TNM Staging: Colon and Rectum
Tonya Brandenburg, MHA, CTR Kentucky Cancer Registry Overview Colorectal Anatomy Common Terms Rules for Colorectal Cancer
Changes in T,N,M Staging from AJCC 6th edition to 7th edition Elements of Staging: TX-T4, NX-N2b, andM0-M1b Stage Groups and Prognostic Factors Helpful Hints Colon/Rectal Examples C18.4 C18.3 C18.5 C18.2 C18.6 C18.0 C18.0 C18.1 C21.--- C18.7 C18.1 Not Shown: Rectosigmoid C20.9 C19.9 Anatomy of the Colon and Rectum
LEFT COLON Splenic Flexure (C18.5) Descending Colon(C18.6): cm fromanal verge Sigmoid Colon (C18.7): cm from verge Rectosigmoid (C19.9): cm from verge Rectum (C20.9): 4-16 cmfrom verge RIGHT COLON Appendix (C18.1) Cecum (C18.0): 150 cm from anal verge Ascending Colon (C18.2): cm from verge Hepatic Flexure (C18.3) Transverse Colon (C18.4): cm from verge Colon and Rectum Anatomic subsites of the rectum
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer Anatomic subsites of the rectum Common Terms . Circumferential margin Any aspect of thecolorectum that is not covered by a serosal layerand must be dissected from the retroperitoneum orsubperitoneum to remove the viscus. Familial polyposis, familial adenomatous polyposis(FAP) a condition characterized by thedevelopment of many adenomatous polyps, oftenseen in several members of the same family Polyp, adenoma These mean the same thing! Adenoma - A benign lesion composed of tubular orvillous structures showing intraepithelial neoplasia Non-Peritonealized Surface or Serosalized Area
Some colon surfaces have no serosa at the exteriorsurface (around the hollow organ) The serosa acts as barrier for tumors that begin oninside surface of the colon and invade down intothe mucosa and through the wall of the colon (theserosa) When there is no serosa you lose a natural barrierthat helps contain the colon cancer Non-Peritonealized Surfaces in Colon-Rectum: Rectum no serosa in rectum below peritonealreflection Descending Colon no serosa covering posteriorsurfaces Ascending Colon no serosa covering posteriorsurfaces Non-Peritonealized Surface or Serosalized Area
No Serosa Here Source:Clinical Anatomy for Medical Students, 5th Edition, Richard S. Snell.Little, Brown and Company, 1995. Rules for Colon/Rectal Cancer
Every individual site is a separate primary Use C18.8 for one lesion that overlaps two segments ofcolon where tumor point of origin cannot be determined Code C18.9 for multiple malignant adenomatous polyps ormalignant adenomatous polyposis coli in varioussegments. Tumor size must be 998; histology = 8220/3 or8221/3 Code C19.9 if one lesion overlaps the colon and rectumand point of origin cannot be determined If malignant polyp & frank malignancy in same segment ofcolon, code the frank malignancy Changes in T,N,M Staging for Colon/Rectum from 6th edition to 7th edition
Expansion of Stages II and III based onsurvival and relapse data that was notavailable for the 6th edition. Subdivision of T4, N1, and N2 M1 Also subdivided: M1a for a singlemetastatic site, M1b if multiplemetastatic sites TNM scheme for carcinoma only; GISTand Neuroendocrine tumors now havetheir own chapters Elements of Staging: TX, T0, and Tis
TX: Tumor not seen on films T0: No evidence of primary tumor (use whenyou have metastasis that is consistent withcolon/rectum primary, but no evidence of aprimary tumor can be found) Tis: Tis is confined to glandular basementmembrane or lamina propria with NO extentthrough muscularis mucosa Tumor in stalk of polyp is Tis if limited tolamina propria, but T1, T2, etc. if furtherinvasion is noted The terms tumor confined to lamina propria including intramucosal, invades lamina propria, and confined to andnot through the muscularis mucosae mean in-situ for AJCC staging, but not for behavior code and summary stage. Tumor confined to mucosa and invading lamina propria stage to localized disease in SS. Elements of Staging: T1, T2, and T3
T1: Tumor invades the submucosa T2: Tumor invades the muscularispropria T3: Invasion into subserosa, orthrough subserosa intopericolorectal tissues T1 tumor invades submucosal.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer T1 tumor invades submucosal. T2 tumor invades muscularis propria.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer T2 tumor invades muscularis propria. Compton, C. C. , Byrd, D. R. , et al. , Editors
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer T3 tumor invades through the muscularis propria into pericolorectaltissues. Compton, C. C. , Byrd, D. R. , et al. , Editors
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer Circumferential resection margin. T4a (left side) has perforated the visceral peritoneum. In contrast, T3;R2 (right side) shows macroscopic involvement of the circumferential resection margin of a non- peritonealized surface of the colorectum by tumor with gross disease remaining after surgical excision. Elements of Staging: T4 (T4a and T4b)
T4: Tumor directly invades otherorgans or structures, and/orperforates visceral peritoneum: T4a: tumor penetrates to thesurface of the visceral peritoneum T4b: tumor directly invades or isadherent to other organs orstructures Compton, C. C. , Byrd, D. R. , et al. , Editors
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer T4a tumor penetrates to the surface of the visceral peritoneum. The tumorperforates (penetrates) visceral peritoneum, as illustrated here. Compton, C. C. , Byrd, D. R. , et al. , Editors
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer T4a tumor perforates visceral peritoneum (shown with gross bowelperforation through the tumor). Compton, C. C. , Byrd, D. R. , et al. , Editors
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer T4b tumor directly invades or is adherent to other organs or structures, asillustrated here with extension into an adjacent loop of small bowel. Compton, C. C. , Byrd, D. R. , et al. , Editors
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer T4b tumor directly invades or is adherent to other organs or structures(such as the sacrum shown here). Compton, C. C. , Byrd, D. R. , et al. , Editors
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer The regional lymph nodes of the colon and rectum are colored byanatomic location, e.g., dark brown right colon and cecum;blue hepatic flexure to mid transverse colon; red splenicflexure, left colon and sigmoid colon. Lymphatic Drainage Each subsite of the colon has its own drainage system For all colon subsites, these include: Colic, NOS; Paracolic/ Pericolic. Right Colon Cecum and appendix: Cecal, anterior & posterior;ileocolic, right colic Ascending: Ileocolic, right colic, middlecolic Hepatic Flexure: Right colic, middle colic Transverse: Middle colic Left Colon Splenic flexure: Middle colic & left colic;inferior mesenteric Descending colon: Left colic, sigmoid, inferiormesenteric Sigmoid: Sigmoidal, superiorhemorrhoidal, superiorrectal, inferior mesenteric Satellite Nodules Satellite peritumoral nodule in the pericolorectaltissue of a primary carcinoma without histologicevidence of residual lymph node in the nodulemay represent discontinuous spread, venousinvasion with extravascular spread, or a totallyreplaced lymph node Replaced nodes should be counted separatelyas positive nodes in the N category Elements of Staging: NX, N0, N1a, and N1b
NX: Regional lymph nodes cant beassessed N0: No regional lymph node metastasis N1: Metastasis in 1-3 regional lymph nodes N1a: Metastasis in 1 regional lymphnode N1b: Metastasis in 2-3 regional lymphnodes N1a is defined as metastasis in one regional lymph node.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer N1a is defined as metastasis in one regional lymphnode. N1b is defined as metastasis in 2 to 3 regional lymph nodes.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer N1b is defined as metastasis in 2 to 3 regional lymphnodes. Elements of Staging: N1c
N1c: Tumor deposits in the subserosa, mesentery, ornon peritonealized pericolic or perirectal tissuesWITHOUT regional nodal metastasis Foci of tumor found in the pericolic or perirectalfat or in adjacent mesentery (mesocolic fat)away from the leading edge of the tumor andshowing no evidence of residual lymph nodetissue are classified as N1c If tumor nodules are seen in lesions that wouldotherwise be classified as T1 or T2, then theprimary tumor classification is not changed, butthe nodule is recorded as an N1c positive node. Elements of Staging: N2a and N2b
N2: Metastasis in four or more regionallymph nodes N2a: Metastasis in 4-6 regional lymphnodes N2b: Metastasis is 7 or more regionallymph nodes N2a is defined as metastasis in 4 to 6 regional lymph nodes.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer N2a is defined as metastasis in 4 to 6 regional lymph nodes. N2b is defined as metastasis in seven or more regional lymph nodes.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer N2b is defined as metastasis in seven or more regional lymphnodes. N2b showing nodal masses in more than 7 regional lymph nodes.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, American Joint Committee on Cancer N2b showing nodal masses in more than 7 regional lymph nodes. Elements of Staging: MX, M0, and M1
MX: No longer exists in TNM Staging M0: No distant metastasis (Remember: not possible forpathologic staging) M1: Distant Metastasis M1a: Metastasis confined to one organ or site M1b: Metastasis in more than one organ/site or theperitoneum Common metastatic sites include liver*, lungs, seeding ofother segments of the colon, small intestine, or peritoneum *Involvement of the liver is not considered distant metastasisif tumor has directly extended into the liver from the hepaticflexure or the right side of the transverse colon Stage Groups Prognostic Factors for Colon and Rectum
Preoperative or pretreatment carcinoembryonicantigen (CEA) Tumor deposits Circumferential resection margin (CRM) Perineural invasion Microsatellite instability Tumor regression grade (with neoadjuvanttherapy) KRAS gene analysis Note: None of these are required for staging. Theyare however, clinically significant Hints for Colorectal Cancer
Involvement of serosal surface is T4a Direct extension to certain organs (such asliver) from certain areas of colon (transverse,flexures, ascending, cecum) is T4b If T4 due to direct extent to abdominal organ& there is discontinuous metastasis there aswell, M1a or M1b also applies Tumor that is adherent to other organs orstructures grossly is classified T4b. If no tumoris present microscopically in the adhesion,then it is pT1-4a, depending upon depth ofwall invasion. Colon Case 1 Answers Topography: C18.5 Histology: 8263/3
This case is one primary per rule M2 Clinical Staging cT pTis cN cM Clinical Stage Group Pathological Staging pT 2 pN pM cM0 Pathologic Stage Group 1 SEER Summary Stage: 1 - Localized Rationale for staging choices The rule for carcinoma in-situ is pTis, N0, M0. Clinical stage would be 0. There is a technical advisory group composed of NPCR, SEER, CoC, and AJCC. They are trying to bridge the gap between what AJCC says to assign and uses to assign versus what an abstractor has to code in a registry.This isnt final yet and may only be a solution for 2016, but this will get us through until the 8th edition where they may want to approach it differently, but most software doesnt accommodate blanks. Tumor invading the superficial muscularis propria would be pT2, Lymph nodes negative = N0, No signs or symptoms of mets = M0 Colon Case 2 Answers Topography: C18.4 Histology: 8140/3
This case is one primary per rule M2 Clinical Staging cT X cN cM pM1a Clinical Stage Group IVA Pathological Staging pT 3 pN 2a pM 1b Pathologic Stage Group IVB SEER Summary Stage: 7 - Distant Rationale for staging choices Not enough info to assign clinical T or N, so TX, NX. M is based on supraclavicular ln bx which is pM1a. Clinical stage IVA. The critical thing to make something clinical or pathologic is not only the method obtained, but also the timing rules. For example if a scan is done after the first surgery, that is something clinic but is done after the first surgery.You can use a clinical M0 and M1 only if the criteria for pathological staging has been met. Tumor through muscularis propria and into pericolonic soft tissue = T3, 5 region ln involved = N2a, M1b bc of distant nodal mets and liver mets. Stage group IVB.