Radiation Oncology/Prostate/Staging

Prostate Cancer Staging

Current Staging
AJCC 8th edition (2017)
 * To be used for staging beginning Jan 1, 2018.

Reference:

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 &ge; 10 and < 20, Grade group 1 (Gleason 6)
 * pT2 N0 M0, PSA &ge; 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 &ge; 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

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 &le; 6
 * T2a N0 M0, PSA < 10, Gleason &le; 6
 * T1-2a N0 M0, PSA X, Gleason X
 * Group IIA
 * T1a-c N0 M0, PSA < 20, Gleason 7
 * T1a-c N0 M0, PSA &ge; 10 < 20, Gleason &le; 6
 * T2a-b N0 M0, PSA < 20, Gleason 7 (corrected in erratum)
 * T2a N0 M0, PSA &ge; 10 < 20, Gleason &le; 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 &ge; 20, Any Gleason
 * T1-2 N0 M0, Any PSA, Gleason &ge; 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 &le; 6), IIA is "intermediate risk" (roughly, PSA 10-20, or G7 and PSA<20), IIB is "high risk" (T2c or PSA&ge;20 or G&ge;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 1992 AJCC
 * T1 - same as 2002. T2a - < 1/2 lobe, T2b - > 1/2 lobe or both lobes. No T2c. T3a - unilateral ECE, T3b - bilateral ECE.
 * 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