TNM

Table 25–2. TNM Classification of Rectal Cancer

Table: TNM Staging System for Breast Cancer

Primary tumor (T) Definitions for classifying the primary tumor (T) are the same for clinical and for pathologic classification. If the measurement is made by physical examination, the examiner will use the major headings (T1, T2, or T3); if other measurements, such as mammographic or pathologic measurements, are used, the subsets of T1 can be used. Tumors should be measured to the nearest 0.1-cm increment.

TX

T0

Tis

Tis (DCIS)

Tis (LCIS)

Tis (Paget's)

T1

T1mic

T1a

T1b

T1c

T2

T3

T4

T4a

T4b

T4c

T4d

Primary tumor cannot be assessed

No evidence of primary tumor

Carcinoma in situ

Ductal carcinoma in situ

Lobular carcinoma in situ

Paget's disease of the nipple with no tumor (NOTE: Paget's disease associated with a tumor is classified according to the size of the tumor)

Tumor

2 cm in greatest dimension

Microinvasion

0.1 cm or less in greatest dimension

Tumor >0.1 cm but not >0.5 cm in greatest dimension

Tumor >0.5 cm but not >1 cm in greatest dimension

Tumor >1 cm but not >2 cm in greatest dimension

Tumor >2 cm but not >5 cm in greatest dimension

Tumor >5 cm in greatest dimension

Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described below

Extension to chest wall, not including pectoralis muscle

Edema (including peau d'orange), or ulceration of the skin of the breast, or satellite skin nodules confined to the same breast

Both T4a and T4b

Inflammatory carcinoma

Regional lymph nodes—Clinical (N)

NX

N0

N1

N2

N2a

N3

N3a

N3b

N3c

Regional lymph nodes cannot be assessed (e.g., previously removed)

No regional lymph node metastasis

Metastasis to movable ipsilateral axillary lymph node(s)

Metastases in ipsilateral axillary lymph nodes fixed or matted, or in clinically apparenta ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastasis

Metastasis in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures

Metastasis only in clinically apparenta ipsilateral internal mammary nodes and in the absence of clinically evident axillary lymph node metastasis; metastasis in ipsilateral infraclavicular lymph node(s) with or without axillary lymph node involvement, or in clinically apparenta ipsilateral internal mammary lymph node(s) and in the presence of clinically evident axillary lymph node metastasis; or metastasis in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement

Metastasis in ipsilateral infraclavicular lymph node(s)

Metastasis in ipsilateral internal mammary lymph nodes(s) and axillary lymph node(s)

Metastasis in ipsilateral supraclavicular lymph node(s)

Regional lymph nodes—Pathologic (pN)

pNX

pN0b

pN0(i–)

pN0(i+)

pN0(mol–)

pN0(mol+)

pN1

pN1mi

pN1a

pN1b

pN1c

pN2

pN2a

pN2b

pN3

pN3a

pN3b

pN3c

Regional lymph nodes cannot be assessed (e.g., previously removed, or not removed for pathologic study)

No regional lymph node metastasis histologically, no additional examination for isolated tumor cells [NOTE: Isolated tumor cells (ITC) are defined as single tumor cells or small cell clusters not >0.2 mm, which are usually detected only by immunohistochemical (IHC) or molecular methods but which may be verified on hematoxylin and eosin stains; ITCs do not usually show evidence of malignant activity (e.g., proliferation or stromal reaction)]

No regional lymph node metastasis histologically, negative IHC results

No regional lymph node metastasis histologically, positive IHC results, no IHC cluster >0.2 mm

No regional lymph node metastasis histologically, negative molecular findings [reverse-transcriptase polymerase chain reaction (RT-PCR)]

No regional lymph node metastasis histologically, positive molecular findings (RT-PCR)

Metastasis in 1 to 3 axillary lymph nodes, and/or in internal mammary nodes with microscopic disease detected by sentinel lymph nodes dissection, not clinically apparentc

Micrometastasis (>0.2 mm, none >2.0 mm)

Metastasis in 1 to 3 axillary lymph nodes

Metastasis in internal mammary nodes with microscopic disease detected by sentinel lymph node dissection, not clinically apparentc

Metastasis in 1 to 3 axillary lymph nodes and in internal mammary lymph nodes with microscopic disease detected by sentinel lymph node dissection but not clinically apparentc (if associated with >3 positive axillary lymph nodes, the internal mammary nodes are classified as pN3b to reflect increased tumor burden)

Metastasis in 4 to 9 axillary lymph nodes, or in clinically apparenta internal mammary lymph nodes in the absence of axillary lymph node metastasis

Metastasis in 4 to 9 axillary lymph nodes (at least one tumor deposit >2.0 mm)

Metastasis in clinically apparenta internal mammary lymph nodes in the absence of axillary lymph node metastasis

Metastasis in

10 axillary lymph nodes, or in infraclavicular lymph nodes, or in clinically apparenta ipsilateral internal mammary lymph nodes in the presence of 1 or more positive axillary lymph nodes; or in >3 axillary lymph nodes with clinically negative microscopic metastasis in internal mammary lymph nodes; or in ipsilateral supraclavicular lymph nodes

Metastasis in

10 axillary lymph nodes (at lease one tumor deposit >2.0 mm), or metastasis to the infraclavicular lymph nodes

Metastasis in clinically apparenta ipsilateral internal mammary lymph nodes in the presence of

1 positive axillary lymph nodes; or in >3 axillary lymph nodes and in internal mammary lymph nodes with microscopic disease detected by sentinel lymph node dissection, not clinically apparentc

Metastasis in ipsilateral supraclavicular lymph nodes

Distant metastasis (M)

MX

M0

M1

Distant metastasis cannot be assessed

No distant metastasis

Distant metastasis

Table: TNM Staging for Oral Cavity Carcinoma

TNM Staging of Parotid Cancer

T – Primary Tumor

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

T1 Tumor 2 cm or less in greatest dimension without extraparenchymal extension*

T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension without extraparenchymal extension

T3 Tumor having extraparenchymal extension without VII nerve involvement and / or more than 4 cm but not more than 6 cm in greatest dimension

T4 Tumor invades base of skull, VII nerve, and / or exceeds 6 cm in greatest dimension

* Extraparenchymal extension is clinical or macroscopic (not microscopic alone) evidence of invasion of skin, soft tissues, bone or nerve.

N – Regional Lymph nodes

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension

N2a Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension

N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension

N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension

N3 Metastasis in a lymph node more than 6 cm in greatest dimension

* Midline nodes are considered ipsilateral nodes

M – Distant Metastasis

MX Distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis

Stage Grouping

Stage I T1 / T2 N0 M0

Stage II T3 N0 M0

Stage III T1 / T2 N1 M0

Stage IV T4 N0 M0

T3 /T4 N1 M0

Any T N2 / N3 M0

Any T Any N M1

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BUCCAL MUCOSAL CANCER

T: Primary tumour

Tx Primary tumour cannot be asses

T0 No evidence of primary tumour

Tis Carcinoma in situ

T1 Tumour 2 cm or less in greatest dimension

T2 Tumour more than 2 cm but no more than 4 cm in greatest dimension

T3 Tumour more than 4 cm in greatest dimension

T4 Tumour invades adjacent structures e.g. through cortical bone, Ptrygoid muscles

maxillary sinus, skin Involvement leading to orocutaneous fistula

N: Lymph Nodes

Nx Nodes can’t be assessed

N0 No lymph node metastasis

N1 Single ipsilateral lymph node ≤3 cm in greatest dimension

N2a Single ipsilateral lymph node, ≥3 cm in but not > 6cm in greatest dimension

N2b Multiple ipsilateral lymph nodes, none > 6 cm in reatest dimension

N2c Bilateral or contralateral lymph nodes, none > 6 cms in greatest dimension

N3 Metastasis in lymph node > 6 cm in greatest dimension

M: Metastasis

M0 No distant metastasis

N1 Distant metastasis

TNM Classification of Esophageal Carcinomas

T: Primary Tumor

TO No evidence of a primary tumor

Tis Carcinoma-in-situ (High-grade dysplasia)

T1 The tumor invades the lamina propria, muscularis mucosae, or submucosa but does not breach the boundary between the submucosa and muscularis propria

T2 The tumor invades the muscularis propria but does not breach the boundary between the muscularis propria and periesophageal tissue

T3 The tumor invades the periesophageal tissue but does not invade adjacent structures

T4 The tumor invades adjacent structures

N: Regional Lymph Nodes

NO No regional lymph node metastasis

N1 Regional lymph node metastasis

M: Distant Metastasis

MO No distant metastasis

M1 Distant metastasis

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Staging systems of gastric cancer:

Modified AJCC/UICC system,1997(5)

"T" stage:

T0: No evidence of tumor

Tis: Carcinoma -in-situ- no invasion of the lamina propria

T1: Invasion of the lamina propria/ submucosa

T2: Invasion of the muscularis propria

T3: Invasion of the serosa

T4: Invasion of surrounding structures

"N" Stage: M Stage

N0: No nodal disease M0: No metastases

N1: 1-6 involved nodes M1: Metastases

N2: 7-15 involved nodes

N3: > 15 involved nodes

Stage grouping

Stage I- T1/T2 N0/N1M0

IA T1 N0 M0

IB T1N1 or T2 N0 M0

II- T1N2, T2N1, T3 N0 M0

III- T2/3/4 N2/1/0, T3 N2M0

IV- T4N1M0, Any N3, Any M1

Japanese cancer Society Staging System (6)

Tumor location

C: Upper third/ cardia

M: Middle third

A: Lower third/ Antrum

Macroscopic tumor type:

T Stage: Similar to the AJCC /UICC

0- Flat/Superficial

1- Polypoidal

2- Ulceration with sharp margins

3- Ulceration without definite margins

4- Diffuse infiltration

5- Non-classifiable

N Stage:

N1: Group I nodes (Right & left cardiac, lesser and greater omental, gastroepiploic, suprapyloric and subpyloric)

N2: Nodes along named vascular branches of the celiac trunk (Left gastric, hepatic, splenic)

N3: Hepatoduodenal, retropancreatic, anterior pancreatic, inferior pancreatic, celiac

N4: Para aortic, middle colic

P Stage:

P0: No peritoneal metastases

P1: Metastases to the adjacent peritoneum

P2: Few distant peritoneal metastases

P3: Numerous distant peritonial metastases

H Stage:

H0: No liver metastases

H1: Metastases limited to one lobe of the liver

H2: Few metastases to both lobes

H3: Numerous metastases to both lobes

S Stage:

S0: No serosal spread

S1: Limited serosal spread

S2: Gross serosal spread

S3: Invasion of surrounding structures

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anal cancer

Primary Tumor (T)

Tx Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor 2 cm or less in greatest dimension

T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension

T3 Tumor more than 5 cm in greatest dimension

T4 Tumor of any size invades adjacent organ(s), e.g., vagina, urethra, bladder (involvement of the sphincter muscle(s) alone is not classified as T4)

Regional Lymph Nodes (N)

Nx Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in perirectal lymph node(s)

N2 Metastasis in unilateral internal iliac and/or inguinal lymph nodes

N3 Metastasis in perirectal and inguinal lymph nodes and/or bilateral internal iliac and/or inguinal lymph nodes

Distant Metastasis (M)

Mx Distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis

Stage Grouping

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage II T2 N0 M0

T3 N0 M0

Stage IIIA T1 N1 M0

T2 N1 M0

T3 N1 M0

T4 N0 M0

Stage IIIB T4 N1 M0

Any T N2 M0

Any T N3 M0

Stage IV Any T Any N M1

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Staging of Colorectal Cancer