Highlights of Changes to TNM Staging AJCC Cancer Staging Manual, 6th edition

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Highlights of Changes to TNM StagingAJCC Cancer
Staging Manual, 6th Edition
Frederick L. Greene, MD, FACS Editor
american joint committee on cancer
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TNM 6th EditionGlobal Changes

• New publisher Springer Verlag
• Two-color printing
• Section tabs
• Indexed
• Illustrations from TNM Atlas

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TNM 6th EditionGlobal Changes

• Summary of changes at beginning of each chapter
• ICD-O-3 site codes, morphology codes
• Survival graphs by stage
• More discussion of prognostic factors
• CD-ROM with staging form

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AJCC 6 GENERAL RULES

• New time guidelines for evaluating stage
• Clinical and Pathology Classification guidelines
• M1 may be cM1 or pM1 for path staging

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TNM 6th EditionNO Changes

• Esophagus
• Small intestine
• Anal canal
• Lung
• Carcinoma of skin
• Vulva, vagina
• Cervix
• Ovary
• Fallopian Tube

• Penis
• Testis
• Renal pelvis and ureter
• Urinary bladder
• Urethra
• Carcinoma of lacrimal gland
• Brain and CNS no TNM

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Head and Neck All Sites (1)

• T4 categories
• T4a (resectable)
• T4b (unresectable)
• Revised stage grouping
• Stage IVA advanced resectable disease
• Stage IVB advanced unresectable disease
• Stage IVC advanced distant metastatic disease

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Head and Neck All Sites (2)

• Stage Groupings relatively uniform combinations
  of T and N and M categories for all sites
  including paranasal sinuses, salivary tumors, and
  thyroid tumors.
• No changes N categories for any HN site

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Head and Neck StagingExample Larynx

• Stage 0 Tis N0 M0
• Stage I T1 N0 M0
• Stage II T2 N0 M0
• Stage III T3 N0 M0
• T1 - 3 N1 M0
• Stage IVA T4a N0 - 2 M0
• T1 - 3 N2 M0
• Stage IVB T4b Any N M0
• Any T N3 M0
• Stage IVC Any T Any N M1

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Thyroid Gland (1)

• Tumor categories (T) revised, categories
  redefined
• T1 lt 2 cm
• T2 2 4 cm
• T3 gt 4 cm extrathyroid extension
• T4a Extracapsular extension (resectable)
• T4b Unresectable extension

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Thyroid Gland (2)

• Node categories revised
• N0 No regional lymph node metastasis
• N1 Regional lymph node metastasis
• N1a Metastasis to Level VI (pretracheal, parat
  racheal, and prelaryngeal/Delphian lymph nodes)
• N1b Metastasis to unilateral, bilateral,
  or contralateral cervical or
  superior mediastinal lymph nodes

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Thyroid Gland (3)

• All anaplastic carcinomas are T4
• T4a (intrathyroidal anaplastic carcinoma
  surgically resectable)
• T4b (extrathyroidal anaplastic carcinoma
• surgically unresectable)

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Thyroid Gland (4)

• Papillary and follicular carcinomas revised
  stage grouping for patients gt 45
• Stage III minimal extrathyroid extension
• Stage IVA tumors (any size) beyond the
  thyroid capsule, invading subcutaneous
  soft tissues, larynx, trachea,
  esophagus, recurrent laryngeal nerve
  
• Stage IVB invasion of prevertebral fascia,
  carotid artery, or mediastinal
  vessels
• Stage IVC advanced tumors, distant mets

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Stomach

• T2 category subdivided
• T2a invades the muscularis propria
• T2b invades into subserosa

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Colon and Rectum (1)

• Better description of boundaries between colon,
  rectum and anal canal
• Adenocarcinomas of the appendix classified with
  colon/rectum, but recorded separately
• Anal canal cancers separate staging

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Colon and Rectum (2)

• Tumor nodules
• Smooth, in the pericolic/perirectal fat
• count as lymph node metastases in N category
• Irregularly contoured metastatic nodules in the
  peritumoral fat
• considered vascular invasion
• coded as an extension of the T category
• V1 (microscopic vascular invasion)
• V2 (macroscopic vascular invasion)

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Colon and Rectum(3)

• Stage Group II subdivided
• IIA T3 N0 M0
• IIB T4 N0 M0
• Stage Group III subdivided
• IIIA T1-2 N1 M0
• IIIB T3-4 N1 M0
• IIIC Any T N2 M0

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Liver (1)

• T categories redefined and simplified
• T1 Solitary tumor, no vascular invasion
• T2 Solitary tumor with vascular invasion or
  multiple tumors none gt 5 cm
• T3 Multiple tumors gt 5 cm or tumor
  involving a major branch of the portal or
  hepatic vein(s)
• T4 Direct invasion of adjacent organs other
  than the gallbladder or with perforation
  of visceral peritoneum

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Liver (2)

• Separate Subcategories eliminated
• multiple bilobar tumors
• invasion of adjacent organs
• perforated tumors
• Stage IV metastatic disease only
• IVA and IVB eliminated

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Gallbladder(1)

• T and N classifications simplified to separate
  locally invasive tumors
• T3 potentially resectable
• T4 unresectable
• Depth of liver invasion no longer a factor

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Gallbladder (2)

• Stage Grouping
• Stage IIA large, invasive tumors (resectable),
  no lymph node metastatsis
• Stage IIB lymph node metastasis
• Stage III locally unresectable disease
• Stage IV metastatic disease

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Extrahepatic Bile Ducts

• T and N classifications redefined and simplified
• T1 confined to bile duct, including invasion of
  subepithelial fibromuscular connective
  tissue
• T2 invasion beyond the wall of the bile duct
• T3 resectable including invasion of branches of
  the portal vein (right or left), hepatic
  artery, or liver
• T4 unresectable including invasion of the main
  portal vein, common hepatic artery, and/or
  regional organs
• Stage grouping revised
• Stage III locally unresectable disease
• Stage IV metastatic disease

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Ampulla of Vater

• Depth of pancreatic invasion factor eliminated
• Stage grouping revised
• Stage IA T1 N0 M0
• Stage IB T2 N0 M0
• Stage IIA T3 N0 M0
• Stage IIB T1-3 N1 M0

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Exocrine Pancreas

• T classification revised
• T3 beyond the pancreas except as in
  T4 (potentially resectable)
• T4 celiac axis or the superior mesenteric
  artery (unresectable primary tumor)
• Stage grouping revised
• Stage III unresectable, locally advanced
• Stage IV metastatic disease

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Pleural Mesothelioma (1)

• Applies only to tumors arising in the pleura
• Updated based on information about the
  relationships between tumor T and N status and
  overall survival
• Adopted International Mesothelioma Interest Group
  (IMIG) staging (1995)

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Pleural Mesothelioma (2)

• T categories redefined
• T1a ipsilateral parietal pleura only
• T1b ipsilateral parietal pleura, focal
  visceral pleura
• T2 more extensive visceral pleura, lung,
  diaphragm
• T3 locally advanced but potentially resectable
• T4 locally advanced, technically unresectable

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Bone (1)

• T1 category revised
• Tumor 8 cm or less in greatest dimension
• T2 category revised
• Tumor more than 8 cm in greatest dimension
• T3 skip metastasis defined
• Discontinuous tumors in the primary bone site
  (Stage III)

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Bone (2)

• M1 category subdivided
• M1a lung-only metastasis
• Mlb mets to other distant sites
  including lymph nodes
• Stage Grouping
• Stage IVA Any T N0 M1a Any G
• Stage IVB Any T N1 Any M Any G Any T
  Any N M1b Any G

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Soft Tissue Sarcoma (1)

• Not included
• Angiosarcoma
• Malignant mesenchymoma
• Fibromatosis / desmoid tumor (formerly
  Fibrosarcoma grade I)
• Added
• Gastrointestinal stromal tumor
• Ewings sarcoma/primitive neuroectodermal tumor

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Soft Tissue Sarcoma (2)

• G 1-2, T2b, N0 M0 moved to Stage I

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Melanoma of Skin (1)

• T category
• Uses melanoma thickness and ulceration
• Clark level of invasion not used (except for T1)
• Stage I, II, and III upstaged when melanoma is
  ulcerated
• M category
• M1a skin, subcutaneous tissues, distant nodes
• M1b lung
• M1c other visceral sites or any elevated LDH

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Melanoma of Skin (2)

• N category revised
• N1 One node involved
• N1a as above, microscopic
• N1b as above, macroscopic
• N2 2 to 3 nodes or intralymphatic
  regional mets, no node mets
• N2a as above, microscopic
• N2b as above, macroscopic
• N2c satellite or in-transit mets, no node mets
• N3 4 nodes matted nodes in-transit mets
  or satellite(s) with mets in regional node(s)

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Melanoma of Skin (3)

• Satellite mets (intralymphatic mets w/in 2 cm)
  around primary melanoma and in-transit mets
  (intralymph. gt 2 cm) grouped as Stage IIIC
• Clinical and pathologic staging accommodate
  information from lymphatic mapping and sentinel
  node excision

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Breast (1)

• Micrometastases vs. isolated tumor cells
• Isolated tumor cells (ITCs) single cells/small
  clusters lt 0.2 mm, designated pN0 (i-) or pN0
  (i) i immunohistochemical
• Micromets gt 0.2 mm to 2.0 mm, designated pN1mi
• Sentinel node dissection info only pN_ (sn)
• Molecular techniques pN0 (mol-) or pN0 (mol)
  -RT-PCR

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Breast (2)

• Axillary nodes (routine HE or IHC)
• N1 1 to 3
• N2 4 to 9
• N3 10
• Infraclavicular nodes are N3
• Supraclavicular nodes reclassified as N3

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Breast (3)

• Internal mammary nodes
• N1 Microscopic
• N2 Macroscopic, no axillary nodes
• N3 Macroscopic with axillary nodes

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Breast (4)
examination or imaging (except lymph scanning)
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Gestational Trophoblastic Tumors

• Anatomic T, M retained but not prognostic
• Risk factors revised as separate category
• New scoring system
• Sum of prognostic factors and scoring
• Subdivides stage groups
• A low risk, score of 7 or less
• B high risk, score of 8 or greater

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Prostate

• T2 category subdivided (reverts to 4th edition)
• T2a ½ lobe or less
• T2b gt ½ lobe
• T2c both lobes
• Gleason score--grading system of choice
• Use of terms well differentiated, moderately
  differentiated, and poorly differentiated for
  grading is not recommended

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Kidney

• T1 category subdivided
• T1a tumor lt 4 cm, limited to the kidney
• T1b tumor gt 4 cm and lt 7 cm, limited to kidney

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Staging Publications and Products

• Cancer Staging Manual, 6th Edition with CD-ROM
• Cancer Staging Handbook, 6th Edition
• CD-ROM of Staging Forms
• Comparison Guide between 5th and 6th Editions in
  PDF format
• Staging product for Personal Digital Assistants
  (i.e., Palm, Compaq, etc.)
• Journal editorials highlighting changes

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Educational Initiatives

• Worldwide teleconference on changes in TNM
  November 2002
• CD-ROM focused on
• Knowledge of general staging rules
• Changes to TNM
• Slide library of site-specific TNM, stage
  groupings, and survival data for teaching
  purposes
• Speakers Bureau to make presentations on changes

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For Further Information

• www.cancerstaging.net (publications)
• American Joint Committee on Cancer
• 633 North Saint Clair St.
• Chicago, IL 60611
• [phone] (Valerie Vesich, CTR)
• www.cancerstaging.org (AJCC)