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Rectal Cancer Treatment (Professional) (cont.)

Stage Information for Rectal Cancer

Treatment decisions should be made with reference to the TNM classification system,[1] rather than the older Dukes or the Modified Astler-Coller classification schema.

The American Joint Committee on Cancer (AJCC) and a National Cancer Institute-sponsored panel recommended that at least 12 lymph nodes be examined in patients with colon and rectal cancer to confirm the absence of nodal involvement by the tumor.[2,3,4] This recommendation takes into consideration that the number of lymph nodes examined is a reflection of both the aggressiveness of lymphovascular mesenteric dissection at the time of surgical resection and the pathologic identification of nodes in the specimen. Retrospective studies, such as Intergroup trial INT-0089 [EST-2288], have demonstrated that the number of lymph nodes examined in colon and rectal surgery may be associated with patient outcome.[5,6,7,8]

The staging system does not apply to the following histologies:

  • Sarcoma. (See the PDQ summary on Adult Soft Tissue Sarcoma Treatment for more information.)
  • Lymphoma. (See the PDQ summary on Adult Hodgkin Lymphoma Treatment for more information.)
  • Carcinoid tumors. (See the PDQ summary on Gastrointestinal Carcinoid Tumors Treatment for more information.)
  • Melanoma. (See the PDQ summary on Melanoma Treatment for more information.)

Definitions of TNM

The AJCC has designated staging by TNM classification to define rectal cancer.[1] The same classification is used for both clinical and pathologic staging.[1]

Table 1. Primary Tumora

a Reprinted with permission from AJCC: Colon and rectum. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 143-164.
b Tis includes cancer cells confined within the glandular basement membrane (intraepithelial) or mucosal lamina propria (intramucosal) with no extension through the muscularis mucosae into the submucosa.
c Direct invasion in T4 includes invasion of other organs or other segments of the colorectum as a result of direct extension through the serosa, as confirmed on microscopic examination (e.g., invasion of the sigmoid colon by a carcinoma of the cecum) or, for cancers in a retroperitoneal or subperitoneal location, direct invasion of other organs or structures by virtue of extension beyond the muscularis propria (i.e., respectively, a tumor on the posterior wall of the descending colon invading the left kidney or lateral abdominal wall; or a mid or distal rectal cancer with invasion of prostate, seminal vesicles, cervix, or vagina).
d Tumor that is adherent to other organs or structures, grossly, is classified cT4b. However, if no tumor is present in the adhesion, microscopically, the classification should be pT1–4a depending on the anatomical depth of wall invasion. The V and L classifications should be used to identify the presence or absence of vascular or lymphatic invasion, whereas the PN site-specific factor should be used for perineural invasion.
TXPrimary tumor cannot be assessed.
T0No evidence of primary tumor.
TisCarcinomain situ: intraepithelial or invasion of lamina propria.b
T1Tumor invades submucosa.
T2Tumor invades muscularis propria.
T3Tumor invades through the muscularis propria into pericolorectal tissues.
T4aTumor penetrates to the surface of the visceral peritoneum.c
T4bTumor directly invades or is adherent to other organs or structures.c,d

Table 2. Regional Lymph Nodes (N)a,b

a Reprinted with permission from AJCC: Colon and rectum. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 143-164.
b A satellite peritumoral nodule in the pericolorectal adipose tissue of a primary carcinoma without histologic evidence of residual lymph node in the nodule may represent discontinuous spread, venous invasion with extravascular spread (V1/2), or a totally replaced lymph node (N1/2). Replaced nodes should be counted separately as positive nodes in the N category, whereas discontinuous spread or venous invasion should be classified and counted in the site-specific factor category Tumor Deposits.
NXRegional lymph nodes cannot be assessed.
N0No regional lymph node metastasis.
N1Metastases in 1–3 regional lymph nodes.
N1aMetastasis in 1 regional lymph node.
N1bMetastases in 2–3 regional lymph nodes.
N1cTumor deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastases.
N2Metastases in =4 regional lymph nodes.
N2aMetastases in 4–6 regional lymph nodes.
N2bMetastases in =7 regional lymph nodes.

Table 3. Distant Metastasis (M)a

a Reprinted with permission from AJCC: Colon and rectum. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 143-164.
M0No distant metastasis.
M1Distant metastasis.
M1aMetastasis confined to 1organ or site (e.g., liver, lung, ovary, nonregional node).
M1bMetastases in >1 organ/site or the peritoneum.

Table 4. Anatomic Stage/Prognostic Groupsa,b

StageTNMDukescMACc
a Reprinted with permission from AJCC: Colon and rectum. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 143-164.
b cTNM is the clinical classification, and pTNM is the pathologic classification. The y prefix is used for those cancers that are classified after neoadjuvant pretreatment (e.g., ypTNM). Patients who have a complete pathologic response (ypT0, N0, cM0) 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).
c Dukes B is a composite of better (T3, N0, M0) and worse (T4, N0, M0) prognostic groups, as is Dukes C (any T, N1, M0 and any T, N2, M0). MAC is the modified Astler-Coller classification.
0TisN0M0----
IT1N0M0AA
T2N0M0AB1
IIAT3N0M0BB2
IIBT4aN0M0BB2
IICT4bN0M0BB3
IIIAT1–T2N1/N1cM0CC1
T1N2aM0CC1
IIIBT3–T4aN1/N1cM0CC2
T2–T3N2aM0CC1/C2
T1–T2N2bM0CC1
IIICT4aN2aM0CC2
T3–T4aN2bM0CC2
T4bN1–N2M0CC3
IVAAny TAny NM1a----
IVBAny TAny NM1b----

A major pooled analysis evaluating the impact of T and N stage and treatment on survival and relapse in patients with rectal cancer who are treated with adjuvant therapy has been published.[9] In addition, a new tumor-metastasis staging strategy for node-positive rectal cancer has been proposed.[10]

References:

  1. Colon and rectum. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 143-64.
  2. Colon and rectum. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 113-124.
  3. Compton CC, Greene FL: The staging of colorectal cancer: 2004 and beyond. CA Cancer J Clin 54 (6): 295-308, 2004 Nov-Dec.
  4. Nelson H, Petrelli N, Carlin A, et al.: Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst 93 (8): 583-96, 2001.
  5. Swanson RS, Compton CC, Stewart AK, et al.: The prognosis of T3N0 colon cancer is dependent on the number of lymph nodes examined. Ann Surg Oncol 10 (1): 65-71, 2003 Jan-Feb.
  6. Le Voyer TE, Sigurdson ER, Hanlon AL, et al.: Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 21 (15): 2912-9, 2003.
  7. Prandi M, Lionetto R, Bini A, et al.: Prognostic evaluation of stage B colon cancer patients is improved by an adequate lymphadenectomy: results of a secondary analysis of a large scale adjuvant trial. Ann Surg 235 (4): 458-63, 2002.
  8. Tepper JE, O'Connell MJ, Niedzwiecki D, et al.: Impact of number of nodes retrieved on outcome in patients with rectal cancer. J Clin Oncol 19 (1): 157-63, 2001.
  9. Gunderson LL, Sargent DJ, Tepper JE, et al.: Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis. J Clin Oncol 22 (10): 1785-96, 2004.
  10. Greene FL, Stewart AK, Norton HJ: New tumor-node-metastasis staging strategy for node-positive (stage III) rectal cancer: an analysis. J Clin Oncol 22 (10): 1778-84, 2004.
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