il tumore della prostata. ii. stadiazione - Università degli studi di Pavia

Università degli Studi di Pavia 

AA 2010 - 2011 

Corso Integrato di Clinica Medica 

Insegnamento di Oncologia Medica 

IL TUMORE DELLA PROSTATA. II. 

STADIAZIONE 

Prof. Alberto Riccardi

STAGING METHODS

PROSTATIC CANCER 

Clinical staging. I. 

* TNM staging system includes categories for 

cancers palpable on DRE, those identified solely on 

basis of abnormal PSA (T1c), those palpable but 

clinically confined to gland (T2) and those extended 

outside gland (T3 and T4)


Clinical staging. II. 

* DRE alone inaccurate in assessing extent of 

disease within gland, capsular invasion, involvement 

of seminal vescicles and spread to nodal or more 

distant sites; 

* assessment refined by imaging studies 

[ultrasound, computed tomoghraphy (CT), magnetic 

resonance imaging (MRI) and bone scan]; 

- however, no single test accurately predicts 

pathologic stage (organ - confined disease? seminal 

vesical involvement? lymph node spread?)


Clinical staging. III. Transrectal ultrasound 

* transrectal 

ultrasound (TRUS) 

most frequently used 

→ no consistent 

finding predicts PC 

with certainty → 

primarly used to direct 

prostate biopsy

* CT scans lack 

sensitivity and 

specificity for 

extraprostatic 

extension and 

inferior to MRI in 

visualization of 

lymph nodes 


Clinical staging. IV. CT scan 

* CT scan can show abnormal lymph nodes in pelvis 

and abdomen, but not sensitive enough to identify 

microscopic cancer cells in lymph nodes = CT scans do 

not provide reliable enough information about condition 

of prostate or stage of prostate cancer


Clinical staging. V. MRI 

* MRI (still lacking sensitivity and specificity) ↑ lymph 

node detection, especially of endorectal coil; 

[- T1 - weighted images: periprostatic fat and venous 

plexus, perivesicular tissues, lymph nodes, and bone 

marrow; 

- T2 - weighted images: internal architecture of prostate 

and seminal vesicles (low signal in most cancers, high 

signal in normal peripheral zone)]; 

- MRI also useful for planning of surgery and radiation 

therapy 

= neither TC nor MRI accurately predicts pathologic 

stage at surgery


Clinical staging. VII. 

Molecular diagnostic (experimental) 

* seeks to identify presence of 

circulating PC cells using an 

assay for PSA based on reverse 

transcriptase - polymerase 

chain reaction (RT - PCR) in 

leukocyte fraction of peripheral 

blood or bone marrow; 

- test+ in large % of pts with 

tumors seemingly confined to 

organ (unclear significance)

STAGING

STAGING 

* two schemes commonly used to stage PC; 

- TNM stage system: most common (by 

American Joint Committee on Cancer, AJCC), 

evaluating size of tumor, extent of involved 

lymph nodes, metastasis and cancer grade; 

- Whitmore - Jewett stage: now used less 

commonly for research, but often still used by 

clinicians

TNM STAGING


TNM clinical staging 

* T categories: 

* clinically inapparent, not palpable tumor (T1a 

- T1b) or detected from ↑ serum PSA (T1c); 

* palpable but clinically confined to gland (T2), 

and: 

* extended outside gland (T3 and T4); 

* N categories: presence or absence of nodal 

metastases; 

* M categories: presence or absence of distant 

metastases


TNM clinical staging


Clinical staging 

TNM definitions: T1 

* TX: primary tumor cannot be assessed; 

* T0: no evidence of primary tumor; 

* T1: clinically inapparent tumor not palpable nor 

visible by imaging: 

T1a: incidental histologic finding in ≤ 5% of tissue 

resected; 

T1b: incidental histologic finding in > 5% of tissue 

resected; 

T1c: identified by needle biopsy due to elevated PSA

* T2: confined within prostate: 

- T2a: involving 1 lobe; 

- T2b: involving both lobes; 

[- note: tumor found in 1 or both lobes by needle 

biopsy, but not palpable or visible by imaging, 

classified as T1c] 



TNM definitions: T2



TNM definitions: T3 - T4 

* T3: tumor extends through prostatic capsule: 

T3a: extracapsular extension (uni- or bilateral); 

T3b: tumor invades seminal vesicle(s); 

[- note: invasion into prostatic apex or into (but not 

beyond) prostatic capsule is not classified as T3, but as 

T2]; 

* T4: tumor fixed to or invading adjacent 

structures other than seminal vesicles (bladder 

neck, external sphincter, rectum, levator muscles 

and / or pelvic wall)

LOCAL 

STAGING 

OF 

PROSTATE 

CANCER


Clinical staging. TNM definitions: Regional nodes (N) 

* = nodes of true pelvis (= nodes below 

bifurcation of common iliac arteries, including 

pelvic, hypogastric, obturator, iliac, periprostatic, 

and sacral); 

* distant lymph nodes = outside confines of true 

pelvis (aortic, common iliac, inguinal, superficial 

inguinal, supraclavicular, cervical, scalene, and 

retroperitoneal nodes) and their involvement = 

distant metastases; 

* NX: regional lymph nodes cannot be assessed; 

* N0: no regional lymph node metastasis; 

* N1: metastasis in regional lymph node(s) 

[- note: laterality does not affect N classification]


Clinical staging. TNM definitions 

Distant metastasis (M) 

* MX: distant metastasis cannot be assessed; 

* M0: no distant metastasis; 

* M1: distant metastasis; 

M1a: nonregional lymph node(s); 

M1b: bone(s); 

M1c: other site(s)


Clinical staging: limits. I. 

* limit of TNM system = most PC are now 

diagnosed as T1c (by needle biopsy, often 

because ↑ PSA) or T2 (still confined within 

prostate) disease, leading to attempts at refining 

prediction of local disease extent: 

- multiplex staging models (based on a 

combination of findings of digital examination, 

biopsy, Gleason score and baseline PSA); 

- models based on no. of cores and % of each 

core involved by tumor; 

* unproven efficacy at predicting node 

involvement


Variables in multiplex staging models


Clinical staging. Differentiation (G)

Stage I 

T1a, N0, M0, G1 

Stage II 

T1a, N0, M0, G 2, 3 - 4 

T1b, N0, M0, any G 

T1c, N0, M0, any G 

T2, N0, M0, any G 


AJCC stage groupings 

Stage III 

T3, N0, M0, any G 

Stage IV 

T4, N0, M0, any G 

any T, N1, M0, any G 

any T, any N, M1, any G


AJCC stage groupings

STAGING 

WHITEMORE - JEWETT STAGING


Whitemore - Jewett Staging System. Stage A 

* stage A = clinically undetectable tumor 

confined to prostate gland, as incidental 

finding at prostatic surgery; 

- substage A1: G1 with focal involvement, usually 

left untreated; 

- substage A2: G2 - G3 or involving multiple foci 

in gland

Multicentricity of prostate cancer 

whole mount section of prostate showing two distinct foci of 

adenocarcinoma illustrating the frequent finding of multicentricity


Whitemore - Jewett Staging System. Stages B - C 

* stage B = confined to prostate gland: 

substage B0: nonpalpable, PSA - detected; 

substage B1: single nodule in 1 lobe; 

substage B2: more extensive involvement of 1 lobe or 

involvement of both lobes 

* stage C = clinically localized to periprostatic area 

but extending through prostatic capsule, with 

seminal vesicles possibly involved: 

substage C1: clinical extracapsular extension; 

substage C2: extracapsular tumor producing bladder 

outlet or ureteral obstruction


Whitemore - Jewett Staging System. Stage D 

* Stage D = metastatic disease: 

substage D0: clinically localized disease (prostate 

only) but persistently elevated enzymatic serum 

acid phosphatase titers; 

substage D1: regional lymph nodes only; 

substage D2: metastases to distant lymph nodes, 

bone or visceral organs; 

substage D3: D2 prostate cancer pts who 

relapsed after adequate endocrine therapy

STAGING 

COMPARISON BETWEEN TNM AND 

WHITEMORE - JEWETT STAGING

CLINICAL STAGES 

BY TNM CLASSIFICATION 

AND 

WHITMORE - JEWETT 

STAGING SYSTEM

il tumore della prostata. ii. stadiazione - Università degli studi di Pavia

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