Medical Oncologist
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Neck levels I to VI: a plain guide to the map on your report | CION Cancer Clinics
Neck levels are a map. Doctors divide each side of the neck into six numbered areas, from under the chin down to the front of the lower neck, so that a scan, an operation note and a pathology report all point to the same place. The number is a position, not a stage. This page shows where each level sits and what it means for your plan. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
MI
Medically reviewed by Dr. Mohammed ImaduddinConsultant Surgical Oncologist · MBBS, MS (General Surgery), MCh (Surgical Oncology) · last reviewed September 2026, next review due September 2027
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On this page
- What do neck levels actually mean?
- Where is each neck level?
- Which levels does each cancer usually reach first?
- How does the team decide which levels to clear?
- What do the other words beside the levels mean?
- What do people misread about neck levels?
- What can the level on your report not tell you?
- Common questions about neck lymph node levels
The short answer
What do neck levels actually mean?
Neck levels are a map. Doctors divide each side of the neck into six numbered areas, written as Roman numerals from I to VI, so that everyone reading a scan, an operation note or a report means the same place.
Why the neck needs a map
Each side of the neck holds many lymph nodes, the small bean-shaped glands that filter fluid from the mouth, throat and face. Cancers of the head and neck tend to spread to these nodes in a fairly predictable order. Naming the areas lets the team say exactly where a node is, and plan which areas to treat.
Where you will see the levels
They appear on scan reports ("an enlarged node at level II"), on the consent form ("selective neck dissection, levels I to III"), and on the pathology report after surgery, which lists what was found at each level.
What the numbers do not mean
The numbers are positions, not stages or grades. A node at level IV is not worse than one at level II simply because the number is higher. Seriousness depends on how many nodes hold cancer, their size and other features on the report.
The map, level by level
Where is each neck level?
Imagine standing in front of a mirror. The levels run from under the chin, down the side of the neck, and to the front at the bottom.
Level I
Under the chin and under the jaw bone, around the saliva gland there. Split into IA, under the chin, and IB, under the jaw.
Level II
The upper neck, just below the angle of the jaw. Split into IIA and IIB by the nerve that works the shoulder.
Level III
The middle of the side of the neck, around the level of the voice box. Nodes here sit along the large neck vein.
Level IV
The lower side of the neck, just above the collar bone, still along the large vein.
Level V
The back part of the side of the neck, behind the long muscle that turns your head. Split into VA and VB.
Level VI
The front of the lower neck, around the windpipe and thyroid. Most relevant to thyroid and voice box cancers.
Some reports add level VII, just below the neck behind the breastbone.Not sure whether this applies to you?
Ask an oncologistFollowing the drainage
Which levels does each cancer usually reach first?
Where the cancer starts
Levels most often involved first
Mouth, tongue, gums or cheek lining
Levels I, II and III
Throat behind the mouth, or voice box
Levels II, III and IV
Thyroid
Level VI first, then the side of the neck
Scalp or skin behind the ear
Levels II and V, and nodes near the ear
Back of the nose
Levels II and V, often on both sides
From map to plan
How does the team decide which levels to clear?
Where the cancer began
The starting point predicts the usual route of spread, as in the table above. This sets the levels most at risk.
What the scans show
CT, MRI, ultrasound or PET-CT look for enlarged or unusual nodes. A node that looks abnormal adds its level to the plan.
A needle test, if needed
A thin needle may take cells from a suspicious node to check for cancer before the operation.
The tumour board
Surgeons, radiation and medical oncologists agree which levels and which sides to treat, and whether surgery or radiotherapy suits you better.
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On your report
What do the other words beside the levels mean?
- Ipsilateral and contralateral
- The same side of the neck as the main tumour, or the opposite side.
- Bilateral
- Both sides of the neck.
- Node-negative or N0
- No cancer was seen in the neck nodes, on scans or on the report.
- Skip spread
- Cancer found at a lower level while the level above it is clear. It is uncommon, and one reason surgeons clear more than one level.
- Extranodal extension
- Cancer that has grown through the outer wall of a node. It often changes the plan for treatment after surgery.
Commonly believed
What do people misread about neck levels?
"Level V means the cancer is at stage 5."
Levels and stages are separate systems. A level only says where in the neck a node lies. Staging combines the main tumour, the nodes and any spread beyond the neck.
"More levels removed means the cancer is worse."
Not always. The number of levels cleared often reflects where the cancer started and how it tends to travel, not how advanced it is in you.
"If a level is not on the consent form, it will be left with cancer."
Levels are left when they carry a low chance of spread for that cancer. If the surgeon finds something unexpected during the operation, the plan can be extended, and this is explained on the form.
"A lump I can feel is always at the level named on my scan."
Lumps can be hard to place by touch. Bring your scan report to the clinic, and let the doctor match what you feel to the images.
Being straight with you
What can the level on your report not tell you?
A level tells you where a node was. It does not tell you on its own how the cancer will behave, what treatment you will need, or how things will turn out. Those answers come from the whole report, read with your scans and your general health.
Why two reports can name different levels
The borders between levels are drawn on bony and muscle landmarks. A node sitting on a border may be called level II on a scan and level III in the laboratory. This is common and rarely changes the plan.
What to bring to your appointment
Bring every scan report and CD, the biopsy report and any earlier notes. Ask which levels are involved on each side, which will be treated, and why the others will not. Writing the answers down helps the family member who could not attend.
If the words on your report are frightening you before the appointment, call the helpline. Someone will talk you through them.Questions we are asked
Common questions about neck lymph node levels
How many neck levels are there?
Each side of the neck has six main levels, numbered I to VI. Levels I, II and V are split further into A and B parts. Some reports also mention level VII, which sits just below the neck behind the upper breastbone. The same system is used by surgeons, radiologists and pathologists everywhere.
My scan says "level IB node". What does that mean?
Level IB is the area under the jaw bone, around the saliva gland there. A node described there may be enlarged because of infection, a tooth problem or cancer. The report alone cannot say which. Your doctor may suggest a needle test or read it alongside the rest of your tests.
Why does the report split level II into IIA and IIB?
The nerve that works the shoulder muscle runs through level II. IIA lies in front of it and IIB behind it. Clearing IIB needs more handling of that nerve. So for some cancers, surgeons leave IIB when the chance of spread there is low, to protect shoulder movement.
Can cancer skip a level?
It can, though it is uncommon. Occasionally cancer is found at a lower level while the level above it is clear. This is one reason surgeons clear a group of levels rather than a single node, and why the pathologist checks each level separately.
Are both sides of the neck always checked?
Both sides are always looked at on scans. Whether both sides are treated depends on where the cancer started. Cancers near the middle of the tongue, the floor of the mouth or the throat can drain to both sides. Cancers well to one side usually drain to that side first.
Does the level change which treatment I get?
It shapes the plan. The level decides which areas a surgeon clears or radiotherapy covers. But the treatment choice itself rests on the whole picture: where the cancer started, how many nodes are involved, their size, and your overall health. Your tumour board weighs all of these together.
Why do my scan and my surgery report name different levels?
Level borders follow landmarks that look slightly different on a scan and in the operating theatre. A node near a border can be given either number. It is a common and usually minor difference. If it worries you, ask your surgeon to show you on the scan.
Can I get my reports explained without travelling to Hyderabad?
Yes. Call the helpline and share your scan and biopsy reports. A member of the team will explain what the levels mean and what the next step usually is. The same helpline serves every CION centre, so you can then choose the branch nearest your district.
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MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
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Dr. Vinay Mamidala
MBBS, MS(General Surgery), M.Ch(Surgical Oncology), FMAS, FARIS(Ongoing)
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Dr. Vajja Sandeep Kumar
MBBS, MS (General Surgery), DrNB (Surgical Oncology), FALS Oncology
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Sources
- American Cancer Society — Surgery for oral cavity and oropharyngeal cancers
- National Cancer Institute — Head and neck cancers
- Cancer.Net — Head and neck cancer
- NICE — Cancer of the upper aerodigestive tract: assessment and management (NG36)
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Neck Dissection: What the Operation InvolvesWhat happens when the levels are clearedSelective, Modified Radical and Radical Neck DissectionWhich levels each type of operation removesExtranodal Extension on the Neck Dissection ReportThe other phrase on the report that changes the planThe Pathology Report After SurgeryHow to read the rest of the report
Talk to us
Confused by the levels on your report?
Share your scan and biopsy reports, or call the helpline. A surgical oncologist will explain what they show. One helpline serves every CION centre.