Radiation Oncology/Prostate/Staging

Prostate Cancer Staging AJCC Current Staging AJCC 8th edition (2017) To be used for staging beginning Jan 1, 2018. Reference: Primary Tumor: Clinical (cT) T1 - clinically inapparent tumor neither palpable nor visible by imaging T1a - incidental histologic finding in 5% or less of tissue resected T1b - incidental histologic finding in more than 5% of tissue resected T1c - identified by needle biopsy (e.g., because of elevated PSA) T2 - palpable and confined within prostate T2a - involves one half of one side or less T2b - involves more than one half of one side but not both sides T2c - involves both sides T3 - extraprostatic tumor that is not fixed or does not invade adjacent structures T3a - extracapsular extension (unilateral or bilateral) T3b - invades seminal vesicles T4 - fixed or invades adjacent structures other than seminal vesicles: bladder, external sphincter, rectum, levator muscles, and/or pelvic wall Primary Tumor: Pathologic (pT) T2 - organ confined T3 - extraprostatic extension T3a - extraprostatic extension or microscopic invasion of bladder neck T3b - invades seminal vesicle(s) T4 - fixed or invades adjacent structures other than seminal vesicles: bladder, external sphincter, rectum, levator muscles, and/or pelvic wall Regional Lymph Nodes: N0 - none N1 - yes Regional lymph nodes: pelvic, hypogastric, obturator, iliac (internal, external), sacral Distant lymph nodes: aortic, common iliac, inguinal (deep), inguinal (superficial, femoral), supraclavicular, cervical, scalene, retroperitoneal Distant Metastases: M0 - none M1a - non-regional lymph nodes M1b - bone M1c - other sites Grade groups (1-5) 1: Gleason 6 2: Gleason 3+4=7 3: Gleason 4+3=7 4: Gleason 8 5: Gleason 9-10 Stage Grouping: Group I cT1 or cT2a N0 M0, PSA < 10, Grade group 1 (Gleason 6) pT2 N0 M0, PSA < 10, Grade group 1 (Gleason 6) Group IIA cT1 or cT2a N0 M0, PSA ≥ 10 and < 20, Grade group 1 (Gleason 6) pT2 N0 M0, PSA ≥ 10 and < 20, Grade group 1 (Gleason 6) cT2b-c N0 M0, PSA < 20, Grade group 1 (Gleason 6) Group IIB T1-2 N0 M0, PSA < 20, Grade group 2 (3+4=7) Group IIC T1-2 N0 M0, PSA < 20, Grade group 3 (4+3=7) T1-2 N0 M0, PSA < 20, Grade group 4 (Gleason 8) Group IIIA T1-2 N0 M0, PSA ≥ 20, Grade group 1-4 (Gleason 8 or less) Group IIIB T3-4 N0 M0, any PSA, Grade group 1-4 (Gleason 8 or less) Group IIIC Any T N0 M0, any PSA, Grade group 5 (Gleason 9-10) Group IVA N1 Group IVB M1 Note: when either PSA or Gleason is not available, grouping should be determined by T stage and/or either PSA or Gleason as available + Overview of 8th Edition staging -- comparing to risk groups New 8th Edition stage Gleason Low/Inter/High risk Features I G6 Low PSA < 10 IIA G6 Interm PSA 10-20, or cT2b-c and PSA<20IIB G3+4=7 Interm PSA < 20IIC G4+3=7 G8 Interm High G4+3 and PSA<20 G8 and PSA<20IIIA G6-8 High PSA > 20IIIB G6-8 Very High (prior AJCC Stage III) T3-T4IIIC G9 or 10 HighIVA prior AJCC Stage IV N1IVB prior AJCC Stage IV M1 + Simplified staging chart   PSA   <10 10-20 > 20 G 6 I * IIA IIIA G 3+4 IIB IIIA G 4+3 IIC IIIA G 8 IIC IIIA cT3-4 IIIB G 9-10 IIIC * G6 cT2b-c PSA<20 is IIA Older staging systems AJCC 7th Edition (2009) Note: new staging incorporates Gleason + PSA for risk group determination Primary Tumor: T1 - clinically inapparent tumor neither palpable nor visible by imaging T1a - incidental histologic finding in 5% or less of tissue resected T1b - incidental histologic finding in more than 5% of tissue resected T1c - identified by needle biopsy (e.g., because of elevated PSA) T2 - confined within prostate T2a - involves one half of one lobe or less T2b - involves more than one half of one lobe but not both lobes T2c - involves both lobes T3 - extends through the prostate capsule (note: invasion into the prostatic apex or into, but not beyond, the prostatic capsule is classified not as T3 but as T2.) T3a - extracapsular extension (unilateral or bilateral) or microscopic invasion of bladder neck T3b - invades seminal vesicles T4 - fixed or invades adjacent structures other than seminal vesicles: bladder, external sphincter, rectum, levator muscles, and/or pelvic wall (Note: microscopic invasion of bladder neck is pT3 and not pT4) Pathologic staging: there is no pT1 classification Regional Lymph Nodes: N0 - none N1 - yes Regional lymph nodes: pelvic, hypogastric, obturator, iliac (internal, external), sacral Distant lymph nodes: aortic, common iliac, inguinal (deep), inguinal (superficial, femoral), supraclavicular, cervical, scalene, retroperitoneal Distant Metastases: M0 - none M1a - non-regional lymph nodes M1b - bone M1c - other sites Stage Grouping: Note: the AJCC staging manual distinctly lists these as "groups" in contrast to other tumor sites where they are listed as "stage" Group I T1a-c N0 M0, PSA < 10, Gleason ≤ 6 T2a N0 M0, PSA < 10, Gleason ≤ 6 T1-2a N0 M0, PSA X, Gleason X Group IIA T1a-c N0 M0, PSA < 20, Gleason 7 T1a-c N0 M0, PSA ≥ 10 < 20, Gleason ≤ 6 T2a-b N0 M0, PSA < 20, Gleason 7 (corrected in erratum) T2a N0 M0, PSA ≥ 10 < 20, Gleason ≤ 6 (added in erratum) T2b N0 M0, PSA X, Gleason X Group IIB T2c N0 M0, Any PSA, Any Gleason T1-2 N0 M0, PSA ≥ 20, Any Gleason T1-2 N0 M0, Any PSA, Gleason ≥ 8 Group III T3a-b N0 M0, Any PSA, Any Gleason Group IV T4 N0 M0, Any PSA, Any Gleason N1, Any PSA, Any Gleason M1, Any PSA, Any Gleason Note: when either PSA or Gleason is not available, grouping should be determined by T stage and/or either PSA or Gleason as available Correlation with risk groups for localized disease -- I is "low risk" (PSA < 10, G ≤ 6), IIA is "intermediate risk" (roughly, PSA 10-20, or G7 and PSA<20), IIB is "high risk" (T2c or PSA≥20 or G≥8). Errata: AJCC 5th reprint AJCC 6th Edition (2002) Primary Tumor: T1a - incidental histologic finding in 5% or less of tissue resected T1b - incidental histologic finding in more than 5% of tissue resected T1c - identified by needle biopsy (e.g., because of elevated PSA) T2a - involves one half of one lobe or less T2b - involves more than one half of one lobe but not both lobes T2c - involves both lobes T3a - extracapsular extension (unilateral or bilateral) T3b - invades seminal vesicles T4 - fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall Pathologic staging: there is no pT1 classification Regional Lymph Nodes N0 - none N1 - yes Regional lymph nodes: pelvic, hypogastric, obturator, iliac (internal, external), sacral Distant lymph nodes: aortic, common iliac, inguinal (deep), inguinal (superficial, femoral), supraclavicular, cervical, scalene, retroperitoneal Distant Metastases: M0 - none M1a - non-regional lymph nodes M1b - bone M1c - other sites Stage Grouping: I - T1a N0 G1 II - T1a G2-4, T1b-1c, T2 III - T3 N0 IV - T4, N1, M1 Grade: G1 - well differentiated (Gleason 2-4), G2 - moderately differentiated (Gleason 5-6), G3-4 - poorly differentiated (Gleason 7-10) 1997 AJCC T1 - same as 2002. T2a - < 1/2 lobe, T2b - > 1/2 lobe or both lobes. No T2c. T3a - unilateral ECE, T3b - bilateral ECE. 1992 AJCC T1 and T2 - same as 2002. T3a - unilateral ECE, T3b - bilateral ECE, T3c - seminal vesicle involvement. Jewett Whitmore Staging Historically used in the US, until AJCC become adopted Stage A - no palpable on DRE, no symptoms A1: small tumor focus entirely within the gland A2: diffuse involvement of gland Stage B - palpable, but contained within capsule B1: <1.5 cm in diameter B2: >1.5 cm in diameter, typically involving both lobes Stage C - extracapsular extension, or seminal vesicle invasion Stage D Stage D1: extraprostatic disease limited to pelvic LN Stage D2: widespread metastatic disease