Prostate
191
Rules for Classification The classification applies only to adenocarcinomas. Transitional cell carcinoma of the prostate is classified as a urethral tumour (see page 208). There should be histological confirmation of the disease. The following are the procedures for assessing T, N, and M categories: T categories Physical examination, imaging, endoscopy, biopsy, and biochemical tests N categories Physical examination and imaging M categories Physical examination, imaging, skeletal studies, and biochemical tests
Regional Lymph Nodes The regional lymph nodes are the nodes of the true pelvis, which essentially are the pelvic nodes below the bifurcation of the common iliac arteries. Laterality does not affect the N classification.
TNM Clinical Classification T – Primary Tumour TX T0
Primary tumour cannot be assessed No evidence of primary tumour
T1 Clinically inapparent tumour that is not palpable T1a Tumour incidental histological finding in 5% or less of tissue resected T1b Tumour incidental histological finding in more than 5% of tissue resected T1c Tumour identified by needle biopsy (e.g., because of elevated PSA) T2 Tumour that is palpable and confined within prostate T2a Tumour involves one half of one lobe or less T2b Tumour involves more than half of one lobe, but not both lobes T2c Tumour involves both lobes
Urological
Prostate (ICD‐O‐3 C61.9)
192
Urological Tumours
T3 Tumour extends through the prostatic capsule* T3a Extracapsular extension (unilateral or bilateral) including microscopic bladder neck involvement T3b Tumour invades seminal vesicle(s) T4 Tumour is fixed or invades adjacent structures other than seminal vesicles: external sphincter, rectum, levator muscles, and/or pelvic wall Note * Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is not classified as T3, but as T2.
N – Regional Lymph Nodes NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis Note Metastasis no larger than 0.2 cm can be designated pNmi. (See Introduction, pN, page 7.)
M – Distant Metastasis* M0 No distant metastasis M1 Distant metastasis M1a Non‐regional lymph node(s) M1b Bone(s) M1c Other site(s) Note * When more than one site of metastasis is present, the most advanced category is used. (p)M1c is the most advanced category.
pTNM Pathological Classification The pT and pN categories correspond to the T and N categories. For pM see page 8. However, there is no pT1 category because there is insufficient tissue to assess the highest pT category or subcategories of pT2.
Prostate
193
G Histopathological Grade Group1,2 Grade Group
Gleason Score
Gleason Pattern
1
≤6
≤3 + 3
2
7
3 + 4
3
7
4 + 3
4
8
4 + 4
5
9–10
4 + 5, 5 + 4, 5 + 5
Urological
GX Grade cannot be assessed
Stage* Stage I Stage II Stage III Stage IV
T1, T2a T2b, T2c T3, T4 Any T Any T
N0 N0 N0 N1 Any N
M0 M0 M0 M0 M1
Note * The AJCC also publish a prognostic group for prostate tumours.
Prognostic Factors Grid – Prostate Prognostic factors for prostate cancer Prognostic factor
Tumour related
Host related
Essential
Gleason sum score Grade group TNM stage PSA level
Co‐morbidity Age Performance status
Additional
Alkaline phosphatase (if bone metastases) % involvement of cores on biopsy and number of positive cores
Environment related
Source: UICC Manual of Clinical Oncology, Ninth Edition. Edited by Brian O’Sullivan, James D. Brierley, Anil K. D’Cruz, Martin F. Fey, Raphael Pollock, Jan B. Vermorken and Shao Hui Huang. © 2015 UICC. Published 2015 by John Wiley & Sons, Ltd.
194
Urological Tumours
References 1 Epstein JI, Egevad L, Amin MB, et al. The 2014 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading of Prostatic Carcinoma: Definition of Grading Patterns and Proposal for a New Grading System. Am J Surg Pathol 2016; 40: 244–252. 2 Humphrey PA, Egevard L, Netto GL, et al. Acinar adenocarcinoma. In: WHO Classification of Tumours of the Urinary System and Male Genital Organs. Moch H, et al., eds. Lyon, France: IACR, 2016.