TNM Staging Colon and Rectum TONYA BRANDENBURG MHA

TNM Staging: Colon and Rectum TONYA BRANDENBURG, MHA, CTR KENTUCKY CANCER REGISTRY

Overview � Colorectal Anatomy � Common Terms � Rules for Colorectal Cancer � Changes in T, N, M Staging from AJCC 6 th edition to 7 th edition � Elements of Staging: TX-T 4, NX-N 2 b, and M 0 -M 1 b � Stage Groups and Prognostic Factors � Helpful Hints � Colon/Rectal Examples

C 18. 4 C 18. 3 C 18. 5 C 18. 2 C 18. 6 C 18. 0 C 18. 1 C 18. 7 C 18. 1 C 21. --- C 20. 9 Not Shown: Rectosigmoid C 19. 9

Anatomy of the Colon and Rectum RIGHT COLON Appendix (C 18. 1) Cecum (C 18. 0): 150 cm from anal verge Ascending Colon (C 18. 2): 132 -150 cm from verge Hepatic Flexure (C 18. 3) Transverse Colon (C 18. 4): 82 -132 cm from verge LEFT COLON Splenic Flexure (C 18. 5) Descending Colon (C 18. 6): 57 -82 cm from anal verge Sigmoid Colon (C 18. 7): 17 -57 cm from verge Rectosigmoid (C 19. 9): 15 -17 cm from verge Rectum (C 20. 9): 4 -16 cm from verge

Colon and Rectum Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer Anatomic subsites of the rectum

Common Terms. Circumferential margin – Any aspect of the colorectum that is not covered by a serosal layer and must be dissected from the retroperitoneum or subperitoneum to remove the viscus. � Familial polyposis, familial adenomatous polyposis (FAP) a condition characterized by the development of many adenomatous polyps, often seen in several members of the same family � Polyp, adenoma – These mean the same thing! � Adenoma - A benign lesion composed of tubular or villous structures showing intraepithelial neoplasia �

Non-Peritonealized Surface or Serosalized Area Some colon surfaces have no serosa at the exterior surface (around the hollow organ) � The serosa acts as barrier for tumors that begin on inside surface of the colon and invade down into the mucosa and through the wall of the colon (the serosa) � When there is no serosa – you lose a natural barrier that helps contain the colon cancer � Non-Peritonealized Surfaces in Colon-Rectum: � � Rectum – no serosa in rectum below peritoneal reflection � Descending Colon – no serosa covering posterior surfaces � Ascending Colon – no serosa covering posterior surfaces

Non-Peritonealized Surface or Serosalized Area No Serosa Here Source: Clinical Anatomy for Medical Students, 5 th Edition, Richard S. Snell. Little, Brown and Company, 1995.

Rules for Colon/Rectal Cancer � Every individual site is a separate primary � Use C 18. 8 for one lesion that overlaps two segments of colon where tumor point of origin cannot be determined � Code C 18. 9 for multiple malignant adenomatous polyps or malignant adenomatous polyposis coli in various segments. Tumor size must be 998; histology = 8220/3 or 8221/3 � Code C 19. 9 if one lesion overlaps the colon and rectum and point of origin cannot be determined � If malignant polyp & frank malignancy in same segment of colon, code the frank malignancy

Changes in T, N, M Staging for Colon/Rectum from 6 th edition to 7 th edition � Expansion of Stages II and III based on survival and relapse data that was not available for the 6 th edition. � Subdivision of T 4, N 1, and N 2 � M 1 Also subdivided: M 1 a for a single metastatic site, M 1 b if multiple metastatic sites � TNM scheme for carcinoma only; GIST and Neuroendocrine tumors now have their own chapters

Elements of Staging: TX, T 0, and Tis � TX: Tumor not seen on films � T 0: No evidence of primary tumor (use when you have metastasis that is consistent with colon/rectum primary, but no evidence of a primary tumor can be found) � Tis: Tis is confined to glandular basement membrane or lamina propria with NO extent through muscularis mucosa � Tumor in stalk of polyp is Tis if limited to lamina propria, but T 1, T 2, etc. if further invasion is noted

Elements of Staging: T 1, T 2, and T 3 � T 1: Tumor invades the submucosa � T 2: Tumor invades the muscularis propria � T 3: Invasion into subserosa, or through subserosa into pericolorectal tissues

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer T 1 tumor invades submucosal.

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer T 2 tumor invades muscularis propria.

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer T 3 tumor invades through the muscularis propria into pericolorectal tissues.

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer Circumferential resection margin. T 4 a (left side) has perforated the visceral peritoneum. In contrast, T 3; R 2 (right side) shows macroscopic involvement of the circumferential resection margin of a non-peritonealized surface of the colorectum by tumor with gross disease remaining after surgical excision.

Elements of Staging: T 4 (T 4 a and T 4 b) � T 4: Tumor directly invades other organs or structures, and/or perforates visceral peritoneum: � T 4 a: tumor penetrates to the surface of the visceral peritoneum � T 4 b: tumor directly invades or is adherent to other organs or structures

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer T 4 a tumor penetrates to the surface of the visceral peritoneum. The tumor perforates (penetrates) visceral peritoneum, as illustrated here.

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer T 4 a tumor perforates visceral peritoneum (shown with gross bowel perforation through the tumor).

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer T 4 b tumor directly invades or is adherent to other organs or structures, as illustrated here with extension into an adjacent loop of small bowel.

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer T 4 b tumor directly invades or is adherent to other organs or structures (such as the sacrum shown here).

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer The regional lymph nodes of the colon and rectum are colored by anatomic location, e. g. , dark brown – right colon and cecum; blue – hepatic flexure to mid transverse colon; red – splenic flexure, left colon and sigmoid colon.

Lymphatic Drainage � Each subsite of the colon has its own drainage system � For all colon subsites, these include: Colic, NOS; Paracolic/ Pericolic. Right Colon � Cecum and appendix: � � Right colic, middle colic Transverse: � Middle colic Splenic flexure: � � Ileocolic, right colic, middle colic Hepatic Flexure: � � Cecal, anterior & posterior; ileocolic, right colic Ascending: � Left Colon Descending colon: � � Middle colic & left colic; inferior mesenteric Left colic, sigmoid, inferior mesenteric Sigmoid: � Sigmoidal, superior hemorrhoidal, superior rectal, inferior mesenteric

Satellite Nodules � Satellite peritumoral nodule in the pericolorectal tissue of a primary carcinoma without histologic evidence of residual lymph node in the nodule may represent discontinuous spread, venous invasion with extravascular spread, or a totally replaced lymph node � Replaced nodes should be counted separately as positive nodes in the N category

Elements of Staging: NX, N 0, N 1 a, and N 1 b � NX: Regional lymph nodes can’t be assessed � N 0: No regional lymph node metastasis � N 1: Metastasis in 1 -3 regional lymph nodes � N 1 a: Metastasis in 1 regional lymph node � N 1 b: Metastasis in 2 -3 regional lymph nodes

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer N 1 a is defined as metastasis in one regional lymph node.

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer N 1 b is defined as metastasis in 2 to 3 regional lymph nodes.

Elements of Staging: N 1 c � N 1 c: Tumor deposits in the subserosa, mesentery, or non peritonealized pericolic or perirectal tissues WITHOUT regional nodal metastasis � Foci of tumor found in the pericolic or perirectal fat or in adjacent mesentery (mesocolic fat) away from the leading edge of the tumor and showing no evidence of residual lymph node tissue are classified as N 1 c � If tumor nodules are seen in lesions that would otherwise be classified as T 1 or T 2, then the primary tumor classification is not changed, but the nodule is recorded as an N 1 c positive node.

Elements of Staging: N 2 a and N 2 b � N 2: Metastasis in four or more regional lymph nodes � N 2 a: Metastasis in 4 -6 regional lymph nodes � N 2 b: Metastasis is 7 or more regional lymph nodes

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer N 2 a is defined as metastasis in 4 to 6 regional lymph nodes.

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer N 2 b is defined as metastasis in seven or more regional lymph nodes.

Compton, C. C. , Byrd, D. R. , et al. , Editors. AJCC Cancer. Staging Atlas, 2 nd Edition. New York: Springer, 2012. ©American Joint Committee on Cancer N 2 b showing nodal masses in more than 7 regional lymph nodes.

Elements of Staging: MX, M 0, and M 1 � MX: No longer exists in TNM Staging � M 0: No distant metastasis (Remember: not possible for pathologic staging) � M 1: Distant Metastasis � � M 1 a: Metastasis confined to one organ or site � M 1 b: Metastasis in more than one organ/site or the peritoneum Common metastatic sites include liver*, lungs, seeding of other segments of the colon, small intestine, or peritoneum � *Involvement of the liver is not considered distant metastasis if tumor has directly extended into the liver from the hepatic flexure or the right side of the transverse colon

Stage Groups

Prognostic Factors for Colon and Rectum � Preoperative or pretreatment carcinoembryonic antigen (CEA) � Tumor deposits � Circumferential resection margin (CRM) � Perineural invasion � Microsatellite instability � Tumor regression grade (with neoadjuvant therapy) � KRAS gene analysis � Note: None of these are required for staging. They are however, clinically significant

Hints for Colorectal Cancer � Involvement of serosal surface is T 4 a � Direct extension to certain organs (such as liver) from certain areas of colon (transverse, flexures, ascending, cecum) is T 4 b � If T 4 due to direct extent to abdominal organ & there is discontinuous metastasis there as well, M 1 a or M 1 b also applies � Tumor that is adherent to other organs or structures grossly is classified T 4 b. If no tumor is present microscopically in the adhesion, then it is p. T 1 -4 a, depending upon depth of wall invasion.

Colon Case 1 Answers Topography: C 18. 5 Histology: 8263/3 This case is one primary per rule M 2 Clinical Staging Pathological Staging c. T p. Tis p. T 2 c. N 0 p. N 0 c. M 0 p. M c. M 0 Clinical Stage Group 0 Pathologic Stage Group 1 SEER Summary Stage: 1 - Localized

Colon Case 2 Answers Topography: C 18. 4 Histology: 8140/3 This case is one primary per rule M 2 Clinical Staging Pathological Staging c. T X p. T 3 c. N X p. N 2 a c. M p. M 1 a p. M 1 b Clinical Stage Group IVA Pathologic Stage Group IVB SEER Summary Stage: 7 - Distant