Radiation Oncology/Prostate/Staging

Prostate Cancer Staging

AJCC

Current Staging

AJCC 7th Edition (2009)

Note: new staging incorporates Gleason + PSA for risk group determination

Primary Tumor:

• T1 - clinically inapparent tumor neither palpable nore 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 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:

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 (excluding those that meet criteria for Group I)

  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).

Changes from 6th Edition:

• New stage groupings incorporate Gleason + PSA
• Microscopic bladder neck invasion (previously T4) is now T3a

Older staging systems

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