Colon Cancer Staging
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The American Joint Committee on Cancer (AJCC) tumor/node/metastasis (TNM) classification and staging system for colon cancer are provided below. [1, 2]
See Benign or Malignant: Can You Identify These Colonic Lesions?, a Critical Images slideshow, to help identify the features of benign lesions as well as those with malignant potential.
Table 1. TNM Classification for Colon Cancer (Open Table in a new window)
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ: intraepithelial or or intramucosal carcinoma (involvement of lamina propria with no extension through the muscularis mucosa)
T1
Tumor invades submucosa (through the muscularis mucosa but not into the muscularis propria)
T2
Tumor invades muscularis propria
T3
Tumor invades through the muscularis propria into the pericolorectal tissues
T4
Tumor invades the visceral peritoneum or invades or adheres to adjacent organ or structure
T4a
Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
T4b
Tumor directly invades or is adherent to other organs or structures
Regional lymph nodes (N)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastasis in 1-3 regional lymph nodes (tumor in lymph nodes measuring ≥0.2 mm) or any number of tumor deposits are present and all identifiable nodes are negative
N1a
Metastasis in 1 regional lymph node
N1b
Metastasis in 2-3 regional lymph nodes
N1c
Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized, pericolic, or perirectal/mesorectal tissues without regional nodal metastasis
N2
Metastasis in 4 or more lymph nodes
N2a
Metastasis in 4-6 regional lymph nodes
N2b
Metastasis in 7 or more regional lymph nodes
Distant metastasis (M)
M0
No distant metastasis by imaging or other studies, no evidence of tumor in distant sites or organs. (This category is not assigned by pathologists.)
M1
Metastasis to one or more distant sites or organs or peritoneal metastasis
M1a
Metastasis confined to 1 organ or site (eg, liver, lung, ovary, nonregional node) without peritoneal metastasis
M1b
Metastasis to two or more sites or organs without peritoneal metastasis
M1c
Metastasis to the peritoneal surface alone or with other site or organ metastases
Table 2. Anatomic stage/prognostic groups (Open Table in a new window)
Stage
T
N
M
Dukes
MAC
0
Tis
N0
M0
—
—
I
T1
N0
M0
A
A
T2
N0
M0
A
B1
IIA
T3
N0
M0
B
B2
IIB
T4a
N0
M0
B
B2
IIC
T4b
N0
M0
B
B3
IIIA
T1-T2
N1/N1c
M0
C
C1
T1
N2a
M0
C
C1
IIIB
T3-T4a
N1/N1c
M0
C
C2
T2-T3
N2a
M0
C
C1/C2
T1-T2
N2b
M0
C
C1
IIIC
T4a
N2a
M0
C
C2
T3-T4a
N2b
M0
C
C2
T4b
N1-N2
M0
C
C3
IVA
Any T
Any N
M1a
—
—
IVB
IVC
Any T
Any T
Any N
Any T
M1b
M1c
—
—
Staging information
Compared with the 7th edition of the AJCC staging manual, features of revised staging in the 8th edition give more importance to the poor prognostic features of depth of invasion in spite of fewer positive nodes.
T4 is divided between penetration to surface of visceral peritoneum and direct gross adherence to adjacent structures
T1-2N2 is downstaged from stage IIIC to IIIA or IIIB, depending on the number of nodes involved
Shift T4bN1 from IIIB to IIIC
Subdivide T4/N1/N2
Resolution of staging for issue of mesenteric deposits where nodal tissue is not identified
Revised substaging of stage II based on depth of invasion, with addition of stage IIC
Revised substaging of stage III based on node number (N1a—1 node; N1b—2-3 nodes; N2a—4-6 nodes; N2b—7 or more nodes)
Division of metastases to 1 or more sites in recognition of possibility of cure with aggressive treatment of single site of metastatic disease
Stage M1c has been introduced to represent the poor prognosis of peritoneal carcinomatosis.
Nodal micrometastases (tumor clusters ≥0.2 mm in diameter) are now scored as positive due to results of meta-analysis demonstrating poor prognosis in these patients. [3]
Other tumor deposits in peritoneum, subserosa, and mesentery are given equal weight as nodal metastases.
The following factors are important in determining treatment decisions but are not yet incorporated into the formal staging criteria:
A preoperative serum carcinoembryonic antigen(CEA) levels
Tumor regression score reflective of pathologic response to preoperative chemotherapy, chemoradiotherapy, radiotherapy, or chemobiologic therapy as well as status of circumferential margin for rectal cancer.
Lymphovascular and perineural invasion
Microsatellite instability (MSI), which represents deficiency of mismatch repair enzymes and is both a progostic factor and predictive of lack of response to fluoropyrimidine therapy in the adjuvant setting.
Mutation status of KRAS, NRAS, and BRAF, because mutations in those genes are associated with lack of response to agents targeting epidermal growth factor receptors.
[Guideline] NCCN Clinical Practice Guidelines in Oncology: Colon Cancer. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf. Version 2.2017 — March 13, 2017; Accessed: January 9, 2018.
American Joint Committee on Cancer. Colon and Rectum. Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, et al, eds. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2016.
Sloothaak DA, Sahami S, van der Zaag-Loonen HJ, van der Zaag ES, Tanis PJ, Bemelman WA, et al. The prognostic value of micrometastases and isolated tumour cells in histologically negative lymph nodes of patients with colorectal cancer: a systematic review and meta-analysis. Eur J Surg Oncol. 2014 Mar. 40 (3):263-9. [Medline].
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ: intraepithelial or or intramucosal carcinoma (involvement of lamina propria with no extension through the muscularis mucosa)
T1
Tumor invades submucosa (through the muscularis mucosa but not into the muscularis propria)
T2
Tumor invades muscularis propria
T3
Tumor invades through the muscularis propria into the pericolorectal tissues
T4
Tumor invades the visceral peritoneum or invades or adheres to adjacent organ or structure
T4a
Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
T4b
Tumor directly invades or is adherent to other organs or structures
Regional lymph nodes (N)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastasis in 1-3 regional lymph nodes (tumor in lymph nodes measuring ≥0.2 mm) or any number of tumor deposits are present and all identifiable nodes are negative
N1a
Metastasis in 1 regional lymph node
N1b
Metastasis in 2-3 regional lymph nodes
N1c
Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized, pericolic, or perirectal/mesorectal tissues without regional nodal metastasis
N2
Metastasis in 4 or more lymph nodes
N2a
Metastasis in 4-6 regional lymph nodes
N2b
Metastasis in 7 or more regional lymph nodes
Distant metastasis (M)
M0
No distant metastasis by imaging or other studies, no evidence of tumor in distant sites or organs. (This category is not assigned by pathologists.)
M1
Metastasis to one or more distant sites or organs or peritoneal metastasis
M1a
Metastasis confined to 1 organ or site (eg, liver, lung, ovary, nonregional node) without peritoneal metastasis
M1b
Metastasis to two or more sites or organs without peritoneal metastasis
M1c
Metastasis to the peritoneal surface alone or with other site or organ metastases
Stage
T
N
M
Dukes
MAC
0
Tis
N0
M0
—
—
I
T1
N0
M0
A
A
T2
N0
M0
A
B1
IIA
T3
N0
M0
B
B2
IIB
T4a
N0
M0
B
B2
IIC
T4b
N0
M0
B
B3
IIIA
T1-T2
N1/N1c
M0
C
C1
T1
N2a
M0
C
C1
IIIB
T3-T4a
N1/N1c
M0
C
C2
T2-T3
N2a
M0
C
C1/C2
T1-T2
N2b
M0
C
C1
IIIC
T4a
N2a
M0
C
C2
T3-T4a
N2b
M0
C
C2
T4b
N1-N2
M0
C
C3
IVA
Any T
Any N
M1a
—
—
IVB
IVC
Any T
Any T
Any N
Any T
M1b
M1c
—
—
Lewis J Rose, MD Clinical Associate Professor of Medical Oncology, Division of Regional Cancer Care, Kimmel Cancer Center, Thomas Jefferson University Hospital; Consulting Staff, LRCRZ Associates
Lewis J Rose, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Hematology, Pennsylvania Medical Society, Phi Beta Kappa, Philadelphia County Medical Society
Disclosure: Nothing to disclose.
Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Christopher D Braden, DO Hematologist/Oncologist, Chancellor Center for Oncology at Deaconess Hospital; Medical Director, Deaconess Hospital Outpatient Infusion Centers; Chairman, Deaconess Hospital Cancer Committee
Christopher D Braden, DO is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology
Disclosure: Nothing to disclose.
N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center
N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, Surgical Infection Society
Disclosure: Nothing to disclose.
Colon Cancer Staging
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