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Stages of Squamous Cell Carcinoma

Cancer staging is a way of describing how extensive a cancer is. The stage is related to tumor size. It also relates to whether the cancer has spread from the original tumor to other parts of the body. The cancer stage helps you and your doctor to develop a treatment plan. It also provides information about survival.

Squamous cell carcinoma (SCC) is staged using a system called TNM.1,2 This cancer staging system is used by most hospitals and medical systems.3 Once your doctor has categorized the T, N, and M, these values are combined to assign a cancer stage.2

TNM staging system for SCC of the skin

T – Primary Tumor: Size of the tumor, presence of high-risk features, invasion of facial or skeletal structures
N – Regional Lymph Nodes: Presence, location, and number of lymph nodes with cancer cells and the size of the metastatic tumor
M – Metastasis: Spread of cancer to other parts of the body

T Categories

The T categories describe the main tumor based on its thickness, the presence of high-risk features, and invasion.2 Your doctor begins to gather this information by doing a skin biopsy. If the tumor is invasive, you will need imaging tests.

  • Size. The longest dimension of the tumor is measured in centimeters.
  • Invasion. The tumor is categorized by how far it has invaded the body. Invasion of the facial bones is categorized as T3. Invasion of bones in the rest of the body or the base of the skull is T4. Your doctor determines this using magnetic resonance imaging (MRI) or computed tomography (CT) scan.
  • High-risk features. High-risk features refer to the risk that the cancer returns (recurs) or spreads (metastasizes). High-risk features of SCC are:2
    • > 2 mm thick or Clark level ≥ IV
    • Growing around a nerve
    • Located on the ear or lip
    • Poorly differentiated or undifferentiated cells. Differentiation means how much the cancer cells look like the normal tissue that it came from. Poorly differentiated cells grow and spread more quickly.

T Categories

    • TX – Primary tumor cannot be assessed
    • T0 – No evidence of a primary tumor
    • Tis – Carcinoma in situ (the tumor is only in the epidermis)
    • T1 – Longest dimension is ≤ 2 cm and tumor has <2 high-risk features
    • T2 – Longest dimension is >2 cm or Tumor of any size with ≥2 high-risk features
    • T3 – Tumor has invaded the jawbone, eye socket, or the skull around the ears and temple
    • T4 – Tumor has invaded the skeleton or base of the skull

N Categories

The N categories indicate whether cancer cells have spread to nearby lymph nodes.2 One sign of cancer spread is enlarged or swollen lymph nodes. Another sign is that the lymph nodes may appear abnormal on imaging tests.2 If your doctor suspects that cancer has spread to the lymph nodes, you will need a lymph node biopsy. The biopsy is done with fine needle aspiration or a core needle biopsy.

N Categories

Classification
Number of Metastatic Nodes
Location of Affected Nodes
Size of Metastasis
NX
Regional lymph nodes cannot be assessed.
N0
0
N/A
N/A
N1
1
Same side of the body as the primary tumor.
≤3 cm
N2a
1
Same side of the body as the primary tumor.
3-6 cm
N2b
1
Same side of the body as the primary tumor.
All ≤6 cm
N2c
>1
On both sides of the body or opposite side of the body
All ≤6 cm
N3
≥1
Any nearby lymph node
>6 cm

 

M Categories

The M categories indicate whether the cancer has spread (metastasized) to distant parts of the body.2 Simply, 0 means no metastasis and 1 means metastasis.

M Categories

      • M0 – No distant metastasis
      • M1 – Distant metastasis

Putting it all together: assigning a stage

Once the cancer is characterized, the categories are combined to assign a stage.2 Generally speaking, the lower the stage, the better the chance for long-term cure and survival.

Anatomic Stage

Stage
T Cat
N Cat
M Cat
Stage 0
Tis
N0
M0
Stage I
T1
N0
M0
Stage II
T2
N0
M0
Stage III
T3
N0
M0
T1
N1
M0
T2
N1
M0
T3
N1
M0
Stage IV
T1
N2
M0
T2
N2
M0
T3
N2
M0
Any T
N3
M0
T4
Any N
M0
Any T
Any N
M1

 

Clark level

The Clark Level is based on which layer of skin the tumor has invaded.4,5

Clark Level

      • Level I – All tumor cells are confined to the epidermis (top layer of skin), above the basement membrane.
      • Level II – Tumor passes through basement membrane and invades the top layer of the dermis (papillary dermis).
      • Level III – Tumor fills the papillary dermis and has reached the border (interface) between the top (papillar) and bottom (reticular) layers of dermis.
      • Level IV – Tumor invades the bottom layer (reticular) of the dermis.
      • Level V – Tumor invaded the tissue under the skin (subcutaneous tissue)2
Written by: Sarah O'Brien | Last reviewed: May 2017.
  1. National Cancer Institute. Skin cancer treatment (PDQ) – health professional version. Accessed April 24, 2017 at: https://www.cancer.gov/types/skin/hp/skin-treatment-pdq - link/_292_toc
  2. NCCN Clinical Practice Guidelines in Oncology. Squamous cell skin cancer. Version 1.2017. Published October 3, 2016. https://www.nccn.org/professionals/physician_gls/pdf/squamous.pdf
  3. National Cancer Institute. Staging. Accessed February 7, 2017 at: https://www.cancer.gov/about-cancer/diagnosis-staging/staging
  4. National Cancer Institute. SEER Training Modules: Staging. Accessed February 7, 2017 at: https://training.seer.cancer.gov/melanoma/abstract-code-stage/staging.html
  5. Winslow T. Skin cancer, Clark levels (illustration). 2010. National Cancer Institute Visuals Online. Accessed March 19, 2017 at: https://visualsonline.cancer.gov/details.cfm?imageid=8286