CANCER STAGING
MANUAL
Seventh Edition
EDITORIAL BOARD
STEPHEN B. EDGE, m.d., f.a.c.s., Editor
Roswell Park Cancer Institute
Buffalo, New York
DAVID R. BYRD, m.d., f.a.c.s.,
University of Washington School of Medicine
Seattle, Washington
CAROLYN C. COMPTON, m.d., ph.d.
National Cancer Institute
Bethesda, Maryland
APRIL G. FRITZ, r.h.i.t., c.t.r.
A. Fritz and Associates
Reno, Nevada
FREDERICK L. GREENE, m.d., f.a.c.s.
Carolinas Medical Center
Charlotte, North Carolina
ANDY TROTTI, III, m.d.
H. Lee Moffitt Cancer Center
Tampa, Florida
AJCC
CANCER STAGING
MANUAL
Seventh Edition
AMERICAN JOINT COMMITTEE ON CANCER
Executive Office
633 North Saint Clair Street
Chicago, IL 60611-3211
This manual was prepared and published through the support of the American Cancer Society, the
American College of Surgeons, the American Society of Clinical Oncology, the Centers for
Disease Control and Prevention, and the International Union Against Cancer.
CD-ROM
Included
ISBN 978-0-387-88440-0
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2009930462
First to Fifth Editions of the AJCC Cancer Staging Manual, published by Lippincott Raven Publishers, Philadelphia.
PA.
Sixth Edition of the AJCC Cancer Staging Manual, published by Springer-Verlag, New York, NY.
Seventh Edition 2010 American Joint Committee on Cancer. All rights reserved. The AJCC Cancer Staging
Manual is the Official Publication of the American Joint Committee on Cancer.
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SEVENTH EDITION
Dedicated to Irvin D. Fleming, m.d.
SIXTH EDITION
Dedicated to Robert V. P. Hutter, m.d.
FIFTH EDITION
Dedicated to Oliver Howard Beahrs, m.d.
FOURTH EDITION
Dedicated to the memory of Harvey Baker, m.d.
THIRD EDITION
Dedicated to the memory of W. A. D. Anderson, m.d.
Marvin Pollard, m.d.
Paul Sherlock, m.d.
SECOND EDITION
Dedicated to the memory of Murray M. Copeland, m.d.
Preface
The level of data supporting the staging systems varies among disease sites. For some diseases, particularly less
common cancers, there are few outcome data available. These
staging systems are based on what limited data are available, supplemented by expert consensus. Though potentially
imperfect, these disease schemas are critical to allow the collection of standardized data to support clinical care and for
future evaluation and refinement of the staging system.
Increasingly, the disease teams of the AJCC and UICC use
existing data sets or establish the necessary collaborations to
develop new large data sets to provide high-level evidence
to support changes in the staging system. Examples of this
include the work in melanoma that led to changes in the sixth
edition and their refinement in this seventh edition, use of
the National Cancer Data Base and Surveillance Epidemiology and End Results (SEER) data base for evaluation of the
colorectal staging system, and the use of existing data sets
from the USA, Europe, and Asia in gastric cancer. In addition,
groups have been established to collect very large international data sets to refine staging. In addition to the melanoma
collaborative, the best examples in refining staging for the
seventh edition are the collaborative group of the International Association for the Study of Lung Cancer (IASLC) and
the Worldwide Esophageal Cancer Collaborative (WECC).
A major challenge to TNM staging is the rapid evolution of understanding in cancer biology and the availability
of biologic factors that predict cancer outcome and response
to treatment with better accuracy than purely anatomically
based staging. This has led some cancer experts to conclude
that TNM is obsolete. Although such statements are misguided, the reality is that the anatomic extent of disease only
tells part of the story for many cancer patients.
The question of including nonanatomic prognostic factors in staging has led to intense debate about the purpose and
structure of staging. Beginning with the sixth edition of the
AJCC Cancer Staging Manual, there was judicious addition of
nonanatomic factors to the classifications that modified stage
groups. This shift away from purely anatomic information
has been extended in the current edition. Relevant markers
that are of such importance that they are required for clinicians to make clear treatment decisions have been included
vii
viii
Part I.....................................................................
Brief Contents
by Part
Part II ...................................................................
Head and Neck / 21
Part IV...................................................................
Thorax / 251
Part V ....................................................................
Musculoskeletal Sites / 279
Part VI...................................................................
2
3
4
5
6
Skin / 299
Part VII..................................................................
Breast / 345
Part IX ...................................................................
Part X ....................................................................
10
Part XI ...................................................................
11
12
13
ix
Contents
Dedication .....................................................................v
Preface ........................................................................ vii
Brief Contents by Part .................................................ix
Introduction and Historical Overview ................... xiii
Part I ...................................................................1
General Information on Cancer Staging
and End-Results Reporting
1. Purposes and Principles of Cancer Staging ............3
2. Cancer Survival Analysis ........................................15
Part II ................................................................21
Head and Neck
Part IV.............................................................251
Thorax
5. Larynx .....................................................................57
6. Nasal Cavity and Paranasal Sinuses.......................69
7. Major Salivary Glands
(Parotid, submandibular, and sublingual)..............79
Part V..............................................................279
Musculoskeletal Sites
27. Bone ......................................................................281
28. Soft Tissue Sarcoma .............................................291
8. Thyroid ...................................................................87
9. Mucosal Melanoma of the Head and Neck...........97
Part III .............................................................101
Digestive System
10. Esophagus and Esophagogastric Junction ..........103
11. Stomach ................................................................117
Part VI.............................................................299
Skin
29. Cutaneous Squamous Cell Carcinoma
and Other Cutaneous Carcinomas ......................301
30. Merkel Cell Carcinoma ........................................315
31. Melanoma of the Skin ..........................................325
xi
Part X ..............................................................521
Ophthalmic Sites
Introduction .......................................................377
52. Retinoblastoma.....................................................561
Part XII............................................................599
Lymphoid Neoplasms
xii
Introduction
and Historical Overview
xiii
xiv
AJCC
CANCER STAGING
MANUAL
Seventh Edition