Radiation Oncology/Prostate/Staging

Prostate Cancer Staging

AJCC

Current Staging

AJCC 8th edition (2017)

• To be used for staging beginning Jan 1, 2018.

Reference: [1]

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<20
IIB	G3+4=7	Interm	PSA < 20
IIC	G4+3=7 G8	Interm High	G4+3 and PSA<20 G8 and PSA<20
IIIA	G6-8	High	PSA > 20
IIIB	G6-8	Very High (prior AJCC Stage III)	T3-T4
IIIC	G9 or 10	High
IVA		prior AJCC Stage IV	N1
IVB		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