# Radiation Oncology/Prostate/Staging

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Prostate Cancer Staging

## AJCC
### Current Staging

AJCC 8th edition (2017)
* To be used for staging beginning Jan 1, 2018.
Reference:
Primary Tumor: Clinical (cT)
* T1 - clinically inapparent tumor neither palpable nor visible by imaging
** T1a - incidental histologic finding in 5% or less of tissue resected
** T1b - incidental histologic finding in more than 5% of tissue resected
** T1c - identified by needle biopsy (e.g., because of elevated PSA)
* T2 - palpable and confined within prostate
** T2a - involves one half of one side or less
** T2b - involves more than one half of one side but not both sides
** T2c - involves both sides
* T3 - extraprostatic tumor that is not fixed or does not invade adjacent structures
** T3a - extracapsular extension (unilateral or bilateral)
** T3b - invades seminal vesicles
* T4 - fixed or invades adjacent structures other than seminal vesicles: bladder, external sphincter, rectum, levator muscles, and/or pelvic wall
Primary Tumor: Pathologic (pT)
* T2 - organ confined
* T3 - extraprostatic extension
** T3a - extraprostatic extension or microscopic invasion of bladder neck
** T3b - invades seminal vesicle(s)
* T4 - fixed or invades adjacent structures other than seminal vesicles: bladder, external sphincter, rectum, levator muscles, and/or pelvic wall
Regional Lymph Nodes:
* N0 - none
* N1 - yes
Regional lymph nodes: pelvic, hypogastric, obturator, iliac (internal, external), sacral Distant lymph nodes: aortic, common iliac, inguinal (deep), inguinal (superficial, femoral), supraclavicular, cervical, scalene, retroperitoneal
Distant Metastases:
* M0 - none
* M1a - non-regional lymph nodes
* M1b - bone
* M1c - other sites
Grade groups (1-5)
* 1: Gleason 6
* 2: Gleason 3+4=7
* 3: Gleason 4+3=7
* 4: Gleason 8
* 5: Gleason 9-10
Stage Grouping:
* Group I
    cT1 or cT2a N0 M0, PSA < 10, Grade group 1 (Gleason 6)
    pT2 N0 M0, PSA < 10, Grade group 1 (Gleason 6)
* Group IIA
    cT1 or cT2a N0 M0, PSA ≥ 10 and < 20, Grade group 1 (Gleason 6)
    pT2 N0 M0, PSA ≥ 10 and < 20, Grade group 1 (Gleason 6)
    cT2b-c N0 M0, PSA < 20, Grade group 1 (Gleason 6)
* Group IIB
    T1-2 N0 M0, PSA < 20, Grade group 2 (3+4=7)
* Group IIC
    T1-2 N0 M0, PSA < 20, Grade group 3 (4+3=7)
    T1-2 N0 M0, PSA < 20, Grade group 4 (Gleason 8)
* Group IIIA
    T1-2 N0 M0, PSA ≥ 20, Grade group 1-4 (Gleason 8 or less)
* Group IIIB
    T3-4 N0 M0, any PSA, Grade group 1-4 (Gleason 8 or less)
* Group IIIC
    Any T N0 M0, any PSA, Grade group 5 (Gleason 9-10)
* Group IVA
    N1
* Group IVB
    M1
    Note: when either PSA or Gleason is not available, grouping should be determined by T stage and/or either PSA or Gleason as available
Overview of 8th Edition staging -- comparing to risk groups :
| New 8th Edition stage | Gleason | Low/Inter/High risk | Features |
| I | G6 | Low | PSA < 10 |
| IIA | G6 | Interm | PSA 10-20, or cT2b-c and PSA<20 |
| IIB | G3+4=7 | Interm | PSA < 20 |
| IIC | G4+3=7 G8 | Interm High | G4+3 and PSA<20 G8 and PSA<20 |
| IIIA | G6-8 | High | PSA > 20 |
| IIIB | G6-8 | Very High (prior AJCC Stage III) | T3-T4 |
| IIIC | G9 or 10 | High |
| IVA | | prior AJCC Stage IV | N1 |
| IVB | | prior AJCC Stage IV | M1 |
Simplified staging chart :
| | PSA | PSA | PSA |
| | <10 | 10-20 | > 20 |
| G 6 | I $^*$ | IIA | IIIA |
| G 3+4 | IIB | IIB | IIIA |
| G 4+3 | IIC | IIC | IIIA |
| G 8 | IIC | IIC | IIIA |
| cT3-4 | IIIB | IIIB | IIIB |
| G 9-10 | IIIC | IIIC | IIIC |
| $^*$ G6 cT2b-c PSA<20 is IIA ||||

### Older staging systems

AJCC 7th Edition (2009)
    Note: new staging incorporates Gleason + PSA for risk group determination
Primary Tumor:
* T1 - clinically inapparent tumor neither palpable nor visible by imaging
** T1a - incidental histologic finding in 5% or less of tissue resected
** T1b - incidental histologic finding in more than 5% of tissue resected
** T1c - identified by needle biopsy (e.g., because of elevated PSA)
* T2 - confined within prostate
** T2a - involves one half of one lobe or less
** T2b - involves more than one half of one lobe but not both lobes
** T2c - involves both lobes
* T3 - extends through the prostate capsule (note: invasion into the prostatic apex or into, but not beyond, the prostatic capsule is classified not as T3 but as T2.)
** T3a - extracapsular extension (unilateral or bilateral) or microscopic invasion of bladder neck
** T3b - invades seminal vesicles
* T4 - fixed or invades adjacent structures other than seminal vesicles: bladder, external sphincter, rectum, levator muscles, and/or pelvic wall (Note: microscopic invasion of bladder neck is pT3 and not pT4)
Pathologic staging: there is no pT1 classification
Regional Lymph Nodes:
* N0 - none
* N1 - yes
Regional lymph nodes: pelvic, hypogastric, obturator, iliac (internal, external), sacral Distant lymph nodes: aortic, common iliac, inguinal (deep), inguinal (superficial, femoral), supraclavicular, cervical, scalene, retroperitoneal
Distant Metastases:
* M0 - none
* M1a - non-regional lymph nodes
* M1b - bone
* M1c - other sites
Stage Grouping:
    Note: the AJCC staging manual distinctly lists these as "groups" in contrast to other tumor sites where they are listed as "stage"
* Group I
    T1a-c N0 M0, PSA < 10, Gleason ≤ 6
    T2a N0 M0, PSA < 10, Gleason ≤ 6
    T1-2a N0 M0, PSA X, Gleason X
* Group IIA
    T1a-c N0 M0, PSA < 20, Gleason 7
    T1a-c N0 M0, PSA ≥ 10 < 20, Gleason ≤ 6
    T2a-b N0 M0, PSA < 20, Gleason 7 $^{(correctedinerratum)}$
    T2a N0 M0, PSA ≥ 10 < 20, Gleason ≤ 6 $^{(addedinerratum)}$
    T2b N0 M0, PSA X, Gleason X
* Group IIB
    T2c N0 M0, Any PSA, Any Gleason
    T1-2 N0 M0, PSA ≥ 20, Any Gleason
    T1-2 N0 M0, Any PSA, Gleason ≥ 8
* Group III
    T3a-b N0 M0, Any PSA, Any Gleason
* Group IV
    T4 N0 M0, Any PSA, Any Gleason
    N1, Any PSA, Any Gleason
    M1, Any PSA, Any Gleason
    Note: when either PSA or Gleason is not available, grouping should be determined by T stage and/or either PSA or Gleason as available
* Correlation with risk groups for localized disease -- I is "low risk" (PSA < 10, G ≤ 6), IIA is "intermediate risk" (roughly, PSA 10-20, or G7 and PSA<20), IIB is "high risk" (T2c or PSA≥20 or G≥8).
Errata: AJCC 5th reprint
AJCC 6th Edition (2002)
Primary Tumor:
* T1a - incidental histologic finding in 5% or less of tissue resected
* T1b - incidental histologic finding in more than 5% of tissue resected
* T1c - identified by needle biopsy (e.g., because of elevated PSA)
* T2a - involves one half of one lobe or less
* T2b - involves more than one half of one lobe but not both lobes
* T2c - involves both lobes
* T3a - extracapsular extension (unilateral or bilateral)
* T3b - invades seminal vesicles
* T4 - fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall
Pathologic staging: there is no pT1 classification
Regional Lymph Nodes
* N0 - none
* N1 - yes
Regional lymph nodes: pelvic, hypogastric, obturator, iliac (internal, external), sacral Distant lymph nodes: aortic, common iliac, inguinal (deep), inguinal (superficial, femoral), supraclavicular, cervical, scalene, retroperitoneal
Distant Metastases:
* M0 - none
* M1a - non-regional lymph nodes
* M1b - bone
* M1c - other sites
Stage Grouping:
* I - T1a N0 G1
* II - T1a G2-4, T1b-1c, T2
* III - T3 N0
* IV - T4, N1, M1
Grade: G1 - well differentiated (Gleason 2-4), G2 - moderately differentiated (Gleason 5-6), G3-4 - poorly differentiated (Gleason 7-10)
1997 AJCC
* T1 - same as 2002. T2a - < 1/2 lobe, T2b - > 1/2 lobe or both lobes. No T2c. T3a - unilateral ECE, T3b - bilateral ECE.
1992 AJCC
* T1 and T2 - same as 2002. T3a - unilateral ECE, T3b - bilateral ECE, T3c - seminal vesicle involvement.

## Jewett Whitmore Staging

* Historically used in the US, until AJCC become adopted
* Stage A - no palpable on DRE, no symptoms
** A1: small tumor focus entirely within the gland
** A2: diffuse involvement of gland
* Stage B - palpable, but contained within capsule
** B1: <1.5 cm in diameter
** B2: >1.5 cm in diameter, typically involving both lobes
* Stage C - extracapsular extension, or seminal vesicle invasion
* Stage D
** Stage D1: extraprostatic disease limited to pelvic LN
** Stage D2: widespread metastatic disease