Mediastinum
Miscellaneous
AJCC / TNM staging of malignant pleural mesothelioma (AJCC 8th edition)


Topic Completed: 2 May 2019

Revised: 8 May 2019

Copyright: 2019, PathologyOutlines.com, Inc.

PubMed Search: Malignant pleural mesothelioma [title] staging pathology


Andrey Bychkov, M.D., Ph.D.
Page views in 2019 to date: 82
Cite this page: Bychkov A. AJCC / TNM staging of malignant pleural mesothelioma (AJCC 8th edition). PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/mediastinummalignantpleuralmesotheliomastaging.html. Accessed July 16th, 2019.
Definition / general
Essential features
  • AJCC 7th edition staging was sunset on December 31, 2017; as of January 1, 2018 use of the 8th edition is mandatory (Amin: AJCC Cancer Staging Manual, 8th Edition, 2017)
  • T, N and M categories predict outcome of patients with malignant pleural mesothelioma
  • Tumor histology (epithelioid versus sarcomatoid) is an important prognostic factor beyond TNM
ICD coding
Diagrams / tables

Images hosted on other servers:

Staging schematic

Clinical features
  • Most frequent sites of metastatic disease are the contralateral pleura and lung, peritoneum, extrathoracic lymph nodes, bones and liver
  • Tumor histology is an important prognostic factor: epithelioid tumors have a better prognosis than biphasic or sarcomatoid tumors, while desmoplastic malignant mesothelioma has the worst prognosis
  • Major variables from the largest international database (J Thorac Oncol 2012;7:1631)
    • Median age 63 years, 79% men, 62% epithelioid tumor
    • Stage I (11%), stage II, (21%), stage III (48%) and stage IV (20%)
    • Median survival by TNM stage: 21 months (stage I), 19 months (stage II), 16 months (stage III) and 12 months (stage IV)
    • Median survival by histology: epithelioid 19 months, biphasic 13 months and sarcomatoid 8 months
Primary tumor (pT)
  • pTX: cannot be assessed
  • pT0: no evidence of primary tumor
  • pT1: tumor limited to the ipsilateral parietal surface
  • pT2: tumor involves each of the ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic and visceral pleura) with at least one of the following
    • Involvement of diaphragmatic muscle
    • Extension from visceral pleura into the underlying pulmonary parenchyma
  • pT3: locally advanced but potentially resectable tumor; tumor involves all ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic and visceral pleura) with at least one of the following
    • Involvement of the endothoracic fascia
    • Extension into the mediastinal fat
    • Solitary, completely resectable focus of tumor extending into the soft tissues of the chest wall
    • Nontransmural involvement of the pericardium
  • pT4: locally advanced technically unresectable tumor; tumor involves all ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic and visceral pleura) with at least one of the following
    • Diffuse extension or multifocal masses in the chest wall, with or without associated rib destruction
    • Direct transdiaphragmatic extension to the peritoneum
    • Direct extension to the contralateral pleura
    • Direct extension to mediastinal organs
    • Direct extension into the spine
    • Extension to the internal surface of the pericardium with or without a pericardial effusion; or tumor involving the myocardium
Regional lymph nodes (pN)
  • pNX: regional lymph nodes cannot be assessed
  • pN0: no regional lymph nodes metastasis
  • pN1: metastases in the ipsilateral bronchopulmonary, hilar or mediastinal (including the internal mammary, peridiaphragmatic, pericardial fat pad or intercostal) lymph nodes
  • pN2: metastases in the contralateral mediastinal, ipsilateral or contralateral supraclavicular lymph nodes
Distant metastasis (pM)
  • pM0: no distant metastasis
  • pM1: distant metastasis present
AJCC prognostic stage groups
  • Stage IA:T1 N0 M0
  • Stage IB:T2 - 3 N0 M0
  • Stage II:T1 - 2 N1 M0
  • Stage IIIA:T3 N1 M0
  • Stage IIIB:T1 - 3 N2 M0
  • T4 any N M0
  • Stage IV:any T any N M1

Registry data collection variables
  • Histologic type
  • Age
  • Sex
  • Performance status
  • Laboratory parameters (WBC, platelet count and hemoglobin)
  • Surgical resection with curative intent (pleurectomy / decortications, extended pleurectomy / decortications or extrapleural pneumonectomy)
  • For patients undergoing multimodality therapy, use of chemotherapy or radiotherapy
Histologic grade (G)
  • GX: grade cannot be assessed
  • G1: well differentiated
  • G2: moderately differentiated
  • G3: poorly differentiated
  • G4: undifferentiated
Histopathologic type
  • Epithelioid
  • Biphasic (at least 10% of both epithelioid and sarcomatoid components)
  • Sarcomatoid
  • Desmoplastic
Board review question #1
A 59 year old man presented with a 2 cm malignant pleural tumor with involvement of contralateral lung parenchyma. Biopsy revealed well differentiated epithelioid malignant pleural mesothelioma confirmed by BAP1 immunostaining. What is the prognostic stage group using the AJCC / TNM 8th edition?

  1. I
  2. II
  3. IIIA
  4. IIIB
  5. IV
Board review answer #1
E. IV. Spread of pleural mesothelioma to the contralateral lung is considered as a distant metastasis, which conveys prognostic stage group IV.

Reference: Mediastinum - AJCC / TNM staging of malignant pleural mesothelioma (AJCC 8th edition)

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Board review question #2
Major prognostic factor of malignant mesothelioma except TNM variables

  1. Duration of asbestos exposure
  2. Family history
  3. Genetic/mutation signature
  4. PDL1 expression by microenvironment
  5. Histologic type
Board review answer #2
E. Histologic type. Histologic type is the major prognostic factor beyond TNM (epithelioid tumors have better prognosis than sarcomatoid).

Reference: Mediastinum - AJCC / TNM staging of malignant pleural mesothelioma (AJCC 8th edition)

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