Colon cancer staging is an estimate of the amount of penetration of a particular cancer. It is performed for diagnostic and research purposes, and to determine the best method of treatment. The systems for staging colorectal cancers depend on the extent of local invasion, the degree of lymph node involvement and whether there is distant metastasis.

Definitive staging can only be done after surgery and histopathology of colorectal carcinoma. An exception to this principle would be after a colonoscopic polypectomy of a malignant pedunculated polyp with minimal invasion. Preoperative staging of rectal cancers may be done with endoscopic ultrasound. Adjunct staging of metastasis include abdominal ultrasound, MRI, CT, PET scanning, and other imaging studies.

TNM staging system The most common staging system is the TNM (for tumors/nodes/metastases) system, from the American Joint Committee on Cancer. This system assigns a number based on three categories. "T" denotes the degree of invasion of the intestinal wall, "N" the degree of lymphatic node involvement, and "M" the degree of metastasis. Possibly, the overall Joint Committee stage is a shorter format of the TNM stage, and is usually quoted as a number I, II, III, IV derived from the TNM value grouped by prognosis; a higher number indicates a more advanced cancer and likely a worse outcome. Following is the eighth edition from 2017:

Tumor (T)

Numbers 0 to 4, with subgroups, are used to describe deepest tumor depth: Approved by the Cancer.Net Editorial Board, 11/2018. In turn citing: TX: The primary tumor cannot be evaluated. T0: No evidence of cancer in the colon or rectum. Tis: Carcinoma in situ; Cancer cells are found only in the epithelium or lamina propria T1: Growth into the submucosa T2: Growth into the muscularis propria T3: Growth through the muscularis propria and into the subserosa, or into tissues surrounding the colon or rectum (but not the visceral peritoneum or surrounding organs). T4a: Growth into the surface of the visceral peritoneum. T4b: The tumor has grown into or has attached to other organs or structures.

Node (N) Numbers 0 to 2, and subgroups, are used to describe lymph node involvement: NX: The regional lymph nodes cannot be evaluated. N0: No evidence of spread to regional lymph nodes. N1a: Tumor cells found in 1 regional lymph node. N1b: Tumor cells found in 2 or 3 regional lymph nodes. N1c: There are cancerous nodules near the colon that do not appear to be lymph nodes. N2a: Tumor cells found in 4 to 6 regional lymph nodes. N2b: Tumor cells found in 7 or more regional lymph nodes.

Metastasis (M) Numbers 0 and 1, with subgroups, describe the metastasis status: M0: No evidence of distant metastasis M1a: Spread to 1 other part of the body beyond the colon, rectum or regional lymph nodes. M1b: Spread to more than 1 part of the body other than the colon, rectum or regional lymph nodes. M1c: Spread to the peritoneal surface.

Overall AJCC stage AJCC stage TNM stage TNM stage criteriaStage 0Tis N0 M0Tis: Tumor confined to mucosa; cancer-in-situ Stage IT1 N0 M0T1: Tumor invades submucosaT2 N0 M0T2: Tumor invades muscularis propriaStage II-AT3 N0 M0T3: Tumor invades subserosa or beyond (without other organs involved)Stage II-BT4a N0 M0T4a: Tumor perforates the visceral peritoneumStage II-CT4b N0 M0T4b: Tumor invades adjacent organsStage III-AT1–2 N1 M0 or T1, N2a, M0N1: Tumor cells in 1 to 3 regional lymph nodes. T1 or T2. N2a: Tumor cells in 4 to 6 regional lymph nodes. T1Stage III-BT3–4a, N1 M0 or T2–3, N2a, M0 or T1–2 N2b M0N1: Tumor cells in 1 to 3 regional lymph nodes. T3 or T4 N2a: Tumor cells in 4 to 6 regional lymph nodes. T2 or T3 N2b: Tumor cells in 7 or more regional lymph nodes. T1 or 2Stage III-C T4a N2a M0 or T3–4a N2b M0 or T4b N1–2, M0N2a: Tumor cells in 4 to 6 regional lymph nodes. T4a N2b: Tumor cells in 7 or more regional lymph nodes. T3–4a N1–2: Tumor cells in at least one regional lymph node. T4bStage IVa any T, any N, M1a M1a: Metastasis to 1 other part of the body beyond the colon, rectum or regional lymph nodes. Any T, any N.Stage IVb any T, any N, M1b M1b: Metastasis to more than 1 other part of the body beyond the colon, rectum or regional lymph nodes. Any T, any N.Stage IVc any T, any N, M1c M1c: Metastasis to the peritoneal surface. Any T, any N.

Dukes classification

In 1932 the British pathologist Cuthbert Dukes (1890–1977) devised a classification system for colorectal cancer.Who Named It, showing correct grammatical usage Several different forms of the Dukes classification were developed.Kyriakos M: The President cancer, the Dukes classification, and confusion, Arch Pathol Lab Med 109:1063, 1985Dukes CE. The classification of cancer of the rectum. Journal of Pathological Bacteriology 1932;35:323 However, this system has largely been replaced by the more detailed TNM staging system and is no longer recommended for use in clinical practice.AJCC (American Joint Committee on Cancer) Cancer Staging Manual, 7th ed, Edge, SB, Byrd, DR, Compton, CC, et al (Eds), Springer, New York 2010. p 143.

Dukes A: Invasion into but not through the bowel wall Dukes B: Invasion through the bowel wall penetrating the muscle layer but not involving lymph nodes Dukes C: Involvement of lymph nodes Dukes D: Widespread metastasesSingle Best Answers in Surgery, Patten DK et al. Hodder Education 2009. p.107 ()

Astler–Coller classification An adaptation by the Americans Astler and Coller in 1954 further divided stages B and CAstler VB, Coller FA: The prognostic significance of direct extension of carcinoma of the colon and rectum. Ann Surg 139:846, 1954

Stage A: Limited to mucosa Stage B1: Extending into muscularis propria but not penetrating through it; nodes not involved Stage B2: Penetrating through muscularis propria; nodes not involved Stage B3: Invading into adjacent organs/structures; nodes not involved Stage C1: Extending into muscularis propria but not penetrating through it. Nodes involved Stage C2: Penetrating through muscularis propria. Nodes involved Stage D: Distant metastatic spread

The stage gives valuable information for the prognosis and management of the particular cancer.

Full Dukes classification Another modification of the original Dukes classification was made in 1935 by Gabriel, Dukes and Bussey.Gabriel WB, Dukes C, Busset HJR: Lymphatic spread in cancer of the rectum. Br J Surg 23:395–413, 1935 This subdivided stage C. This staging system was noted to be prognostically relevant to rectal and colonic adenocarcinoma.Grinnell RS: The grading and prognosis of carcinoma of the colon and rectum. Ann Surg 109:500–33, 1939 Stage D was added by Turnbull to denote the presence of liver and other distant metastasesTurnbull RB Jr, Kyle K, Watson FR, et al: Cancer of the colon: the influence of the no touch isolation technique on survival rates. Ann Surg 166:420–7, 1967

Stage A: Limited to muscularis propria; nodes not involved Stage B: Extending beyond muscularis propria; nodes not involved Stage C: Nodes involved but highest (apical) node spared Stage D: Distant metastatic spread

References

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