

Tis

N0

M0

I

T1

N0

M0

II

T2

N0

M0

III

T3

N0

M0

T1

N1

M0

T2

N1

M0

T3

N1

M0

IVA

T4a

N0

M0

T4a

N1

M0

T1

N2

M0

T2

N2

M0

T3

N2

M0

T4a

N2

M0

IVB

T Any

N3

M0

T4b

N Any

M0

IVC

T Any

N Any

M1

Nasopharynx

Table. Nasopharynx (Open Table in a new window)

WHO criteria

Type 1

Differentiated squamous cell carcinoma

Type 2

Nonkeratinizing carcinoma

Type 3

Undifferentiated carcinoma

Table. TNM classification (Open Table in a new window)

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

Table. Histologic grade (Open Table in a new window)

Histologic grade (G)

GX

Grade cannot be assessed

G1

Well differentiated

G2

Moderately differentiated

G3

Poorly differentiated

G4

Undifferentiated

Table. Anatomic stage/prognostic groups (Open Table in a new window)

Stage

T

N

M

0

Tis

N0

M0

I

T1

N0

M0

II

T1

N1

M0

T2

N0

M0

T2

N1

M0

III

T1

N2

M0

T2

N2

M0

T3

N0

M0

T3

N1

M0

T3

N2

M0

IVA

T4

N0

M0

T4

N1

M0

T4

N2

M0

IVB

T Any

N3

M0

IVC

T Any

N Any

M1

 

Oropharynx and hypopharynx

Table. Oropharynx and hypopharynx (Open Table in a new window)

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

Table. Histologic grade (Open Table in a new window)

Histologic grade (G)

GX

Grade cannot be assessed

G1

Well differentiated

G2

Moderately differentiated

G3

Poorly differentiated

G4

Undifferentiated

Table. Anatomic stage/prognostic groups (Open Table in a new window)

Stage

T

N

M

0

Tis

N0

M0

I

T1

N0

M0

II

T2

N0

M0

III

T3

N0

M0

T1

N1

M0

T2

N1

M0

T3

N1

M0

IVA

T4a

N0

M0

T4a

N1

M0

T1

N2

M0

T2

N2

M0

T3

T4a

N2

N2

M0

M0

IVB

T Any

N3

M0

T4b

N Any

M0

IVC

T Any

N Any

M1

Nasal cavity and paranasal sinuses

Table. Nasal cavity and paranasal sinuses (Open Table in a new window)

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

Table. Histologic grade (Open Table in a new window)

Histologic grade (G)

GX

Grade cannot be assessed

G1

Well differentiated

G2

Moderately differentiated

G3

Poorly differentiated

G4

Undifferentiated

Table. Anatomic stage/prognostic groups (Open Table in a new window)

Stage

T

N

M

0

Tis

N0

M0

I

T1

N0

M0

II

T2

N0

M0

III

T3

N0

M0

T1

N1

M0

T2

N1

M0

T3

N1

M0

IVA

T4a

N0

M0

T4a

N1

M0

T1

N2

M0

T2

N2

M0

T3

N2

M0

T4a

N2

M0

IVB

T Any

N3

M0

T4b

N Any

M0

IVC

T Any

N Any

M1

Major salivary glands (parotid, submandibular, and sublingual)

Table. Major salivary glands (parotid, submandibular, and sublingual) (Open Table in a new window)

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

Table. Anatomic stage/prognostic groups (Open Table in a new window)

Stage

T

N

M

0

Tis

N0

M0

I

T1

N0

M0

II

T2

N0

M0

III

T3

N0

M0

T1

N1

M0

T2

N1

M0

T3

N1

M0

IVA

T4a

N0

M0

T4a

N1

M0

T1

N2

M0

T2

N2

M0

T3

N2

M0

T4a

N2

M0

IVB

T Any

N3

M0

T4b

N Any

M0

IVC

T Any

N Any

M1

Mucosal melanoma

Table. Mucosal melanoma (Open Table in a new window)

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

Table. Anatomic stage/prognostic groups (Open Table in a new window)

Stage

T

N

M

III

T3

N0

M0

IVA

T4a

N0

M0

T3

N1

M0

T4a

N1

M0

IVB

T4b

N Any

M0

IVC

T Any

N Any

M1