Cancer stages by tnm. Principles of classification of malignant neoplasms. Mammary cancer

It is always important for physicians to have a standardized description of colorectal cancer, and there are several reasons for this. First of all, the patient's prognosis directly depends on the degree of spread of the tumor during the initial diagnosis. Tumors that have distant spread (metastases) to other organs are more aggressive and common than small tumors that are confined to the intestinal wall. Secondly, the common system allows physicians to communicate very important information to each other and adhere to an accurate treatment plan. It also makes it possible to determine which patients need special investigations, surgery or chemotherapy. For example, surgery alone may be sufficient to treat small tumors, while more advanced tumors may require a combination of surgery and chemotherapy. The stage of the tumor is the language in which doctors describe the nature of the tumor, as well as the degree of its local and distant spread.

Tumor staging is based on three criteria: the depth of tumor ingrowth into the intestinal wall (T), the presence of spread of tumor cells in the lymph nodes (N) and, finally, the presence or absence of metastases (M). These three components form the TNM system for colorectal cancer staging (see tables below).

Stage T (tumor)- depth of tumor ingrowth into the intestinal wall. The lower the value of this stage, the less invasive tumor growth. Stage T0 tumor can still be considered fairly benign, since the growth of this tumor is limited only to the intestinal mucosa. Stage T4 tumor means that the tumor has sprouted not only all layers of the intestinal wall, but also neighboring organs.

Stage N (lymphnodes)- indicates the number of lymph nodes in which cancer cells were found. The N0 stage means that no cancer cells were found in any of the lymph nodes in the post-mortem examination. The Nx stage means that the number of affected lymph nodes is unknown. This may be at the stage of examination before surgery, when it is impossible to determine whether the lymph nodes are affected or not. Until a post-mortem examination is performed, the stage is considered as Nx.

Stage M (metastases)- indicates whether the tumor has distant screenings - metastases.

Tumor stage according to TNM system

T	N	M
is - tumor growth within the mucosa	0 - no evidence for lymph node involvement	0 - no data for the presence of distant metastases
1 the tumor grows, but the submucosal layer of the intestine does not germinate	1 involvement of 1 to 3 lymph nodes	1 the presence of distant tumor metastases
2 the tumor grows, but the muscular layer of the intestine does not germinate	2 more than 3 lymph nodes affected	X not known if there are metastases
3 the tumor grows through the muscle layer into the surrounding tissues	X unknown if lymph nodes are affected
4 tumor grows into surrounding organs

General tumor stage

	T	N	M
Stage	1,2	0	0
Stage	3,4	0	0
Stage	Any	1,2	0
Stage	Any	Any	1

To understand how the stage is set, look in the table for the headings T, N, and M. Each column contains numbers or the word "any". The second row in the table corresponds to stage I, the columns contain the following data: stage T 1 or 2, stages N and M - 0. This means that if the tumor grows only into the intestinal wall (stage T1 or T2) and there are no cancer cells in any lymph node cells (stage N0) and no distant metastases (stage M0), then the tumor will be classified as a stage I cancer. A tumor that has grown through the intestinal wall (stage T3 or T4) but has no involved lymph nodes or distant metastases is stage II, and so on.

Staging plays a very important role in determining treatment tactics. Stage I tumors are usually treated with surgery alone, while stage III tumors are usually treated with both surgery and chemotherapy. Thus, tumor staging is a very important step in preoperative diagnosis. In order to determine the stage before surgery, many studies may be required. Computed tomography (CT), chest x-ray, ultrasound (ultrasound), magnetic resonance imaging (MRI) and positron emission tomography (PET) are very informative tests to help determine the extent of tumor spread. However, the most accurate method for determining the stage of a tumor is to examine the part of the intestine removed during surgery using a microscope.

It is very important that patients understand the principles of tumor staging and how it is done in order to competently discuss treatment options and prognosis with the doctor.

When treating patients with thyroid cancer, it is very important to maintain continuity in the work of various medical institutions. To put it simply, doctors somehow need to communicate information about the patient's disease to each other, while it is not enough just to write "Papillary thyroid cancer" in the diagnosis, it is necessary to note a number of the most important parameters of the tumor. It is on these distinctive features that the doctors of the next link will plan the treatment of the patient.

It is clear that describing all the features of the tumor in words is long and ineffective. Imagine such a "verbal" diagnosis (for example, "Papillary thyroid carcinoma, in which the tumor node was 3 cm in size, grew into the capsule of the thyroid gland, metastases of the tumor were noted in the lymph nodes of the paratracheal group, and an in-depth examination did not reveal metastases to other organs") . The verbal formulation of the diagnosis will inevitably lead in some cases to the appearance of unnecessary information in the diagnosis, and in others to the omission of a description of really important parameters of the tumor.

The problem of correct formulation of the diagnosis is also important in statistical studies. It is no secret that physicians around the world regularly exchange statistical information in order to correctly evaluate the effectiveness of treatment methods and, as a result, use methods with proven effectiveness more widely and exclude from their therapeutic arsenal methods that have not proven their usefulness for patients. In such international cooperation, it is very important to "speak the same language" - i.e. to have the possibility of a standard description of the disease, which will be understandable to a doctor in any country on our planet. That is why physicians around the world had to develop a classification system for thyroid cancer that would take into account the main parameters of this disease, the most important for the treatment of the patient.

Of several proposed classifications, the TNM staging system developed by the American Joint Cancer Committee (AJCC) and the International Union Against Cancer (UICC) has proven to be the most popular and reliable. The classification of thyroid cancer according to the TNM system was based on two parameters: the extent of the tumor and the age of the patient.

Tumor extent is coded as follows:

"T" (from the Latin tumor - tumor) - describes the prevalence of the primary tumor;

"N" (from the Latin nodus - node) - describes the tumor involvement of regional lymph nodes, i.e. nodes that collect lymph from the region of the tumor;

"M" (from the Latin metastasis - metastasis) - describes the presence of distant tumor metastases, i.e. new tumor foci that appeared in remote areas of the human body, outside the regional lymph nodes.
Currently, the TNM classification of the 6th edition, adopted in 2002, is in force. Now let's look at the classification itself.

Prevalence of the primary tumor

T0— the primary tumor in the tissue of the thyroid gland was not detected during the operation

T1 tumor 2 cm or less in greatest dimension within the thyroid gland

Sometimes an addition may be used:
T1a Tumor 1 cm or less
T1b Tumor more than 1 cm but not more than 2 cm

T2- Tumor more than 2 cm but less than 4 cm in greatest dimension within the thyroid gland (i.e. not growing into the capsule of the gland)

T3 Tumor larger than 4 cm in greatest dimension within the thyroid gland, or any tumor with minimal extension beyond the thyroid capsule (eg, extension to short muscles or adjacent fatty tissue). Thus, even small thyroid tumors that grow into its capsule are staged as T3.

T4 Tumors at this stage are divided into two substages:

T4a Tumor of any size that invades the thyroid capsule with invasion of the subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve

T4b- a tumor that invades the prevertebral fascia, carotid artery or retrosternal vessels.

It is important to note that all undifferentiated thyroid carcinomas are classified as stage T4, regardless of their size. For these carcinomas, staging is slightly different:

T4a- undifferentiated carcinoma located within the thyroid gland - surgically resectable (i.e. completely removed during surgery)

T4b- undifferentiated carcinoma that extends beyond the thyroid gland - surgically unresectable (i.e., surgically completely unremovable)

Presence of metastases in the regional lymph nodes of the neck

NX- the presence of regional metastases cannot be assessed

N0- absence of regional metastases

N1- presence of regional metastases

N1a- metastases in the VI zone of the lymphatic drainage (pretracheal, paratracheal and prelaryngeal lymph nodes)

N1b- metastases in the lateral cervical lymph nodes on one or both sides, on the opposite side or in the retrosternal lymph nodes

Distant metastases

MX- the presence of distant metastases cannot be assessed

M0- absence of distant metastases

M1- presence of distant metastases

Tumor staging is carried out based on the study of tumor parameters using the TNM system. determination of the prognosis for its treatment. There are four stages in total, from I (the most favorable) to IV (the most unfavorable). Given the different properties of thyroid tumors (papillary and follicular cancer - on the one hand, anaplastic - on the other), staging for various forms of thyroid cancer is carried out according to different rules.

Age up to 45 years
	Any stage T Any stage T	Any stage N Any stage N
Papillary and follicular thyroid cancer Age 45 and over
Stage III IVA stage Stage IVB IVC stage	Any stage T	Any stage N Any stage N
Medullary thyroid cancer
Stage III IVA stage Stage IVB IVC stage	Any stage T	Any stage N Any stage N
Anaplastic thyroid cancer (separation by age is not used)
IVA stage Stage IVB IVC stage	Any stage T	Any stage N Any stage N Any stage N

Finishing the description of the TNM classification, it should be noted that the definition of the stage according to this system is mandatory for all hospitals performing thyroid surgery. The doctor who operated on a patient with thyroid cancer must indicate the stage of the disease and a description of the tumor according to the TNM system in the discharge summary. Without TNM data, the final diagnosis is incomplete, since it will not be possible to plan further treatment on its basis.

Tumors of the mammary gland. (International Cancer Union. Seventh edition, 2009. Editors: L.H.Sobin, M.K.Gospodarowicz, Ch.Wittekind. A John Willey & Sons. Ltd., Publication. Translated by S.M. Portnoy).

"The wise are those who correctly determine the order of things"

Thomas Aquinas

Preliminary remarks

The description is presented under the following headings:

Classification Rules with evaluation procedures for categories T, N and M; additional methods may be used when they improve the accuracy of pre-treatment assessment
Anatomical subsections
Definition of regional lymph nodes
TNM Clinical classification
pTNM Pathological classification
G Histological determination of the grade of malignancy
R Classification
Grouping by stages
Conclusion

Classification rules

The classification applies to both male and female breast carcinomas. Histological confirmation of the diagnosis is required. The anatomical location of the primary tumor should be reported, but is not included in the classification. In the case of multiple primary tumors in the same breast, the tumor with the maximum category T is used for classification. Multiple bilateral breast cancers should be classified independently, using the ability to differentiate tumors by histological type.

category T - medical examination and imaging methods, such as mammography;
category N - medical examination and imaging methods;
category M - medical examination and imaging methods.

Anatomical subsections

Nipple (C50.0)
Central department (C50.1)
Superior-internal quadrant (C50.2)
Inferior-internal quadrant (C50.3)
Superior outer quadrant (C50.4)
Infero-outer quadrant (C50.5)
Tail lobe (C50.6)

Regional lymph nodes

Regional lymph nodes include:

Axillary (ipsilateral): interpectoral (Rotter) nodes and lymph nodes located along the axillary vein and its tributaries, which can be divided into the following levels:
- Level I (lower axillary): lymph nodes located lateral to the lateral edge of the pectoralis minor muscle;
- Level II (middle axillary): lymph nodes located between the medial and lateral edges of the pectoralis minor muscle, as well as interpectoral lymph nodes (Rotter);
- Level III (apical axillary): apical axillary lymph nodes and lymph nodes located medial to the medial border of the pectoralis minor muscle, with the exception of lymph nodes referred to as subclavian.
  Note: Intramammary lymph nodes are coded as level I axillary lymph nodes.
Subclavian (ipsilateral).
Internal chest(ipsilateral): lymph nodes located in the intercostal spaces along the edge of the sternum on the intrathoracic fascia.
Supraclavicular (ipsilateral).
Note: metastases in any other lymph nodes are coded as distant metastases (M1), including cervical or contralateral internal mammary lymph nodes.

Clinical classification of TNM

T- primary tumor
TX– the primary tumor cannot be assessed
T0- No primary tumor found
Tis carcinoma in situ– non-invasive cancer
Tis (DCIS)– ductal non-invasive cancer
Tis (LCIS)– lobular non-invasive cancer
Tis (Paget)- Paget's disease of the nipple not associated with invasive cancer or non-invasive cancer (ductal and/or lobular) in the underlying breast tissue. Cancers in the breast tissue associated with Paget's disease are classified based on the size and characteristics of these tumors, and the presence of Paget's disease should also be noted.
T1– tumor 2 cm or less in maximum dimension.
- T1mi– microinvasion 0.1 cm or less in maximum dimension*
  Note:* microinvasion is the spread of cancer cells through the basement membrane into the underlying tissues without forming a focus greater than 0.1cm in the greatest dimension. When there are multiple foci of microinvasion, only the size of the largest foci is used for staging. (Do not add up the sizes of all the individual foci.) The presence of multiple foci of microinvasion should be noted, as well as their association with multiple larger invasive cancers.
- T1a- more than 0.1 cm, but not more than 0.5 cm in maximum dimension
- T1b– more than 0.5 cm, but not more than 1 cm in maximum dimension
- T1c– more than 1 cm, but not more than 2 cm in maximum dimension
T2– Tumor more than 2 cm, but not more than 5 cm in maximum dimension
T3– Tumor more than 5 cm in maximum dimension
T4– Tumor of any size with direct extension to the chest wall and/or skin (ulceration or skin nodules)
Note: mere skin ingrowth does not qualify as T4. The chest wall refers to the ribs, intercostal muscles, serratus anterior, but not the pectoral muscle.
- T4a– extension to the chest wall (this does not apply to isolated ingrowth into the pectoral muscle)
- T4b– ulceration, ipsilateral skin satellites, or skin edema (including orange peel symptom)
- T4c– combination of characteristics described in T4a and T4b
- T4d- edematous-infiltrative form of cancer
  Note: The edematous-infiltrative form of breast cancer is characterized by a pronounced induration of the skin with an edge similar to that of erysipelas, usually without an underlying tumor. A clinically classified edematous-infiltrative form of cancer (T4d) in cases of no signs of a tumor lesion of the skin during its biopsy and the absence of a measurable primary tumor is assessed as pTX during pathoanatomical staging. Skin indrawing, nipple retraction, or other skin symptoms other than those listed in T4b and T4d; may be observed at T1, T2, or T3 without affecting classification.

N- regional lymph nodes
NX– regional lymph nodes cannot be assessed (for example, removed earlier)
N0- no metastases in regional lymph nodes
N1- metastases in mobile ipsilateral axillary lymph nodes (node) I, II levels
N2- metastases in the ipsilateral axillary lymph nodes (node) I, II levels, which, according to clinical data, are fixed or soldered to each other; or clinically detectable* metastases (metastasis) in the ipsilateral internal mammary lymph nodes (node) in the absence of clinically detectable metastases in the axillary lymph nodes
- N2a- metastases in the axillary lymph nodes (node), fixed between themselves or with other structures
- N2b– clinically detectable* metastases (metastasis) only in the internal mammary lymph nodes (node) in the absence of clinically detectable metastases in the axillary lymph nodes
N3- metastases in the ipsilateral subclavian (axillary level III) lymph nodes (node) with or without damage to the axillary lymph nodes of levels I, II; or clinically detectable* metastases (metastasis) in the ipsilateral internal thoracic lymph nodes (node) with clinical signs of metastases in the axillary lymph nodes of I, II levels; or metastases in the ipsilateral supraclavicular lymph nodes (node) with or without involvement of the axillary or internal mammary lymph nodes.
- N3a- metastases in the subclavian lymph nodes (node)
- N3b- metastases in the internal thoracic and axillary lymph nodes
- N3c- metastases in the supraclavicular lymph nodes (node)
  Note:*Clinically detectable is defined as being truly detectable only clinically or detectable by imaging techniques (excluding lymphoscintigraphy) and having features highly suggestive of malignancy or confirmed by fine needle biopsy with cytology. Confirmation of clinically detectable metastasis by fine-needle biopsy without excisional biopsy is indicated by the addition (f), for example, cN3a(f). Excisional lymph node biopsy or sentinel lymph node biopsy in the absence of a pT score allows classification of cN, e.g., cN1. Pathological classification (pN) is used in removal or biopsy of the sentinel lymph node only in combination with a pathological T score.

M- distant metastases
M0- no distant metastases
M1- there are distant metastases

Light: PUL
Bone marrow: BRA
Bones: OSS
Pleura: PLE
Liver: HEP
Abdomen: PER
Brain: BRA
Adrenals: ADR
Lymph nodes: LYM
Skin: SKI
Others: O.T.H.

pTNM pathological classification

pT- primary tumor
Pathological classification requires assessment of the primary tumor in the absence of a macroscopically detectable tumor at the resection margin. A case can be classified if the tumor at the resection margin is only visible microscopically. pT categories correspond to T categories.
Note: To classify pT, the size of the invasive tumor component is taken into account. If there is a large non-invasive component (in situ) (eg 4 cm) and a small invasive component (eg 0.5 cm), the tumor is coded as pT1a.
pN– Regional lymph nodes
Pathological classification requires removal and examination of at least the lower (level I) lymph nodes (see page Regional lymph nodes). This operation usually examines 6 or more lymph nodes. If the lymph nodes are negative but less than normal, the case is classified as pN0.
pNx– Status of regional lymph nodes cannot be assessed (e.g. removed earlier or not removed)
pN0– no metastases in regional lymph nodes*
Note:*cluster of isolated tumor cells (ITC) refers to single tumor cells or small aggregations of tumor cells no larger than 0.2 mm in greatest dimension, which can be determined by conventional staining with hematoxylin and eosin or immunohistochemically. An additional criterion for ITC can be an assessment of the number of cells: an accumulation of no more than 200 cells in one histological section. Nodes containing only ITC are excluded from the number of affected nodes for N qualification purposes and included in the total number of nodes examined. Isolated tumor cells usually do not show metastatic activity (eg, proliferation or stromal reaction) or spread beyond the lymphatic or sinus wall. Cases with ITC in lymph nodes or distant organs should be classified as N0 or M0, respectively. The same approach applies to cases where tumor cells or their components are detected by non-morphological methods such as flow cytometry or DNA analysis. These cases are considered separately. They are classified as follows:
- pN0– No lymph node metastases on histological examination, no search for ITC was performed
- pN0(i-)– No lymph node metastases on histological examination, no ITC on morphological examination
- pN0(i+)– No lymph node metastases on histological examination, ITC detected on morphological examination
- pN0(mol-)– No lymph node metastases on histological examination, no ITC on non-morphological examination
- pN0(mol+)
Cases with search for ITC in sentinel lymph nodes can be classified as follows:
- pN0(i-)(sn)– No metastases in the sentinel lymph nodes on histological examination, ITC were not detected on morphological examination
- pN0(i+)(sn)– No metastases in sentinel lymph nodes on histological examination, ITC detected on morphological examination
- pN0(mol-)(sn)– No metastases in sentinel lymph nodes on histological examination, no ITC on non-morphological examination
- pN0(mol+)(sn)– No metastases in sentinel lymph nodes on histological examination, ITC detected on non-morphological examination
- pN0(mol+)– No lymph node metastases on histological examination, ITC detected on non-morphological examination
pN1– Micrometastases; or metastases in 1-3 axillary lymph nodes; and / or in the internal thoracic lymph nodes with metastases, determined by biopsy of the sentinel lymph node, but not clinically detectable 1
- pN1mi– Micrometastases (more than 0.2 mm and/or more than 200 cells, but not more than 2.0 mm)
- pN1a– Metastases in 1-3 axillary lymph nodes, including at least 1 more than 2 mm in greatest dimension
- pN1b- internal thoracic lymph nodes with microscopic or macroscopic metastases, determined by biopsy of the sentinel lymph node, but not clinically detectable 1
- pN1c– Metastases in 1-3 axillary lymph nodes and internal mammary lymph nodes with microscopic or macroscopic metastases, determined by biopsy of the sentinel lymph node, but not clinically detectable 1
pN2- metastases in 4-9 ipsilateral axillary lymph nodes or in clinically 1 detected ipsilateral internal mammary lymph nodes in the absence of metastases in axillary lymph nodes
- pN2a- metastases in 4-9 ipsilateral axillary lymph nodes, including at least one more than 2 mm in greatest dimension
- pN2b- metastases in clinically 1 detected ipsilateral internal mammary lymph nodes in the absence of metastases in axillary lymph nodes
pN3– Metastases in:
- pN3a 10 or more axillary lymph node metastases, including at least one greater than 2 mm in greatest dimension, or subclavian lymph node metastases
- pN3b metastases in 1 clinically detectable ipsilateral internal mammary lymph nodes in the presence of metastases in the axillary lymph nodes; or metastases in more than 3 axillary lymph nodes and internal mammary lymph nodes with microscopic or macroscopic metastases detected by sentinel lymph node biopsy but not clinically detectable
- pN3c metastases in ipsilateral supraclavicular lymph nodes
ypN after treatment. ypN after treatment is assessed in the same way as described above in assessing clinical N (before treatment). If the status of the sentinel lymph node was assessed after treatment, the signature sn is used. If there is no such signature, then the assessment of axillary lymph nodes was performed on the removed axillary lymph nodes. X is used (ypNX) in cases where neither sentinel lymph node biopsy nor axillary lymphadenectomy has been performed. The categories of N are the same as for pN.
Note: 1 - Clinically detectable is defined by imaging techniques (excluding lymphoscintigraphy) or by clinical examination, and has features highly suggestive of malignancy, or suspected macrometastasis based on fine needle biopsy with cytology. Not clinically detectable means not detectable by imaging techniques (excluding lymphoscintigraphy) or by clinical examination.
pM- distant metastases
pM1– distant metastases confirmed by microscopy
Note: pM0 and pMX are not valid categories. The pM1 category can be refined in the same way as M1 according to the location of the metastases. Isolated tumor cells (ITC) found in the bone marrow by morphological methods are classified according to the scheme described for N, ie, M0(i+). For non-morphological ITC detection methods, the addition of “mol” to M is used, for example, M0(mol+).

G histopathological grade.

For histopathological grades, see: Elston C.W., Ellis I.O. Pathological prognostic factors in breast cancer. I. The value of histological grade in breast cancer: experience from a large study with long-term follow-up. Histopathology 1991; 19:403-410.

R classification of residual tumor

The presence or absence of a residual tumor is described by the symbol R (residual). TNM and pTNM describe the anatomical extent of the tumor as a whole, without regard to treatment. They can be supplemented by the R classification, which describes the status of the tumor after treatment. It reflects the effect of treatment, influences subsequent treatment and is a strong prognostic factor.

RX– Presence of residual tumor cannot be assessed
R0– No residual tumor
R1– Microscopic residual tumor
R2– Macroscopic residual tumor

Grouping by stages

Stage IA: T1*: N0: M0
Stage IB: T0, T1*: Nmi: M0
Stage IIA: T0, T1*: N1: M0; T2:N0:M0
Stage IIB: T2: N1: M0; T3:N0:M0
Stage IIIA: T0, T1*, T2: N2: M0; T3: N1, N2: M0
Stage IIIB: T4: N0, N1, N2: M0
Stage IIIC: any T: N3: M0
Stage IV: any T: any N: M1

Note: *T1 includes T1mi.

Generalization

T1: ≤ 2cm
T1mi: ≤ 0.1cm
T1a: >0.1 cm to 0.5 cm
T1b: >0.5 cm to 1.0 cm
TT1c: >1.0 cm to 2.0 cm
T2: >2.0cm to 5cm
T3: >5cm
T4: Chest wall, skin ulceration, skin satellites, skin edema
T4a: Chest wall
T4b: Skin ulceration, skin satellites, skin edema
T4c: Combination of T4a and T4b symptoms
T4d: Edema-infiltrative form
N1: Movable axillae
pN1mi: micrometastases >0.2 to 2.0 mm
pN1a: 1-3 axillary nodes
pN1b: internal thoracic nodes with microscopic or macroscopic metastases in the sentinel nodes, but not clinically detectable
pN1c: 1-3 axillary and internal mammary nodes with microscopic or macroscopic sentinel node metastases, but not clinically detectable
N2a: Fixed axillary
pN2a: 4-9 axillary nodes
N2b: internal thoracic, clinically certain
pN2b: internal thoracic nodes, clinically detectable without axillary nodes
N3a: subclavian
pN3a: ≥10 axillary nodes or
N3b: internal thoracic and axillary
pN3b: Clinically detectable internal thoracic nodes with axillary node(s) or more than 3 axillary nodes with microscopic metastases identified by sentinel lymph node biopsy but not clinically detectable
N3c: Supraclavicular
pN3c: Supraclavicular

In pancreatic cancer, unlike other malignant neoplasms, this classification is rarely used. Many patients with pancreatic cancer do not need surgery.

Classification according to the TNM system involves an assessment of the tumor itself, its spread to the lymph nodes and metastasis to distant organs. The combined evaluation of the results allows you to set the stage of pancreatic cancer in each case. There are five stages of pancreatic cancer from I to IV, the very first stage is zero.

TNM are abbreviations for the English words "tumor" ( T umor), "lymph node" ( N ode) and "metastasis" ( M etastasis). To determine the stage of the tumor, doctors evaluate the following factors:

Primary tumor size
Spread of tumor to lymph nodes
Metastases in distant organs

Category T

TX: Impossible to assess the state of the primary tumor

T0: No signs of cancer in the pancreas

Tis: The earliest manifestations of cancer without tumor spread - carcinoma in situ

T1: Tumor diameter 2 cm or less, located within the pancreas

T2: Tumor diameter more than 2 cm, located within the pancreas

T3: The tumor extends beyond the pancreas, but does not penetrate into large arteries or veins near the organ

T4: The tumor extends beyond the pancreas and invades large arteries or veins near the organ. Tumor category T4 is inoperable.

Category N

NX: It is impossible to assess the state of regional lymph nodes.

N0: There are no signs of cancer in the regional lymph nodes.

N1: The tumor has spread to regional lymph nodes.

Category M

MX: Unable to detect distant metastases.

M0: The tumor does not metastasize.

M1: Metastases are found in distant organs. Pancreatic cancer metastasizes predominantly to the liver, lungs, and peritoneum.

Stage grouping

The exact stage of cancer can be determined by combining categories T, N and M.

Stage 0:(Tis, N0, M0) Cancer in situ. The tumor does not extend beyond the pancreatic ducts.

Stage IA:(T1, N0, M0) Tumor up to 2 cm within the pancreas that has not spread to lymph nodes or other organs.

Stage IB:(T2, N0, M0) Tumor larger than 2 cm within the pancreas that has not spread to the lymph nodes or other organs.

Stage IIA:(T3, N0, M0) The tumor extends beyond the pancreas. Does not spread to adjacent arteries or veins. Does not spread to lymph nodes or distant organs.

Stage IIB:(T1, T2, or T3; N1; M0) Tumor of any size. Does not apply to neighboring arteries or veins. Spreads to lymph nodes or other organs.

Stage III:(T4, N1, M0) The tumor has spread to nearby arteries, veins, and/or lymph nodes. It does not metastasize to distant organs.

Stage IV:(any T, any N, M1) Tumor of any size. Metastasizes to distant organs.

Recurrent pancreatic cancer: Reappearance of the tumor after treatment.

The main task of the clinician is planning the most effective course of treatment and determining the prognosis of the disease, which is impossible without an objective assessment of the anatomical extent of the tumor process. For this purpose, a classification is needed, the basic principles of which would be applicable to most malignant tumors and which could subsequently be supplemented by information obtained from histological examination and / or surgical intervention.

The TNM system, which meets these requirements, was developed by P. Denoix (France) in the period from 1943 to 1952. In 1954, the International Anticancer Union founded a special Committee on Clinical Classification and the Application of Statistics "for the purpose of research in this area and the application of general rules classification for all malignant tumors of any localization. In the period from 1954 to 1968, a number of brochures were published with proposals for the classification of malignant tumors of 23 localizations, and in 1969 these brochures were combined into the book Livre de Poche, published and translated into 11 languages, including Russian. Subsequent editions contained classifications of malignant tumors of new localizations, as well as additions and corrections to previous, already published classifications. The current 5th (1997) edition of the classification has been approved by all TNM National Committees. After the completion of the latest version of the TNM classification, the International Cancer Union decided that this classification would remain unchanged until there were radical changes in the possibilities of diagnosing and treating malignant tumors that would require its revision, but in 2002 the 6th A TNM edition approved and accepted by the American Joint Committee on Cancer and the International Cancer Union, which has been recommended for use since January 2003.

The TNM classification used to describe the anatomical extent of a tumor process is based on three components:

T - size and spread of the primary tumor;
N - absence or presence of metastases in regional lymph nodes and the degree of their damage;
M - absence or presence of distant metastases.

The numbers added to these three main components indicate the prevalence of the process:

TO, Tl, Т2, ТЗ, Т4 N0, N1, N2, N3 MO, M1

The brevity of the designation of the degree of spread of a malignant tumor and the generality of the rules used for all localizations of solid tumors ensure the effectiveness of the application of the International Classification. There are general rules that apply to tumors of all localizations:

In as many cases as possible, there should be histological confirmation of the diagnosis; cases without morphological confirmation are described separately.
In each case, two classifications are described: clinical (TNM or cTNM), based on clinical, radiological, endoscopic, morphological, surgical and other research methods; morphological (post-surgical classification), designated pTNM. It is based on data available before the start of treatment, but supplemented or modified on the basis of information obtained during surgical intervention and histological examination of the surgical material. In the morphological assessment of the primary tumor, its resection and biopsy is necessary to correctly assess the extent of its spread (pT). For pathohistological assessment of the state of regional lymph nodes (pN), their adequate removal is required, which allows determining the absence or presence of metastases in them. For morphological assessment of distant metastases (RM), their microscopic examination is necessary.
Once the T, N, M and/or pT, pN, pM categories have been determined, staging can be performed. The established degree of spread of the tumor process according to the TNM system or by stages should remain unchanged in the medical records. Clinical classification is especially important for the selection and evaluation of treatment methods, while histopathological classification provides the most accurate data for the prognosis and evaluation of long-term treatment results.
If there is any doubt about the correctness of the definition of categories T, N or M, then the lowest (ie, less common) category should be chosen. This rule also applies to grouping by stages.
In the case of multiple synchronous malignant tumors that have arisen in one organ, the classification is based on the assessment of the tumor with the highest category T, and the multiplicity and number of tumors are additionally indicated: T2(m) or T2(5). When synchronous bilateral tumors of paired organs occur, each tumor is classified separately.
The description of TNM and staging may be narrowed or extended for clinical or scientific purposes while maintaining the established basic categories of TNM, so T, N, or M may be subdivided into subgroups.

The clinical classification of TNM uses general principles:

T - primary tumor:
Tx - it is not possible to estimate the size and local spread of the primary tumor;
TO - the primary tumor is not determined;
Tis - preinvasive carcinoma (carcinoma in situ);
T1, T2, TK, T4 - reflects the increase in the size and / or local spread of the primary tumor.
N - regional lymph nodes:
Nx - insufficient data to evaluate regional lymph nodes;
N0 - no signs of metastatic lesions of regional lymph nodes;
N1, N2, N3 - reflects the varying degree of metastatic damage to regional lymph nodes.

Note. Direct spread of the primary tumor to the lymph nodes is regarded as their metastatic lesion. Metastases in any lymph nodes that are not regional for this localization are classified as distant,

M - distant metastases:

Mx - insufficient data to evaluate distant metastases; MO - no signs of distant metastases; Ml - there are distant metastases. The Ml category can be supplemented with symbols depending on the location of distant metastases:

Lungs - PUL
Bone marrow - MAR
Bones - OSS
Pleura - PLE
Liver - HEP
Peritoneum - PER
Brain - BRA
Adrenals - ADR
Lymph nodes - LYM
Leather - SKI
Others - OTN

The pathohistological classification of pTNM in all cases uses the following general principles:

pT - primary tumor:
pTX - the primary tumor cannot be assessed histologically;
pTO - histological examination did not reveal any signs of a primary tumor;
pTis - preinvasive carcinoma (carcinoma in situ);
pT1, pT2, pT3, pT4 - histologically confirmed increase in the degree of spread of the primary tumor.
pN - regional lymph nodes:
pNx - the state of regional lymph nodes cannot be assessed;
pNO - metastatic lesions of regional lymph nodes were not detected;
pN1, pN2, pN3 - histologically confirmed increase in the degree of damage to regional lymph nodes.

Note. Direct spread of the primary tumor to the lymph nodes is regarded as a metastatic lesion.

A tumor nodule larger than 3 mm found in connective tissue or in lymphatic vessels outside the lymph node tissue is considered a regional metastatic lymph node. A tumor nodule up to 3 mm is classified in the pT category as tumor extension.

When the size of the metastasized lymph node is the criterion for determining pN, as in breast cancer, only the affected lymph nodes are evaluated, not the entire group.

pM - distant metastases:
pMx - the presence of distant metastases cannot be determined microscopically;
rMO - microscopic examination did not reveal distant metastases;
pM1 - microscopic examination confirmed distant metastases.

Also, if more detail is needed, a subdivision of the main categories (for example, pT1a and / or pN2a) is possible.

Histological differentiation - G

Additional information regarding the primary tumor can be noted as follows:

Gx - the degree of differentiation cannot be established;
G1 - high degree of differentiation;
G2 - average degree of differentiation;
G3 - low degree of differentiation;
G4 - undifferentiated tumors.

Note. Grade 3 and 4 may be combined in some cases as "G3-4, poorly differentiated or undifferentiated tumor".

When encoding according to the TNM classification, additional characters may be used.

Thus, in cases where the classification is determined during or after the use of various treatments, the TNM or pTNM categories are marked with the symbol "y" (for example, yT2NlM0 or pyTlaN2bM0).

Tumor recurrences are shown with the symbol g (for example, r T1N1aMO or r pT1aN0M0).

The symbol a indicates the establishment of TNM after autopsy.

The symbol m denotes the presence of multiple primary tumors of the same localization.

The symbol L defines the invasion of the lymphatic vessels:

Lx - invasion of the lymphatic vessels cannot be detected;
L0 - no invasion of lymphatic vessels;
L1 - invasion of the lymphatic vessels detected.
Symbol V describes invasion of venous vessels:
Vx - invasion of venous vessels cannot be detected;
V0 - no invasion of venous vessels;
V1 - microscopically revealed invasion of venous vessels;
V2 - macroscopically determined invasion of venous vessels.

Note. Macroscopic lesion of the venous wall without the presence of a tumor in the lumen of the vessel is classified as V2.

It is also informative to use the C-factor, or the level of reliability, which reflects the reliability of the classification, taking into account the diagnostic methods used. The C factor is divided into:

C1 - data obtained using standard diagnostic methods (clinical, radiological, endoscopic studies);
C2 - data obtained using special diagnostic techniques (X-ray examination in special projections, tomography, computed tomography, angiography, ultrasound, scintigraphy, magnetic resonance, endoscopy, biopsy, cytological studies);
SZ - data obtained as a result of a trial surgical intervention, including biopsy and cytological examination;
C4 - data obtained after radical surgery and morphological examination of the surgical material; C5 - data obtained after autopsy.

For example, a specific case can be described as follows: T2C2 N1C1 M0C2. Thus, the clinical classification of TNM before treatment corresponds to CI, C2, C3 with varying degrees of reliability, pTNM is equivalent to C4.

The presence or absence of a residual (residual) tumor after treatment is indicated by the R symbol. The R symbol is also a prognostic factor:

Rx - not enough data to determine the residual tumor;
R0 - no residual tumor;
R1 - residual tumor is determined microscopically;
R2 - residual tumor is determined macroscopically.

The use of all the additional characters listed is optional.

Thus, the classification according to the TNM system gives a fairly accurate description of the anatomical distribution of the disease. Four degrees for T, three degrees for N, and two how long does viagra last degrees for M make up the 24 TNM categories. For comparison and analysis, especially of large material, it becomes necessary to combine these categories into groups by stages. Depending on the size, degree of germination in the surrounding organs and tissues, metastasis to the lymph nodes and distant organs, the following stages are distinguished:

stage 0 - carcinoma in situ;
Stage 1 - a tumor of small size, usually up to 2 cm, not extending beyond the affected organ, without metastases to the lymph nodes and other organs;
Stage II - a tumor of somewhat large size (2-5 cm), without single metastases or with single metastases to regional lymph nodes;
Stage III - a tumor of considerable size that has sprouted all layers of the organ, and sometimes the surrounding tissues, or a tumor with multiple metastases to regional lymph nodes;
Stage IV - a significant tumor that has sprouted all layers of the organ, and sometimes the surrounding tissues, or a tumor of any size with metastases to distant organs.