TNM Classification of Malignant Tumours E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 262

Veröffentlichungsjahr: 2016

Beschreibung

TNM Classification of Malignant Tumours eighth edition provides the latest, internationally agreed-upon standards to describe and categorize cancer stage. * Published in affiliation with the Union for International Cancer Control (UICC) * Arranged by anatomical region, this authoritative pocket sized guide contains many important updated organ-specific classifications * There are new classifications for p16 positive oropharyngeal carcinomas, carcinomas of the thymus, neuroendocrine tumours of the pancreas, and sarcomas * To facilitate the collection of stage data for cancer surveillance in low and middle income countries there are new sections on Essential TNM and Paediatric Cancer Stage * New colour presentation TNM Classification of Malignant Tumours, 8th edition is available as an app for iOS and Android. This Wiley app-book is developed by MedHand Mobile Libraries. Improve your performance with relevant, valid material which is accessed quickly and with minimal effort in the palm of your hand using MedHand's patented technology.

Leseprobe

Table of Contents

Cover

Title Page

Preface

References

Acknowledgments

Organizations Associated with the TNM System

Members of UICC Committees Associated with the TNM System

Section Editors

Introduction

References

Head and Neck Tumours

Lip and Oral Cavity

Pharynx

References

Larynx

Nasal Cavity and Paranasal Sinuses

Unknown Primary – Cervical Nodes

Malignant Melanoma of Upper Aerodigestive Tract

Major Salivary Glands

Thyroid Gland

Digestive System Tumours

Oesophagus

Stomach

Reference

Small Intestine

Appendix

Colon and Rectum

Anal Canal and Perianal Skin

Liver

Intrahepatic Bile Ducts

Gallbladder

Perihilar Bile Ducts

Distal Extrahepatic Bile Duct

Ampulla of Vater

Pancreas

Well‐Differentiated Neuroendocrine Tumours of the Gastrointestinal Tract

Lung, Pleural, and Thymic Tumours

Lung

References

Pleural Mesothelioma

Thymic Tumours

References

Tumours of Bone and Soft Tissues

Bone

Soft Tissues

Gastrointestinal Stromal Tumour (GIST)

Skin Tumours

Carcinoma of Skin (excluding eyelid, head and neck, perianal, vulva, and penis)

Skin Carcinoma of the Head and Neck

Carcinoma of Skin of the Eyelid

Malignant Melanoma of Skin

Merkel Cell Carcinoma of Skin

Breast Tumours

Reference

Gynaecological Tumours

Reference

Vulva

Vagina

Cervix Uteri

Uterus – Endometrium

Reference

Uterine Sarcomas

References

Ovarian, Fallopian Tube, and Primary Peritoneal Carcinoma

Reference

Gestational Trophoblastic Neoplasms

Reference

Urological Tumours

Penis

Prostate

References

Testis

Kidney

Renal Pelvis and Ureter

Urinary Bladder

Urethra

Adrenal Cortex (ICD‐O‐3 C74.0)

Ophthalmic Tumours

Reference

Carcinoma of Conjunctiva

Malignant Melanoma of Conjunctiva

Malignant Melanoma of Uvea

Retinoblastoma

Sarcoma of Orbit

Carcinoma of Lacrimal Gland

Hodgkin Lymphoma

Reference

Non‐Hodgkin Lymphomas

Essential TNM

Paediatric Tumours

Gastrointestinal Tumours

Bone and Soft Tissue Tumours

Gynaecological Tumours

Urological Tumours

Ophthalmic Tumours

Malignant Lymphoma

Central Nervous System

References

End User License Agreement

List of Tables

Chapter 02

Prognostic factors for carcinoma of the oral cavity

Prognostic risk factors for survival of OPC

Prognostic factors for nasopharyngeal carcinoma

Prognostic factors for survival for laryngeal and hypopharyngeal carcinoma

Prognostic factors for paranasal sinus tumours

Prognostic factors for head and neck unknown primary

Prognostic factors for salivary gland tumour survival

Prognostic factors for survival in differentiated thyroid carcinoma of follicular cell derivation

Chapter 03

Prognostic factors for survival in oesophageal cancer

Prognostic factors for survival in gastric adenocarcinoma

Prognostic factors for survival in differentiated colorectal cancer

Prognostic factors for outcome in anal cancer

Prognostic factors for liver cancer (HCC)

Prognostic risk factors in biliary tract carcinoma

Prognostic risk factors for pancreatic cancer

Chapter 04

Prognostic factors in surgically resected NSCLC

Prognostic risk factors in advanced (locally‐advanced or metastatic) NSCLC

Prognostic risk factors in SCLC

Chapter 05

Prognostic factors for osteosarcoma

Prognostic factors for soft tissue sarcomas

Chapter 06

Tumour‐, host‐ and environment‐related prognostic factors for skin cancer

Prognostic factors for survival for eyelid cancers

Prognostic factors for melanoma

Chapter 07

Prognostic factors for breast cancer

Chapter 08

Prognostic risk factors for cancer of the vulva

Prognostic risk factors in cervical cancer

Prognostic factors for endometrial carcinoma

Prognostic risk factor for epithelial ovarian cancer

Chapter 09

Prognostic factors for survival for squamous cell carcinoma

Prognostic factors for prostate cancer

Prognostic factors for testicular cancer

Prognostic factors for cancers of the kidney

Prognostic factors for progression to invasive disease in superficial bladder cancer (Ta, T1, Tis)

Prognostic factors for metastatic risk and survival in invasive, locally‐advanced and/or node positive bladder cancer (T2–4 N0–1)

Chapter 10

Prognostic factors for survival in ACC

Chapter 11

Prognostic factors for survival for uveal melanoma

Prognostic factors for survival for retinoblastoma

List of Illustrations

Chapter 11

Figure 1 Classification for ciliary body and choroid uveal melanoma based on thickness and diameter.

Chapter 14

Figure 2 Colon and rectum essential TNM.

Figure 3 Breast essential TNM.

Figure 4 Cervix essential TNM.

Figure 5 Prostate essential TNM.

Guide

Cover

Table of Contents

Begin Reading

Pages

iii

iv

vii

v

vi

xii

xiii

xiv

xv

xvi

xvii

xviii

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100

101

102

103

105

106

107

108

109

110

111

112

113

114

115

116

117

119

120

121

122

123

124

125

126

127

128

129

130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

151

152

153

154

155

156

157

158

159

160

161

162

163

164

165

166

167

168

169

170

171

172

173

174

175

176

177

178

179

180

181

182

183

184

185

186

187

188

189

190

191

192

193

194

195

196

197

198

199

200

201

202

203

204

205

206

207

208

209

211

212

213

215

216

217

218

219

220

221

222

223

224

225

226

227

228

229

230

231

232

233

235

236

237

239

241

242

243

244

245

246

247

248

249

250

251

252

253

Union for International Cancer Control (UICC)

TNM Classification of Malignant Tumours

Eighth Edition

Editors in Chief

James D. Brierley BSc, MB, FRCP, FRCR, FRCPCMary K. Gospodarowicz MD, FRCPC, FRCR (Hon)Christian Wittekind MD

Editors

B. O’Sullivan MDM. Mason MDH. Asamura MDA. Lee MDE. Van Eycken MDL. Denny MB, ChBM.B. Amin MDS. Gupta MD

This edition first published 2017 © 2017 UICCPublished 2017 by John Wiley & Sons, Ltd

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of the authors to be identified as the authors of this work has been asserted in accordance with law.

Registered OfficeJohn Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial Offices9600 Garsington Road, Oxford, OX4 2DQ, UK111 River Street, Hoboken, NJ 07030, USA

For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.

Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.

Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the authors make no representations or warranties with respect to the accuracy and completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or website is referred to in this work as a citation and/or potential source of further information does not mean that the author or the publisher endorses the information the organization or website may provide or recommendations it may make. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this works was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging‐in‐Publication Data

Names: Brierley, James, editor. | Gospodarowicz, M. K. (Mary K.), editor. | Wittekind, Ch. (Christian), editor.Title: TNM classification of malignant tumours / editors in chief, James D. Brierley, Mary K. Gospodarowicz, Christian Wittekind ; editors, B. O’Sullivan [and 7 others].Description: Eighth edition. | Oxford, UK ; Hoboken, NJ : John Wiley & Sons, Inc., 2017. | Includes bibliographical references.Identifiers: LCCN 2016039430| ISBN 9781119263579 (paper) | ISBN 9781119263548 (Adobe PDF) | ISBN 9781119263562 (epub)Subjects: | MESH: Neoplasms–classificationClassification: LCC RC258 | NLM QZ 15 | DDC 616.99/40012–dc23LC record available at https://lccn.loc.gov/2016039430

Cover image: © UICC

Editors in Chief

James D. Brierley, BSc, MB, FRCP, FRCR, FRCPC

Professor, Department of Radiation Oncology, University of Toronto; Princess Margaret Cancer Centre, Toronto, Ontario, Canada

Dr Brierley trained in Clinical Oncology in the UK and developed his interest in cancer staging and surveillance when moving to Canada and has been involved in cancer surveillance, locally, nationally and internationally. He is Co‐Chair of the UICC TNM Prognostic Factors Project. He has co‐edited the TNM Supplement 4th edition (Wiley 2012) and the UICC Manual of Clinical Oncology (Wiley 2015).

Mary K. Gospodarowicz, MD, FRCPC, FRCR (Hon)

Professor, Department of Radiation Oncology, University of Toronto; Medical Director, Princess Margaret Cancer Centre, University Health Network; Regional Vice‐President of Cancer Care Ontario for Toronto South, Toronto, Ontario, Canada

Dr Gospodarowicz is the Past‐President of UICC. She has a long‐standing interest in cancer classification with an emphasis on staging and prognostic factors and she has been involved in the UICC TNM Project for many years. Her interests include the application of modern information and communication technologies in cancer control. Dr Gospodarowicz was co‐editor of the 7th edition of the TNM Classification of Malignant Tumours (Wiley 2009) and editor of the 2nd and 3rd editions of the UICC Prognostic Factors in Cancer (Wiley 2001, 2006).

Christian Wittekind, MD

Professor of Pathology, Chairman Institute of Pathology, University of Leipzig, Leipzig, Germany

Dr Wittekind been involved in cancer staging and tumour classifications for over 20 years. He is a member of the UICC TNM Core Committee, Head of the German Speaking TNM‐Komittee, and personally responds to all the questions to the UICC TNM helpdesk. He was the co‐editor of the 5th, 6th and 7th editions of the TNM Classification of Malignant Tumours (Wiley 1997, 2002, 2009), editor of the 2nd 3rd, and 4th editions of the TNM Supplement (Wiley 2001, 2003 and 2012) and editor of the 6th edition of the TNM Atlas (Wiley 2014).

Editors

B. O’Sullivan, MDProfessor, Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada

M. Mason, MDProfessor of Cancer Studies, School of Medicine, Cardiff University, Cardiff, UK

H. Asamura, MDProfessor of Surgery, Chief, Division of Thoracic Surgery, Keio University School of Medicine, Tokyo, Japan

A. Lee, MDProfessor and Head, Department of Clinical Oncology, The University of Hong Kong and the University of Hong Kong‐Shenzhen Hospital, Hong Kong, China

E. Van Eycken, MDBelgian Cancer Registry, Brussels, Belgium

L. Denny, MB, ChBHead, Department of Obstetrics and Gynaecology, SA Medical Research Council, Gynaecological Cancer Research Centre, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa

M.B. Amin, MDProfessor and Chair of the Department of Pathology, the College of Medicine, University of Tennessee, Tennessee, USA

S. Gupta, MDAssistant Professor, Department of Paediatrics, University of Toronto, Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada

They are called wisewho put things in their right order

              Thomas Aquinas

This Eighth Edition is dedicated to Dr Leslie H. Sobin MD, a pathologist and previous long term Chair of UICC TNM Prognostic Factor Committee. Les, as he is known to colleagues all over the world, has devoted most of his career to help promote globally unified classifications of disease in particular in pathology and cancer staging. This is the first edition since the fourth that has not benefitted from his direct involvement; however his imprint is found throughout this edition.

Preface

In this eighth edition of TNM Classification of Malignant Tumours, many of the tumour sites are unchanged from the seventh edition1. However, some tumour entities and anatomic sites have been newly introduced and some tumours contain modifications: this follows the basic philosophy of maintaining stability of the classification over time. The modifications and additions reflect new data on prognosis as well as new methods for assessing prognosis.2 Some changes had already appeared in the TNM Supplement3 as proposals. Subsequent support warrants their incorporation into the classification. New proposals for tumours of parathyroid carcinoma, and paraganglionoma will be published in the next edition of the TNM Supplement.

In the seventh edition a new approach was adopted to separate stage groupings from prognostic groupings in which other prognostic factors are added to T, N, and M categories. These new prognostic groupings were presented for oesophagus and prostate. In this eighth edition, the term ‘stage’ is used when only descriptions of anatomic extent of disease are used and ‘prognostic group’ for when additional prognostic factors are incorporated.

Changes made between the seventh and eighth editions are indicated by a bar at the left‐hand side of the text. To avoid ambiguity, users are encouraged to cite the edition and year of the TNM publication they have used in their list of references.

A TNM homepage with Frequently Asked Questions (FAQs) and a form for submitting questions or comments on the TNM can be found at: http://www.uicc.org. Readers are also encouraged to go to http://www.uicc.org for updates and errata.

The UICC’s TNM Prognostic Factors Project has a process for evaluating proposals to change the TNM Classification. This procedure aims at a continuous systematic approach composed of two arms: (1) review formal proposals from investigators and (2) an annual literature search for articles concerning improvements to TNM. The proposals and results of the literature search are evaluated by a UICC panel of experts as well as by the TNM Prognostic Factors committee members.5 The national TNM Committees participated in this process. More details and a checklist that will facilitate the formulation of proposals can be obtained at www.uicc.org.

Union for International Cancer Control (UICC)

62, route de Frontenex

CH‐1207 Geneva, Switzerland

Fax [phone]

References

1 Sobin LH, Gospodarowicz MK, Wittekind Ch., eds.

International Union Against Cancer (UICC). TNM Classification of Malignant Tumours

, 7th edn. New York: Wiley, 2009.

2 Gospodarowicz MK, O’Sullivan B, Sobin LH, eds.

International Union Against Cancer (UICC): Prognostic Factors in Cancer

, 3rd edn. New York: Wiley, 2006.

3 Wittekind Ch, Compton CC, Brierley J, Sobin LH, eds.

International Union Against Cancer (UICC): TNM Supplement. A Commentary on Uniform Use

, 4th edn. Oxford: Wiley Blackwell Publications, 2012.

4 Amin MB, Edge SB, Greene FL, et al., eds.

American Joint Committee on Cancer (AJCC) Cancer Staging Manual

, 8th edn. New York: Springer, 2017.

5 Webber C, Gospodawowicz M, Sobin LH, et al. Improving the TNM Classification: findings from a 10 year continuous literature review.

Int J Cancer

2014; 135: 371–378.

Acknowledgments

The Editors have much pleasure in acknowledging the great help received from the members of the TNM Prognostic Factors Project Committee and the National Staging Committees Global Representatives and international organizations listed on pages xvi, all of whom volunteered their time.

We thank Professor Patti Groome and Ms Colleen Webber for supervising and performing the literature watch from its inception until 2015 and 2016, respectively. The eighth edition of the TNM Classification is the result of a number of consultative meetings organized and supported by the UICC and AJCC secretariats.

This publication was made possible by grants 1U58DP001818 and 1U58DP004965 from the Centers for Disease Control and Prevention (CDC) (USA). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

Organizations Associated with the TNM System

CDC

Centers for Disease Control and Prevention (USA)

FIGO

International Federation of Gynaecology and Obstetrics

IACR

International Association of Cancer Registries

IARC

International Agency for Research on Cancer

IASLC

International Association for the Study of Lung Cancer

ICCR

International Collaboration on Cancer Reporting

WHO

World Health Organization

National Committees

Australia and New Zealand

National TNM Committee

Austria, Germany, Switzerland

Deutschsprachiges TNM‐Komitee

Belgium

National TNM Committee

Brazil

National TNM Committee

Canada

National Staging Steering Committee

China

National TNM Cancer Staging Committee of China

Denmark

National TNM Committee

Gulf States

TNM Committee

India

National TNM Committee

Israel

National Cancer Staging Committee

Italy

Italian Prognostic Systems Project

Japan

Japanese Joint Committee

Latin America

Sociedad Latinoamericana y del

and Caribbean

Caribe de Oncología Médica

Netherlands

National Staging Committee

Poland

National Staging Committee

Singapore

National Staging Committee

Spain

National Staging Committee

South Africa

National Staging Committee

Turkey

Turkish National Cancer Staging Committee

United Kingdom

National Staging Committee

United States of America

American Joint Committee on Cancer

Members of UICC Committees Associated with the TNM System

In 1950 the UICC appointed a Committee on Tumour Nomenclature and Statistics. In 1954 this Committee became known as the Committee on Clinical Stage Classification and Applied Statistics and in 1966 it was named the Committee on TNM Classification. Taking into consideration new prognostic factors the Committee was named in 1994 the TNM Prognostic Factors Project Committee, and in 2003 the main committee was named “TNM Prognostic Factors Core Group”. A list of members who have served on these committees is available at: www.uicc.org

UICC TNM Prognostic Factors Core Group 2016

Asamura, H.

Japan

Brierley, J.D.

Canada

Compton, C.C.

USA

Gospodarowicz, M.K.

Canada

Lee, Anne

China

Mason, M.

UK

O'Sullivan, B.

Canada

Van Eycken, E.

Belgium

Wittekind, Ch.

Germany

Section Editors

General Rules

J.D. BrierleyM. K. GospodarowiczB. O’SullivanCh. Wittekind

Head and Neck

B. O’Sullivan

Thyroid

J.D. Brierley

Upper Gastrointestinal Tract

Ch. Wittekind

Lower Gastrointestinal Tract

J.D. Brierley

Hepatobiliary

Ch. Wittekind

Lung, Pleura and Thymic Tumours

H. Asamura

Bone and Soft Tissues

B. O’Sullivan

Skin

A. Lee, J.D. Brierley, B. O’Sullivan

Breast

E. Van Eycken

Gynecological

L. Denny

Genitourinary

M.K. Gospodarowicz, M. Mason

Ophthalmic Tumours

Ch. Wittekind

Malignant Lymphoma

M.K. Gospodarowicz

Paediatric Tumours

S. Gupta, J.D. Brierley

Essential TNM

J.D. Brierley, B. O’Sullivan

AJCC Liaison

M.B. Amin

In addition, the Editors wish to acknowledge the invaluable contributions of:

Head and Neck Cancers

UICC Advisory Committee (see

www.uicc.org

)

Thymic Tumours

F. Detterbeck

Cutaneous Squamous Cell Carcinoma

C. Schmults, K. Nehal

Essential TNM

F. Bray, M. Parkin, M. Pineros, K. Ward, M. Ervik, A. Znaor

Paediatric Tumours

L. Frazier, J. Aitken

Expert Panel Members

See

www.uicc.org

Global Advisory Group Members

See

www.uicc.org

Introduction

The History of the TNM System*

The TNM system for the classification of malignant tumours was developed by Pierre Denoix (France) between the years 1943 and 1952.1

In 1950, the UICC appointed a Committee on Tumour Nomenclature and Statistics. As a basis for its work on clinical stage classification, it adopted the general definitions of local extension of malignant tumours suggested by the World Health Organization (WHO) Sub‐Committee on The Registration of Cases of Cancer as well as Their Statistical Presentation.2

In 1958, the Committee published the first recommendations for the clinical stage classification of cancers of the breast and larynx and for the presentation of results.3

A second publication in 1959 presented revised proposals for the breast, for clinical use and evaluation over a 5‐year period (1960–1964).4 In 1968, a booklet, the Livre de Poche5 and, a year later, a complementary booklet was published detailing recommendations for the setting‐up of field trials, for the presentation of end results, and for the determination and expression of cancer survival rates.6 The Livre de Poche was subsequently translated into 11 languages. In 1974 and 1978, second and third editions7,8 were published containing new site classifications, and the fourth edition of TNM in 1987.9

In 1993, the project published the TNM Supplement10 to promote the uniform use of TNM by providing detailed explanations of the TNM rules with practical examples. Second, third, and fourth editions appeared in 2001, 2003, and 2012.11–13

The project also publishes the TNM Atlas an Illustrated Guide to the TNM Classification of Malignant Tumours, the sixth edition was published in 2014 as a companion to the seventh edition of the TNM Classification.14

In 1995, the project published Prognostic Factors in Cancer,15 a compilation and discussion of prognostic factors in cancer, both anatomical and non‐anatomical, at each of the body sites. This was expanded in the second edition in 200116 and the third edition in 2006.17

The current eighth edition of TNM contains rules of classification and staging that correspond with those appearing in the eighth edition of the AJCC Cancer Staging Manual (2017).18 While the aim of the UICC and AJCC is to have identical classifications, small differences exist and are identified as footnotes to the text. Wherever possible, the UICC classification is based on published evidence‐based recommendation.

To develop and sustain a classification system acceptable to all requires the closest liaison between national and international organizations. As noted, while the classification is based on published evidence, in areas where high‐level evidence is not available it is based on international consensus. The continuing objective of the UICC is to present the classification of anatomical extent of cancer globally.

Note

*

A more detailed history is available on the website at

www.uicc.org

The Principles of the TNM System

The practice of classifying cancer cases into groups according to anatomical extent, termed ‘stage’, arose from the observation that survival rates were higher for cases in which the disease was localized than for those in which the disease had extended beyond the organ of origin. The stage of disease at the time of diagnosis is a reflection not only of the rate of growth and extension of the neoplasm but also the type of tumour and the tumour–host relationship.

It is important to record accurate information on the anatomical extent of the disease for each site at the time of diagnosis, to meet the following objectives:

to aid the clinician in the planning of treatment

to give some indication of prognosis for survival

to assist in evaluation of the results of treatment

to facilitate the exchange of information between treatment centres

to contribute to the continuing investigation of human cancer

to support cancer control activities.

Cancer staging is essential to patient care, research, and cancer control. Cancer control activities include direct patient care‐related activities, the development and implementation of clinical practice guidelines, and centralized activities such as recording disease extent in cancer registries for surveillance purposes and planning cancer systems. Recording of stage is essential for the evaluation of outcomes of clinical practice and cancer programmes. However, in order to evaluate the long‐term outcomes of populations, it is important for the classification to remain stable. There is therefore a conflict between a classification that is updated to include the most current forms of medical knowledge while also maintaining a classification that facilitates longitudinal studies. The UICC TNM Project aims to address both needs.

International agreement on the classification of cancer by extent of disease provides a method of conveying disease extent to others without ambiguity.

There are many axes of tumour classification: for example, the anatomical site and the clinical and pathological extent of disease, the duration of symptoms or signs, the gender and age of the patient, and the histological type and grade of the tumour. All of these have an influence on the outcome of the disease. Classification by anatomical extent of disease is the one with which the TNM system primarily deals.

The clinician's immediate task when meeting a patient with a new diagnosis of cancer is to make a judgment as to prognosis and a decision as to the most effective course of treatment. This judgment and this decision require, among other things, an objective assessment of the anatomical extent of the disease.

To meet the stated objectives a system of classification is needed:

that is applicable to all sites regardless of treatment; and

that may be supplemented later by further information that becomes available from histopathology and/or surgery.

The TNM system meets these requirements.

The General Rules of the TNM Systema,b

The TNM system for describing the anatomical extent of disease is based on the assessment of three components:

T–

the extent of the primary tumour

N–

the absence or presence and extent of regional lymph node metastasis

M–

the absence or presence of distant metastasis.

The addition of numbers to these three components indicates the extent of the malignant disease, thus:

T0, T1, T2, T3, T4, N0, N1, N2, N3, M0, M1

In effect, the system is a ‘shorthand notation’ for describing the extent of a particular malignant tumour.

The general rules applicable to all sites are as follows:

All cases should be confirmed microscopically. Any cases not so proved must be reported separately.

Two classifications are described for each site, namely:

Clinical classification:

the pretreatment clinical classification designated

TNM

(or cTNM) is essential to select and evaluate therapy. This is based on evidence acquired before treatment. Such evidence is gathered from physical examination, imaging, endoscopy, biopsy, surgical exploration, and other relevant examinations.

Pathological classification:

the postsurgical histopathological classification, designated

pTNM

, is used to guide adjuvant therapy and provides additional data to estimate prognosis and end results. This is based on evidence acquired before treatment, supplemented or modified by additional evidence acquired from surgery and from pathological examination. The pathological assessment of the primary tumour (pT) entails a resection of the primary tumour or biopsy adequate to evaluate the highest pT category. The pathological assessment of the regional lymph nodes (pN) entails removal of the lymph nodes adequate to validate the absence of regional lymph node metastasis (pN0) or sufficient to evaluate the highest pN category. An excisional biopsy of a lymph node without pathological assessment of the primary is insufficient to fully evaluate the pN category and is a clinical classification. The pathological assessment of distant metastasis (pM) entails microscopic examination of metastatic deposit.

After assigning T, N, and M and/or pT, pN, and pM categories, these may be grouped into stages. The TNM classification and stages, are established at diagnosis and must remain unchanged in the medical records.

Only for cancer surveillance purposes, clinical and pathological data may be combined when only partial information is available either in the pathological classification or the clinical classification.

If there is doubt concerning the correct T, N, or M category to which a particular case should be allotted, then the lower (i.e., less advanced) category should be chosen. This will also be reflected in the stage.

In the case of multiple primary tumours in one organ, the tumour with the highest T category should be classified and the multiplicity or the number of tumours should be indicated in parenthesis, e.g., T2(m) or T2(5). In simultaneous bilateral primary cancers of paired organs, each tumour should be classified independently. In tumours of the liver, ovary and fallopian tube, multiplicity is a criterion of T classification, and in tumours of the lung multiplicity may be a criterion of the M classification.

Definitions of the TNM categories and stage may be telescoped or expanded for clinical or research purposes as long as the basic definitions recommended are not changed. For instance, any T, N, or M can be divided into subgroups.

Notes

a

For more details on classification the reader is referred to the TNM Supplement.

b

An educational module is available on the UICC website

www.uicc.org

.

Anatomical Regions and Sites

The sites in this classification are listed by code number of the International Classification of Diseases for Oncology.19 Each region or site is described under the following headings:

Rules for classification with the procedures for assessing the T, N, and M categories

Anatomical sites, and subsites if appropriate

Definition of the regional lymph nodes

TNM Clinical classification

pTNM Pathological classification

G Histopathological grading if different from that described on page 9

Stage and prognostic groups

Prognostic factors grid

TNM Clinical Classification

The following general definitions are used throughout:

T – Primary Tumour

TX

Primary tumour cannot be assessed

T0

No evidence of primary tumour

Tis

Carcinoma in situ

T1–T4

Increasing size and/or local extent of the primary tumour

N – Regional Lymph Nodes

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1–N3

Increasing involvement of regional lymph nodes

M – Distant Metastasis*

M0

No distant metastasis

M1

Distant metastasis

Note

*