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130 american joint committee on cancer 2010 introduction previous stage groupings of esophageal cancer were based on a simple, orderly arrangement of increasing ...
AMERICAN JOINT COMMITTEE ON CANCER
AJCC
CANCER STAGING
HANDBOOK
Seventh Edition
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American Joint Committee on Cancer
Executive Office
633 North Saint Clair Street
Chicago, IL 60611-3211
Editors
Stephen B. Edge,
M
.
D
.,
F
.
A
.
C
.
S
.
Roswell Park Cancer Institute
Buffalo, NY, USA
David R. Byrd,
M
.
D
.,
F
.
A
.
C
.
S
.
University of Washington
School of Medicine
Seattle, WA, USA
Carolyn C. Compton,
M
.
D
.,
P
h.
D
.
National Cancer Institute
Bethesda, MD, USA
April G. Fritz,
R
.
H
.
I
.
T
.,
C
.
T
.
R
.
A. Fritz and Associates
Reno, NV, USA
Frederick L. Greene,
M
.
D
.,
F
.
A
.
C
.
S
.
Carolinas Medical Center
Charlotte, NC, USA
Andy Trotti, III,
M
.
D
.
H. Lee Moffitt Cancer Center
Tampa, FL, USA
ISBN 978-0-387-88442-4
e-ISBN 978-0-387-88443-1
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2009930461
First to Fifth Editions of the
AJCC Cancer Staging Manual,
and the
AJCC Cancer Staging
Handbook,
published by Lippincott Raven Publishers, Philadelphia. PA.
Sixth Edition of the
AJCC Cancer Staging Handbook,
published by Springer-Verlag,
New York, NY.
Seventh Edition © 2010 American Joint Committee on Cancer. All rights reserved.
The
AJCC Cancer Staging Handbook
is the Official Publication of the American Joint
Committee on Cancer.
This book may not be translated or copied in whole or in part without the written permission
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Materials appearing in this book prepared by individuals as part of their official duties as
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The use in this publication of trade names, trademarks, service marks, and similar terms,
even if they are not identified as such, is not to be taken as an expression of opinion as to
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While the advice and information in this book are believed to be true and accurate at the date
of going to press, neither the authors nor the editors nor the publisher nor the AJCC can accept
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warranty, express or implied, with respect to the material contained therein.
Printed on acid-free paper
(Corrected at 5
th
printing 2010)
Springer is part of Springer Science+Business Media (www.springer.com)
5
Larynx
(Nonepithelial tumors such as those of lymphoid
tissue, soft tissue, bone, and cartilage are
not included)
At-A-Glance
SUMMARY OF CHANGES
●
T4 lesions have been divided into T4a (moderately advanced local disease)
and T4b (very advanced local disease), leading to the stratification of Stage
IV into Stage IVA (moderately advanced local/regional disease), Stage IVB
(very advanced local/regional disease), and Stage IVC (distant metastatic
disease)
ICD-O-3
TOPOGRAPHY
CODES
C10.1 Anterior
(lingual)
surface of
epiglottis
C32.0 Glottis
C32.1 Supraglottis
(laryngeal
surface)
C32.2 Subglottis
C32.8* Overlapping
lesion of larynx
C32.9* Larynx, NOS
* Stage by location of
tumor bulk
or epicenter
ICD-O-3 HISTOLOGY
CODE RANGES
8000–8576, 8940–8950,
8980–8981
5
ANATOMIC STAGE/PROGNOSTIC GROUPS
Stage 0
Stage I
Stage II
Stage III
Tis
T1
T2
T3
T1
T2
T3
T4a
T4a
T1
T2
T3
T4a
T4b
Any T
Any T
N0
N0
N0
N0
N1
N1
N1
N0
N1
N2
N2
N2
N2
Any N
N3
Any N
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M1
Stage IVA
Stage IVB
Stage IVC
ANATOMY
Primary Site.
The following anatomic definition of the larynx allows
classification of carcinomas arising in the encompassed mucous membranes
but excludes cancers arising on the lateral or posterior pharyngeal wall,
pyriform fossa, postcricoid area, or base of tongue.
Larynx
81
9
Mucosal Melanoma of the
Head and Neck
At-A-Glance
SUMMARY OF CHANGES
●
This is a new chapter for classification of this rare tumor
ICD-O-3
TOPOGRAPHY
CODES
For a complete
description of codes,
refer to the appropriate
anatomic site chapter
based on the location of
the mucosal melanoma
(see Chapters 3–6)
ANATOMIC STAGE/PROGNOSTIC GROUPS
Stage III
Stage IVA
Stage IVB
Stage IVC
T3
T4a
T3–T4a
T4b
Any T
N0
N0
N1
Any N
Any N
M0
M0
M0
M0
M1
Additionally, mucosal
melanomas are staged
for the following
topography codes;
however, no staging
exists for nonmucosal
melanoma in the same
anatomic site:
C14.0 Pharynx, NOS
C14.2 Waldeyer’s
ring
C14.8 Overlapping
lesion of lip,
oral cavity and
pharynx
The following topography codes are excluded:
C07.9 Parotid gland
C30.1 Middle ear
C08.0 Submandibular gland
C73.9 Thyroid
C08.1 Sublingual gland
C08.8 Overlapping lesion of major
ICD-O-3 HISTOLOGY CODE
RANGES
salivary glands
C08.9 Major salivary glands, NOS 8720–8790
9
Mucosal Melanoma of the Head and Neck
123
ANATOMIC STAGE/PROGNOSTIC GROUPS
CONTINUED
C16.2
Adenocarcinoma
Stage T
N
0
IA
IB
IIA
IIB
IIIA
Tis (HGD) N0
T1
T1
T2
T2
T3
T1–2
T1–2
T3
T4a
T3
T4a
T4b
Any
Any
N0
N0
N0
N0
N0
N1
N2
N1
N0
N2
Body of
stomach,
proximal 5 cm
only*
M Grade
M0 1, X
M0 1–2, X
M0 3
M0 1–2, X
M0 3
M0 Any
M0 Any
M0 Any
M0 Any
M0 Any
M0 Any
*Note: If gastric tumor
extends to or above
esophagogastric
junction.
ICD-O-3 HISTOLOGY
CODE RANGES
8000–8576, 8940–8950,
8980–8981 (C15 only)
8000–8152, 8154–8231,
8243–8245, 8247–8248,
8250–8576, 8940–8950,
8980–8981 (C16 only)
IIIB
IIIC
N1–2 M0 Any
Any M0 Any
N3 M0 Any
Any M1 Any
IV
INTRODUCTION
Previous stage groupings of esophageal cancer were based on a simple,
orderly arrangement of increasing pathologic anatomic T, then N, and then
M classifications. In contrast, this revision is data driven, based on a risk-
adjusted random-survival-forest analysis of worldwide data. The previous
system was neither consistent with these data nor biologically plausible.
Some explanations for the discrepancy relate to the interplay among T,
N, and M, histopathologic type, biologic activity of the tumor (histologic
grade), and location.
The unique lymphatic anatomy of the esophagus links N to T, permit-
ting lymph node metastases from superficial cancers (pT1); this renders
prognosis similar to that of more advanced (higher pT) N0 cancers. Simi-
larly, advanced cancers (higher pT) with a few positive nodes may have a
similar prognosis to those of less advanced cancers (lower pT) with more
positive nodes. Biologic activity of the cancer, reflected by histologic grade
(G), modulates stage such that prognosis of well-differentiated (G1) higher-
pT cancers is similar to that of less well-differentiated (G2–G4) lower-pT
cancers. Previous staging recommendations ignored histopathologic
type, but availability of data on a large mixture of adenocarcinoma and
squamous cell carcinomas from around the world has permitted assessing
the association of histopathologic type with survival.
Although at first glance these multiple trade-offs seem to create a
less orderly arrangement of cancer classifications within and among stage
130
American Joint Committee on Cancer • 2010
ANATOMIC STAGE/PROGNOSTIC GROUPS
CONTINUED
C16.6
Stage IIIB
T4b
T4b
T4a
T3
T4b
T4b
T4a
Any T
N0
N1
N2
N3
N2
N3
N3
Any N
M0
M0
M0
M0
M0
M0
M0
M1
C16.8
C16.9
Greater
curvature of
stomach, NOS
Overlapping
lesion of
stomach
Stomach, NOS
Stage IIIC
Stage IV
ICD-O-3 HISTOLOGY
CODE RANGES
8000–8152, 8154–8231,
8243–8245, 8247–8248,
8250–8576, 8940–8950,
8980–8990
INTRODUCTION
Gastric cancer remains the fourth most common cancer worldwide and the
second leading cause of cancer deaths (700,000 deaths annually worldwide).
The highest rates of this disease continue to be in areas of Asia and Eastern
Europe. Although gastric adenocarcinoma has declined significantly in the
USA over the past 70 years, during the early twenty-first century an estimated
22,000 patients develop the disease each year, and of these patients, 13,000
will die, mainly because of nodal and metastatic disease present at the time
of initial diagnosis. Trends in survival rates from the 1970s to the 1990s have
unfortunately shown very little improvement. During the 1990s, 20% of
gastric carcinoma cases were diagnosed while localized to the gastric wall,
whereas 30% had evidence of regional nodal disease. Disease resulting from
metastasis to other solid organs within the abdomen, as well as to extraab-
dominal sites, represents 35% of all cases. Although overall 5-year survival
is approximately 15–20%, the 5-year survival is approximately 55% when
disease is localized to the stomach (Figure 11.1). The involvement of regional
nodes reduces the 5-year survival to approximately 20%.
A notable shift in the site of gastric cancer reflects a proportionate
increase in disease of the proximal stomach over the past several decades.
Previously, there was a predominance of distal gastric cancers presenting
as mass lesions or ulceration. Although other malignancies occur in the
stomach, approximately 90% of all gastric neoplasms are adenocarcino-
mas. Tumors of the esophagogastric junction (EGJ) may be difficult to
stage as either a gastric or an esophageal primary, especially in view of the
increased incidence of adenocarcinoma in the esophagus that presumably
results from acid reflux disease.
ANATOMY
Primary Site.
The stomach is the first division of the abdominal portion of
the alimentary tract, beginning at the esophagogastric junction and extend-
ing to the pylorus. The proximal stomach is located immediately below
the diaphragm and is termed the cardia. The remaining portions are the
146
American Joint Committee on Cancer • 2010
12
Small Intestine
(Lymphomas, carcinoid tumors, and visceral
sarcomas are not included)
At-A-Glance
SUMMARY OF CHANGES
●
T1 lesions have been divided into T1a (invasion of lamina propria) and
T1b (invasion of submucosa) to facilitate comparison with tumors of other
gastrointestinal sites
Stage II has been subdivided into Stage IIA and Stage IIB
The N1 category has been changed to N1 (1–3 positive lymph nodes) and
N2 (four or more positive lymph nodes), leading to the division of Stage III
into Stage IIIA and Stage IIIB
ICD-O-3
TOPOGRAPHY
CODES
C17.0 Duodenum
C17.1 Jejunum
C17.2 Ileum
C17.8 Overlapping
lesion of small
intestine
C17.9 Small
intestine, NOS
ICD-O-3 HISTOLOGY
CODE RANGES
8000–8152, 8154–8231,
8243–8245, 8247–8248,
8250–8576, 8940–8950,
8980–8981
●
●
ANATOMIC STAGE/PROGNOSTIC GROUPS
Stage 0
Stage I
Stage IIA
Stage IIB
Stage IIIA
Stage IIIB
Stage IV
Tis
T1
T2
T3
T4
Any T
Any T
Any T
N0
N0
N0
N0
N0
N1
N2
Any N
M0
M0
M0
M0
M0
M0
M0
M1
INTRODUCTION
Although the small intestine accounts for one of the largest surface areas
in the human body, it is one of the least common cancer sites in the diges-
tive system, accounting for less than 2% of all malignant tumors of the
gastrointestinal tract. A variety of tumors occur in the small intestine, with
approximately 25–50% of the primary malignant tumors being adeno-
carcinomas, depending upon the population surveyed. At the beginning of
the twenty-first century, approximately 5,600 new cases of cancer involving
the small intestine are seen annually in the USA. The 1,100 deaths predicted
Small Intestine
12
153
ANATOMIC STAGE/PROGNOSTIC GROUPS
Stage T
0
I
IIA
IIB
IIC
Tis
T1
T2
T3
T4a
T4b
N
N0
N0
N0
N0
N0
N0
M
Dukes* MAC*
–
A
B1
B2
B2
B3
C1
C1
C2
C1/C2
C1
C2
C2
C3
–
–
M0 –
M0 A
M0 A
M0 B
M0 B
M0 B
IIIA T1–T2 N1/N1c M0 C
T1
N2a
M0 C
IIIB T3–T4a N1/N1c M0 C
T2–T3 N2a
M0 C
T1–T2 N2b
M0 C
IIIC T4a
N2a
M0 C
T3–T4a N2b
M0 C
T4b
N1–N2 M0 C
IVA
Any T
Any N
Any N
M1a –
M1b –
IVB Any T
ICD-O-3
TOPOGRAPHY
CODES
C18.0 Cecum
C18.2 Ascending
colon
C18.3 Hepatic flexure
of colon
C18.4 Transverse
colon
C18.5 Splenic flexure
of colon
C18.6 Descending
colon
C18.7 Sigmoid colon
C18.8 Overlapping
lesion of colon
C18.9 Colon, NOS
C19.9 Rectosigmoid
junction
C20.9 Rectum, NOS
ICD-O-3 HISTOLOGY
CODE RANGES
8000–8152, 8154–8231,
8243–8245, 8247–8248,
8250–8576, 8940–8950,
8980–8981
Note
: cTNM is the clinical classification, pTNM is the
pathologic classification. The y prefix is used for those
cancers that are classified after neoadjuvant pretreat-
ment (e.g., ypTNM). Patients who have a complete
pathologic response are ypT0N0cM0 that may be
similar to Stage Group 0 or I. The r prefix is to be used
for those cancers that have recurred after a disease-free
interval (rTNM).
*Dukes B is a composite of better (T3 N0 M0) and
worse (T4 N0 M0) prognostic groups, as is Dukes C
(Any TN1 M0 and Any T N2 M0). MAC is the modi-
fied Astler-Coller classification.
INTRODUCTION
The TNM classification for carcinomas of the colon and rectum provides
more detail than other staging systems. Compatible with the Dukes’ sys-
tem, the TNM adds greater precision in the identification of prognostic
subgroups. TNM staging is based on the depth of tumor invasion into
or beyond the wall of the colorectum (T), invasion of or adherence to
adjacent organs or structures (T), the number of regional lymph nodes
involved (N), and the presence or absence of distant metastasis (M). The
TNM classification applies to both clinical and pathologic staging. Most
cancers of the colon and many cancers of the rectum are staged after
pathologic examination of a resected specimen. However, patients with
174
American Joint Committee on Cancer • 2010
specimens of ascending colon, descending colon, or upper rectum is only
partially peritonealized, and the demarcation between the peritonealized
surface and the nonperitonealized surface (corresponding to the CRM) of
such specimens is not always easily appreciated on pathologic examination.
Therefore, the surgeon is encouraged to mark the peritoneal reflection and/
or the area of deepest tumor penetration adjacent to a nonperitonealized
surface with a clip or suture so that the pathologist may accurately identify
and evaluate the CRM.
For mid and distal rectal cancers (subperitoneal location), the entire sur-
face of the resection specimen corresponds to a CRM (anterior, posterior,
medial, lateral). For proximal rectal or retroperitoneal colon cancers (ascend-
ing, descending, possibly cecum), surgically dissected margins will include
those that lie in a retroperitoneal or subperitoneal location as described
above (Figure 14.3). For segments of the colon that are entirely covered by
a visceral peritoneum (transverse, sigmoid, possibly cecum), the only speci-
men margin that is surgically dissected is the mesenteric margin, unless the
cancer is adherent to or invading an adjacent organ or structure. Therefore,
for cancers of the cecum, transverse or sigmoid colon that extends to the cut
edge of the mesentery, assignment of a positive CRM is appropriate.
For rectal cancer, the quality of the surgical technique is likely a key
factor in the success of surgical outcomes relative to local recurrence and
possibly long-term survival. Numerous nonrandomized studies have dem-
onstrated that total mesorectal excision (TME) with adequate surgical
clearance around the penetrating edge of the tumor decreases the rate of
local relapse. The TME technique entails precise sharp dissection within
the areolar plane of loose connective tissue outside (lateral to) the visceral
mesorectal fascia in order to remove the rectum. With this approach, all
mesorectal soft tissues encasing the rectum, which includes the mesentery
14
FIGURE 14.3.
Circumferential resection margin.
Colon and Rectum
193
15
FIGURE 15.1.
Anatomic subsites of the anal canal.
Determination of the anatomic site of origin of carcinomas that over-
lap the anorectal junction may be problematic. For staging purposes, such
tumors should be classified as rectal cancers if their epicenter is located
more than 2 cm proximal to the dentate line or proximal to the anorectal
ring on digital examination and as anal canal cancers if their epicenter is
2 cm or less from the dentate line. For rectal cancers that extend beyond
the dentate line, as for anal canal cancers, the superficial inguinal lymph
nodes are among the regional nodal groups at risk of metastatic spread and
included in cN/pN analysis (see later).
Regional Lymph Nodes.
Lymphatic drainage and nodal involvement of
anal cancers depend on the location of the primary tumor. Tumors above
the dentate line spread primarily to the anorectal, perirectal, and paraverte-
bral nodes, whereas tumors below the dentate line spread primarily to the
superficial inguinal nodes.
The regional lymph nodes are as follows (Figure 15.2):
Perirectal
Anorectal
Perirectal
Lateral sacral
Internal iliac (hypogastric)
Inguinal
Superficial
All other nodal groups represent sites of distant metastasis.
Metastatic Sites.
Cancers of the anus may metastasize to any organs, but
the liver and lungs are the distal organs that are most frequently involved.
Involvement of the abdominal cavity is not unusual.
Anus
209
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