Cancer Staging Lung, breast, colon, ovarian, cervical, prostate, RCC, Wilms.

LUNG CANCER STAGING

Primary tumor

Tis - Carcinoma in situ

o
TX - Positive malignant cytologic findings, no lesion observed
o
T1 < 3 cm,
o
surrounded by lung or visceral pleura
endobronchial tumor distal to the lobar bronchus
o T2 - >3 cm, extension to visceral pleura, obstructive pneumopathy
involving <1 lung; lobar endobronchial tumor > 2 cm from the carina
o T3 - Tumor at the apex;
total atelectasis of 1 lung;
tumor < 2 cm from carina but not invading it;
tumor any size, direct extension to the adjacent structures
(chest wall, mediastinal pleura, diaphragm, pericardium
parietal layer, or mediastinal fat of the phrenic nerve)
o T4 - Invasion of the mediastinal organs (esophagus trachea, carina great
vessels, heart);
obstruction of SVC;
involvement of vert body or recurrent nerve;
malignant pleural or pericardial effusion;
satellite pulmonary nodules in same lobe as 1ary tumor.
Regional lymph node involvement
o N0 - No lymph nodes involved
o N1 - Ipsilateral bronchopulmonary or hilar nodes involved
o N2 - Ipsilateral mediastinal nodes or ligament involved
Upper paratracheal lower paratracheal nodes
Pretracheal and retrotracheal nodes
Aortic and aortic window nodes, Subcarinal nodes
Para-aortic nodes, Para-esophageal nodes
o N3 - contralateral mediastinal/hilar nodes or scalene/ supraclavicular LN
Metastatic involvement
o M0 - No metastases M1 - Metastases present

Lung Cancer Stage groupings are as follows:

IA - T1N0M0
IB - T2N0M0
IIA - T1N1M0
IIB - T2N1M0 or T3N0M0
IIIA - T1-3N2M0 or T3N1M0
IIIB - Any T4 or any N3M0
 IV - Any M1

N0 N1 N2 N3
T1 IA IIA IIIA IIIB
T2 IB IIB IIIA IIIB
T3 IIB IIIA IIIA IIIB
T4 IIIB IIIB IIIB IIIB

BREAST The standard staging system is that of the American Joint Committee
on Breast Cancer. The system is based on tumor size, LN, and metastatic dz.
Primary tumor = T

o Tx - Primary tumor cannot be assessed

o T0 - No evidence of primary tumor
o Tis - Carcinoma in situ
o T1 - Tumor 2 cm in greatest dimension
o T2 - Tumor > 2 cm but 5 cm
o T3 - Tumor > 5 cm
o T4 - Tumor of any size with direct extension to chest wall or skin
(including inflammatory carcinoma)

Regional lymph nodes = N

o Nx - Regional lymph nodes cannot be assessed

o N0 - No regional lymph node metastases
o N1 - Metastases to ipsilateral axillary lymph nodes without fixation
o N2 - Metastases to ipsilateral axillary lymph nodes with fixation
o N3 - Metastasis to ipsilateral internal mammary lymph nodes

Distant metastases = M

o Mx - Cannot be assessed
o M0 - No metastases
o M1 - Distant mets including ipsilateral supraclavicular lymph nodes

Stage groups

o Stage 0 - TisN0M0
o Stage I - T1N0M0
o Stage IIa - T0N1M0, T1N1M0, T2N0M0
o Stage IIb - T2N1M0, T3N0M0
o Stage IIIb - T4 Any N M0, Any T N3 M0
o Stage IV - Any T Any N M1
RENAL CELL CANCER STAGING

The Robson modification of the Flocks and Kadesky system is uncomplicated and is used
commonly in clinical practice. This system was employed to correlate stage at
presentation with prognosis. The Robson staging system is as follows:

o Stage I - Tumor confined within capsule of kidney

o Stage II - Tumor invading perinephric fat but still contained within the
Gerota fascia

o Stage III - Tumor invading the renal vein or inferior vena cava (A), or
regional lymph-node involvement (B), or both (C)

o Stage IV - Tumor invading adjacent viscera (excluding ipsilateral adrenal)

or distant metastases

The TNM classification is endorsed by the AJCC. The major advantage of TNM is
that it differentiates individuals with tumor thrombi from those with local nodal
disease. In the Robson system, IVC involvement (IIIA) is the same stage as local
LN metastases (IIIB). Although patients with Robson stage IIIB RCC have greatly
decreased survival rates, the prognosis for patients with stage Robson IIIA is not
markedly different from that for patients with Robson stage I or II RCC.

Staging by TNM classification.

Primary tumor (T)

TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1: Tumor 7 cm or less in greatest dimension limited to the kidney
T2: Tumor more than 7 cm in greatest dimension limited to the kidney
T3: Tumor extends into major veins or invades adrenal gland or perinephric
tissues but not beyond Gerotas fascia
o T3a: Invades adrenal gland/perinephric tissues but not beyond Gerotas
fascia
o T3b: Tumor extends into the renal vein or IVC below the diaphragm
o T3c: Tumor extends into the renal vein(s) or IVC above the diaphragm
T4: Tumor invades beyond Gerotas fascia

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single regional lymph node
N2: Metastasis in more than 1 regional lymph node
 Laterality does not affect the N classification.

Distant metastasis (M)

MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis

AJCC stage groupings for RCC

Stage I : T1, N0, M0

Stage II : T2, N0, M0
Stage III
T1, N1, M0
T2, N1, M0
T3a, N0/1, M0
T3b, N0/1, M0
T3c, N0/1, M0
Stage IV
T4, N0/1, M0
Any T, N2, M0
Any T, any N, M1

WILMS TUMOR STAGING: NWTSG recommends surgical staging.

Stage I: The tumor is limited to the kidney and is excised completely.

Stage II: The tumor extends beyond the kidney but is excised completely.
Capsular penetration, renal vein involvement, and renal sinus involvement also
may be found. A biopsy of the tumor is performed, and local spillage occurs.

Stage III: Residual intra-abdominal tumor exists after surgery. LN (+), or

peritoneal implants are found. The resected specimen has histologically positive
margins, or the tumor has been spilled into the abdominal cavity.

Stage IV: Hematogenous or LN mets have occurred outside abdomen or pelvis.

Stage V: Synchronous bilateral involvement has occurred. Each side is assigned a

stage from I to III, and histology is based on biopsy findings.

CERVICAL Staging With The FIGO System

The FIGO classifications are grouped within basic stages labelled stage 0
through stage IV (0-4):

Stage 0 - Carcinoma in situ. Tumor is present only in the epithelium (cells

lining the cervix).
Stage I - Invasive cancer with tumor strictly confined to the cervix.
o Stage IA - Tumor can be seen under a microscope.
o Stage IA1 - Tumor has penetrated < 3 mm deep and < 7 mm wide.
o Stage IA2 - Tumor has penetrated 3-5 mm deep, < 7 mm wide.
o Stage IB - Tumors can be seen without a microscope or with a
microscope but > 7 mm wide and penetrated >5 mm of cervical CT.
o Stage IB1 - Tumor < 4 cm.
o Stage IB2 - Tumor > 4 cm. Spread to organs and tissues outside
the cervix but is still limited to the pelvic area.
Stage II - Invasive cancer with tumor extending beyond the cervix and/or
the upper 2/3 of vagina, but not onto the pelvic wall.
o Stage IIA - Spread beyond cervix to the upper part of the vagina.
o Stage IIB - Tumor has spread to the tissue next to the cervix.
Stage III - Invasive cancer with tumor spreading to the lower 1/3 of the
vagina or the pelvic wall; tumor may obstruct ureters ,kidneys or bladder.
o Stage IIIA - Tumor has spread to the lower 1/3 of the vagina.
o Stage IIIB - Tumor has spread to the pelvic wall and/or blocks the
flow of urine from the kidneys to the bladder.
Stage IV - Invasive cancer with tumor spreading to other parts of the body.
This is the most advanced stage of cervical cancer.
o Stage IVA - Tumor has spread to organs located near the cervix,
such as the bladder or rectum.
o Stage IVB - Tumor has spread to parts of the body far from the
cervix.

OVARIAN CANCER STAGING: FIGO staging for ovarian cancer

Stage I - Growth limited to the ovaries

o Stage Ia - 1 ovary, no ascites, no tumor on external surface, capsule intact

o Stage Ib-both ovaries, no ascites, no tumor on external surface, capsule intact

o Stage Ic - Tumor either stage Ia/Ib with tumor on surface of one/both ovaries,
ruptured capsule, ascites with malignant cells or + peritoneal washings

Stage II - Growth involving one or both ovaries, with pelvic extension

 o Stage IIa - Extension and/or metastases to the uterus or tubes

o Stage IIb - Extension to other pelvic tissues

o Stage IIc - Stage IIa/ IIb with tumor on surface of one or both ovaries,
ruptured capsule, ascites + malignant cells or + peritoneal washings

Stage III - Tumor involving one or both ovaries, with peritoneal implants outside the
pelvis and/or positive retroperitoneal or inguinal LN; superficial liver mets.

o Stage IIIa - Tumor grossly limited to pelvis, (-) LN but histological proof
of microscopic disease on abdominal peritoneal surfaces
o Stage IIIb - Confirmed implants outside of pelvis in the abdominal
peritoneal surface; no implant exceeds 2 cm in diameter and (-) LN.
o Stage IIIc - Abdominal implants >2 cm in diameter +/- positive LN.

Stage IV - Distant metastases; pleural effusion must have a positive cytology to be

classified as stage IV; parenchymal liver metastases equals stage IV

COLON CANCER Dukes Classification (or TNM)

Stage Characteristics
Dukes stage A Carcinoma in situ limited to mucosa or submucosa (T1, N0, M0)
Dukes stage B Extends into the muscularis (B1), into or through the serosa (B2)
Dukes stage C Cancer that extends to regional lymph nodes (T1-4, N1, M0)
Dukes stage D Modified classification; distant mets (T1-4, N1-3, M1)

An excellent correlation exists between stage and 5-year survival rate in patients with
colon cancer. For stage I or Dukes stage A, the 5-year survival rate following surgical
resection exceeds 90%. For stage II or Dukes stage B, 5-year survival rate is 70-85%
following resection, with or without adjuvant therapy. For stage III or Dukes stage C, 5-
year survival rate is 30-60% following resection and adjuvant chemotherapy. For stage IV
or Dukes stage D, 5-year survival rate is poor (approximately 5%).

TNM STAGING of COLON CANCER

 TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ: intraepithelial or invasion of the lamina propria
T1: Tumor invades submucosa
T2: Tumor invades muscularis propria
T3: Tumor invades through the muscularis propria into the subserosa, or into non-peritonealized pericolic or
perirectal tissues
T4: Tumor directly invades other organs or structures, and/or perforates visceral peritoneum

Regional lymph nodes (N)

NX: Regional nodes cannot be assessed

N0: No regional lymph node metastasis
N1: Metastasis in 1 to 3 regional lymph nodes
N2: Metastasis in 4 or more regional lymph nodes

TNM Staging System for Colon Cancer

Regional Remote
Stage Primary Tumor (T)
LN (N) Metastasis (M)
Stage 0 Carcinoma in situ N0 M0
May invade submucosa
Stage I N0 M0
(T1) or muscularis (T2).
Invades muscularis (T3) or
Stage II N0 M0
perirectal tissues (T4).
Stage IIIA T1-4 N1 M0
Stage IIIB T1-4 N2-3 M0
Stage IV T1-4 N1-3 M1

PROSTATE CANCER STAGING: TNM System.

T Stages

T1: The tumor can't be felt during DRE, or seen by

imaging studies, but bx +.

T1a found incidentally, when benign tissue is removed.

<5% of the tissue is cancerous.

T1b cancers are also found incidentally during TURP, but

more than 5 percent of the tissue removed is cancerous.

T1c cancers are identified by bx because of elevated PSA.

 T2 : The tumor can be felt during a DRE and the cancer
is confined within the prostate gland.
T2a: Tumor involves < of one lobe (R or L).
T2b: Involves > of one lobe, but not both lobes.

T2c: The tumor involves both left and right lobes.

T3 : The tumor has extended through the capsule

and/or to seminal vesicles, but no other organs.

T3a: The tumor extends through one side of the

prostatic capsule, but has not spread to SV
T3b: The tumor extends through both sides of the
prostatic capsule, but has not spread to the SV

T3c: The tumor has spread to the seminal vesicles

T4: The tumor has spread or attached to tissues next
to the prostate (other than the seminal vesicles).

T4a: The tumor has spread to the neck of the

bladder, the external sphincter or the rectum.

T4b: The tumor has spread to the floor and/or the

wall of the pelvis.

N Stages
N1 - 3: Any T stage with lymph node involvement

N0: Cancer has not spread to any lymph nodes.

N1: Spread to a 1 regional LNand is < 2 cm.
N2: Spread to 1 or > regional LN, > 2 but < 5 cm.

N3: Cancer has spread to a lymph node and is

larger than 5 centimeters (2 inches).

Lymph node involvement

M Stages
 M0: Mets beyond the regional LN.

M1: Mets to distant LN, bones, lungs, liver, brain.

Metastasis to distant sites

NEUROBLASTOMA STAGING

The International Neuroblastoma Staging System (INSS) currently is used in all

cooperative group studies. A comparison of INSS, POG, and CCG staging
criteria is detailed in Table 1. In general, the CCG staging system is based on
clinical findings, whereas the POG system is clinicopathologic. INSS uses
features of the other 2 systems.

Table 1. Staging Systems for Neuroblastoma

International Neuroblastoma Children's Cancer Study Pediatric Oncology Group

Staging System Group System System

Stage 1 Stage I Stage A

Localized tumor, complete gross Tumor confined to the Complete gross resection of 1ry
excision +/- micro residual dz organ or structure of origin tumor +/- micro residual dz

Ipsilateral LN (-) for tumor (LN Intracavitary LN not adhered to

attached to1ary tumor may be 1ary tumor, which are
(+) for tumor. histologically free of tumor

Stage 2A
Localized tumor with incomplete
gross resection
Representative ipsilateral
nonadherent LN (-) for tumor
microscopically
Stage II Stage B
Tumor extending in Grossly unresected primary
continuity beyond the organ tumor
or structure of origin but not
crossing the midline Nodes and nodules the same as
in stage A
Possible regional lymph
Stage 2B
Localized tumor and/or complete
gross excision, with ipsilateral
non adherent LN (+) for tumor
Enlarged contralateral LN, (-) for
microscopic tumor
Stage 3
Unresectable unilateral tumor
infiltrating across the midline +/-
regional LN
Localized unilateral tumor with
contralateral LN
Stage 4
Any 1ary tumor with distant LN,
bone, bone marrow, liver, skin,
and/or other organs (except as
defined for stage 4S)
Stage 4S
Localized 1ary tumor (as defined
for stages 1, 2A, or 2B) with
dissemination limited to skin,
liver, and/or bone marrow (<10%
involvement)
Limited to infants <1 y
node involvement on the
ipsilateral side
Stage III
Tumor extending in
continuity beyond the
midline
Possible regional LN
involvement bilaterally
Stage IV
Remote disease involving
the skeleton, bone marrow,
soft tissue, and distant LN
(see stage IV-S)
Stage IV-S
As defined in stage I or II,
except for the presence of
metastatic dz confined to
the liver, skin, or marrow
(<10% involvement)
No bone metastases
Stage C
Complete or incomplete
resection of primary tumor
Intracavitary LN not adhered to
primary tumor, which are (+) for
tumor
Liver as in stage A
Stage D
Dissemination of disease
beyond intracavitary nodes (eg,
extracavitary nodes, liver, skin,
bone marrow, bone)
Stage DS
Infants <1 year with stage 1 or
2, except for the presence of
remote disease confined to the
liver, skin, or marrow (<10%
involvement)
No bone metastases