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Prostate

Miscellaneous

Staging

Reviewers: Komal Arora, M.D., (see Reviewers page)
Revised: 29 July 2012, last major update July 2012
Copyright: (c) 2003-2012, PathologyOutlines.com, Inc.

General
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References: AJCC Cancer Staging Manual (7th ed), staging forms, National Cancer Institute (US)

Primary tumor (T) - Clinical staging
● TX: Primary tumor cannot be assessed
● T0: No evidence of primary tumor
● T1: Clinically inapparent tumor neither palpable nor visible by imaging
● T1a: Tumor incidental histologic finding in 5% or less of tissue resected
● T1b: Tumor incidental histologic finding in more than 5% of tissue resected
● T1c: Tumor identified by needle biopsy (e.g. because of elevated PSA)
● T2: Tumor confined within prostate
● T2a: Tumor involves one half of one lobe or less
● T2b: Tumor involves more than one half of one lobe, but not both lobes
● T2c: Tumor involves both lobes
● T3: Tumor extends through the prostatic capsule
● T3a: Extracapsular extension (unilateral or bilateral)
● T3b: Tumor invades seminal vesicle(s)
● T4: Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles or pelvic wall

Notes:
   ● Tumor found in one or both lobes by needle biopsy, but not palpable or reliably visible by imaging, is classified as T1c
   ● Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is classified as T2, not T3

Primary tumor (T) - Pathologic staging
● pT2: Organ confined
● pT2a: Unilateral, one half of one side or less
● pT2b: Unilateral, involving more than one half of one side, but not both sides
● pT2c: Bilateral disease
● pT3: Extraprostatic extension
● pT3a: Extraprostatic extension or microscopic invasion of bladder neck
● pT3b: Seminal vesicle invasion
● pT4: Invasion of rectum, levator muscles or pelvic wall

Notes:
   ● Tumor found in one or both lobes by needle biopsy, but not palpable or reliably visible by imaging, is classified as T1c
   ● Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is classified as T2, not T3
   ● There is no pathologic T1 classification
   ● Value of T2 substaging has been questioned (J Urol 2011;186:790)
   ● Margins are important, and margin status is independent of T classification; classify positive margins as either focal or extensive based on the length of involvement of the inked line of resection
   ● Laterality of extraprostatic extension (EPE) is not prognostically important
   ● EPE should be quantitated as focal (< 1 HPF on 1-2 sections) or nonfocal
   ● Determine EPE in radical prostatectomy specimens by comparing the presence of tumor to the normal edge of the prostate gland
   ● Seminal vesicle invasion means tumor invades its muscular coat, seen first at the base of the seminal vesicles
   ● The amount of tumor in the seminal vesicles is not important
   ● pT3 can have positive or negative margins
   ● Patients with clinical T3 disease are usually not surgical candidates - 50% have nodal metastases at diagnosis, 50% develop metastases at 5 years and 75% die of prostate carcinoma within 10 years
   ● Margins: apex is most frequent site of positive margin; positive margins at base usually indicate extensive disease; tumor at anterior region margin usually is considered extraprostatic extension because usually is exterior to prostate; Close margins (< 1 mm) are considered adequate for prostate

Regional lymph nodes (N)
● NX: Regional lymph nodes were not assessed
● N0: No regional lymph node metastasis
● N1: Metastasis in regional lymph node(s)

Notes:
   ● pNX, pN0 and pN1 are the same as cNX, cN0 and cN1
   ● NX, N0, N1 may lack clinical relevance; Some surgeons proceed with radical prostatectomy even if nodes are positive at frozen section if preoperative Gleason score is 7 or less, since time to onset of distant metastases is long
   ● Metastases to periprostatic or periseminal vesicle lymph nodes suggests poor prognosis (Am J Surg Pathol 2001;25:1429)

Distant metastases
● M0: No distant metastasis
● M1: Distant metastasis
● M1a: Distant metastasis to non-regional lymph node(s)
● M1b: Distant metastasis to bone(s)
● M1c: Distant metastasis to other site(s) with or without bone disease

Notes:
   ● When more than one site of metastasis is present, the most advanced category is used
   ● pM1c is most advanced

Anatomic stage / Prognostic groups
● Stage I: T1a-2a N0 M0 PSA<10 Gleason 6 or less OR T1-2a N0 M0 PSA unknown Gleason unknown
● Stage IIA: T1a-c N0 M0 PSA < 20 Gleason 7 OR T1a-c N0 M0 PSA 10-19.9 Gleason 6 or less OR
T2a-b N0 M0 PSA < 20 Gleason 7 or less OR T2b N0 M0 PSA unknown Gleason unknown
● Stage IIB: T2c N0 M0 Any PSA Any Gleason OR T1-2 N0 M0 PSA 20 or higher Any Gleason OR
T1-2 N0 M0 Any PSA Gleason 8 or higher
● Stage III: T3a-b N0 M0 Any PSA Any Gleason score
● Stage IV: T4 or N1 or M1

Notes:
● When either PSA or Gleason is not available, grouping should be determined by T stage or either PSA or Gleason as available
● Partin tables: Nomograms predicting pathologic stage based on TNM clinical stage, PSA and Gleason score (Johns Hopkins, J Urol 1993;150:110)
● Close relationship between pathologist and urologist is essential (European Urology Supplements 2008;7:1)

Diagrams
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Clinical staging

Micro images
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Extraprostatic extension


Radical prostatectomy with periprostatic fat tissue invasion (pT3a): left - direct invasion, right - invasion through neurovascular bundle


Radical prostatectomy with periprostatic fat tissue invasion (pT3a): adenocarcinoma is outside the edge of the extraprostatic area (discontinuous line) at the level of periprostatic fat tissue (arrows)

End of Prostate > Miscellaneous > Staging

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