The generally accepted TNM system (from the English The Tumor, Node, Metastasis - tumor, node, metastases), developed and adopted by the American Joint Committee on Cancer Research AJCC and the International Union Against Cancer UICC, is based on the key and available characteristics of the tumor, which in underlie cancer staging. An accurate assessment of the stage of the disease allows you to clearly determine the extent of tumor spread and the prognosis of the disease, as well as predict the response to various treatments. In most cases, the main goal of cancer staging based on the TNM classification is the anatomical description of the tumor and its metastases, on the basis of which decisions on further therapeutic tactics are made. In clinical practice, TNM staging is combined with the individual clinical characteristics of the patient and sometimes with the molecular characteristics of the tumor itself. In some cases, histological and molecular features of the tumor are included in the classification.

8th revision TNM lung cancer classification: milestones

Unlike previous editions of the TNM classifications of lung cancer, a wide range of multidisciplinary specialists in the field of surgical, radiation, medical oncology, anatomical and molecular beam pathology, imaging, biostatistics and other areas took part in the work on the last, 8th edition. A total of 420 experts from 181 institutions, who work in 21 countries of the world, participated. Their activities were coordinated by the chief editor.

Major adjustments for the seventh edition were made to improve the predictive value of staging. Within their framework, several general staging rules, histological classification and grading system, and the WHO / IARS histological code system were identified.

It should be noted that the work on the eighth edition of the TNM classification has not yet been finally completed: the possibility of including additional rules for staging cancer when using software for electronic medical records is being studied with the aim of total systematization of information for further observation and research.

The TNM classification of lung cancer is based on the assessment of three parameters:

• T is the size and location of the primary tumor,
• N - involvement of the mediastinal lymph nodes,
• M - the presence of distant metastases to other organs, including another lung.

Primary tumor (T)

Major changes in the 8th edition of the classification regarding primary tumor staging include:

• T1 changes: in the new edition, tumors are divided into T1 and T1a (≤1 cm), T1b (\u003e 1 ... ≤2 cm) and T1c (\u003e 2 ... ≤3 cm)
• T2 changes: according to the new edition for T2 tumors, the borderline size is set at 5 cm (in the previous edition - 7 cm). Involvement of the main bronchus in the process, regardless of the distance from the tracheal keel, is more likely T2 than T3. Both partial and general atelectasis / pneumonitis in the 2017 edition is T2
• Changes in T3 and T4: Tumors greater than 5 cm and less than or equal to 7 cm are characterized as T3 (not T2). Tumors larger than 7 cm are combined into a new T4A group. Diaphragm invasion is now T4, not T3

A new stage has been developed for T3 and T4 tumors, which, according to the 2017 revision, are classified as stage IIIC if accompanied by involvement of the contralateral lymph node N3.

Changes in the staging of the primary tumor in the 8th edition of the TNM classification were introduced based on the analysis of data from 33,115 patients according to the new clinical or pathological classification, tumor size, information on its spread, taking into account the degree of metastasis. The analysis led to the following conclusions:

• The increase in the tumor per centimeter correlated with a clear decrease in survival, which indicates the need to create a new T-system with a large number of divisions per stage depending on the size
• Tumors greater than 5 but equal to or less than 7 cm were associated with a better prognosis if they were categorized as T3 rather than T2b, and survival for tumors greater than 7 cm was comparable to that for T4 tumors. These data substantiated the need to establish new dimensions for T3 and T4 tumors.
• Bronchial invasion less than 2 cm from the keel, classified as T3 in the previous revision, had a better prognosis than previously thought when classified as T2

Table 1... Primary tumor classification
in accordance with TNM 8th revision.

Regional lymph nodes (N)

In the 7th edition classification, gradation according to regional lymph node involvement was fairly consistent in predicting prognosis. It was also taken as a basis in the 2016 edition, but it was proposed to supplement it with a subclassification based on the number of involved groups of lymph nodes or individual nodes.

pN1 - involvement of ipsilateral intrapulmonary, peribronchial or thoracic lymphatic catches:

• pN1a - metastases in one group,
• pN1b - metastases in several groups.

pN2 - involvement of ipsilateral mediastinal or bifurcated lymph nodes:

• pN2a1 - one N2 group without concomitant N1 group involvement,
• pN2a2 - one N2 group with simultaneous involvement of the N1 group.

pN2b - metastases in multiple N2 groups.

It should be noted that regional lymph nodes are divided into groups according to the side of the lesion (right or left) and localization. Groups of lymph nodes are numbered from 1 to 14 in accordance with the international scheme (Fig. 1).

Picture 1

Subclassification of regional lymph node involvement in lung cancer was adopted based on the analysis of the clinical (c) and pathological (p) status of the lymph nodes (N) in 38,910 and 31,426 patients with NSCLC, respectively. His results showed that the five-year survival rate depending on cN and pN status was 60% and 75% (N0), 37% and 49% (N1), 23% and 36% (N2) and 9% and 20% (N3) respectively.

Based on additional analysis data, it was found that in pathological staging, survival correlates with the number of individual lymph nodes involved in groups N1 and N2. This finding became the basis for the creation of new subgroups in the 8th edition of the classification.

The presence of "missed" and "bouncing" metastases, in which N2 lesion is present without affecting N1 lymph nodes (pN2a1), was associated with better survival compared with the disease in which both groups (N2 and N1) were affected by metastases. In patients with pN1b and pN2a diseases, the 5-year survival rate was comparable, amounting to approximately 50%.

The 8th edition subclass conventions do not define treatment options. Rather, they should be considered in combination with the individual characteristics of the patient.

table 2... Classification of lung cancer by
from the involved lymph nodes according to the TNM 8 revision system.

Metastases (M)

In the 8th edition of the TNM system, metastatic cancer is still classified as M1a if it is confined to the chest (discrete nodules in the contralateral lung, tumor with pleural dissemination, malignant or pericardial effusion). The subclassification for distant metastases has changed: unlike the 7th revision system, which provides only stage M1b (other distant metastases), in the 8th revision system, a division into M1b (single distant metastasis) and M1c (multiple distant metastases in one or more organ).

These changes led to the introduction of stage IVa, in which the disease is limited to either intrathoracic metastatic lesion or a single distant metastasis, and stage IVb, in which there are multiple distant metastases. It is expected that these innovations in lung cancer staging will help determine the treatment of oligometastatic disease.

Table 3... Lung cancer staging
in accordance with the TNM classification of the 8th revision.

* Tis - carcinoma in situ; T1a (mi) is a minimally invasive carcinoma.

Lung cancer prognosis depending on the stage

According to the TNM staging system, the median lung cancer survival is associated with both clinical (at the stage of examination) and surgical pathological stages. In most cases, there is a significant difference in survival when comparing diseases with two adjacent stages.

Figure 2
according to TNM 7th edition.

Figure 3... Overall survival according to pathological stage
according to the TNM system of the 8th edition.

List of references

1. Amin M.B., et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging. CA. Cancer J. Clin. 2017. Vol.67, No. 2, P. 93-99.
2. Goldstraw P., et al. The IASLC Lung Cancer Staging Project: Proposals for the Revision of the TNM Stage Groupings in the Forthcoming (Seventh) Edition of the TNM Classification of Malignant Tumours. J. Thorac. Oncol. 2007. Vol.2, No. 8, P. 706-714.
3. Goldstraw P., et al. The IASLC lung cancer staging project: Proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM Classification for lung cancer. J. Thorac. Oncol. 2016. Vol.11, No. 1, P. 39-51.
4. Rami-Porta R., et al. The IASLC Lung Cancer Staging Project: Proposals for the Revisions of the T Descriptors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. J. Thorac. Oncol. 2015. Vol.10, No. 7, P. 990-1003.
5. Kim J. H., et al. The International Association for the Study of Lung Cancer Lymph Node Map: A Radiologic Atlas and Review. Tuberc. Respir. Dis. (Seoul). The Korean Academy of Tuberculosis and Respiratory Diseases, 2015. Vol. 78, No. 3, P. 180-189.

When treating patients with thyroid cancer, it is very important to maintain continuity in the work of various medical institutions. To put it simply, doctors somehow need to convey information about the patient's illness to each other, while it is not enough just to write in the diagnosis "Papillary thyroid cancer", it is necessary to note a number of the most important parameters of the tumor. It is on these distinctive features that doctors of the next level will plan the treatment of the patient.

It is clear that describing all the features of a tumor in words is long and ineffective. Imagine a similar "verbal" diagnosis (for example, "Papillary carcinoma of the thyroid gland, in which the tumor node was 3 cm in size, grew into the thyroid capsule, there were metastases of the tumor to the lymph nodes of the paratracheal group, and an in-depth examination did not reveal metastases to other organs") ... The verbal formulation of the diagnosis will inevitably lead in some cases to the appearance of unnecessary information in the diagnosis, and in others to the omission of the description of the really important parameters of the tumor.

The problem of correctly formulating a diagnosis is also important when conducting statistical research. It is no secret that doctors around the world regularly exchange statistical information in order to correctly assess the effectiveness of treatment methods and, as a result, to use methods with proven efficacy more widely and to exclude methods that have not proven their usefulness for patients from their therapeutic arsenal. In such international cooperation, it is very important to "speak the same language" - i.e. to have the possibility of a standard description of the disease, which will be understandable to a doctor in any country on our planet. That is why doctors all over the world had to develop a classification system for thyroid cancer, which would take into account the main parameters of this disease, the most important for the patient's treatment.

Of the several proposed classifications, the most popular and reliable was the TNM staging system developed by the American Joint Cancer Committee (AJCC) and the International Union Against Cancer (UICC). The TNM classification of thyroid cancer was based on two parameters: the prevalence of the tumor and the age of the patient.

The prevalence of the tumor is coded as follows:

"T" (from Latin for tumor) - describes the prevalence of the primary tumor;

"N" (from the Latin nodus - node) - describes the tumor affection of regional lymph nodes, i.e. nodes collecting lymph from the region of the tumor;

"M" (from the Latin metastasis - metastasis) - describes the presence of distant tumor metastases, ie new tumor foci that have appeared in distant parts of the human body, outside the regional lymph nodes.
Currently, the TNM classification of the 6th edition, adopted in 2002, is in force. Now let's look at the classification itself.

Prevalence of primary tumor

T0 - the primary tumor in the thyroid tissue was not detected during the operation

T1 - a tumor of 2 cm or less in the largest dimension within the thyroid gland

Sometimes an addition can be used:
T1a - tumor 1 cm or less
T1b - tumor more than 1 cm, but not more than 2 cm

T2 - a tumor more than 2 cm, but less than 4 cm in greatest dimension within the thyroid gland (i.e., not growing into the capsule of the gland)

T3 - a tumor larger than 4 cm in greatest dimension within the thyroid gland, or any tumor with minimal spread outside the thyroid capsule (for example, invading short muscles or adjacent adipose tissue). Thus, even small tumors of the thyroid gland growing into its capsule are staged as T3

T4 - tumors at this stage are divided into two substages:

T4a - a tumor of any size, invading the thyroid capsule with invasion of the subcutaneous soft tissues, larynx, trachea, esophagus or recurrent laryngeal nerve

T4b - a tumor invading the prevertebral fascia, carotid artery or retrosternal vessels.

It is important to note that all undifferentiated thyroid carcinomas are classified as stage T4, regardless of their size. For these carcinomas, the staging is slightly different:

T4a - undifferentiated carcinoma located within the thyroid gland - surgically resectable (i.e. completely removed during surgery)

T4b - undifferentiated carcinoma that extends beyond the thyroid gland - surgically unresectable (i.e., completely unremovable surgically)

Presence of metastases in the regional lymph nodes of the neck

NX - the presence of regional metastases cannot be assessed

N0 - absence of regional metastases

N1 - the presence of regional metastases

N1a - metastases in the VI zone of lymphatic drainage (pretracheal, paratracheal and pre-laryngeal lymph nodes)

N1b - metastases in the lateral cervical lymph nodes on one or both sides, on the opposite side or in the retrosternal lymph nodes

Distant metastases

MX - the presence of distant metastases cannot be assessed

M0 - absence of distant metastases

M1 - presence of distant metastases

Based on the study of tumor parameters using the TNM system, tumor staging is performed, i.e. determination of the prognosis for its treatment. There are four stages in total, from I (most favorable) to IV (most unfavorable). Taking into account the different properties of thyroid tumors (papillary and follicular cancers on the one hand, anaplastic cancers on the other), staging for different forms of thyroid cancer is carried out according to different rules.

In pancreatic cancer, unlike other malignant neoplasms, this classification is rarely used. Many patients with pancreatic cancer do not undergo surgery.

TNM classification implies the assessment of the tumor itself, its spread to the lymph nodes and metastasis to distant organs. The combined assessment of the results allows you to establish the stage of pancreatic cancer in each case. There are five stages of pancreatic cancer from I to IV, the very first stage is zero.

TNM is an abbreviation of the English word for tumor ( Tumor), "lymph node" ( Node) and "metastasis" ( Metastasis). To determine the stage of a tumor, doctors evaluate the following factors:

• Primary tumor size
• Tumor spread to lymph nodes
• Metastases in distant organs

Category T

TX: It is impossible to assess the condition of the primary tumor

T0: No signs of cancer in the pancreas

Tis: The earliest manifestation of cancer without tumor spread is carcinoma in situ

T1: Tumor diameter 2 cm or less, located within the pancreas

T2: Tumor diameter over 2 cm, located within the pancreas

T3: The tumor extends outside the pancreas, but does not penetrate into large arteries or veins near the organ

T4: The tumor extends outside the pancreas and invades large arteries or veins near the organ. A T4 tumor is inoperable.

Category N

NX: It is impossible to assess the state of the regional lymph nodes.

N0: There are no signs of cancer in the regional lymph nodes.

N1: The tumor spreads to regional lymph nodes.

Category M

MX: It is impossible to detect distant metastases.

M0: The tumor does not metastasize.

M1: In distant organs, metastases are detected. Pancreatic cancer metastases primarily to the liver, lungs and peritoneum.

Grouping stages

The exact stage of cancer can be determined by combining the T, N, and M categories.

Stage 0: (Tis, N0, M0) Cancer in situ. The tumor does not extend beyond the pancreatic ducts.

Stage IA: (T1, N0, M0) A tumor up to 2 cm in size within the pancreas, does not spread to the lymph nodes or other organs.

Stage IB: (T2, N0, M0) A tumor larger than 2 cm within the pancreas, does not spread to the lymph nodes or other organs.

Stage IIA: (T3, N0, M0) The tumor extends outside the pancreas. Does not spread to adjacent arteries or veins. Does not spread to lymph nodes or distant organs.

Stage IIB: (T1, T2 or T3; N1; M0) Tumor of any size. It does not spread to adjacent arteries or veins. It spreads to lymph nodes or other organs.

Stage III: (T4, N1, M0) The tumor has spread to nearby arteries, veins, and / or lymph nodes. It does not metastasize to distant organs.

Stage IV: (any T, any N, M1) Tumor of any size. Metastasizes to distant organs.

Recurrent pancreatic cancer:Reappearance of a tumor after treatment.

It is always important for clinicians to have a standardized description of colorectal cancer, and there are several reasons for this. First of all, the patient's prognosis directly depends on the extent of the tumor spread during the initial diagnosis. Tumors that have spread far away (metastases) to other organs are more aggressive and widespread than small tumors that are limited only to the intestinal wall. Secondly, the common system allows doctors to pass on very important information to each other and adhere to an accurate treatment plan. It also makes it possible to determine which patients need to undergo special examinations, surgery or chemotherapy. For example, surgery alone may be sufficient to treat small tumors, while more common tumors may require a combination of surgery and chemotherapy. Tumor stage is the language in which doctors describe the nature of the tumor, as well as the extent of its local and distant spread.

Tumor staging is based on three criteria: the depth of tumor growth into the intestinal wall (T), the presence of spread of tumor cells through the lymph nodes (N), and, finally, the presence or absence of metastases (M). These three constituents form the TNM system for staging colorectal cancer (see tables below).

Stage T (tumor) - the depth of growth of the tumor into the intestinal wall. The lower the value of this stage, the less invasive tumor growth. A stage T0 tumor can still be considered quite benign, since the growth of this tumor is limited only by the intestinal mucosa. A stage T4 tumor means that the tumor has grown not only all layers of the intestinal wall, but also the organs adjacent to it.

Stage N (lymphnodes) - indicates the number of lymph nodes in which cancer cells have been found. Stage N0 means that no cancer cells were found in any of the lymph nodes during the pathological examination. Stage Nx means that the number of affected lymph nodes is unknown. This may be at the stage of examination before the operation, when it is impossible to determine whether the lymph nodes are affected or not. Until a postmortem examination is done, the stage is considered Nx.

Stage M (metastases) - indicates whether the tumor has distant screenings - metastases.

Tumor stage according to TNM system

General tumor stage

Look for headings T, N, and M in the table to understand how the stage is set. Each column contains numbers or the word "any". The second row in the table corresponds to stage I, the columns contain the following data: stage T 1 or 2, stages N and M - 0. This means that if the tumor grows only into the intestinal wall (stage T1 or T2) and there are no cancerous lymph nodes in any cells (stage N0) and there are no distant metastases (stage M0), the tumor will be classified as stage I cancer. A tumor that grows through the intestinal wall (stage T3 or T4), but does not have affected lymph nodes and distant metastases, has stage II, and so on.

Staging plays a very important role in determining treatment tactics. Stage I tumors are usually treated with surgery alone, and stage III tumors are usually treated with both surgery and chemotherapy. Thus, tumor staging is a very important step in preoperative diagnosis. In order to determine the stage before surgery, it may be necessary to perform many studies. Computed tomography (CT), chest x-ray, ultrasound (ultrasound), magnetic resonance imaging (MRI), and positron emission tomography (PET) are very informative tests to help determine the extent of tumor spread. However, the most accurate method for determining the stage of the tumor is to examine the part of the intestine removed during the operation using a microscope.

It is very important that patients understand the principles of tumor staging and have an idea of \u200b\u200bhow it is done in order to competently discuss treatment options and prognosis with a doctor.

T index (tumor) - indicates the size of the tumor:

TO - the primary tumor is not detected;

T1 - tumor up to 2 cm, located on the surface of the organ;

T2 - a tumor of the same or large size, but with infiltration of deeper layers or with a transition to adjacent anatomical parts of the organ; TK - a tumor of significant size, or growing deep into the organ, or passing to adjacent organs and tissues;

T4 - the tumor grows into adjacent structures with complete restriction of organ mobility.

Index N (nodes) - characterizes the defeat of regional lymph nodes:

N0 - no metastases;

N1 - single (less than 3) metastases;

N2 - multiple metastases to the nearest regional lymph nodes, displaced in relation to the surrounding tissues;

N3 - multiple non-displaceable metastases or lymph node involvement in more distant areas of regional metastasis; nx - it is impossible to judge the involvement of the lymph nodes before the operation.

Index M (metastases) - denotes distant hematogenous or lymphogenous metastases:

MO - no metastases;

Ml - there are distant metastases.

P index (germination) - characterizes the degree of germination of the wall of the gastrointestinal tract (determined after histological examination).

Index G (degree) - indicates the degree of malignancy in tumors of the gastrointestinal tract and ovaries (determined after histological examination).

CLASSIFICATION BY STAGE

Lip cancer

Stage I. A limited tumor or ulcer up to 1 cm in diameter in the thickness of the mucous membrane and submucosal layer of the red border of the lip without metastases.

Stage II. a) Tumor or ulcer, limited to the mucous membrane and submucosa, up to 2 cm in size, occupying no more than half of the red border of the lips; b) a tumor or ulcer of the same size or smaller, but in the presence of a single displaced metastasis in the regional lymph nodes.

Stage III. a) A tumor or ulcer up to 3 cm in diameter, occupying most of the lip, with the germination of its thickness or spread to the corner of the mouth, cheek and soft tissues of the chin; b) a tumor or ulcer of the same size or less spread, but with the presence of limited displaced metastases in the chin, submandibular regions.

Stage IV. a) A disintegrating tumor that occupies most of the lip, with the germination of its entire thickness and spread not only to the corner of the mouth, chin, but also to the bony skeleton of the jaw. Non-displaced metastases in regional lymph nodes; b) a tumor of any diameter with metastases.

Cancer of the tongue

Stage I. Tumor of the mucous membrane or submucosa up to 1 cm in diameter, without metastases.

Stage II. a) Tumor up to 2 cm in diameter, not spreading beyond the midline of the tongue, without metastases; b) a tumor of the same size, but with the presence of single displaced regional metastases.

Stage III. a) Tumor or ulcer up to 3 cm in diameter, passing over the middle line of the tongue, to the bottom of the oral cavity, without metastases; b) the same with the presence of multiple displaced or single non-displaceable metastases.

Stage IV. a) The tumor affects most of the tongue, spreads to adjacent soft tissues and to the jaw bone, with multiple limited displaceable or single non-displaceable metastases; b) a tumor of the same size with non-displaceable regional or distant metastases.

Laryngeal cancer

Stage I. A tumor or ulcer confined to the mucous membrane and submucosa and does not extend beyond one section of the larynx.

Stage II. A tumor or ulcer occupies almost entirely any one section of the larynx, but does not go beyond it, the mobility of the larynx is preserved, a displaced metastasis is determined on the neck on one side.

Stage III. The tumor spreads to the underlying tissues of the larynx, causes immobility of its corresponding half, there are single or multiple movable metastatic nodes on the neck on one or both sides.

Stage IV. An extensive tumor occupying a large part of the larynx, infiltrating the underlying tissues, invading the adjacent organs with infiltration of the underlying tissues.

Thyroid cancer

Stage I. A localized tumor within the thyroid gland.

Stage II. A tumor of the same size with single metastases to regional lymph nodes.

Stage III. The tumor grows into the capsule of the gland, there are metastases in the regional lymph nodes.

Stage IV. The tumor grows into neighboring organs, there are distant metastases.

Skin cancer

Stage I. A tumor or ulcer no more than 2 cm in diameter, limited by the epidermis and the dermis itself, is completely mobile together with the skin (without infiltration of adjacent tissues) and without metastases.

A tumor or ulcer more than 2 cm in diameter, invading the entire thickness of the skin, without spreading to adjacent tissues. In the nearest lymph nodes there may be one small mobile metastasis.

Stage III. a) A significant size, a limitedly mobile tumor that has grown through the entire thickness of the skin, but has not yet passed on to bone or cartilage, without metastases; b) the same tumor or smaller, but in the presence of multiple mobile or one sedentary metastasis.

Stage IV. a) Tumor or ulcer, widespread in the skin, overgrowing the underlying soft tissue, cartilage or bone skeleton; b) a tumor of smaller size, but in the presence of motionless regional or distant metastases.

Melanoma of the skin

Stage I. Malignant nevus or a limited tumor up to 2 cm in size in the largest diameter, flat or warty pigmented, invading only the skin without underlying tissues. Regional lymph nodes are not affected by metastases.

Stage II. a) Pigmented tumors of a warty or papillomatous nature, as well as flat ulcers, more than 2 cm in maximum diameter, with infiltration of the underlying tissue without metastases in regional lymph nodes; b) the same tumors as in stage Pa, but with damage to regional lymph nodes.

Stage III. a) Pigmented tumors of various sizes and shapes, growing into the subcutaneous tissue, limited displacement, without metastases; b) melanomas of any size with multiple regional metastases.

Stage IV. Primary tumor of any size, but with the formation of small pigmented metastatic formations of satellites in the adjacent skin areas (lymphogenous dissemination) or the presence of distant metastases.

Mammary cancer

Stage I. The tumor is small (less than 3 cm), located in the thickness of the mammary gland, without transition to the surrounding tissue and skin, without metastases.

Stage II. Tumors not exceeding 5 cm in largest diameter, with a transition from breast tissue to fiber, with a symptom of adhesion to the skin, without metastases; b) a tumor of the same or smaller size with the defeat of single lymph nodes of the first stage.

Stage III. a) Tumors more than 5 cm in diameter, with germination (ulceration) of the skin, penetration into the underlying fascial muscle layers, but without metastases in regional lymph nodes; b) tumors of any size with multiple axillary or subclavian and subscapularis metastases; c) tumors of any size with metastases in the supraclavicular lymph nodes with identified parasternal metastases.

Stage IV. Widespread lesions of the mammary gland with dissemination in the skin, tumors of any size, invading the chest wall, tumors with distant metastases.

Lung cancer

Stage I. A small limited tumor of a large bronchus with endo or peribronchial growth, and such a small tumor of small or smallest bronchi without damage to the pleura, without metastases.

Stage II. A tumor of the same or large size, but without damage to the pleura in the presence of single metastases in the nearest regional lymph nodes.

Stage III. A tumor invading the pleura, growing into one of the neighboring organs, in the presence of multiple metastases in the regional lymph nodes.

Stage IV. A tumor with extensive spread to the chest wall, mediastinum, diaphragm, with dissemination along the pleura, with extensive regional or distant metastases.

Esophageal carcinoma

Stage I. A well-defined small tumor, invading only the mucous and submucous layer. The tumor does not narrow the lumen of the esophagus, it makes little difficulty for the passage of food. There are no metastases.

Stage II. A tumor or ulcer that invades the muscular layer of the esophagus, but does not go beyond its wall. The tumor significantly disrupts the patency of the esophagus. There are single metastases in regional lymph nodes.

Stage III. A tumor or ulcer that occupies more than the semicircle of the esophagus or encloses it circularly, invading the entire wall of the esophagus and surrounding tissue, fused with adjacent organs. The patency of the esophagus is significantly or completely impaired. There are mental metastases in regional lymph nodes.

Stage IV. A tumor that affects the esophagus circularly extends beyond the organ, causing perforation into the nearest organs. There are conglomerates of immobile regional lymph nodes and metastases in distant organs.

Stomach cancer

Stage I. A small tumor localized in the mucous and submucous layer of the stomach without regional metastases.

Stage II. A tumor that invades the muscular layer of the stomach, but does not invade the serous membrane, with single regional metastases.

Stage III. A tumor of considerable size, invading the entire wall of the stomach, soldered or grown into adjacent organs, limiting the mobility of the stomach. The same or smaller tumor, but with multiple regional metastases.

Stage IV. Tumor of any size with distant metastases.

Colon cancer

Stage I... A small tumor infiltrating the mucous and submucous layer of the intestinal wall in the absence of metastases.

Stage II. a) A tumor of a larger size, occupying no more than a semicircle of the intestine, not going beyond its limits and not growing into neighboring organs, without metastases; b) a tumor of the same or smaller size, but with the presence of metastases in regional lymph nodes.

Stage III. a) The tumor occupies more than a semicircle of the intestine, invades its entire wall or the adjacent peritoneum, without metastases; b) a tumor of any size with the presence of multiple regional metastases.

Stage IV. An extensive tumor that has grown into adjacent organs, with multiple regional metastases, or any tumor with distant metastases.

Rectal cancer

Stage I. A small, well-defined mobile tumor or ulcer, localized in a small area of \u200b\u200bthe mucous membrane and submucosa, not going beyond, without metastases.

Stage II. and) A tumor or ulcer occupies up to half of the circumference of the rectum, without going beyond it, without metastases; b) a tumor of the same or smaller size with single mobile regional metastases.

Stage III. a) The tumor occupies more than a semicircle of the rectum, grows into the wall or is fused with the surrounding organs and tissues; b) a tumor of any size with multiple metastases in regional lymph nodes.

Stage IV. An extensive disintegrating immobile tumor, invading surrounding organs and tissues, with regional or distant metastases.

Renal adenocarcinoma

Stage I. The tumor does not extend beyond the kidney capsule.

Stage II. Lesion of the vascular pedicle or peri-renal tissue.

Stage III. The defeat of the tumor of regional lymph nodes.

Stage IV. The presence of distant metastases.

Bladder cancer

Stage I. The tumor does not extend beyond the bladder mucosa.

Stage II. The tumor infiltrates the inner muscle layer.

Stage III. The tumor invades all the walls of the bladder; there are metastases in regional lymph nodes.

Stage IV, The tumor invades adjacent organs, there are distant metastases.

Testicular cancer

Stage I.The tumor does not extend beyond the testicular tunica, does not enlarge or deform it.

Stage II. The tumor, without leaving the tunica albuginea, leads to deformation and enlargement of the testicle.

Stage III. The tumor invades the tunica albuginea and spreads to the epididymis, there are metastases in the regional lymph nodes.

Stage IV. The tumor spreads beyond the testicle and its epididymis, invades the scrotum and / or spermatic cord; there are distant metastases.

Prostate cancer

Stage I. The tumor occupies less than half of the prostate gland without invading its capsule, there are no metastases.

Stage II. a) The tumor occupies half of the prostate gland, does not cause its enlargement or deformation, there are no metastases; b) a tumor of the same or smaller size with single removable metastases in the regional lymph nodes.

Stage III. a) The tumor occupies the entire prostate gland or a tumor of any size grows into the capsule, there are no metastases; b) a tumor of the same or lesser extent of spread with multiple removable regional metastases.

Stage IV. a) The tumor of the prostate gland invades the surrounding tissues and organs, there are no metastases; b) a tumor of the same degree of local spread with any variants of local metastasis or a tumor of any size in the presence of distant metastases.

Cervical cancer

Stage I. a) The tumor is limited to the cervix with invasion into the stroma of no more than 0.3 cm with a diameter of no more than 1 cm; b) the tumor is limited to the cervix with invasion of more than 0.3 cm, there are no regional metastases.

Stage II. a) The tumor spreads beyond the cervix, infiltrates the vagina within the upper 2/3 or spreads to the body of the uterus, regional metastases are not detected; b) a tumor of the same degree of local spread with infiltration of cellulose from one or both sides. Regional metastases are not detected.

Stage III. a) The tumor spreads to the lower third of the vagina and / or there are metastases in the uterine appendages, there are no regional metastases; b) the tumor spreads from one or both sides to the parametric tissue to the walls of the pelvis, there are regional metastases in the lymph nodes of the pelvis.

Stage IV. a) The tumor invades the bladder and / or rectum, regional metastases are not detected; b) a tumor of the same degree of spread with regional metastases, any spread of a tumor with distant metastases.

Cancer of the body of the uterus

Stage I. The tumor is limited to the body of the uterus, regional metastases are not detected. It has three options: a) the tumor is limited to the endometrium, b) invasion into the myometrium up to 1 cm, c) invasion into the myometrium more than 1 cm, but there is no germination of the serous membrane.

Stage II. The tumor affects the body and cervix, regional metastases are not detected.

Stage III. It has two options: a) cancer with parametrium infiltration on one or both sides, which has passed onto the pelvic wall; b) cancer of the body of the uterus with invasion of the peritoneum, but without involvement. nearby bodies.

Stage IV. Has two options: a) cancer of the body of the uterus with the transition to the bladder or rectum; b) cancer of the body of the uterus with distant metastases.

Ovarian cancer

Stage I. The tumor is within one ovary.

Stage II. Both ovaries, uterus, fallopian tubes are affected.

Stage III. In addition to the appendages and the uterus, the parietal peritoneum is affected, metastases in the regional lymph nodes, in the omentum, ascites is determined.

Stage IV. The process involves neighboring organs: the bladder, intestines, there is dissemination along the parietal and visceral peritoneum of metastasis to distant lymph nodes, omentum; ascites, cachexia.

Clinical classification TNM

The TNM system adopted to describe the anatomical spread of a lesion is based on 3 components:

T- spread of the primary tumor;

N - absence or presence of metastases in regional lymph nodes and the degree of their damage;

M- absence or presence of distant metastases.

TOthese three components are added with numbers indicating the prevalence of the malignant process:

T0, T1, T2, TK, T4 N0, N1, N2, N3 M0, Ml

The effectiveness of the system is in the "multiplicity of designation" of the extent of the spread of the malignant tumor.

General rules applicable to all tumor sites

1. In all cases, there must be

histological confirmation diagnosis, if not, then such cases are described separately.

2. For each location, two classifications are described:

Clinical classification it is used before the start of treatment and is based on data from clinical, radiological, endoscopic examination, biopsy, surgical research methods and a number of additional methods.

Pathological classification (post-surgical, pathohistological classification), denoted by pTNM, is based on data obtained before the start of treatment, but supplemented or modified based on information obtained during surgery or examination of surgical material. Pathological assessment of the primary tumor (pT) makes it necessary to perform a biopsy or resection of the primary tumor in order to assess the highest grade of pT.

For a pathological assessment of the state of regional lymph nodes (pN), their adequate removal is necessary, which makes it possible to determine the absence (pN0) or to estimate the highest boundary of the pN category. For pathological assessment of distant metastases (PM), their microscopic examination is necessary.

3. After determining the T, N M and (or) pT, pN and pM categories can be performed

grouping by stage... The established degree of spread of the tumor process by the TNM system or by stages should remain unchanged in the medical documentation. Clinical classification is especially sculpted for the selection and evaluation of treatment methods, while the pathological one allows obtaining the most accurate data for prognosis and evaluation of long-term treatment results.

4. If there is doubt about the correctness of the definition of the categories T, N or M, then the lowest (ie less common) category should be chosen. This also applies to grouping by stages.

5. In the case of multiple synchronous malignant tumors in one organ, the classification is based on the assessment of the tumor with the highest T category, and the multiplicity and number of tumors are additionally indicated as T2 (m) or T2 (5). When synchronous bilateral tumors of paired organs occur, each tumor is classified separately. In tumors of the thyroid gland, liver and ovary, multiplicity is the criterion for the T category.