Laryngeal and Hypopharyngeal Cancer: Stages and Grades

Approved by the Lineagotica Editorial Board, 12/2017

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread, as well as what the cancer cells look like under a microscope. This is called the stage and grade. Use the menu to see other pages.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.

Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

TNM staging system

One tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?

  • Node (N): Has the tumor spread to the lymph nodes? If so, where and how many? 

  • Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person. There are 5 stages: stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Here are more details on each part of the TNM system for both laryngeal cancer and hypopharyngeal cancer.

Tumor (T)

Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below and has been divided into an outline of tumors of the larynx and tumors of the hypopharynx.

Tumors of the larynx

TX: The primary tumor cannot be evaluated. 

Tis: This is a stage called carcinoma (cancer) in situ. It is a very early cancer where cancer cells are found in only 1 layer of tissue. 

When describing T1 to T4 tumors, doctors divide the larynx into 3 regions: the glottis, the supraglottis, and the subglottis (see the Introduction).

Glottis tumor of the larynx

T1: The tumor is limited to the vocal cords, but it does not affect the movement of the cords. 

  • T1a: The tumor is only in the right or left vocal cord.

  • T1b: The tumor is in both vocal folds. 

T2: The tumor has spread to the supraglottis and/or the subglottis. The tumor may also affect the movement of the vocal cord.

T3: The tumor is limited to the larynx and paralyzes at least 1 of the vocal cords. The tumor may also invade the space inside the larynx and/or the cartilage around the thyroid gland. 

T4: The tumor has spread beyond the larynx. 

  • T4a: The tumor has spread to the thyroid cartilage and/or the tissue beyond the larynx.

  • T4b: The tumor has spread to the area in front of the spine (prevertebral space) or the chest area, or it encases the arteries.

Supraglottis tumor of the larynx

T1: The tumor is located in a single area above the vocal cords that does not affect the movement of the vocal cords. 

T2: The tumor started in the supraglottis, but it has spread to the mucous membranes that line other nearby areas, such as the base of the tongue. The vocal cords are not affected. 

T3: The tumor is limited to the larynx and affects the vocal cords. The tumor may have spread to surrounding tissue. 

T4: The tumor has spread beyond the larynx. 

  • T4a: The tumor has spread through the thyroid cartilage and/or the tissue beyond the larynx.

  • T4b: The tumor has spread to the area in front of the spine (prevertebral space) or the chest area, or it encases the arteries.

Subglottis tumor of the larynx

T1: The tumor is limited to the subglottis.

T2: The tumor has spread to the vocal cords. Movement of the vocal cords may be affected. 

T3: The tumor is limited to the larynx and affects the vocal folds. It may also invade the space inside the larynx and/or the cartilage of the thyroid. 

T4: The tumor has spread beyond the larynx. 

  • T4a: The tumor has spread to the cricoids, the ring-shaped cartilage near the bottom of the larynx, or thyroid cartilage and/or the tissue beyond the larynx.

  • T4b: The tumor has spread to the area in front of the spine or the chest area, or it encases the arteries.

Tumors of the hypopharynx

TX: The primary tumor cannot be evaluated. 

Tis: This is a stage called carcinoma (cancer) in situ. It is a very early cancer where cancer cells are found in only 1 layer of tissue. 

T1: The tumor is 2 centimeters (cm) or smaller and is limited to a single place in the lower throat. 

T2: The tumor involves more than 1 site in the lower throat, or the tumor measures between 2 cm and 4 cm but does not touch the voice box. 

T3: The tumor is larger than 4 cm or has spread to the larynx or esophagus. 

T4a: The tumor has spread into nearby structures, such as the thyroid gland, the arteries that carry blood to the brain, or the esophagus. 

T4b: The tumor has spread to the prevertebral fascia (space in front of the spinal cord), encases the arteries, or involves the chest area.

Node (N)

The “N” in the TNM staging system stands for lymph nodes. These tiny, bean-shaped organs help fight infection. Lymph nodes near the head and neck are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. Since there are many lymph nodes in the head and neck area, the doctor’s careful assessment of lymph nodes is an important part of staging. 

When cancer has spread through a lymph node and into the tissues directly surrounding it, it is called extranodal extension (ENE). Knowing whether ENE is present plays an important role in the evaluation of lymph nodes in hypopharyngeal cancer. 

Staging can be clinical or pathological. Clinical staging is based on the results of physical examinations, imaging scans, and biopsies. Pathological staging is based on what is found during surgery plus the results of physical examinations, imaging scans, and biopsies. Pathological staging gives the health care team the most amount of information to make a prognosis. Here are more details on each part of the TNM system for cancers of the larynx and hypopharynx.

Clinical N

NX: The regional lymph nodes cannot be evaluated. 

N0 (N plus zero): There is no evidence of cancer in the regional lymph nodes. 

N1: The cancer has spread to a single lymph node on the same side as the primary tumor, and the cancer found in the node is 3 cm or smaller. There is no ENE. 

N2a: Cancer has spread to a single lymph node on the same side as the primary tumor and is larger than 3 cm but not larger than 6 cm. There is no ENE. 

N2b: Cancer has spread to more than 1 lymph node on the same side as the primary tumor, and none measures larger than 6 cm. There is no ENE. 

N2c: Cancer has spread to more than 1 lymph node on either side of the body, and none measures larger than 6 cm. There is no ENE. 

N3a: The cancer is found in a lymph node and is larger than 6 cm. There is no ENE. 

N3b: There is ENE in any lymph node.

Pathological N

NX: The regional lymph nodes cannot be evaluated. 

N0 (N plus zero): There is no evidence of cancer in the regional lymph nodes. 

N1: The cancer has spread to a single lymph node on the same side as the primary tumor, and the cancer found in the node is 3 cm or smaller. There is no ENE. 

N2a: Cancer has spread to 1 lymph node and is 3 cm or smaller, but there is ENE. Or, cancer has spread to a single lymph node on the same side as the primary tumor and is larger than 3 cm but not larger than 6 cm, and there is no ENE. 

N2b: Cancer has spread to more than 1 lymph node on the same side as the primary tumor, and none measures larger than 6 cm. There is no ENE. 

N2c: Cancer has spread to more than 1 lymph node on either side of the body, and none measures larger than 6 cm. There is no ENE. 

N3a: The cancer is found in a lymph node and is larger than 6 cm. There is no ENE. 

N3b: There is ENE in a single lymph node on the same side as the primary tumor, and it is larger than 3 cm. Or, cancer has spread to many lymph nodes, and at least 1 has ENE. Or, there is ENE in a single lymph node on the opposite side of the primary tumor that is 3 cm or smaller.

Metastasis (M)

The "M" in the TNM system indicates whether the cancer has spread to other parts of the body, called distant metastasis.

M0: The cancer has not spread to other parts of the body. 

M1: The cancer has spread to other parts of the body.

Cancer stage grouping

Doctors assign the stage of the laryngeal or hypopharyngeal cancer by combining the T, N, and M classifications.

Larynx

Stage 0: This stage describes a carcinoma in situ with no spread to lymph nodes or distant metastasis (Tis, N0, M0).

Stage I: This stage describes a small tumor with no spread to lymph nodes or distant metastasis (T1, N0, M0).

Stage II: This stage describes a tumor that has spread to some nearby areas but has not spread to lymph nodes or to distant parts of the body (T2, N0, M0).

Stage III: Either of the following applies:

  • A larger tumor with no spread to regional lymph nodes or metastasis (T3, N0, M0).

  • A tumor that has spread to regional lymph nodes but has no sign of distant metastasis (T1–T3, N1, M0). 

Stage IVA: Either of the following applies:

  • There is an invasive tumor. If it has spread to the lymph nodes, it is only to a single lymph node on the same side of the primary tumor. There is no distant metastasis (T4a, N0 or N1, M0).

  • There is significant spread to the lymph nodes but no distant metastasis (T1–T4a, N2, M0).

Stage IVB: Either of the following applies:

  • There is extensive spread to the lymph nodes but no distant metastasis (any T, N3, M0).

  • The tumor is locally advanced and may involve the lymph nodes, but there is no distant metastasis (T4b, any N, M0). 

Stage IVC: There is evidence of distant spread (any T, any N, M1).

Hypopharynx

Stage 0: There is carcinoma in situ, with no spread to lymph nodes or other parts of the body (Tis, N0, M0).

Stage I: The tumor is 2 cm or less in size, but cancer has not spread to lymph nodes or other parts of the body (T1, N0, M0).

Stage II: The tumor is between 2 cm and 4 cm, but cancer has not spread to lymph nodes or other parts of the body (T2, N0, M0).

Stage III: Either of the following applies: 

  • The tumor is larger than 4 cm or has spread to the epiglottis, but the cancer has not spread to lymph nodes or other parts of the body (T3, N0, M0).

  • The tumor has not invaded nearby tissues, except the epiglottis. Cancer is in 1 lymph node on the same side as the primary tumor, and it is 3 cm or smaller, with no ENE. Cancer has not spread to other parts of the body (T1–T3, N1, M0). 

Stage IVA: Either of the following applies: 

  • The tumor has invaded the larynx, muscle of the tongue, muscles in the jaw, roof of the mouth, or jawbone. Cancer may have spread to 1 lymph node, but it has not spread to other parts of the body (T4a, N0 or N1, M0).

  • The tumor may be small or it may have invaded nearby structures, like the larynx, muscles of the tongue or jaw, roof of the mouth, or jawbone. Cancer has spread to 1 or more lymph nodes, but none is larger than 6 cm. There is no ENE. Cancer has not spread to other parts of the body (T1–T4a, N2, M0). 

Stage IVB: Either of the following applies: 

  • The tumor is any size. The cancer is found in a lymph node and is larger than 6 cm, but there is no ENE; or there is ENE in any lymph node. Cancer has not spread to other parts of the body (any T, N3, M0).

  • The tumor has invaded muscles and bones in the region of the mouth; the nasopharynx, which is the air passageway at the upper part of the throat behind the nose; or the base of the skull, or the tumor encases the carotid artery. Lymph nodes may or may not be involved. Cancer has not spread to other parts of the body (T4b, any N, M0).

Stage IVC: Cancer has spread to other parts of the body (any T, any N, M1). 

Recurrent: Recurrent cancer is cancer that has come back after treatment.  If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Grade (G)

Doctors also describe these types of cancer by their grade (G), which describes how much cancer cells look like healthy cells when viewed under a microscope.

The doctor compares the cancerous tissue with healthy tissue. Healthy tissue usually contains many different types of cells grouped together. If the cancer looks similar to healthy tissue and contains different cell groupings, it is called differentiated or a low-grade tumor. If the cancerous tissue looks very different from healthy tissue, it is called poorly differentiated or a high-grade tumor. The cancer’s grade can help the doctor predict how quickly the cancer will spread. In general, the lower the tumor’s grade, the better the prognosis.

GX: The grade cannot be evaluated.

G1: The cells look more like normal tissue (well differentiated). 

G2: The cells are moderately differentiated. 

G3: The cells don’t resemble healthy tissue (poorly differentiated). 

G4 (hypopharynx only): The cells don’t look like health tissue at all (undifferentiated). 

Used with permission of the American College of Surgeons, Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017), published by Springer International Publishing.  

Information about the cancer’s stage and grade will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. You may use the menu to choose a different section to read in this guide.