Stages

If oral cavity cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has spread, and if so, to what parts of the body.

The Spreading of Cancer

There are three ways that cancer spreads in the body:

Through tissue.
Cancer invades the surrounding normal tissue.

Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.

Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary tumor and travel through the lymph or blood to other places in the body, another, or secondary tumor, may form. This process is called metastasis. The secondary, or metastatic, tumor is the same type of cancer as the primary tumor. For example, if oral cancer spreads to the bones, the cancer cells in the bones are actually orall cancer cells. The disease is metastatic oral cancer, not bone cancer.

Stages of Oral Cancer

The most common system used to describe the extent of oral cavity cancers is the TNM System of the American Joint Committee on Cancer (AJCC). The TNM system for staging describes three key pieces of information:

T - Indicates the size of the primary tumor and which, if any, tissues of the oral cavity or oropharynx it has spread to

N - Describes the extent of spread to nearby lymph nodes.

M - Indicates whether the cancer has metastasized to other organs of the body. (The most common site of spread is to the lungs. The next most common sites are the liver and bones.)

Numbers or letters appear after T, N, and M to provide details about each of these factors. The numbers 0 through 4 indicate increasing severity. The letter X means "cannot be assessed" because the information is not available.

T Categories of Oral Cavity Cancer

TX: primary tumor cannot be assessed; information not known

T0: no evidence of primary tumor

Tis: carcinoma in situ. This means the cancer is still within the epithelium (the top layer of cells lining the oral cavity and oropharynx) and has not yet grown into deeper layers of oral or oropharyngeal tissue

T1: tumor is 2 cm (about ¾ inch) across or smaller

T2: tumor is larger than 2 cm across, but smaller than 4 cm (about 1 ½ inch)

T3: tumor is larger than 4 cm across

T4a: The tumor is growing into nearby structures. This is known as moderately advanced local disease.
For oral cavity cancers: the tumor is growing into nearby structures, such as the bones of the jaw or face, deep muscle of the tongue, 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.

T4b: The tumor has grown through nearby structures and into deeper areas or tissues. This is known as very advanced local disease. Any of the following may be true:

The tumor is growing into other bones, such as the pterygoid plates and/or the skull base (for any oral cavity or oropharyngeal cancer)

The tumor surrounds the internal carotid artery (for any oral cavity or oropharyngeal cancer)

The tumor is growing into an area called the masticator space

N Categories Of Oral Cavity Cancer

NX: nearby lymph nodes cannot be assessed; information not known

N0: the cancer has not 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; this lymph node is smaller than three centimeters (about 1 ¼ inch) across

N2a: the cancer has spread to one lymph node on the same side as the primary tumor; the lymph node is larger than three centimeters across but smaller than six centimeters (about 2 ½ inches)

N2b: the cancer has spread to two or more lymph nodes on the same side as the primary tumor, but none are larger than six cm 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 larger than six cm across

N3: the cancer has spread to a lymph node that is larger than six cm across

M Categories of Oral Cavity Cancer

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 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 two centimeters (about ¾ inch) across or smaller (T1) and has not spread to nearby structures, lymph nodes (N0), or distant sites (M0).

Stage II: T2, N0, M0: The tumor is larger than 2 cm across but smaller 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 three centimeters across, but it hasn't grown into nearby structures or spread to the lymph nodes (N0) or distant sites (M0)

Or

T1 to T3, N1, M0: The tumor is any size and hasn't grown into nearby structures (T1 to T3). It has spread to one lymph node on the same side of the head or neck, which is smaller than three centimeters across (N1). The cancer hasn't 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, which is smaller than three centimeters across (N1). The cancer hasn't spread to distant sites (M0).

Or

T1 to T4a, N2, M0: The tumor is any size and may or may not grow into nearby structures. It has not spread to distant sites (M0). It has spread to one of the following:

One lymph node one the same side of the head and neck that is between three and six centimeters across (N2a)

One lymph node on the opposite side of the head and neck that is less than six centimeters across (N2b)

Two or more lymph nodes, all of which are smaller than six centimeters across. The lymph nodes can be on any 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).

Or

Any T, N3, M0:
The tumor is any size and it 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 lymph nodes. It has spread to distant sites, most commonly the lungs.

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