Head and Neck Cancer Staging
Pareen Mehta, MD and Patrick M. Colletti, MD
Head and neck cancers represent a wide spectrum of potentially lethal malignancies
involving the many different anatomic compartments extending from the skull base to
the mediastinum. Most malignant tumors in these locations are histologically squamous
cell carcinomas, with a small, but significant minority of cases consisting of minor
salivary gland neoplasms. The major risk factor for malignancy in these locations is a
history of smoking. However, alcohol abuse and HPV are also contributing factors.
Regardless of histology, the staging for these lesions is similar based upon the
anatomic location of the primary site. Lesions typically spread via local invasion and via
lymphatic channels to the cervical lymph nodes. It is important to note that lesions near
the midline or that cross the midline can metastasize to contralateral lymph nodes.
Additionally, identification of extracapsular spread is vital, as these lesions portend a
worse prognosis and a higher risk of recurrence. Distant metastasis can be seen, most
commonly to the lungs, then to the liver and bones.
Accurate staging is critical in these patients, as localized disease will be typically treated
with local therapy (surgery or radiation therapy), while advanced disease tends to be
treated with a combination of surgery and radiation therapy, with the possible addition of
chemotherapy. MRI and PET/CT are similar in evaluating the local extent of a tumor.
However, PET/CT is superior to MRI or CT alone in the detection of nodal metastasis or
distant metastasis. This is especially true for lymph nodes that are normal by CT size
criteria, but demonstrate increased metabolic activity. PET/CT is also excellent in
identifying recurrent disease, especially given its ability to distinguish between posttreatment changes and early recurrence.
Staging Overview of Oral Cavity and Lip Carcinomas
Stage 1
Primary tumor is less than 2cm in greatest dimension.
No evidence of nodal disease or distant metastasis.
Stage 2
Primary tumor is greater than 2cm, but less than 4cm,
in greatest dimension. No evidence of nodal disease or
distant metastasis.
Stage 3
Primary tumor greater than 4cm in greatest dimension
without direct invasion into adjacent structures OR
nodal metastasis to a single ipsilateral lymph node less
than 3cm in size. No evidence of distant metastases.
Stage 4
Stage 4A: Moderately advanced local disease
(including direct invasion into adjacent structures, such
as cortical bone, floor of mouth, maxillary sinus, or
skin) OR any nodal metastasis (ipsilateral, contralateral
or both), none of which are greater than 6cm in size.
No evidence of distant metastasis.
Stage 4B: Very advanced local disease (including
direct invasion of the masticator space, pterygoid
plates, or skull base) OR any nodal metastasis with a
lymph node greater than 6cm in greatest dimension.
Stage 4C: Characterized by distant metastasis.
Clinical Pearls:
***Stage I and Stage II lesions are typically treated with radiation therapy or
surgery alone, depending on patient factors and local clinical expertise.
***It is very important to differentiate between stage II and stage III lesions, as
stage III (and stage IV) lesions cannot be typically treated with surgery or radiation
therapy alone. These patients are candidates for combined surgical and radiation
therapy with considerations for adjuvant chemotherapy.
***PET/CT may be superior to MRI in identifying direct invasion of adjacent
anatomical structures. Nevertheless, this is critical, as this can by itself upstage
the patient.
***Identification of nodal metastases is paramount, as this will obligate a lymph
node dissection. In many cases where nodal status is determined to be negative, a
lymph node dissection may not be performed.
***PET/CT is superior to CT or MRI in the detection of nodal metastases, distant
metastases and a second synchronous primary neoplasm.
Figure 1. Tongue base squamous cell cancer (arrow)with a single level 2 FDG avid
node (circled), SUVmax = 7: Stage 3
Staging Overview of Nasal Cavity and Paranasal Sinus (except maxillary sinus)
Cancers
Stage 1
Tumor isolated to one anatomic subsite/location with or
Stage 2
Stage 3
Stage 4
without osseous destruction. No evidence of nodal
disease or distant metastasis.
Tumor invading two adjacent
anatomic subsites/locations, including two adjacent areas
within the nasoethmoidal complex. No evidence of nodal
disease or distant metastasis.
Primary tumor directly invades floor or medial wall of
orbit, maxillary sinus, palate or cribiform plate OR nodal
metastasis to a single ipsilateral lymph node less than
3cm in size. No evidence of distant metastases.
Stage 4A: Moderately advanced local disease (including
direct invasion into anterior orbital contents,
skin, pterygoid plates, frontal or sphenoid sinus) OR any
nodal metastasis (ipsilateral, contralateral or both), none
of which are greater than 6cm in size. No evidence of
distant metastasis.
Stage 4B: Very advanced local disease (including direct
invasion of the orbital apex, skull base, cranial nerves
other than V2, nasopharynx or clivus) OR any nodal
metastasis with a lymph node greater than 6cm in
greatest dimension.
Stage 4C: Characterized by distant metastasis.
Clinical Pearls:
***Except for mucosal Stage I lesions, most cases are treated with combination of
surgery and radiation therapy.
***CT (and therefore PET/CT) is greater than MRI in identifying osseous
destruction
***Destruction of the skull base, pterygoid plates, cavernous sinus and
nasopharyngeal involvement are typical contraindications to surgery.
***It is very important to identify lymph node metastases, as the rate of lymph node
involvement is low (less than 20%), and routine lymph node dissection is typically
only performed in node positive patients.
***PET/CT is superior to CT or MRI in the detection of nodal metastases, distant
metastases and a second synchronous primary neoplasm.
***PET/CT is very useful in the surveillance of these patients for locoregional
recurrence, as the greatest morbidity and mortality in these patients is due to
rapidly recurring local disease or direct extension into vital areas of the skull base.
Figure 2. Left nasopharyngeal squamous cell cancer (arrow)with ipsilater and
contralateral pharyngeal spread (arrowheads)and several 3 cm level 2 nodes (circled).
Stage 4A nasopharyngeal cancer.
Staging Overview of Hypopharyngeal Cancers
Stage 1
Tumor isolated to one anatomic subsite/location and less
than 2cm in greatest dimension. No evidence of nodal
Stage 2
Stage 3
Stage 4
disease or distant metastasis.
Tumor extension into greater than one subsite/location of
hypopharynx and/or measures greater than 2 cm, but not
greater than 4 cm in greatest dimension. No evidence of
nodal disease or distant metastasis.
Tumor greater than 4cm dimension or fixation
of hemilarynx or esophageal invasion OR nodal
metastasis to a single ipsilateral lymph node less than
3cm in size. No evidence of distant metastases.
Stage 4A: Moderately advanced local disease (including
direct invasion into thyroid cartilage, cricoid cartilage,
hyoid, or thyroid gland) OR any nodal metastasis
(ipsilateral, contralateral or both), none of which are
greater than 6cm in size. No evidence of distant
metastasis.
Stage 4B: Very advanced local disease (including direct
invasion of the prevertebral fascia, mediastinum or carotid
artery encasement) OR any nodal metastasis with a
lymph node greater than 6cm in greatest dimension.
Stage 4C: Characterized by distant metastasis.
Clinical Pearls:
***It is important to identify advanced stage lesions (usually Stage 2 or greater), as
these patients may be offered chemotherapy in addition to combined surgery and
radiation.
***Hypopharyngeal carcinomas have a propensity for skip lesions (skip
metastasis) and recurrence at locations remote from the primary site
***Compared to other head and neck neoplasms, hypopharyngeal masses have
increased rate of nodal and distant metastases.
***PET/CT is superior to CT or MRI in the detection of nodal metastases, distant
metastases and a second synchronous primary neoplasm.
*** Overall, PET/CT has a very high negative predictive value in excluding distant
metastatic disease in the setting of a negative scan.
Figure 3. 53 year old man with left piriform sinus hypopharyngeal squamous cell cancer
(h), SUVmax = 12. There is prominent left level 2 adenopathy (n, arrow). Tumor extends
inferiorly and apparently invades the left cricoid cartilage. A small midline level 6 node is
noted(circled).
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