Prostate Cancer Staging 

Prostate Cancer Staging 

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The clinical staging of prostate cancer was devised from the American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) system. Risk stratification is based on the clinical stage as well as the following pretreatment parameters:

Pathological staging is determined following prostatectomy and depends on factors such as tumor burden, status of surgical margins, extracapsular disease, and seminal vesicle and pelvic lymph node involvement. Pathological staging is a more accurate measure of the extent of disease and allows for better prediction of outcomes. [1]

The TNM classification for prostate cancer is provided below. [2]

Table 1. TNM Classification for Prostate Cancer (Open Table in a new window)

Primary tumor (T)

Clinical (cT)

TX

Primary tumor cannot be assessed

T0

No evidence of primary tumor

T1

Clinically inapparent tumor not palpable or visible by imaging

T1a

Tumor incidental histologic finding in ≤5% of tissue resected (at time of transurethral resection of the prostate [TURP])

T1b

Tumor incidental histologic finding in >5% of tissue resected (at time of TURP)

T1c

Tumor identified by needle biopsy (because of elevated prostate specific antigen [PSA] level)

T2

Tumor confined within prostate (Note: tumors found in 1 or both lobes by needle biopsy but not palpable on DRE or reliably visible by imaging are classified as T1c)

T2a

Tumor involves one-half of 1 lobe or less

T2b

Tumor involves more than one-half of 1 lobe but not both lobes

T2c

Tumor involves both lobes

T3

Tumor extends through the prostatic capsule (Note: invasion into the prostatic apex, or into—but not beyond—the prostatic capsule is classified as T2

T3a

Extracapsular extension (unilateral or bilateral)

T3b

Tumor invading seminal vesicle(s)

T4

Tumor fixed or invades adjacent structures other than seminal vesicles (eg, bladder, levator muscles, and/or pelvic wall)

Pathologic (pT)*

pT2

Organ confined

pT3

Extraprostatic extension

pT3a

Extraprostatic extension or microscopic invasion of the bladder neck**

pT3b

Seminal vesicle invasion

pT4

Tumor is fixed or invades adjacent structures other than the seminal vesicles (eg, bladder, rectum)

*There is no pathologic T1 classification.

**Positive surgical margin should be indicated by an R1 descriptor (residual microscopic disease).

Regional lymph nodes (N)

Clinical (cN)

NX

Regional lymph nodes were not assessed

N0

No regional lymph node metastasis

N1

Metastasis in regional lymph node(s)

Pathologic (pN)

pNX

Regional nodes not sampled

pN0

No positive regional nodes

pN1

Metastases in regional nodes(s)

Distant metastasis (M)*

M0

No distant metastasis

M1

Distant metastasis

M1a

Nonregional lymph nodes(s)

M1b

Bone(s)

M1c

Other site(s) with or without bone disease

*If more than 1 site of metastasis is present, use the most advanced category.

An additional factor influencing prognosis is histopathologic grading. Tissue obtained from a needle biopsy or a prostatectomy is graded using the Gleason Grading System. Gleason grades range from 1 to 5. Each specimen is assigned two grades based on the most common and second most common pattern. These numerical values are added to calculate the Gleason Score.

  Table 2. Gleason Score (Open Table in a new window)

Histopathologic grade (G)

GX

Gleason score cannot be assessed

Gleason ≤6

Well differentiated (slight anaplasia)

Gleason 7

Moderately differentiated (moderate anaplasia)

Gleason 8-10

Poorly differentiated or undifferentiated (marked anaplasia)

The 8th edition of the AJCC Cancer Staging Manual took effect on January 1, 2018. A major change is that tumor grading now involves the Gleason Score, as well as the grade group. [3]

Table 3. Grade Group (Open Table in a new window)

Prostate cancer risk stratification is based on groups defined by D’Amico et al in 1998. This system has been adopted by the National Comprehensive Cancer Network (NCCN) and is used widely in clinical practice when making decisions regarding treatment and/or active surveillance. [2, 4]

Table 4. Anatomic stage/prognostic groups (Open Table in a new window)

Stage*

T

N

M

PSA

Grade Group

 

*If PSA or Gleason is not available, grouping should be determined by T stage and/or either PSA or Gleason, as available.

See Prostate Cancer: Diagnosis and Staging, a Critical Images slideshow, to help determine the best diagnostic approach for this potentially deadly disease.

Also see the Advanced Prostate Cancer: Signs of Metastatic Disease slideshow for help identifying the signs of metastatic disease.

Loeb S, Eastham JA. Diagnosis and Staging of Prostate Cancer. Wein AJ, Kavoussi LR, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 11th ed. Philadelphia, PA: Elsevier; 2011. 2601–2608.e7. [Full Text].

[Guideline] National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer. Available at http://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Version 2.2017 — February 21, 2017; Accessed: January 23, 2018.

Buyyounouski MK, Choyke PL, McKenney JK, Sartor O, Sandler HM, Amin MB, et al. Prostate cancer – major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017 May 6. [Medline]. [Full Text].

[Guideline] Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. American Urological Association. Available at http://www.auanet.org/guidelines/clinically-localized-prostate-cancer-new-(aua/astro/suo-guideline-2017). 2017; Accessed: January 23, 2018.

Primary tumor (T)

Clinical (cT)

TX

Primary tumor cannot be assessed

T0

No evidence of primary tumor

T1

Clinically inapparent tumor not palpable or visible by imaging

T1a

Tumor incidental histologic finding in ≤5% of tissue resected (at time of transurethral resection of the prostate [TURP])

T1b

Tumor incidental histologic finding in >5% of tissue resected (at time of TURP)

T1c

Tumor identified by needle biopsy (because of elevated prostate specific antigen [PSA] level)

T2

Tumor confined within prostate (Note: tumors found in 1 or both lobes by needle biopsy but not palpable on DRE or reliably visible by imaging are classified as T1c)

T2a

Tumor involves one-half of 1 lobe or less

T2b

Tumor involves more than one-half of 1 lobe but not both lobes

T2c

Tumor involves both lobes

T3

Tumor extends through the prostatic capsule (Note: invasion into the prostatic apex, or into—but not beyond—the prostatic capsule is classified as T2

T3a

Extracapsular extension (unilateral or bilateral)

T3b

Tumor invading seminal vesicle(s)

T4

Tumor fixed or invades adjacent structures other than seminal vesicles (eg, bladder, levator muscles, and/or pelvic wall)

Pathologic (pT)*

pT2

Organ confined

pT3

Extraprostatic extension

pT3a

Extraprostatic extension or microscopic invasion of the bladder neck**

pT3b

Seminal vesicle invasion

pT4

Tumor is fixed or invades adjacent structures other than the seminal vesicles (eg, bladder, rectum)

*There is no pathologic T1 classification.

**Positive surgical margin should be indicated by an R1 descriptor (residual microscopic disease).

Regional lymph nodes (N)

Clinical (cN)

NX

Regional lymph nodes were not assessed

N0

No regional lymph node metastasis

N1

Metastasis in regional lymph node(s)

Pathologic (pN)

pNX

Regional nodes not sampled

pN0

No positive regional nodes

pN1

Metastases in regional nodes(s)

Distant metastasis (M)*

M0

No distant metastasis

M1

Distant metastasis

M1a

Nonregional lymph nodes(s)

M1b

Bone(s)

M1c

Other site(s) with or without bone disease

*If more than 1 site of metastasis is present, use the most advanced category.

Histopathologic grade (G)

GX

Gleason score cannot be assessed

Gleason ≤6

Well differentiated (slight anaplasia)

Gleason 7

Moderately differentiated (moderate anaplasia)

Gleason 8-10

Poorly differentiated or undifferentiated (marked anaplasia)

Stage*

T

N

M

PSA

Grade Group

 

*If PSA or Gleason is not available, grouping should be determined by T stage and/or either PSA or Gleason, as available.

Natasza M Posielski, MD Resident Physician, Department of Urology, University of Wisconsin Hospital and Clinics

Natasza M Posielski, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Kyle A Richards, MD Assistant Professor, Department of Urology, University of Wisconsin School of Medicine and Public Health; Chief of Urology, Division of Urology, William S Middleton Memorial Veterans Hospital

Kyle A Richards, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Urological Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Christopher D Braden, DO Hematologist/Oncologist, Chancellor Center for Oncology at Deaconess Hospital; Medical Director, Deaconess Hospital Outpatient Infusion Centers; Chairman, Deaconess Hospital Cancer Committee

Christopher D Braden, DO is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology

Disclosure: Nothing to disclose.

E Jason Abel, MD Associate Professor of Urologic Oncology, Department of Urology, Associate Professor of Radiology (Affiliate Appointment), Department of Radiology, University of Wisconsin School of Medicine and Public Health; Attending Urologist, William S Middleton Memorial Veterans Hospital

E Jason Abel, MD is a member of the following medical societies: American Medical Association, American Society of Clinical Oncology, American Urological Association, Harris County Medical Society, Kidney Cancer Association, Society for Basic Urologic Research, Society of Urologic Oncology, Texas Medical Association

Disclosure: Nothing to disclose.

Reza Ghavamian, MD Professor of Clinical Urology, Albert Einstein College of Medicine; Director of Urologic Oncology, Director of Minimally Invasive and Robotic Urologic Surgery, Montefiore Medical Center

Reza Ghavamian, MD is a member of the following medical societies: American Urological Association, Society of Urologic Oncology

Disclosure: Nothing to disclose.

Prostate Cancer Staging 

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