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Ronny Allan
Stage of cancer
What is stage? The extent of a cancer in the body. Staging is usually based on the size of the tumour, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.
What are the stage numbers? Most types of cancer have 4 stages, numbered from 1 to 4 indicating a rising spread as the number is bigger. Some cancer have a stage 0 but I don’t believe this applies to Neuroendocrine Neoplasms (NENs). Often doctors write the stage down in Roman numerals, so you may see stages written as I, II, III and IV.
Wil my staging ever change? You may be given an initial staging based on physical examination, imaging tests, and biopsies of affected areas. After any surgery, pathologists combine the results of both the clinical staging with the surgical results which may result in an update. In certain scenarios, a recurrence or retreatment staging is used to determine the extent of the disease if a cancer comes back after treatment. Recurrence or retreatment staging helps determine the best treatment options for cancer that has returned.
Restaging may also be done to find out how the cancer responded to treatment. If restaging is done and a new stage is assigned, the new stage will be marked with an “r” in front of it to show that it’s different from the original stage. Usually, the original stage stays the same, even if the cancer comes back or gets worse. The same tests that were carried out to diagnose the cancer are usually carried out again. Restaging helps doctors plan the best treatment for cancer that has come back or become worse.
Staging Models
There are two main staging systems in use, AJCC and ENETs. Both are based on the TNM Staging System although the content may differ.
What Is the TNM Staging System?
The TNM Staging System was developed and is maintained by the AJCC and the Union for International Cancer Control (UICC). It is the most commonly used staging system by medical professionals around the world. The TNM classification system was developed as a tool for doctors to stage different types of cancer based on certain, standardised criteria. Please note with different TNM models, there could be different stage descriptions depending on the location of the primary tumour and similarly different TNM models for different tumour locations. Although most seem to synchronise, this is a really important point for Neuroendocrine Neoplasms (NENs) interpretation due to their multiple primary locations.
The TNM Staging System includes the extent of the tumor (T), extent of spread to the lymph nodes (N), and presence of metastasis (M).
The T category describes the original (primary) tumor.
TX
Primary tumor cannot be evaluated
T0
No evidence as primary tumor
Tis
Carcinoma in situ (early cancer that has not spread to neighboring tissue)
T1–T4
Size and/or extent of the primary tumor
The N category describes whether or not the cancer has reached nearby lymph nodes
NX
Regional lymph nodes cannot be evaluated
N0
No regional lymph node involvement (no cancer found in the lymph nodes)
N1-N3
Involvement of regional lymph nodes (number and/or extent of spread)
The M category tells whether there are distant metastases (spread of cancer to other parts of the body).
M0
No distant metastasis (cancer has not spread to other parts of the body)
M1
Distant metastasis (cancer has spread to distant parts of the body)
Because each cancer type has its own classification system, letters and numbers do not always mean the same thing for every kind of cancer. Once the T, N, and M are determined, they are combined and an overall stage of 0, I, II, III, IV is assigned. Sometimes these stages are subdivided using letters such as IIIA and IIIB.
Staging of NETs
As above, each cancer type has a different staging definition based on the TNM template. NENs are unique in that there are multiple types based on different organs. Consequently each NEN type has its own staging definition. NEN staging is therefore more complex than most other cancer types.
Access to AJCC and ENETS staging info is difficult, normally behind a paywall and only accessible to healthcare professionals. However, there are some sites providing useful and up to date extracts. To those reading, it’s worth pointing out that certain NET types may have different TNM definitions in AJCC and ENETS although most are synchronised.
Until this is more publicly available, I will use one of these sources which I know is kept up to date. They also quite often quote from both AJCC and ENETS when there are differences. Click as required.
Lung NET (use Lung Cancer staging definitions).
Pheochromocytoma/Paraganglioma
I will update as I find it. Neuroendocrine Carcinoma (NEC) is more complex, I’m working on it. Also working on access to ENETS.
Miscellaneous Pathology terms supporting TNM
You may see some letters preceding or succeeding TNM data. The most common are listed here.
Other descriptors
| Optional descriptors | |
|---|---|
| Pn – Perineural invasion | |
| PnX | Perineural invasion cannot be assessed |
| Pn0 | No perineural invasion |
| Pn1 | Perineural invasion |
| L – Lymphatic invasion | |
| LX | Lymphatic invasion cannot be assessed |
| L0 | No lymphatic invasion |
| L1 | Lymphatic invasion |
| V – Venous invasion | |
| VX | Venous invasion cannot be assessed |
| V0 | No venous invasion |
| V1 | Microscopic venous invasion |
| V2 | Macroscopic venous invasion |
Prefix modifiers
- c: stage is determined from evidence acquired before treatment (including clinical examination, imaging, endoscopy, biopsy, surgical exploration). The c-prefix is implicit in absence of the p-prefix.
- p: stage given by histopathologic examination of a surgical specimen
- y: stage assessed after chemotherapy and/or radiation therapy; in other words, the individual had neoadjuvant therapy.
- r: stage for a recurrent tumor in an individual that had some period of time free from the disease.
- a: stage determined at autopsy.
- m: tumor is multifocal (more than 1 tumors). The opposite, s, can be used when there is particular reason to emphasize that the tumor is solitary/single.
References;
- The Eighth Edition AJCC Cancer Staging Manual (p.s Ninth edition being rolled out 2024 and NET is front of the line!).
- ENETS
- Pathology Outlines
Now read about Grade and the WHO 2022 Classification
Click here or on the graphic below
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I am not a doctor or any form of medical professional, practitioner or counsellor. None of the information on my website, or linked to my website(s), or conveyed by me on any social media or presentation, should be interpreted as medical advice given or advised by me.
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Please also note that mention of a clinical service, trial/study or therapy does not constitute an endorsement of that service, trial/study or therapy by Ronny Allan, the information is provided for education and awareness purposes and/or related to Ronny Allan’s own patient experience. This element of the disclaimer includes any complementary medicine, non-prescription over the counter drugs and supplements such as vitamins and minerals.
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