At The Mount Sinai Health System, our ear, nose, and throat doctors are highly skilled in detection and diagnosis. To diagnose the cause of your symptoms, we will conduct a thorough medical history and perform a physical examination. The examination will include not only looking at the suspicious area for cancer, but also feeling the area with a gloved finger or an instrument. Your doctor will likely examine the entire head and neck region, including your ears, nose, and throat. Your doctor will pay particular attention to your neck to determine whether any cancer has spread to your lymph nodes (metastases).

Once your physical examination is complete, your doctor may recommend a specialized type of X-ray, such as a CT scan, MRI, or PET scan. At this point, your doctor may take a small piece of tissue from a suspected tumor for examination under a microscope (biopsy). Your doctor can perform the biopsy safely in his or her office. From this tissue sample, a pathologist will determine which types of cells make up your tumor.

Staging

Tumors are categorized by the following "stages":

T1: Tumor is no more than 2 cm (about ¾ inch) across.

T2: Tumor is more than 2 cm across but less than 4 cm (about 1 ½ inch).

T3: Tumor is more than 4 cm across.

T4a: Tumor is growing into nearby structures, known as "moderately advanced local disease."

• For oral cancers: The tumor is growing into nearby structures, such as the bones of the jaw or face, the deep muscle of the tongue, the skin of the face, or the maxillary sinus.
• For lip cancers: The tumor is growing into nearby bone, the inferior alveolar nerve (the nerve to the jawbone), the floor of the mouth, or the skin of the chin or nose.
• For oropharyngeal cancers: The tumor is growing into the larynx (voicebox), the tongue muscle, or bones such as the medial pterygoid, the hard palate, and the jaw.

T4b: The tumor has grown through nearby structures and into deeper areas or tissues. This is known as very advanced local disease.

N categories

Doctors use the following stages to identify the spread of the cancer into the lymph nodes:

N0: No spread to nearby lymph nodes.

N1: The cancer has spread to one lymph node on the same side of the head or neck as the primary tumor. The lymph node is smaller than 3 cm (about 1 ¼ inch) across.

N2 includes three subgroups:

• N2a: The cancer has spread to one lymph node on the same side as the primary tumor. The lymph node is 3 cm to 6 cm across (about 1 ¼ inch to 2 ½ inches).
• N2b: The cancer has spread to two or more lymph nodes on the same side as the primary tumor, but neither is more than 6 cm (about 2 ½ inches) across.
• N2c: The cancer has spread to one or more lymph nodes on both sides of the neck or on the side opposite the primary tumor, but none are more than 6 cm (about 2 ½ inches) across.

N3: The cancer has spread to a lymph node that measures more than 6 cm (about 2 ½ inches) across.

M categories

Doctors use M categories to describe cancer spread (metastasis) beyond the lymph nodes.

M0: No distant spread.

M1: The cancer has spread to distant sites outside the head and neck region, for example, the lungs.

Stage grouping

Once the T, N, and M categories have been assigned, this information is combined by a process called stage grouping to assign an overall stage of 0, I, II, III, or IV. Stage IV is further divided into A, B, and C.

Stage 0: Tis, N0, M0: Carcinoma in situ. The cancer is only growing in the epithelium, the outer layer of oral or oropharyngeal tissue (Tis). It has not yet grown into a deeper layer or spread to nearby structures, lymph nodes (N0), or distant sites (M0).

Stage I: T1, N0, M0: The tumor is no more than 2 cm (about ¾ inch) across (T1) and has not spread to nearby structures, lymph nodes (N0), or distant sites (M0).

Stage II: T2, N0, M0: The tumor is more than 2 cm across but less than 4 cm (T2) and has not spread to nearby structures, lymph nodes (N0), or distant sites (M0).

Stage III: One of the following applies:

• T3, N0, M0: The tumor is larger than 4 cm across but it hasn't grown into nearby structures or spread to the lymph nodes (N0) or distant sites (M0).
• T1 to T3, N1, M0: The tumor is any size and has not grown into nearby structures (T1 to T3). It has spread to one lymph node, on the same side of the head or neck, and is less than 3 cm across (N1). The cancer has not spread to distant sites (M0).

Stage IVa: One of the following applies:

• T4a, N0 or N1, M0: The tumor is growing into nearby structures (T4a). It can be any size. It has either not spread to the lymph nodes (N0) or has spread to one lymph node, on the same side of the head or neck, that is less than 3 cm across (N1). The cancer has not spread to distant sites (M0).
• T1 to T4a, N2, M0: The tumor is any size and may or may not invade nearby structures. It has not spread to distant sites (M0). However, it has spread to one of the following:
  • One lymph node between 3 and 6 cm across (N2a) that is located on the same side of the head and neck
  • One lymph node less than 6 cm across (N2b) that is located on the opposite side of the head and neck
  • Two or more lymph nodes, all of which are less than 6 cm across, on either side of the neck (N2c)

Stage IVB: One of the following applies:

• T4b, any N, M0: The tumor is growing into deeper areas and/or tissues (very advanced local disease — T4b). It may or may not have spread to lymph nodes (any N). It has not spread to distant sites (M0).
• Any T, N3, M0: The tumor is any size and may or may not have grown into other structures (any T). It has spread to one or more lymph nodes larger than 6 cm across (N3), but it hasn't spread to distant sites (M0).
• Stage IVC: Any T, any N, M1: The tumor is any size, and it may or may not have spread to the lymph nodes. It has spread to distant sites, though, most often the lungs.