Rectal cancer (staging)
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Staging strongly influences the success of, and rate of local recurrence following rectal cancer resection. In rectal cancer, pre-treatment MRI is the evaluation of choice, guiding surgical and non-surgical management options.
TNM staging
See: TNM staging system for a general description.
Primary tumour staging (T)
Strictly speaking TMN staging, such as American Joint Committee on Cancer (AJCC) 7th ed, does not sub-classify T3. This is a feature of MRI staging but does have treatment and prognostic significance 7,8.
- Tx: primary tumour cannot be assessed
- T0: no evidence of primary tumour
- Tis: carcinoma in situ: intraepithelial or invasion of lamina propria
- T1: tumour invades submucosa
- T2: tumour invades muscularis propria
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T3: tumour invades through the muscularis propria into the subserosa or into non-peritonealised perirectal tissues
- T3a: tumour extends <1 mm beyond muscularis propria 4
- T3b: tumour extends 1-5 mm beyond muscularis propria 4
- T3c: tumour extends 5-15 mm beyond muscularis propria 4
- T3d: tumour extends 15 mm beyond muscularis propria 4
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T4: tumour invades directly into other organs or structures and/or perforates visceral peritoneum
- T4a: tumour penetrates to the surface of the visceral peritoneum
- T4b: tumour directly invades or is adherent to other organs or structures
Regional lymph nodes (N)
The size cut off for mesorectal nodes is usually taken at 5mm 6
More recent analysis of data puts into question the importance of lymph nodes as a predictors of local recurrence and also questions the rational of size criteria for node assessment 9
- Nx: regional nodes not assessed
- N0: no regional lymph nodes
-
N1: metastasis in 1-3 regional (peri-rectal) lymph nodes
- N1a: metastasis in one regional lymph node
- N1b: metastasis in 2-3 regional lymph nodes
-
N1c: tumour deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or perirectal
tissuestissues without regional nodal metastasis
-
N2: metastasis in 4 or more regional lymph nodes
- N2a: metastasis in 4-6 regional lymph nodes
- N2b: metastasis in 7 or more regional lymph nodes
Metastases
- Mx: cannot be assessed
- M0: no distant metastasis
-
M1: distant metastasis
- M1a: metastasis confined to one organ or site (for example, liver, lung, ovary, nonregional node)
- M1b: metastases in more than one organ/site or the peritoneum
Stage groupings
- stage 0: Tis N0 M0
- stage I: T1-2, N0 M0
-
stage II
- IIa: T3, N0, M0
- IIb: T4a, N0, M0
- IIc: T4b, No, Mo
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stage III
- IIIa: T1-2, N1, M0
- IIIb: T3-4, N1, M0
- IIIc: T3-4b, N2, M0
- stage IV: any T, any N M1
Additional prognostic indicators
The following are significant prognostic indicators, and should be commented on when staging rectal cancer with MRI, alongside the TNM stage:
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extramural venous invasion (EMVI)
- may be contiguous or non-contiguous
- non-contigous deposits reflect N1c
- imparts poor prognosis as a predictor of haematogenous spread
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circumferential resection margin (CRM)
- represented by the mesorectal fascia (MRF)
- CRM positive if either tumour, involved lymph node, or EMVI (continous or discontinous) is within 1mm of the mesorectal fascia
- peritoneal reflection does not constitute CRM, which if involved reflects at least stage T4a disease
See also
-<p><strong>Staging</strong> strongly influences the success of, and rate of local recurrence following <a href="/articles/rectal-cancer">rectal cancer</a> resection. In rectal cancer, pre-treatment MRI is the evaluation of choice, guiding surgical and non-surgical management options. </p><h5>TNM staging</h5><p><strong>See:</strong> <a href="/articles/tnm-staging-system">TNM staging system</a> for a general description.</p><h6>Primary tumour staging (T)</h6><ul>- +<p><strong>Staging</strong> strongly influences the success of, and rate of local recurrence following <a href="/articles/rectal-cancer">rectal cancer</a> resection. In rectal cancer, pre-treatment MRI is the evaluation of choice, guiding surgical and non-surgical management options. </p><h5>TNM staging</h5><p><strong>See:</strong> <a href="/articles/tnm-staging-system">TNM staging system</a> for a general description.</p><h6>Primary tumour staging (T)</h6><p>Strictly speaking TMN staging, such as American Joint Committee on Cancer (AJCC) 7th ed, does not sub-classify T3. This is a feature of MRI staging but does have treatment and prognostic significance <sup>7,8</sup>.</p><ul>
-</ul><h6>Regional lymph nodes (N)</h6><p>The size cut off for mesorectal nodes is usually taken at 5mm <sup>6</sup></p><ul>- +</ul><h6>Regional lymph nodes (N)</h6><p>The size cut off for mesorectal nodes is usually taken at 5mm <sup>6</sup> </p><p>More recent analysis of data puts into question the importance of lymph nodes as a predictors of local recurrence and also questions the rational of size criteria for node assessment <sup>9</sup></p><ul>
-<strong>N1c:</strong> tumour deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastasis</li>- +<strong>N1c:</strong> tumour deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastasis</li>
- +<li>non-contigous deposits reflect N1c</li>
-<li>CRM positive if either tumour, involved lymph node, or EMVI is within 1mm of the mesorectal fascia</li>- +<li>CRM positive if either tumour, involved lymph node, or EMVI (continous or discontinous) is within 1mm of the mesorectal fascia</li>
- +<li>peritoneal reflection does not constitute CRM, which if involved reflects at least stage T4a disease</li>
References changed:
- 7. Extramural Depth of Tumor Invasion at Thin-Section MR in Patients with Rectal Cancer: Results of the MERCURY Study. Radiology. 2007;243(1):132-9. <a href="https://doi.org/10.1148/radiol.2431051825">doi:10.1148/radiol.2431051825</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/17329685">Pubmed</a>
- 8. Steel MC, Woods R, Mackay JM et-a. Extent of mesorectal invasion is a prognostic indicator in T3 rectal carcinoma. (2002) ANZ journal of surgery. 72 (7): 483-7. <a href="https://www.ncbi.nlm.nih.gov/pubmed/12123507">Pubmed</a> <span class="ref_v4"></span>
- 9. Balyasnikova S & Brown G. Optimal Imaging Strategies for Rectal Cancer Staging and Ongoing Management. Curr Treat Options Oncol. 2016;17(6):32. <a href="https://doi.org/10.1007/s11864-016-0403-7">doi:10.1007/s11864-016-0403-7</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27255100">Pubmed</a>
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