11/21/22, 4:27 PM Colon Cancer Staging: TNM Classification for Colon Cancer

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Colon Cancer Staging

Updated: Feb 05, 2021
Author: Shamudheen Rafiyath, MD; Chief Editor: N Joseph Espat, MD, MS, FACS more...

TNM Classification for Colon Cancer

Colon cancer is staged using the American Joint Committee on Cancer (AJCC)
tumor/node/metastasis (TNM) classification and staging system. In this system, stages are
assigned on the basis of the characteristics of the primary tumor (T) and the extent of regional
lymph node involvement (N) and distant metastasis (M). In addition, metastasis may be defined
clinically or pathologically, on the basis of preoperative clinical assessment (c) or pathologic
evaluation of metastatic tissue (p). [1, 2]

Table 1. TNM Classification for Colon Cancer (Open Table in a new window)

Primary tumor (T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Carcinoma in situ: intraepithelial or intramucosal carcinoma (involvement of

Tis
lamina propria with no extension through the muscularis mucosa)

Tumor invades submucosa (through the muscularis mucosa but not into the
T1
muscularis propria)

T2 Tumor invades muscularis propria

T3 Tumor invades through the muscularis propria into the pericolorectal tissues
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Tumor invades the visceral peritoneum or invades or adheres to adjacent organ

T4
or structure

Tumor invades through the visceral peritoneum (including gross perforation of

T4a the bowel through tumor and continuous invasion of tumor through areas of
inflammation to the surface of the visceral peritoneum)

T4b Tumor directly invades or is adherent to other organs or structures

T Suffix Definition

(m) Select if synchronous primary tumors are found in a single organ

Definition of regional lymph nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

Metastasis in 1-3 regional lymph nodes (tumor in lymph nodes measuring ≥0.2
N1 mm) or any number of tumor deposits are present and all identifiable nodes are
negative

N1a Metastasis in 1 regional lymph node

N1b Metastasis in 2-3 regional lymph nodes

Tumor deposit(s) in the subserosa, mesentery, or nonperitonealized, pericolic, or

N1c
perirectal/mesorectal tissues without regional nodal metastasis

N2 Metastasis in 4 or more lymph nodes

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N2a Metastasis in 4-6 regional lymph nodes

N2b Metastasis in 7 or more regional lymph nodes

N Suffix Definition

Select if regional lymph node metastasis identified by sentinel lymph node

(sn)
biopsy only

Select if regional lymph node metastasis identified by fine needle aspiration or

(f)
core needle biopsy

Definition of distant metastasis (M)

The terms pM0 and Mx are not valid categories in the TNM system. Assignment of the M
category for clinical classification may be cM0, cM1 or pM1. Any of the categories (cM0, CM1
or pM1) may be used with pathological stage grouping.

MCategory M Criteria

No distant metastasis by imaging or other studies, no evidence of tumor in

cM0
distant sites or organs. (This category is not assigned by pathologists.)

Metastasis to one or more distant sites or organs or peritoneal metastasis is

cM1
identified

cM1a Metastasis confined to 1 organ or site is identified without peritoneal metastasis

Metastasis to two or more sites or organs is identified without peritoneal

cM1b
metastasis

M1c Metastasis to the peritoneal surface alone or with other site or organ metastases

Metastasis to one or more distant sites or organs or peritoneal metastasis is

pM1
identified and microscopically confirmed

Metastasis to one site or organ is identified without peritoneal metastasis and

pM1a
microscopically confirmed

pM1b Metastasis to two or more sites or organs is identified without peritoneal

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metastasis and microscopically confirmed.

Metastasis to the peritoneal surface is identified alone or with other site or organ
pM1c
metastasis and microscopically confirmed

Table 2. Anatomic stage/prognostic groups (Open Table in a new window)

0 Tis N0 M0

I T1 N0 M0

T2 N0 M0

IIA T3 N0 M0

IIB T4a N0 M0

IIC T4b N0 M0

IIIA T1-T2 N1/N1c M0

T1 N2a M0

IIIB T3-T4a N1/N1c M0

T2-T3 N2a M0

T1-T2 N2b M0

IIIC T4a N2a M0

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T3-T4a N2b M0

T4b N1-N2 M0

IVA Any T Any N M1a

IVB Any T Any N M1b

IVC Any T Any T M1c

Staging information

Compared with the 7th edition of the AJCC staging manual, features of revised staging in the 8th
edition give more importance to the poor prognostic features of the depth of invasion in spite of
fewer positive nodes.

T4 is divided between penetration to the surface of visceral peritoneum and direct gross
adherence to adjacent structures

T1-2N2 is downstaged from stage IIIC to IIIA or IIIB, depending on the number of nodes
involved

Shift T4bN1 from IIIB to IIIC

Subdivide T4/N1/N2

Resolution of staging for the issue of mesenteric deposits where nodal tissue is not identified

Revised substaging of stage II based on depth of invasion, with the addition of stage IIC

Revised substaging of stage III based on node number (N1a—1 node; N1b—2-3 nodes; N2a
—4-6 nodes; N2b—7 or more nodes)

Division of metastases to 1 or more sites in recognition of the possibility of cure with

aggressive treatment of single site of metastatic disease

Stage M1c has been introduced to represent the poor prognosis of peritoneal carcinomatosis.

Nodal micrometastases (tumor clusters ≥0.2 mm in diameter) are now scored as positive due
to results of meta-analysis demonstrating poor prognosis in these patients. [3]

Other tumor deposits in the peritoneum, subserosa, and mesentery are given equal weight as
nodal metastases.

The following factors are important in determining treatment decisions but are not yet incorporated
into the formal staging criteria:

Preoperative serum carcinoembryonic antigen (CEA) levels

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Tumor regression score reflective of the pathologic response to preoperative chemotherapy,

chemoradiotherapy, radiotherapy, or chemobiologic therapy as well as the status of
circumferential margin for rectal cancer.

Lymphovascular and perineural invasion

Microsatellite instability (MSI), which represents deficiency of mismatch repair enzymes and
is both a prognostic factor and predictive of lack of response to fluoropyrimidine therapy in
the adjuvant setting.

Mutation status of KRAS, NRAS, and BRAF, because mutations in those genes are
associated with lack of response to agents targeting epidermal growth factor receptors.

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