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==Overview==
==Overview==
 
Prostate cancer may be classified into several subtypes based on [[TNM system]] and [[UICC]].
'''Prostate cancer staging''' is the process by which physicians evaluate the spread of [[prostate cancer]]. This is important because in a good [[cancer staging]] system, the stage of disease helps determine [[prognosis]] and assists in selecting therapies. A combination of [[physical examination]], [[blood tests]], and [[medical imaging]] is used to determine the clinical stage; if tissue is obtained via [[biopsy]] or [[surgery]], examination of the tissue under a microscope can provide pathologic staging. <ref name="pmid17936849">{{cite journal |author=Smith JA, Chan RC, Chang SS, ''et al'' |title=A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy |journal=J. Urol. |volume=178 |issue=6 |pages=2385–9; discussion 2389–90 |year=2007 |pmid=17936849 |doi=10.1016/j.juro.2007.08.008 |url=http://linkinghub.elsevier.com/retrieve/pii/S0022-5347(07)01979-9}}</ref>
 
There are two schemes commonly used to stage prostate cancer. The most common is the [[TNM]] system, which evaluates the size of the [[tumor]], the extent of involved [[lymph node]]s, and any [[metastasis]] (distant spread). As with many other cancers, these are often grouped into four stages (I&ndash;IV). Another scheme, used less commonly, is the Whitmore-Jewett stage.
 
Briefly, Stage I disease is cancer that is found incidentally in a small part of the sample when prostate tissue was removed for other reasons, such as [[benign prostatic hypertrophy]], and the cells closely resemble normal cells and the gland feels normal to the examining finger. In Stage II  more of the prostate is involved and a lump can be felt within the gland. In Stage III, the tumor has spread through the prostatic capsule and the lump can be felt on the surface of the gland. In Stage IV disease, the tumor has invaded nearby structures, or has spread to lymph nodes or other organs. Grading is based on cellular content and tissue architecture from biopsies (Gleason) which provides an estimate of the destructive potential and ultimate prognosis of the disease.
 
The most important distinction made by any staging system is whether or not the cancer is still confined to the prostate. In the TNM system, clinical T1 and T2 cancers are found only in the prostate, while T3 and T4 cancers have spread elsewhere. Several tests can be used to look for evidence of spread. These include [[computed tomography]] to evaluate spread within the pelvis, [[bone scan]]s to look for spread to the bones, and [[endorectal coil magnetic resonance imaging]] to closely evaluate the prostatic capsule and the [[seminal vesicles]]. Bone scans should reveal osteoblastic appearance due to ''increased'' bone density in the areas of bone metastasis - opposite to what is found in many other cancers that metastasize.
 
[[Computed tomography]] (CT) and [[magnetic resonance imaging]] (MRI) currently do not add any significant information in the assessment of possible lymph node metastases in patients with prostate cancer according to a meta-analysis.<ref name="pmid17936849">{{cite journal |author=Smith JA, Chan RC, Chang SS, ''et al'' |title=A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy |journal=J. Urol. |volume=178 |issue=6 |pages=2385–9; discussion 2389–90 |year=2007 |pmid=17936849 |doi=10.1016/j.juro.2007.08.008 |url=http://linkinghub.elsevier.com/retrieve/pii/S0022-5347(07)01979-9}}</ref> The [[sensitivity (tests)|sensitivity]] of CT was 42% and [[specificity (tests)|specificity]] of CT was 82%. The [[sensitivity (tests)|sensitivity]] of MRI was 39% and the [[specificity (tests)|specificity]] of MRI was 82%. For patients at similar risk to those in this study (17% had positive pelvic lymph nodes in the CT studies and 30% had positive pelvic lymph nodes in the MRI studies), this leads to a [[positive predictive value]] (PPV) of 32.3% with CT, 48.1% with MRI, and [[negative predictive value]] (NPV) of 87.3% with CT, 75.8% with MRI.
 
After a prostate biopsy, a [[pathology|pathologist]] looks at the samples under a microscope. If cancer is present, the pathologist reports the [[Grading (tumors)|grade]] of the tumor. The grade tells how much the tumor tissue differs from normal prostate tissue and suggests how fast the tumor is likely to grow. The Gleason system is used to grade prostate tumors from 2 to 10, where a [[Gleason score]] of 10 indicates the most abnormalities. The pathologist assigns a number from 1 to 5 for the most common pattern observed under the microscope, then does the same for the second most common pattern. The sum of these two numbers is the Gleason score. The [[Whitmore-Jewett stage]] is another method sometimes used. Proper grading of the tumor is critical, since the grade of the tumor is one of the major factors used to determine the treatment recommendation.


==TNM staging==
==TNM staging==
From the [[American Joint  Committee on Cancer|AJCC]] 6th edition (2002) and [[International Union Against Cancer|UICC]] 6th edition.
===Evaluation of the (primary) tumor ('T')===


*'''TX''': cannot evaluate the primary tumor
'''Evaluation of the (primary) tumor ('T')'''<ref name=”cancergov”>National Cancer Institute. Physician Data Query Database 2015. http://www.cancer.gov/publications/pdq</ref>
*'''T0''': no evidence of tumor
*'''T1''': tumor present, but not detectable clinically or with imaging
**'''T1a''': tumor was incidentally found in less than 5% of prostate tissue resected (for other reasons)
**'''T1b''': tumor was incidentally found in greater than 5% of prostate tissue resected
**'''T1c''': tumor was found in a [[needle biopsy]] performed due to an elevated serum [[prostate-specific antigen|PSA]]
*'''T2''': the tumor can be felt (palpated) on examination, but has not spread outside the prostate
**'''T2a''': the tumor is in half or less than half of one of the prostate gland's two [[lobe]]s
**'''T2b''': the tumor is in more than half of one lobe, but not both
**'''T2c''': the tumor is in both lobes
*'''T3''': the tumor has spread through the prostatic [[capsule]] (if it is only part-way through, it is still '''T2''')
**'''T3a''': the tumor has spread through the capsule on one or both sides
**'''T3b''': the tumor has invaded one or both [[seminal vesicle]]s
*'''T4''': the tumor has invaded other nearby structures


It should be stressed that the designation "T2c" implies a tumor which is ''palpable'' in both lobes of the prostate. Tumors which are found to be bilateral on biopsy only but which are not palpable bilaterally should not be staged as T2c.
{| style="border: 0px; font-size: 90%; margin: 3px; width: 400px" align=center
 
|valign=top|
===Evaluation of the regional lymph nodes ('N')===
|+
 
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|T}}
*'''NX''': cannot evaluate the regional lymph nodes
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Definition}}
*'''N0''': there has been no spread to the regional lymph nodes
|-
*'''N1''': there has been spread to the regional lymph nodes
| style="padding: 5px 5px; background: #DCDCDC;" |TX
 
| style="padding: 5px 5px; background: #F5F5F5;" |Cannot evaluate the primary [[tumor]]
===Evaluation of distant metastasis ('M')===
|-
*'''MX''': cannot evaluate distant metastasis
| style="padding: 5px 5px; background: #DCDCDC;" |T0
*'''M0''': there is no distant metastasis
| style="padding: 5px 5px; background: #F5F5F5;" |No evidence of tumor
*'''M1''': there is distant metastasis
|-
**'''M1a''': the cancer has spread to lymph nodes beyond the regional ones
| style="padding: 5px 5px; background: #DCDCDC;" |T1
**'''M1b''': the cancer has spread to [[bone]]
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor present, but not detectable clinically or with imaging
**'''M1c''': the cancer has spread to other sites (regardless of bone involvement)
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" |T1a
===Evaluation of the histologic grade ('G')===
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor was incidentally found in less than 5% of prostate [[tissue]] resected (for other reasons)
Usually, the [[Grading (tumors)|grade]] of the cancer (how different the tissue is from normal tissue) is evaluated separately from the stage; however, for prostate cancer, grade information is used in conjunction with TNM status to group cases into four overall stages.
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" |T1b
*'''GX''': cannot assess grade
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor was incidentally found in greater than 5% of prostate tissue resected
*'''G1''': the tumor closely resembles normal tissue ([[Gleason score|Gleason]] 2&ndash;4)
|-
*'''G2''': the tumor somewhat resembles normal tissue (Gleason 5&ndash;6)
| style="padding: 5px 5px; background: #DCDCDC;" |T1c
*'''G3&ndash;4''': the tumor resembles normal tissue barely or not at all (Gleason 7&ndash;10)
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor was found in a [[needle biopsy]] performed due to an elevated serum [[prostate-specific antigen|PSA]]
 
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" |T2
Of note, this system of describing tumors as "well-", "moderately-", and "poorly-" differentiated based on Gleason score of 2-4, 5-6, and 7-10, respectively, persists in SEER and other databases but is generally outdated. In recent years pathologists rarely assign a tumor a grade less than 3, particularly in biopsy tissue. A more contemporary consideration of Gleason grade is:
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor can be felt (palpated) on examination, but has not spread outside the prostate
 
|-
* Gleason 3+3: tumor is low grade (favorable prognosis)
| style="padding: 5px 5px; background: #DCDCDC;" |T2a
* Gleason 3+4 / 3+5: tumor is mostly low grade with some high grade
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor is in half or less than half of one of the prostate gland's two [[lobe]]s
* Gleason 4+3 / 5+3: tumor is mostly high grade with some low grade
|-
* Gleason 4+4 / 4+5 / 5+4 / 5+5: tumor is all high grade
| style="padding: 5px 5px; background: #DCDCDC;" |T2b
 
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor is in more than half of one lobe, but not both
=== Prostate: Adenocarcinoma (Gleason grade 1)===
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" |T2c
<youtube v=F7V0Zl7a2FY/>
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor is in both lobes
 
|-
=== Prostate : Adenocarcinoma (Gleason grade 2)===
| style="padding: 5px 5px; background: #DCDCDC;" |T3
 
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor has spread through the prostatic [[capsule]] (if it is only part-way through, it is still T2)
<youtube v=YSOLiSklIXw/>
 
=== Prostate : Adenocarcinoma (Gleason grade 3)===
 
<youtube v=TG8vR_pE7yA/>
 
=== Prostate: Adenocarcinoma (Gleason grade 4)===
 
<youtube v=R2Cl4HScdGc/>
 
=== Prostate: Adenocarcinoma (Gleason grade 5)===
 
<youtube v=F7V0Zl7a2FY/>
 
===Overall staging===
 
The tumor, lymph node, metastasis, and grade status can be combined into four stages of worsening severity.
 
{| class="wikitable"
! Stage !! Tumor !! Nodes !! Metastasis !! Grade
|- style="border-top:2px black solid"
! Stage I
| T1a || N0 || M0 || G1
|- style="border-top:2px black solid"
! rowspan="5" | Stage II
| T1a || N0 || M0 || G2&ndash;4
|-
|-
| T1b || N0 || M0 || Any G
| style="padding: 5px 5px; background: #DCDCDC;" |T3a
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor has spread through the [[capsule]] on one or both sides
|-
|-
| T1c || N0 || M0 || Any G
| style="padding: 5px 5px; background: #DCDCDC;" |T3b
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor has invaded one or both [[seminal vesicle]]s
|-
|-
| T1 || N0 || M0 || Any G
| style="padding: 5px 5px; background: #DCDCDC;" |T4
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor has invaded other nearby structures
|}
 
'''Evaluation of the regional lymph nodes ('N')'''
{| style="border: 0px; font-size: 90%; margin: 3px; width: 400px" align=center
|valign=top|
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|N}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Definition}}
|-
|-
| T2 || N0 || M0 || Any G
| style="padding: 5px 5px; background: #DCDCDC;" |NX
|- style="border-top:2px black solid"
| style="padding: 5px 5px; background: #F5F5F5;" |Cannot evaluate the regional [[lymph nodes]]
! Stage III
| T3 || N0 || M0 || Any G
|- style="border-top:2px black solid"
! rowspan="3" | Stage IV
| T4 || N0 || M0 || Any G
|-
|-
| Any T || N1 || M0 || Any G
| style="padding: 5px 5px; background: #DCDCDC;" |N0
| style="padding: 5px 5px; background: #F5F5F5;" |There has been no spread to the regional lymph nodes
|-
|-
| Any T || Any N || M1 || Any G
| style="padding: 5px 5px; background: #DCDCDC;" |N1
| style="padding: 5px 5px; background: #F5F5F5;" |There has been spread to the regional lymph nodes
|}
|}


==Whitmore-Jewett staging==
'''Evaluation of distant metastasis ('M')'''
{| style="border: 0px; font-size: 90%; margin: 3px; width: 400px" align=center
|valign=top|
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|M}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Definition}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |M0
| style="padding: 5px 5px; background: #F5F5F5;" |There is no distant metastasis
|-
| style="padding: 5px 5px; background: #DCDCDC;" |M1
| style="padding: 5px 5px; background: #F5F5F5;" |There is distant metastasis
|}


The Whitmore-Jewett system is similar to the TNM system, with approximately equivalent stages. Roman numerals are sometimes used instead of Latin letters for the overall stages (for example, Stage I for Stage A, Stage II for Stage B, and so on).
==UICC staging==
The [[UICC]] further groups the [[TNM]] data into the stages listed in the table below:<ref>{{Cite web | title =Stages of prostate cancer| url =http://www.cancer.ca/en/cancer-information/cancer-type/prostate/staging/?region=ab }}</ref>
* '''Stage I'''
{| style="border: 0px; font-size: 90%; margin: 3px; width: 400px" align=center
|valign=top|
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|T}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|N}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|M}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Definition}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |T1, T2a
| style="padding: 5px 5px; background: #DCDCDC;" |N0
| style="padding: 5px 5px; background: #DCDCDC;" |M0
| style="padding: 5px 5px; background: #F5F5F5;" |[[Tumor]] involves half a [[lobe]] or less
|}


*'''A''': tumor is present, but not detectable clinically; found incidentally
* '''Stage II'''
**'''A1''': tissue resembles normal cells; found in a few chips from one lobe
{| style="border: 0px; font-size: 90%; margin: 3px; width: 400px" align=center
**'''A2''': more extensive involvement
|valign=top|
*'''B''': the tumor can be felt on physical examination but has not spread outside the prostatic capsule
|+
**'''BIN''': the tumor can be felt, it does not occupy a whole lobe, and is surrounded by normal tissue
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|T}}
**'''B1''': the tumor can be felt and it does not occupy a whole lobe
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|N}}
**'''B2''': the tumor can be felt and it occupies a whole lobe or both lobes
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|M}}
*'''C''': the tumor has extended through the capsule
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Definition}}
**'''C1''': the tumor has extended through the capsule but does not involve the seminal vesicles
|-
**'''C2''': the tumor involves the seminal vesicles
| style="padding: 5px 5px; background: #DCDCDC;" |T2b, T2c
*'''D''': the tumor has spread to other organs
| style="padding: 5px 5px; background: #DCDCDC;" |N0
| style="padding: 5px 5px; background: #DCDCDC;" |M0
| style="padding: 5px 5px; background: #F5F5F5;" |[[Tumor]] involves more than half a lobe but is limited to the prostate
|}


==Risk groups==
* '''Stage III'''
While TNM staging is important, the TNM stage alone is not sufficient for deciding what treatment is best for a patient with prostate cancer.  Instead, a different category called "risk groups" is used, which is based on the T-stage of the TNM system and adds additional information from the [[Gleason score]] and [[prostate specific antigen]] (PSA) value.  The risk can be described as ''low risk'', ''intermediate risk'', or ''high risk''.  The risk is a useful predictor of having extraprostatic extension, which is spread of the cancer beyond the prostate gland itself.  Although slightly different criteria are used for assigning risk, one such system defines ''low risk'' as a PSA less than 10, a Gleason score of 6 or lower, and a T-stage of T2a or lower; ''high risk'' is a PSA more than 20, a Gleason score of 8 or higher, or T2c; ''intermediate risk'' is a PSA of 10 to 20, T2b, or a Gleason of 7.
{| style="border: 0px; font-size: 90%; margin: 3px; width: 400px" align=center
|valign=top|
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|T}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|N}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|M}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Definition}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |T3
| style="padding: 5px 5px; background: #DCDCDC;" |N0
| style="padding: 5px 5px; background: #DCDCDC;" |M0
| style="padding: 5px 5px; background: #F5F5F5;" |[[Tumor]] has spread beyond the prostatic [[capsule]] or into the [[bladder]] neck or [[seminal vesicles]]
|}


Patients with low risk disease may be treated with [[prostatectomy]] or [[radiotherapy]] alone.  Patients with intermediate risk disease are usually treated with radiotherapy and a short duration (less than 6 months) of hormonal ablation (medical castration using a [[gonadotropin-releasing hormone analog]]), and those with high risk disease are usually treated with radiotherapy and a long duration of hormonal ablation.
* '''Stage IV'''
{| style="border: 0px; font-size: 90%; margin: 3px; width: 400px" align=center
|valign=top|
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|T}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|N}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|M}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Definition}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |T4
| style="padding: 5px 5px; background: #DCDCDC;" |N0
| style="padding: 5px 5px; background: #DCDCDC;" |M0
| style="padding: 5px 5px; background: #F5F5F5;" |[[Tumor]] has become fixed to adjoining structures like the [[rectum]] or [[pelvic wall]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" |any T
| style="padding: 5px 5px; background: #DCDCDC;" |N1
| style="padding: 5px 5px; background: #DCDCDC;" |M0
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor has spread to regional [[lymph nodes]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" |any T
| style="padding: 5px 5px; background: #DCDCDC;" |any N
| style="padding: 5px 5px; background: #DCDCDC;" |M1
| style="padding: 5px 5px; background: #F5F5F5;" |Tumor has spread to distant sites such as [[lungs]] or [[liver]]
|}


==References==
==References==
{{Reflist}}
{{Reflist|2}}


==See Also==
[[Category:Disease]]
 
* [[Prostate cancer]]
* [[Gleason score]]
* [[BPH]]
 
 
 
 
[[Category:Andrology]]
[[Category:Urology]]
[[Category:Urology]]
[[Category:Types of cancer]]
[[Category:Types of cancer]]
[[Category:Oncology]]


{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Urology]]
[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Medicine]]

Latest revision as of 05:17, 6 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Steven C. Campbell, M.D., Ph.D. Syed Musadiq Ali M.B.B.S.[2]

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Overview

Prostate cancer may be classified into several subtypes based on TNM system and UICC.

TNM staging

Evaluation of the (primary) tumor ('T')[1]

T Definition
TX Cannot evaluate the primary tumor
T0 No evidence of tumor
T1 Tumor present, but not detectable clinically or with imaging
T1a Tumor was incidentally found in less than 5% of prostate tissue resected (for other reasons)
T1b Tumor was incidentally found in greater than 5% of prostate tissue resected
T1c Tumor was found in a needle biopsy performed due to an elevated serum PSA
T2 Tumor can be felt (palpated) on examination, but has not spread outside the prostate
T2a Tumor is in half or less than half of one of the prostate gland's two lobes
T2b Tumor is in more than half of one lobe, but not both
T2c Tumor is in both lobes
T3 Tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2)
T3a Tumor has spread through the capsule on one or both sides
T3b Tumor has invaded one or both seminal vesicles
T4 Tumor has invaded other nearby structures

Evaluation of the regional lymph nodes ('N')

N Definition
NX Cannot evaluate the regional lymph nodes
N0 There has been no spread to the regional lymph nodes
N1 There has been spread to the regional lymph nodes

Evaluation of distant metastasis ('M')

M Definition
M0 There is no distant metastasis
M1 There is distant metastasis

UICC staging

The UICC further groups the TNM data into the stages listed in the table below:[2]

  • Stage I
T N M Definition
T1, T2a N0 M0 Tumor involves half a lobe or less
  • Stage II
T N M Definition
T2b, T2c N0 M0 Tumor involves more than half a lobe but is limited to the prostate
  • Stage III
T N M Definition
T3 N0 M0 Tumor has spread beyond the prostatic capsule or into the bladder neck or seminal vesicles
  • Stage IV
T N M Definition
T4 N0 M0 Tumor has become fixed to adjoining structures like the rectum or pelvic wall
any T N1 M0 Tumor has spread to regional lymph nodes
any T any N M1 Tumor has spread to distant sites such as lungs or liver

References

  1. ↑ National Cancer Institute. Physician Data Query Database 2015. http://www.cancer.gov/publications/pdq
  2. ↑ "Stages of prostate cancer".

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