Table Of ContentAMERICAN JOINT COMMITTEE ON CANCER
AJCC
CANCER STAGING
ATLAS
EDITORS
FREDERICK L.GREENE,m.d.
Chair,Department ofGeneral Surgery
Carolinas Medical Center
Charlotte,North Carolina
CAROLYN C.COMPTON,m.d.,ph.d
Director ofBiorepositories and BiospecimentResearch
National Cancer Institute
Bethesda,Maryland
APRIL G.FRITZ,c.t.r.,r.h.i.t.
Division ofCancer Control and Population Sciences
National Cancer Institute
Bethesda,Maryland
JATIN P.SHAH,m.d.
Chief,Head and Neck Service
Memorial Sloan-Kettering Cancer Center
New York,New York
DAVID P.WINCHESTER,m.d.
Professor and Chair,Department ofSurgery
Evanston Northwestern Healthcare
Evanston,Illinois
AJCC
CANCER STAGING
ATLAS
AMERICAN JOINT COMMITTEE ON CANCER
Executive Office
633 North Saint Clair Street
Chicago,Illinois 60611
FOUNDING ORGANIZATIONS
American Cancer Society
American College ofPhysicians
American College ofRadiology
American College ofSurgeons
College ofAmerican Pathologists
National Cancer Institute
SPONSORING ORGANIZATIONS
American Cancer Society
American College ofSurgeons
American Society ofClinical Oncology
Centers for Disease Control and Prevention
LIAISON ORGANIZATIONS
American Urological Association
Association ofAmerican Cancer Institutes
National Cancer Registrars Association
North American Association ofCentral Cancer Registries
American Society ofColon and Rectal Surgeons
Society ofGynecologic Oncologists
Society ofUrologic Oncology
American Joint Committee on Cancer
Executive Office
633 North Saint Clair Street
Chicago,IL 60611,USA
Editors:
Frederick L.Greene,M.D. Carolyn C.Compton,M.D.,PH.D.
April G.Fritz,C.T.R.,R.H.I.T. Jatin P.Shan,M.D.
David P.Winchester,M.D.
Illustrator:Alice Y.Chen
This atlas was prepared and published through the support ofthe American Cancer Society,the Amer-
ican College ofSurgeons,the American Society ofClinical Oncology,the Centers for Disease Control
and Prevention,and the International Union Against Cancer.
Library ofCongress Control Number:2005932559
ISBN-10:0-387-29014-1
ISBN-13:978-0387-29014-0
Printed on acid-free paper.
© 2006 Springer Science+Business Media,Inc.
All rights reserved.This work may not be translated or copied in whole or in part without the
written permission ofthe publisher (Springer Science+Business Media,Inc.,233 Spring Street,
New York,NY 10013,USA),except for briefexcerpts in connection with reviews or scholarly
analysis. Use in connection with any form of information storage and retrieval, electronic
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While the advice and information in this book are believed to be true and accurate at the date of
going to press,neither the authors nor the editors nor the publisher can accept any legal respon-
sibility for any errors or omissions that may be made.The publisher makes no warranty,express
or implied,with respect to the material contained herein.
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Preface
This first edition ofthe AJCC Cancer Staging Atlashas been created as a com-
pendium to the AJCC Cancer Staging Manual and Handbook which have
now been developed through six editions and which continue to promulgate
the importance of anatomical and pathological staging in the management of
cancer.This Atlashas been viewed as a companion to illustrate the TNM clas-
sifications ofall the regions included under the head and neck,digestive,tho-
racic,musculoskeletal,soft tissue,breast,genital,urinary and gynecologic sites.
This monograph has been fully illustrated to give meaningful visualization to
the TNM classifications and stage groupings and will serve as a useful reference
for the clinician and patient alike.
Since there have been changes in staging strategies in the 6th Edition ofthe
AJCC Cancer StagingManual,the differences between the 5th edition and 6th
edition have been included throughout the Atlas.This will provide a meaning-
ful comparison for the experienced clinician as well as serve as a teaching refer-
ence for the student and trainee.
The 432 outstanding illustrations have been developed exclusively for the
AJCCCancer Staging Atlasby Alice Y.Chen,our exceptional medical illustrator.
Every illustration provides detailed and thorough anatomic depictions to clarify
critical structures and to allow the reader to instantly visualize the progressive
extent ofmalignant disease.Appropriate labeling has been incorporated to iden-
tify significant anatomic structures.A significant number (28%) ofthe illustra-
tions are devoted solely to the representation of the TNM changes which are
new in the AJCC Cancer Staging Manual,6th Edition.Throughout all anatomic
sites,the newly developed illustrations reflect concepts that are more completely
discussed in the AJCC Cancer Staging ManualandHandbook.
TheAJCC Cancer Staging Atlasis an official publication of the American
Joint Committee on Cancer and reinforces the AJCC’s position as the leader in
disseminating state ofthe art information on TNM staging.The AJCC contin-
ues to have as its mission the education of physicians,registrars and patients.
TheAtlas,a portable and easily referenced representation ofthe AJCC mono-
graphs,continues to enhance this mission.This project has been fully supported
by our publishing colleagues at Springer and especially Laura diZerega and Bill
Curtis,our longtime friends and AJCC supporters.
The editors ofthis most recent AJCC project wish to reinforce the concept
that TNM is a universal “language”which must be applied by all clinicians caring
for the cancer patients.In order to make this language come alive,a pictorial
representation ofclinical and pathological staging is necessary.We dedicate this
work to all of our patients and colleagues and hope that they too will benefit
from this illustrated resource.
Frederick L.Greene,m.d.
Carolyn C.Compton,m.d.,ph.d.
April G.Fritz,c.t.r.,r.h.i.t.
Jatin P.Shah,m.d.
David P.Winchester,m.d.
American Joint Committee on Cancer • 2006 v
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
1. Purposes and Principles ofStaging . . . . . . . . . . . . . . . . . . . . . . . 1
Part I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Head and Neck Sites
2. Introduction to Head and Neck Sites . . . . . . . . . . . . . . . . . . . . . 13
3. Lip and Oral Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4. Pharynx (Including Base ofTongue,Soft Palate,
and Uvula) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5. Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
6. Nasal Cavity and Paranasal Sinuses . . . . . . . . . . . . . . . . . . . . . . . 53
7. Major Salivary Glands (Parotid,Submandibular,
and Sublingual) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
8. Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Part II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Digestive System
9. Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
10. Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
11. Small Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
12. Colon and Rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
13. Anal Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
14. Liver (Including Intrahepatic Bile Ducts) . . . . . . . . . . . . . . . . . . . 127
15. Gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
16. Extrahepatic Bile Ducts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
17. Ampulla ofVater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
18. Exocrine Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
American Joint Committee on Cancer • 2006 vii
Part III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Thorax
19. Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
20. Pleural Mesothelioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Part IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Musculoskeletal Sites
21. Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
22. Soft Tissue Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Part V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Skin
23. Carcinoma ofthe Skin (Excluding Eyelid,Vulva,
and Penis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
24. Melanoma ofthe Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Part VI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Breast
25. Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Part VII . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Gynecologic Sites
26. Vulva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
27. Vagina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
28. Cervix Uteri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
29. Corpus Uteri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
30. Ovary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
31. Fallopian Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
32. Gestational Trophoblastic Tumors . . . . . . . . . . . . . . . . . . . . . . . . 279
Part VIII . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Genitourinary Sites
33. Penis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
34. Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
viii American Joint Committee on Cancer • 2006
35. Testis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
36. Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
37. Renal Pelvis and Ureter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
38. Urinary Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
39. Urethra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
American Joint Committee on Cancer • 2006 ix
1
1
Purposes and Principles ofStaging
PHILOSOPHY OF CLASSIFICATION AND STAGING
BY THE TNM SYSTEM
A clinically useful classification scheme for cancer must encompass the attrib-
utes ofthe tumor that define its behavior.The American Joint Committee on
Cancer (AJCC) classification is based on the premise that cancers ofthe same
anatomic site and histology share similar patterns of growth and similar
outcomes.
As the size ofthe untreated primary cancer (T) increases,regional lymph
node involvement (N) and/or distant metastasis (M) become more frequent.A
simple classification scheme,which can be incorporated into a form for staging
and can be universally applied,is the goal ofthe TNM system as proposed by
the AJCC. This classification is identical to that of the International Union
Against Cancer(UICC).
The three significant events in the life history of a cancer—local tumor
growth (T),spread to regional lymph nodes (N),and metastasis (M)—are used
as they appear (or do not appear) on clinical examination, before definitive
therapy begins,to indicate the anatomic extent of the cancer.This shorthand
method of indicating the extent of disease (TNM) at a particular designated
time is an expression ofthe stage ofthe cancer at that time in its progression.
Spread to regional lymph nodes and/or distant metastasis occur before they
are discernible by clinical examination.Thus,examination during the surgical
procedure and histologic examination of the surgically removed tissues may
identify significant additional indicators ofthe prognosis ofthe patient (T,N,
and M) as different from what could be discerned clinically before therapy.
Because this is the pathologic (pTNM) classification and stage grouping (based
on examination ofa surgically resected specimen with sufficient tissue to eval-
uate the highest T,N,or M classification),it is recorded in addition to the clin-
ical classification.It does not replace the clinical classification.Both should be
maintained in the patient’s permanent medical record.The clinical stage is used
as a guide to the selection ofprimary therapy.The pathologic stage can be used
as a guide to the need for adjuvant therapy,to estimation ofprognosis,and to
reporting end results.
Therapeutic procedures,even ifnot curative,may alter the course and life
history of a cancer patient.Although cancers that recur after therapy may be
staged with the same criteria that are used in pretreatment clinical staging,the
significance ofthese criteria may not be the same.Hence,the “restage”classifi-
cation ofrecurrent cancer (rTNM) is considered separately for therapeutic guid-
ance, estimation of prognosis, and end-results reporting at that time in the
patient’s clinical course.
The significance of the criteria for defining anatomic extent of disease
differs for tumors at different anatomic sites and of different histologic types.
Therefore, the criteria for T, N, and M must be defined for tumors of each
anatomic site to attain validity.With certain types oftumors,such as Hodgkin’s
disease and lymphomas, a different system for designating the extent of the
American Joint Committee on Cancer • 2006 1
