0306~301617910701L1013/$02
l Current Concepts
00/O
in Cancer
STAGING HOWARD
CLASSIFICATIONS ULFELDER,
M.D.
Joe V. Meigs Professor of Gynecology, Emeritus, Harvard Medical School and Deputy to the Director for Cancer Affairs, Massachusetts General Hospital, Boston, MA 02114, U.S.A. Gynecologic
tumors,
Staging systems:
TNM, FIGO, UICC
The staging of tumors at the time of diagnosis is a refinement of our efforts to evaluate the success of treatment. It permits valid comparisons and in order to do this it must be simple, easily understood, and universally reproducible. The necessity for subdividing tumors of a specific category according to their extent became apparent when physicians reporting their case studies as series noticed that some clinics saw and treated patients with much more advanced disease than others did, which made comparison quite impossible. Therefore, in 1929 the Cancer Commission of the League of Nations Health Organization adopted a set of rules for the allocation to stages of carcinoma of the cervix-rules designed to facilitate the presentation of exact and comparable therapeutic statistics. Annual reports of the results of treatment at collaborating institutions were begun in 1937; in 1968 the International Federation of Gynecology and Obstetrics (FIGO) assumed the patronage and editorial responsibility of the Report. At present, publication occurs at intervals of 3 years; over 100 institutions contribute their statistics, and Vol. XVII,2 which is in preparation, will report on cancer of the cervix, corpus, ovary, vagina, and vulva. Over the years numerous other staging systems have been promulgated and several, such as those of the American College of Surgeons and of Henry Schmitz, gained considerable acceptance. In 1958 the International Union Against Cancer (UICC) under the guidance of Denoix published a system3 known as TNM to be applied to all solid tumors. Staging is assigned in this method to each of the 3 components of cancer: Tumor, Regional Nodes, and Metastases. The combined hieroglyph in each individual case provides a staging or, what is more apt, a description which is considerably more precise than assignment to 1 of 4 stages. Since the possible combinations are numerous, for purposes of statistical analysis it is customary to combine the subgroups within the appropriate stage as usually defined.
In 1959 the American Joint Committee on Cancer Staging and End Results Reporting (AJC) was organized to develop a system and encourage uniformity in reporting by physicians in this country. The TNM classification was adopted as a basis and field studies designed and carried out to test its validity and reproducibility at specified sites. These studies, and the conferences held to discuss them, disclosed ambiguities in the text of published classifications and disagreement between professionals based on honest differences of opinion and the variability of each one’s personal experience with disease. During recent years the AJC has taken the lead in bringing together at its conferences representatives of the TNM committee of the UICC and also of the Cancer Committee of FIGO. They conferred with their own colleagues and after acceptable concessions were made all around, the 3 classifications are in accordance in all but a few minor points. The results of this fruitful collaboration were published in the AJC Manual for Staging of Cancer’ and will also be reported in the next volumes from the UICC and FIGO. The classification in current use is shown in Table 1. Details of procedures acceptable for clinical staging and further explanation of the rules for staging are spelled out in the text accompanying the classification at each of the sources referenced. The most important basic requirement is that cases reasonably in doubt between two stages must be assigned for classification to the lesser stage. In addition to the clinical staging which must be recorded on every case, it is often possible to determine more precisely the extent of disease because of surgical exploration, histologic examination of removed tissues, autopsy, etc. Each of these developments can be recorded by a staging hieroglyph with suitable subscript, i.e. sTNM and pTNM for surgical and pathologic staging.
1014
Radiation
Oncology
0 Biology
Table
July 1979, Volume 5, No. 7
0 Physics
1. Carcinoma
FIG0 nomenclature Stage 0 ih situ, intraepithelial carcinoma Carcinoma Stage I The carcinoma is strictly confined to the to the corpus should be cervix (extension disregarded) carcinoma (early stromal Stage IA Microinvasive invasion) Stage IB A11 other cases of Stage I; occult cancer should be marked “occ” Stage II The carcinoma extends beyond the cervix, but has not extended to the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third Stage IIA No obvious parametrial involvement Stage IIB Obvious parametrial involvement Stage III The carcinoma has extended to the pelvic wall. On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the lower third of the vagina. All cases with a hydronephrosis or nonfunctioning kidney are included Stage IIIA No extension to the pelvic wall Stage IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney Stage IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. A bullous edema as such such does not permit a case to be allotted to Stage IV Stage IVA Spread of the growth to adjacent organs Stage IVB Spread to distant organs
of the cervix
uteri
TNM nomenclature Primary Tumor (T) Tis Carcinoma Tl, la, lb, 2a, 2b, 3a, 3b, 4
in situ
See Stage 0 See corresponding FIG0 stages
Nodal Involvement (N) NX Not possible to assess the regional nodes NO No involvement of regional nodes Nl Evidence of regional node involvement N4 Involvement of lumbo-aortic nodes Distant MX MO Ml
Metastases (M) Not possible to assess No evidence of distant metastases Evidence of distant metastases
Correlation between TNM and stage grouping: Tis Stage 0 Ia Tla NX-NO Ib Tlb NX-NO IIa T2a NX-NO IIb T2b NX-NO IIIa T3a NX-NO IIIb T3a Nl T3b NX-NO-N 1 T4 IVa NX-NO-N 1 Any T N4 IVb Any T Any N
MO MO MO MO MO MO MO MO MO Ml
REFERENCES 1. American Joint Committee for Cancer Staging and Manual for Staging of Cancer. Results Reporting: cage: American Joint Committee, 1977, pp. X9-100. 2. Annual Report on the Results of Treatment in cinema of the Uterus, Vagina, Ovary, and Vulva. XVII. ed. by Kottmeier, H.L. Stockholm, Sweden:
End ChiCarVol. 1979.
published privately under the patronage 3. UICC (International Union Against Classification of Malignant Tumors. national Union Against Cancer, 1974. Werf-Messing, B. pp. 57-72.
of the FIGO. Cancer): TNM Geneva: Intered. by van der
l Current Concepts
00/O
in Cancer
STAGING HOWARD
CLASSIFICATIONS ULFELDER,
M.D.
Joe V. Meigs Professor of Gynecology, Emeritus, Harvard Medical School and Deputy to the Director for Cancer Affairs, Massachusetts General Hospital, Boston, MA 02114, U.S.A. Gynecologic
tumors,
Staging systems:
TNM, FIGO, UICC
The staging of tumors at the time of diagnosis is a refinement of our efforts to evaluate the success of treatment. It permits valid comparisons and in order to do this it must be simple, easily understood, and universally reproducible. The necessity for subdividing tumors of a specific category according to their extent became apparent when physicians reporting their case studies as series noticed that some clinics saw and treated patients with much more advanced disease than others did, which made comparison quite impossible. Therefore, in 1929 the Cancer Commission of the League of Nations Health Organization adopted a set of rules for the allocation to stages of carcinoma of the cervix-rules designed to facilitate the presentation of exact and comparable therapeutic statistics. Annual reports of the results of treatment at collaborating institutions were begun in 1937; in 1968 the International Federation of Gynecology and Obstetrics (FIGO) assumed the patronage and editorial responsibility of the Report. At present, publication occurs at intervals of 3 years; over 100 institutions contribute their statistics, and Vol. XVII,2 which is in preparation, will report on cancer of the cervix, corpus, ovary, vagina, and vulva. Over the years numerous other staging systems have been promulgated and several, such as those of the American College of Surgeons and of Henry Schmitz, gained considerable acceptance. In 1958 the International Union Against Cancer (UICC) under the guidance of Denoix published a system3 known as TNM to be applied to all solid tumors. Staging is assigned in this method to each of the 3 components of cancer: Tumor, Regional Nodes, and Metastases. The combined hieroglyph in each individual case provides a staging or, what is more apt, a description which is considerably more precise than assignment to 1 of 4 stages. Since the possible combinations are numerous, for purposes of statistical analysis it is customary to combine the subgroups within the appropriate stage as usually defined.
In 1959 the American Joint Committee on Cancer Staging and End Results Reporting (AJC) was organized to develop a system and encourage uniformity in reporting by physicians in this country. The TNM classification was adopted as a basis and field studies designed and carried out to test its validity and reproducibility at specified sites. These studies, and the conferences held to discuss them, disclosed ambiguities in the text of published classifications and disagreement between professionals based on honest differences of opinion and the variability of each one’s personal experience with disease. During recent years the AJC has taken the lead in bringing together at its conferences representatives of the TNM committee of the UICC and also of the Cancer Committee of FIGO. They conferred with their own colleagues and after acceptable concessions were made all around, the 3 classifications are in accordance in all but a few minor points. The results of this fruitful collaboration were published in the AJC Manual for Staging of Cancer’ and will also be reported in the next volumes from the UICC and FIGO. The classification in current use is shown in Table 1. Details of procedures acceptable for clinical staging and further explanation of the rules for staging are spelled out in the text accompanying the classification at each of the sources referenced. The most important basic requirement is that cases reasonably in doubt between two stages must be assigned for classification to the lesser stage. In addition to the clinical staging which must be recorded on every case, it is often possible to determine more precisely the extent of disease because of surgical exploration, histologic examination of removed tissues, autopsy, etc. Each of these developments can be recorded by a staging hieroglyph with suitable subscript, i.e. sTNM and pTNM for surgical and pathologic staging.
1014
Radiation
Oncology
0 Biology
Table
July 1979, Volume 5, No. 7
0 Physics
1. Carcinoma
FIG0 nomenclature Stage 0 ih situ, intraepithelial carcinoma Carcinoma Stage I The carcinoma is strictly confined to the to the corpus should be cervix (extension disregarded) carcinoma (early stromal Stage IA Microinvasive invasion) Stage IB A11 other cases of Stage I; occult cancer should be marked “occ” Stage II The carcinoma extends beyond the cervix, but has not extended to the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third Stage IIA No obvious parametrial involvement Stage IIB Obvious parametrial involvement Stage III The carcinoma has extended to the pelvic wall. On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the lower third of the vagina. All cases with a hydronephrosis or nonfunctioning kidney are included Stage IIIA No extension to the pelvic wall Stage IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney Stage IV The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. A bullous edema as such such does not permit a case to be allotted to Stage IV Stage IVA Spread of the growth to adjacent organs Stage IVB Spread to distant organs
of the cervix
uteri
TNM nomenclature Primary Tumor (T) Tis Carcinoma Tl, la, lb, 2a, 2b, 3a, 3b, 4
in situ
See Stage 0 See corresponding FIG0 stages
Nodal Involvement (N) NX Not possible to assess the regional nodes NO No involvement of regional nodes Nl Evidence of regional node involvement N4 Involvement of lumbo-aortic nodes Distant MX MO Ml
Metastases (M) Not possible to assess No evidence of distant metastases Evidence of distant metastases
Correlation between TNM and stage grouping: Tis Stage 0 Ia Tla NX-NO Ib Tlb NX-NO IIa T2a NX-NO IIb T2b NX-NO IIIa T3a NX-NO IIIb T3a Nl T3b NX-NO-N 1 T4 IVa NX-NO-N 1 Any T N4 IVb Any T Any N
MO MO MO MO MO MO MO MO MO Ml
REFERENCES 1. American Joint Committee for Cancer Staging and Manual for Staging of Cancer. Results Reporting: cage: American Joint Committee, 1977, pp. X9-100. 2. Annual Report on the Results of Treatment in cinema of the Uterus, Vagina, Ovary, and Vulva. XVII. ed. by Kottmeier, H.L. Stockholm, Sweden:
End ChiCarVol. 1979.
published privately under the patronage 3. UICC (International Union Against Classification of Malignant Tumors. national Union Against Cancer, 1974. Werf-Messing, B. pp. 57-72.
of the FIGO. Cancer): TNM Geneva: Intered. by van der
