Transcript TNM Staging: Colon and Rectum

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, and
M0-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
C18.7
C18.1
C21.---
C20.9
Not Shown:
Rectosigmoid
C19.9
Anatomy of the Colon
and Rectum
RIGHT COLON
Appendix (C18.1)
Cecum (C18.0): 150 cm
from anal verge
Ascending Colon (C18.2):
132-150 cm from verge
Hepatic Flexure (C18.3)
Transverse Colon
(C18.4): 82-132 cm
from verge
LEFT COLON
Splenic Flexure (C18.5)
Descending Colon
(C18.6): 57-82 cm from
anal verge
Sigmoid Colon (C18.7):17-57
cm from verge
Rectosigmoid (C19.9): 1517 cm from verge
Rectum (C20.9): 4-16 cm
from verge
Colon and Rectum
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
Anatomic subsites of the rectum
Common Terms
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
.
Circumferential margin – Any aspect of the
colorectum that is not covered by a serosal layer
and must be dissected from the retroperitoneum or
subperitoneum to remove the viscus.
Familial polyposis, familial adenomatous polyposis
(FAP) a condition characterized by the
development of many adenomatous polyps, often
seen in several members of the same family
Polyp, adenoma – These mean the same thing!
Adenoma - A benign lesion composed of tubular or
villous structures showing intraepithelial neoplasia
Non-Peritonealized Surface
or Serosalized Area
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


Some colon surfaces have no serosa at the exterior
surface (around the hollow organ)
The serosa acts as barrier for tumors that begin on
inside surface of the colon and invade down into
the mucosa and through the wall of the colon (the
serosa)
When there is no serosa – you lose a natural barrier
that helps contain the colon cancer
Non-Peritonealized Surfaces in Colon-Rectum:

Rectum – no serosa in rectum below peritoneal
reflection

Descending Colon – no serosa covering posterior
surfaces

Ascending Colon – no serosa covering posterior
surfaces
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 of
colon where tumor point of origin cannot be determined

Code C18.9 for multiple malignant adenomatous polyps or
malignant adenomatous polyposis coli in various
segments. Tumor size must be 998; histology = 8220/3 or
8221/3

Code C19.9 if one lesion overlaps the colon and rectum
and point of origin cannot be determined

If malignant polyp & frank malignancy in same segment of
colon, 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 on
survival and relapse data that was not
available for the 6th edition.

Subdivision of T4, N1, and N2

M1 Also subdivided: M1a for a single
metastatic site, M1b if multiple
metastatic sites
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TNM scheme for carcinoma only; GIST
and Neuroendocrine tumors now have
their own chapters
Elements of Staging: TX,
T0, and Tis
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TX: Tumor not seen on films
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T0: No evidence of primary tumor (use when
you have metastasis that is consistent with
colon/rectum primary, but no evidence of a
primary tumor can be found)
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Tis: Tis is confined to glandular basement
membrane or lamina propria with NO extent
through muscularis mucosa

Tumor in stalk of polyp is Tis if limited to
lamina propria, but T1, T2, etc. if further
invasion is noted
Elements of Staging: T1, T2,
and T3
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T1: Tumor invades the submucosa

T2: Tumor invades the muscularis
propria

T3: Invasion into subserosa, or
through subserosa into
pericolorectal tissues
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T1 tumor invades submucosal.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T2 tumor invades muscularis propria.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T3 tumor invades through the muscularis propria into pericolorectal
tissues.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©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 nonperitonealized surface of the colorectum by tumor with gross disease remaining after
surgical excision.
Elements of Staging: T4
(T4a and T4b)

T4: Tumor directly invades other
organs or structures, and/or
perforates visceral peritoneum:

T4a: tumor penetrates to the
surface of the visceral peritoneum

T4b: tumor directly invades or is
adherent to other organs or
structures
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T4a tumor penetrates to the surface of the visceral peritoneum. The tumor
perforates (penetrates) visceral peritoneum, as illustrated here.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T4a tumor perforates visceral peritoneum (shown with gross bowel
perforation through the tumor).
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
T4b tumor directly invades or is adherent to other organs or structures, as
illustrated here with extension into an adjacent loop of small bowel.
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©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. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
The regional lymph nodes of the colon and rectum are colored by
anatomic location, e.g., dark brown – right colon and cecum;
blue – hepatic flexure to mid transverse colon; red – splenic
flexure, left colon and sigmoid colon.
Lymphatic Drainage

Each subsite of the colon has its own drainage system
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For all colon subsites, these include: Colic, NOS;
Paracolic/ Pericolic.
Right Colon
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Cecum and appendix:
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Right colic, middle colic
Transverse:
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Middle colic
Splenic flexure:
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Ileocolic, right colic, middle
colic
Hepatic Flexure:
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Cecal, anterior & posterior;
ileocolic, right colic
Ascending:

Left Colon
Descending colon:
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
Middle colic & left colic;
inferior mesenteric
Left colic, sigmoid, inferior
mesenteric
Sigmoid:

Sigmoidal, superior
hemorrhoidal, superior
rectal, inferior mesenteric
Satellite Nodules
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Satellite peritumoral nodule in the pericolorectal
tissue of a primary carcinoma without histologic
evidence of residual lymph node in the nodule
may represent discontinuous spread, venous
invasion with extravascular spread, or a totally
replaced lymph node

Replaced nodes should be counted separately
as positive nodes in the N category
Elements of Staging: NX,
N0, N1a, and N1b
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NX: Regional lymph nodes can’t be
assessed
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N0: No regional lymph node metastasis
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N1: Metastasis in 1-3 regional lymph nodes
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N1a: Metastasis in 1 regional lymph
node
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N1b: Metastasis in 2-3 regional lymph
nodes
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
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, 2012. ©American Joint Committee on
Cancer
N1b is defined as metastasis in 2 to 3 regional lymph
nodes.
Elements of Staging:
N1c

N1c: Tumor deposits in the subserosa, mesentery, or
non peritonealized pericolic or perirectal tissues
WITHOUT regional nodal metastasis

Foci of tumor found in the pericolic or perirectal
fat or in adjacent mesentery (mesocolic fat)
away from the leading edge of the tumor and
showing no evidence of residual lymph node
tissue are classified as N1c

If tumor nodules are seen in lesions that would
otherwise be classified as T1 or T2, then the
primary tumor classification is not changed, but
the nodule is recorded as an N1c positive node.
Elements of Staging: N2a
and N2b
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N2: Metastasis in four or more regional
lymph nodes
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N2a: Metastasis in 4-6 regional lymph
nodes

N2b: Metastasis is 7 or more regional
lymph nodes
Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,
2nd Edition. New York: Springer, 2012. ©American Joint Committee on
Cancer
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, 2012. ©American Joint Committee on
Cancer
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, 2012. ©American Joint Committee on
Cancer
N2b showing nodal masses in more than 7 regional lymph nodes.
Elements of Staging: MX,
M0, and M1
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MX: No longer exists in TNM Staging
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M0: No distant metastasis (Remember: not possible for
pathologic staging)
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M1: Distant Metastasis
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M1a: Metastasis confined to one organ or site
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M1b: Metastasis in more than one organ/site or the
peritoneum
Common metastatic sites include liver*, lungs, seeding of
other segments of the colon, small intestine, or peritoneum

*Involvement of the liver is not considered distant metastasis
if tumor has directly extended into the liver from the hepatic
flexure or the right side of the transverse colon
Stage Groups
Prognostic Factors for
Colon and Rectum
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Preoperative or pretreatment carcinoembryonic
antigen (CEA)
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Tumor deposits
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Circumferential resection margin (CRM)
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Perineural invasion
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Microsatellite instability
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Tumor regression grade (with neoadjuvant
therapy)
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KRAS gene analysis
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Note: None of these are required for staging. They
are however, clinically significant
Hints for Colorectal
Cancer
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Involvement of serosal surface is T4a

Direct extension to certain organs (such as
liver) from certain areas of colon (transverse,
flexures, ascending, cecum) is T4b
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If T4 due to direct extent to abdominal organ
& there is discontinuous metastasis there as
well, M1a or M1b also applies

Tumor that is adherent to other organs or
structures grossly is classified T4b. If no tumor
is present microscopically in the adhesion,
then it is pT1-4a, depending upon depth of
wall invasion.
Colon Case 1 Answers
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Topography: C18.5
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Histology: 8263/3
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This case is one primary per rule M2
Clinical Staging
Pathological Staging
cT
pTis
pT
2
cN
0
pN
0
cM
0
pM
cM0
Clinical Stage
Group
0
Pathologic Stage 1
Group
SEER Summary Stage: 1 - Localized
Colon Case 2 Answers

Topography: C18.4
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Histology: 8140/3

This case is one primary per rule M2
Clinical Staging
Pathological Staging
cT
X
pT
3
cN
X
pN
2a
cM
pM1a
pM
1b
Clinical Stage
Group
IVA
Pathologic Stage IVB
Group
SEER Summary Stage: 7 - Distant