Table Of Content

Brief Contents by Chapter Title/Subject Adrenal Gland ...................................................................515 Melanoma of the Conjunctiva ......................................539 Ampulla of Vater ..............................................................235 Melanoma of the Uvea .................................................547 Anus .....................................................................................165 Melanoma of the Skin ....................................................325 Appendix.............................................................................133 Merkel Cell Carcinoma ....................................................315 Bone .....................................................................................281 Mucosal Melanoma of the Head and Neck .................97 Brain and Spinal Cord ....................................................593 Multiple Myeloma and Plasma Cell Disorders .........617 Breast ..................................................................................347 Nasal Cavity and Paranasal Sinuses ..............................69 Carcinoma of the Conjunctiva .......................................531 Neuroendocrine Tumors .................................................181 Carcinoma of the Eyelid.................................................523 Ocular Adnexal Lymphoma ..........................................583 Carcinoma of the Lacrimal Gland ...............................569 Ovary and Primary Peritoneal Carcinoma .................419 Cervix Uteri .......................................................................395 Pancreas (Endocrine and Exocrine) .............................241 Colon and Rectum............................................................143 Pediatric Lymphoid Malignancy ...................................619 Corpus Uteri ......................................................................403 Penis ....................................................................................447 Cutaneous Squamous Cell Carcinoma and other Perihilar Bile Ducts ...........................................................219 Cutaneous Carcinomas ...................................................301 Pharynx .................................................................................41 Distal Bile Duct .................................................................227 Pleural Mesothelioma ......................................................271 Esophagus and Esophagogastric Junction .................103 Primary Cutaneous Lymphomas ..................................613 Exocrine and Endocrine Pancreas ................................241 Prostate ..............................................................................457 Fallopian Tube ..................................................................429 Renal Pelvis and Ureter ...................................................491 Gallbladder .........................................................................211 Retinoblastoma .................................................................561 Gastrointestinal Stromal Tumor ....................................175 (Major) Salivary Glands .....................................................79 Gestational Trophoblastic Tumors ...............................437 Sarcoma of the Orbit ......................................................577 Hodgkin and Non-Hodgkin Lymphomas ..................607 Small Intestine ...................................................................127 Intrahepatic Bile Ducts ....................................................201 Soft Tissue Sarcoma .........................................................291 Kidney .................................................................................479 Stomach ..............................................................................117 Larynx ....................................................................................57 Testis ...................................................................................469 Lip and Oral Cavity ............................................................29 Thyroid ..................................................................................87 Liver ......................................................................................191 Urethra................................................................................507 Lung ....................................................................................253 Urinary Bladder ................................................................497 Lymphoid Neoplasms .....................................................599 Vagina.................................................................................387 Major Salivary Glands .......................................................79 Vulva ....................................................................................379 AJCC CANCER STAGING MANUAL Seventh Edition EDITORIAL BOARD STEPHEN B. EDGE, M.D., F.A.C.S., Editor Roswell Park Cancer Institute Buffalo, New York DAVID R. BYRD, M.D., F.A.C.S., University of Washington School of Medicine Seattle, Washington CAROLYN C. COMPTON, M.D., Ph.D. National Cancer Institute Bethesda, Maryland APRIL G. FRITZ, R.H.I.T., C.T.R. A. Fritz and Associates Reno, Nevada FREDERICK L. GREENE, M.D., F.A.C.S. Carolinas Medical Center Charlotte, North Carolina ANDY TROTTI, III, M.D. H. Lee Moffi tt Cancer Center Tampa, Florida AJCC CANCER STAGING MANUAL Seventh Edition AMERICAN JOINT COMMITTEE ON CANCER Executive Offi ce 633 North Saint Clair Street Chicago, IL 60611-3211 This manual was prepared and published through the support of the American Cancer Society, the American College of Surgeons, the American Society of Clinical Oncology, the Centers for Disease Control and Prevention, and the International Union Against Cancer. CD-ROM Included American Joint Committee on Cancer Executive Offi ce 633 North Saint Clair Street Chicago, IL 60611-3211 Editors Stephen B. Edge, M.D., F.A.C.S. April G. Fritz, R.H.I.T., C.T.R. Roswell Park Cancer Institute A. Fritz and Associates Buffalo, NY, USA Reno, NV, USA David R. Byrd, M.D., F.A.C.S. Frederick L. Greene, M.D., F.A.C.S. University of Washington School of Medicine Carolinas Medical Center Seattle, WA, USA Charlotte, NC, USA Carolyn C. Compton, M.D., Ph.D. Andy Trotti, III, M.D. National Cancer Institute H. Lee Moffi tt Cancer Center Bethesda, MD, USA Tampa, FL, USA ISBN 978-0-387-88440-0 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2009930462 First to Fifth Editions of the AJCC Cancer Staging Manual, published by Lippincott Raven Publishers, Philadelphia. PA. Sixth Edition of the AJCC Cancer Staging Manual, published by Springer-Verlag, New York, NY. Seventh Edition © 2010 American Joint Committee on Cancer. All rights reserved. The AJCC Cancer Staging Manual is the Offi cial Publication of the American Joint Committee on Cancer. This book consists of a printed book and a CD-ROM packaged with the book, both of which are protected by federal copy-right law and international treaty. The book, except for the Staging Forms, may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science + Business Media LLC, 233 Spring Street, New York, NY 10013, USA), or the copyright holder, except for brief excerpts in connection with reviews or scholarly analysis. For copyright information regarding the CD-ROM, please consult the printed information packaged with the CD-ROM in the back of this publication. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodo- logy now known or hereafter developed is forbidden. Materials appearing in this book prepared by individuals as part of their offi cial duties as U.S. Government employees are not covered by the above-mentioned copyright. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identifi ed as such, is not to be taken as an expression of opinion as to whether or not they are subject to p roprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher nor the AJCC can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained therein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) SEVENTH EDITION Dedicated to Irvin D. Fleming, . . M D SIXTH EDITION Dedicated to Robert V. P. Hutter, M.D. FIFTH EDITION Dedicated to Oliver Howard Beahrs, M.D. FOURTH EDITION Dedicated to the memory of Harvey Baker, M.D. THIRD EDITION Dedicated to the memory of W. A. D. Anderson, M.D. Marvin Pollard, M.D. Paul Sherlock, M.D. SECOND EDITION Dedicated to the memory of Murray M. Copeland, M.D. Seventh Edition Dedication This seventh edition of the AJCC Cancer Staging Manual is on Cancer, the National Cancer Registrars Association, and dedicated to Irvin D. Fleming. Dr. Fleming is a past Chair the North American Association of Central Cancer Registries. of the AJCC and a giant in American oncology. The major Dr. Fleming’s infl uence on cancer care and commitment to changes in cancer staging being introduced with this edition patients extends well beyond the AJCC as evidenced by his are largely the outgrowth of Dr. Fleming’s vision in estab- leadership in many organizations, including service as Presi- lishing a landmark collaboration between the AJCC and dent of the American Cancer Society. For his vision, leader- the National Cancer Institute SEER Program, the National ship, friendship, and support, we dedicate this M anual in his Program for Cancer Registries of the CDC, the Commission honor. v American Joint Committee on Cancer (cid:129) 2010 Preface Cancer staging plays a pivotal role in the battle on cancer. It The level of data supporting the staging systems var- forms the basis for understanding the changes in population ies among disease sites. For some diseases, particularly less cancer incidence, extent of disease at initial presentation, and common cancers, there are few outcome data available. These the overall impact of improvements in cancer treatment. Stag- staging systems are based on what limited data are avail- ing forms the base for defi ning groups for inclusion in clinical able, supplemented by expert consensus. Though potentially trials. Most importantly, staging provides those with cancer and imperfect, these disease schemas are critical to allow the col- their physicians the critical benchmark for defi ning prognosis lection of standardized data to support clinical care and for and the likelihood of overcoming the cancer and for determin- future evaluation and refi nement of the staging system. ing the best treatment approach for their cases. Increasingly, the disease teams of the AJCC and UICC use Refi ning these standards to provide the best possible existing data sets or establish the necessary collaborations to staging system is a never-ending process. Toward this end, develop new large data sets to provide high-level evidence the American Joint Committee on Cancer (AJCC) has led to support changes in the staging system. Examples of this these efforts in the USA since 1959. A collaborative effort include the work in melanoma that led to changes in the sixth between the AJCC and the International Union for Cancer edition and their refi nement in this seventh edition, use of Control (UICC) maintains the system that is used worldwide. the National Cancer Data Base and Surveillance Epidemiol- This system classifi es the extent of disease based mostly on ogy and End Results (SEER) data base for evaluation of the anatomic information on the extent of the primary tumor, colorectal staging system, and the use of existing data sets regional lymph nodes, and distant metastases. This classifi ca- from the USA, Europe, and Asia in gastric cancer. In addition, tion was developed in the 1940s by Pierre Denoix of France groups have been established to collect very large interna- and formalized by the UICC in the 1950s with the formation tional data sets to refi ne staging. In addition to the melanoma of the Committee on Clinical Stage Classifi cation and Applied collaborative, the best examples in refi ning staging for the Statistics. The AJCC was founded in 1959 to complement this seventh edition are the collaborative group of the Interna- work. The AJCC published its fi rst cancer staging manual in tional Association for the Study of Lung Cancer (IASLC) and 1977. Since the 1980s, the work of the UICC and AJCC has the Worldwide Esophageal Cancer Collaborative (WECC). been coordinated, resulting in the simultaneous publication A major challenge to TNM staging is the rapid evolu- of the TNM Classifi cation of Malignant Tumours by the UICC tion of understanding in cancer biology and the availability and the AJCC Cancer Staging Manual . The revision cycle is of biologic factors that predict cancer outcome and response 6–8 years, a time frame that provides for accommodation of to treatment with better accuracy than purely anatomically advances in cancer care while allowing cancer registry systems based staging. This has led some cancer experts to conclude to maintain stable operations. that TNM is obsolete. Although such statements are mis- The work of the AJCC is made possible by the dedicated guided, the reality is that the anatomic extent of disease only volunteer effort of hundreds, and perhaps thousands, of com- tells part of the story for many cancer patients. mitted health professionals including physicians, nurses, popu- The question of including nonanatomic prognostic fac- lation scientists, statisticians, cancer registrars, supporting staff, tors in s taging has led to intense debate about the purpose and and others. These volunteers, representing all relevant disci- structure of staging. Beginning with the sixth edition of the plines, are organized into disease teams chaired by leading cli- AJCC Cancer Staging Manual , there was judicious addition of nicians. These teams make recommendations for change in the nonanatomic factors to the classifi cations that modifi ed stage staging system based on available evidence supplemented with groups. This shift away from purely anatomic information expert consensus. Supporting these teams is a panel of expert has been extended in the current edition. Relevant markers statisticians who provide critical support in evaluation of exist- that are of such importance that they are required for clini- ing data and in analysis of new data when this is available. cians to make clear treatment decisions have been included vii American Joint Committee on Cancer (cid:129) 2010 in groupings. Examples include the mitotic rate in staging manual were adopted for application to cases diagnosed on or gastrointestinal stromal tumors and prostate-specifi c antigen after January 1, 2010. and Gleason score in staging prostate cancer. In the future, the This work involved many professionals in all fi elds in discovery of new markers will make it necessary to include the clinical oncology, cancer registry, population surveil- these markers in staging and will likely require the develop- lance, and statistical communities. It is hard to single out ment of new strategies beyond the current grouping systems. individuals, but certain people were central to this effort. That said, it must also be clearly stated that it is critical Irvin Fleming, to whom we dedicate this M anual , showed to maintain the anatomic base to cancer staging. Anatomic the leadership and the vision over a decade ago that led to extent of disease remains the key prognostic factor in most the development of the Collaborative Stage Data Collection diseases. In addition, it is necessary to have clear links to past System. Frederick Greene, as senior editor of the sixth edi- data to assess trends in cancer incidence and the impact of tion, paved the way for this work, developed the extremely advances in screening and treatment and to be able to apply popular and useful A JCC Cancer Staging Atlas, and did the stage and compare stage worldwide in situations where new legwork to enhance the collaboration between the UICC nonanatomic factors are not or cannot be collected. There- and AJCC. The work of our publisher Springer provided the fore, the staging algorithms in this edition of the AJCC Cancer resources to support this work and the patience needed as Staging Manual using nonanatomic factors only use them as the Task Forces and editors fi nished their work. The many modifi ers of anatomic groupings. These factors are n ot used cancer registrars and the Collaborative Stage Version 2 Work to defi ne the T, N, and M components, which remain purely Group who worked on the disease teams kept us all properly anatomic. Where they are used to defi ne groupings, there is focused. And the AJCC staff, most notably Donna Gress, always a convention for assigning a group without the non- Karen Pollitt, and Connie Bura provided the glue and the anatomic factor. These conventions have been established and sweat to keep us all together. defi ned in collaboration with the UICC. We believe that this, the seventh edition of the AJCC The work for the seventh edition of the AJCC Cancer Cancer Staging Manual , and the electronic and print products Staging Manual began immediately on publication of the built on this manual, will provide strong support to patients sixth edition. Under the leadership of the Prognostic Fac- and physicians alike as they face the battle with cancer, and we tors Task Force of the UICC, an ongoing review of literature hope that it provides the concepts and the foundation for the relevant to staging was performed and updated annually. A future of cancer staging as we move to the era of personalized new data collection system that allows capture of nonana- molecular oncology. tomic information in conjunction with anatomic staging data was developed and implemented in the USA. A number of working groups continued data collection and analysis with Stephen B. Edge, Buffalo, NY the plan to advise AJCC Task Forces. The AJCC provided a David R. Byrd, Seattle, WA competitive grant program to support work to lead to stag- Carolyn C. Compton, Bethesda, MD ing revision. An enhanced statistical task force was empan- April G. Fritz, Reno, NV elled. Finally, in 2006, the disease task forces were convened Frederick L. Greene, Charlotte, NC to review available evidence and recommend changes to Andy Trotti, Tampa, FL TNM. After review by the UICC, the changes refl ected in this viii American Joint Committee on Cancer (cid:129) 2010 1 Part I..................................................................... General Information on Cancer Staging Brief Contents and End-Results Reporting / 1 by Part Part II ................................................................... 2 Head and Neck / 21 Part III .................................................................. 3 Digestive System / 101 Part IV ................................................................... 4 Thorax / 251 Part V .................................................................... 5 Musculoskeletal Sites / 279 Part VI ................................................................... 6 Skin / 299 Part VII .................................................................. 7 Breast / 345 8 Part VIII ................................................................ Gynecologic Sites / 377 9 Part IX ................................................................... Genitourinary Sites / 445 10 Part X .................................................................... Ophthalmic Sites / 521 11 Part XI ................................................................... Central Nervous System / 591 12 Part XII ......................................................................... Lymphoid Neoplasms / 599 13 Part XIII ........................................................................ Personnel and Contributors / 629 ix American Joint Committee on Cancer (cid:129) 2010