Staging of cancer defines prognosis, determines appropriate treatment, and allows comparison of outcomes across treatment centers. The TNM system classifies cancers by tumor size/extent (T), lymph node involvement (N), and metastasis (M). The AJCC collaborates with UICC to develop the TNM system. Staging requires input from multiple professionals and considers physical exam, imaging, and pathology results. Stage groupings (I-IV) provide prognostic information. Non-anatomic factors also provide prognostic data and predict therapy benefits.

1. STAGING OF
CANCER
DR ALLWIN GEORGE

2. Why staging
needed ?
• Defines prognosis
• Determining appropriate treatment based on the
experience and outcomes of groups of previous
patients with similar stage
• For clinical trials
• Evaluate the results of treatments and clinical
trials
• Facilitate the exchange and comparison of
information across treatment centers and within
and between cancer-specific registries, and to
serve as a basis for clinical and translational
cancer research
• Conveying clinical experience to others without
ambiguity

3. Staging system
• Tumor, Node, and
Metastasis (TNM) staging
system
• Most clinically useful staging
system
• Developed by the American
Joint Committee on Cancer
(AJCC) in collaboration with
the union for international
cancer control (UICC) (AJCC
TNM staging system)

4. AJCC TNM
CLASSIFICATION
• Classifies cancers by
• Size and extent of the
primary tumor (T)
• Involvement of
regional lymph nodes
(N)
• Presence or absence
of distant metastases
(M)
• Supplemented in
recent years by
evidence-based
prognostic and
predictive factors
• Exception - pediatric
cancers

5. Who assigns the stage of cancer in a patient?
• Staging requires the collaborative effort of many
professionals
• Managing physician,
• Pathologist - an accurate microscopic
diagnosis
• Radiologist,
• Cancer registrar,
• others.
• Pathologist and the radiologist
• provide important staging information, and
may provide important t-, n-, and/or m-related
information
• Stage is defined ultimately from the synthesis of
an array of patient history and physical
examination findings supplemented by imaging
and pathology data.
• Only the managing physician can assign the
patient's stage,
• he routinely has access to all the pertinent
information from physical examination,

6. Related
Publications
to Facilitate
Staging
• World Health Organization Classification of Tumours,
Pathology and Genetics
• WHO International Classification of Diseases for
Oncology (ICD-O), 3rd edition.
• American College of Radiology Appropriateness
Criteria®
• CAP Cancer Protocols. CAP publishes standards for
pathology reporting of cancer specimens for
• National Comprehensive Cancer Network Clinical
Practice Guidelines in Oncology (NCCN
Guidelines®).The National Comprehensive Cancer
Network (NCCN) provides practice guidelines for most
types of cancer
• American Society of Clinical Oncology (ASCO)
Guidelines. ASCO develops guidelines and technical
assessments for an array of clinical situations and
tools

7. Evolving use of
nonanatomic factors
• Nonanatomic cancer-
and host-related
factors
• Provide critical
prognostic
information
• May predict the
benefit of specific
therapies.
• Gleason score in
early-stage prostate
cancer
• Genomic profiles in
women with node-
negative breast
cancer

8. TNM Staging Classification
• Stage may be defined at several time points
• Clinical Classification (cTNM)
• Based on
• patient history, physical examination, and any imaging done before initiation of treatment.
• Should not be changed based on:
• subsequent information obtained from the pathological examination of resected tissue, or information
obtained after initiation of definitive therapy
• Pathological Classification (pTNM)
• Based on
• clinical stage information - supplemented/modified by operative findings and pathological evaluation of the
resected specimens
• Post-therapy or Post Neoadjuvant Therapy (ycTNM and ypTNM)
• Determined after treatment for patients receiving systemic and/or radiation therapy alone or as a component of
their initial treatment, or as neoadjuvant therapy before planned surgery
• Recurrence or Retreatment (rTNM)
• At the time of retreatment for a recurrence or disease progression
• Autopsy (aTNM)
• For cancers identified only at autopsy

9. AJCC Prognostic Stage
Groups
• T, N, and M are grouped
into prognostic stage
groups, commonly
referred to as stage
groups
• For the purposes of
tabulation and to
analyze the care of
patients who
generally have a
similar prognosis,
• Stage I, II, III, IV

10. ORAL CAVITY AJCC TNM STAGING AND
GROUPING

11. ORAL CAVITY
On Examination
Tumor size – 3 cm in left
buccal mucosa, not
invading adjacent
structures
Nodes – single 7 cm in left
neck (level 3)
No Metastasis
What is the TNM staging
and prognostic grouping?

12. c T2 N3a M0 -
prognostic group IV B

13. ORAL CAVITY
After NACT he underwent surgery , Post op HPE - Tumor size – 1 cm residual
disease, Nodes – absent What is the TNM staging ?

14. yp T1 N0 M0 - prognostic group 1

15. Elements of
TNM
• Classification
• • c: clinical
• • p: pathological
• • yc: post neoadjuvant
(radiation or systemic)
therapy—clinical
• • yp: post neoadjuvant
(radiation or systemic)
therapy—pathological
• • r: recurrence or retreatment
• • a: autopsy
• Category/ Subcategory
• T
• Tis, T1 mi, T1 a,
T1 b, T1 c
• N
• N2a, N2b
• M
• M1a, M1b

16. Elements of TNM
Category
• T-. N-. and M-specific data
are used to assign a cancer
site-specific T, N and M
category for a patient at a
given classification.
Eg :
• c T2 N1 M0
• ypT1N0M0
• aT1N0M0

17. Elements of
TNM
Subcategory - Examples:
• breast cancer: T lm i, T Ia , T lb , T Ic
• breast cancer: N2a, N2b
• prostate cancer: M Ia , M Ib,
Note: If there is uncertainty in
assigning a subcategory, the patient
is assigned to the general category

18. Category of
TNM
• T
• The size and/or contiguous
extension o f the primary tumor.
• The roles o f the size component
and the extent of contiguous
spread are specifically defined for
each cancer site.
• N
• Cancer in the regional lymph
nodes as defined for each cancer
site, including
• Absence or presence of cancer in
regional node(s), and/or
• Number of positive regional
nodes, and/or
• Involvement of specific regional
nodal groups, and/or
• Size of nodal metastasis or
extension through the regional
node capsule, and/or
• In-transit and satellite metastases,
somewhat unique manifestations
ofnonnodal intralymphatic
regional disease, usually found
between the primary tumorsite
and draining nodal basins.
• M
• The absence or
presence of distant
metastases in sites
and/or organs outside
the local tumor area
and regional nodes as
defined for each
cancer site

19. Category of TNM - T
• TX
• No information about the T category for
the primary tumor, or it is unknown or
cannot be Assessed
• T0
• No evidence o f a primary tumor
• Tis
• Carcinoma in situ
• T1,2,3,4
• Primary invasive tumor, for which a higher
category generally means
• an increasing size
• an increasing local extension, or
• both

20. Clinical TNM, c T –
COMPONENTS
• Synchronous primary tumors in
a single organ
• For multiple tumors in a
single organ,
• T is assigned to the
highest T category;
• The preferred
designation is: m suffix;
for example, pt3(m) NO
MO
• If the number o f
tumors is important:
suffix number of
tumors; eg, pt3(4) NO
MO
• Note: The (m) suffix applies to
multiple invasive cancers. It is
not applicable to multiple foci
of in situ cancer or a mixed
invasive and in situcancer.

21. c T - COMPONENTS • Direct extension of a
primary tumor into a
contiguous or adjacent
organ
• classified as part of the
tumor (T) classification
• not classified as
metastasis (M).
• Example
• Direct extension into the
liver from a primary colon
cancer –
• T category
• not in the M category.

22. Category of TNM
- N
• NX
• No information about the N category
for the Regional Lymph node, or it is
unknown or cannot be Assessed
• N0
• No Regional lymph node involvement
• N1,2,3,4
• Evidence of regional node(s)
containing cancer, with
• an increasing number, and/or
• regional nodal group
involvement, and/or
• size o f the nodal
metastaticcancer deposit, or
• non-nodal regional disease
asnoted earlier for melanomaand
Merkel cell carcinoma, and for
colorectal carcinoma

23. N- components
• N(sn) , N (f)
• If SLN biopsy is performed as part of the
diagnostic workup:
• the cN category should have the sn suffix; for
example, cNl(sn).
• If an FNA or a core biopsy is performed on lymph
nodes as part o f the diagnostic workup
• the cN category should have the f suffix for
example, cN 1 (f).
• N0(i+)
• ITCs - single tumor cells or small clusters of cells
<0.2 mm in greatest diameter, generally without
stromal response in the lymph node
• N0 (mol+)
• minimal deposits of cancer in lymph nodes
detected using Non-morphologic techniques,
including flow cytometry and reverse
transcriptase polymerase chain reaction studies,
• N(mi)
• 0.2 to 2 mm micrometastasis

24. Category of
TNM - M
•No evidence of distant
metastasis
M0
•Evidence of distant
metastasis
M1

25. M -
components
• M(i+)
• Patients with
• CTCs ( circulating tumor cells), or
• DTCs ( disseminated tumor cells)
in organs and micrometastasis
• In bone marrow, detected by IHC or
molecular techniques, are categorized
as cM0(i+).
• The cM0(i+) category denotes the
uncertain prognostic significance of
these findings.

26. Classification
of TNM –
Clinical TNM,
c TNM
Used for all patients with cancer identified before
treatment
It is composed of diagnostic workup information,
until first treatment, including:
• Clinical history and symptoms
• Physical examination
• Imaging
• Endoscopy
• Biopsy of the primary site
• Biopsy or excision o f a single regional node or sentinel nodes,
or sampling of regional nodes, with clinical T
• Biopsy of distant metastatic site
• Surgical exploration without resection
• Other relevant examinations

27. Classification of TNM –
Pathological TNM/pTNM
Used for patients if surgery is
the first definitive therapy
It is composed of information
from:
• Diagnostic workup from clinical staging
combined with
• Operative findings, and
• Pathology review o f resected surgical
specimens

28. Classification
of TNM – Post
therapy TNM/
post
neoadjuvant
TNM / yc
TNM, yp TNM
Neoadjuvant therapy is defined as systemic and/or
radiation therapy given before surgery;
Primary radiation and/or systemic therapy is treatment
given as definitive therapy without surgery.
yc
• Used for staging after primary systemic and/or radiation therapy. Or
after neoadjuvant therapy and before planned surgery
• Criteria: first therapy is systemic and/or radiation therapy
yp
• Used for staging after neoadjuvant therapy and planned post
neoadjuvant therapy surgery.
• Criteria: first therapy is systemic and/or radiation therapy and is
followed by surgery

29. Residual
Tumor and
Surgical
Margins
cTNM and pTNM may be supplemented by the R designation to
categorize the absence or presence of residual tumor status after
treatment
Rx
•Residual tumor cannot be assessed
R0
•No residual tumor
R1
•Microscopic residual tumor
R2
•Macroscopic residual tumor