Colorectal Cancer

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Early Detection, Diagnosis, and Staging TOPICS

How is colorectal cancer staged?

The stage describes the extent of the cancer in the body. It is based on how far the cancer has grown into the wall of the intestine, whether or not it has reached nearby structures, and whether or not it has spread to the lymph nodes or distant organs. The stage of a cancer is one of the most important factors in determining prognosis and treatment options.

Staging is the process of finding out how far a cancer has spread. It is based on the results of the physical exam, biopsies, and imaging tests (CT or MRI scan, x-rays, PET scan, etc.), which are described in the section “How is colorectal cancer diagnosed?” as well as the results of surgery.

There are actually 2 types of staging for colorectal cancer.

  • The clinical stage is your doctor's best estimate of the extent of your disease, based on the results of the physical exam, biopsy, and any imaging tests you have had.
  • If you have surgery, your doctor can also determine the pathologic stage, which is based on the same factors as the clinical stage, plus what is found as a result of the surgery.

The clinical and pathologic stages may be different in some cases. For example, during surgery the doctor may find cancer in an area that did not show up on imaging tests, which might give the cancer a more advanced pathologic stage.

Most patients with colorectal cancer have surgery, so the pathologic stage is most often used when describing the extent of this cancer. Pathologic staging is likely to be more accurate than clinical staging, as it allows your doctor to get a firsthand impression of the extent of your disease.

AJCC (TNM) Staging System

A staging system is a standardized way in which the cancer care team describes the extent of the cancer. The most commonly used staging system for colorectal cancer is that of the American Joint Committee on Cancer (AJCC), sometimes also known as the TNM system. Older staging systems for colorectal cancer, such as the Dukes and Astler-Coller systems, are mentioned briefly below for comparison. The TNM system describes 3 key pieces of information:

  • T describes how far the main (primary) tumor has grown into the wall of the intestine and whether it has grown into nearby areas.
  • N describes the extent of spread to nearby (regional) lymph nodes. Lymph nodes are small bean-shaped collections of immune system cells that are important in fighting infections.
  • M indicates whether the cancer has spread (metastasized) to other organs of the body. (Colorectal cancer can spread almost anywhere in the body, but the most common sites of spread are the liver and lungs.)

Numbers or letters appear after T, N, and M to provide more details about each of these factors. The numbers 0 through 4 indicate increasing severity. The letter X means "cannot be assessed because the information is not available."

T categories for colorectal cancer

T categories of colorectal cancer describe the extent of spread through the layers that form the wall of the colon and rectum. These layers, from the inner to the outer, include:

  • The inner lining (mucosa)
  • A thin muscle layer (muscularis mucosa)
  • The fibrous tissue beneath this muscle layer (submucosa)
  • A thick muscle layer (muscularis propria) that contracts to force the contents of the intestines along
  • The thin, outermost layers of connective tissue (subserosa and serosa) that cover most of the colon but not the rectum

Tx: No description of the tumor's extent is possible because of incomplete information.

Tis: The cancer is in the earliest stage (in situ). It involves only the mucosa. It has not grown beyond the muscularis mucosa (inner muscle layer).

T1: The cancer has grown through the muscularis mucosa and extends into the submucosa.

T2: The cancer has grown through the submucosa and extends into the muscularis propria (thick outer muscle layer).

T3: The cancer has grown through the muscularis propria and into the outermost layers of the colon or rectum but not through them. It has not reached any nearby organs or tissues.

T4a: The cancer has grown through the serosa (also known as the visceral peritoneum), the outermost lining of the intestines.

T4b: The cancer has grown through the wall of the colon or rectum and is attached to or invades into nearby tissues or organs.

N categories for colorectal cancer

N categories indicate whether or not the cancer has spread to nearby lymph nodes and, if so, how many lymph nodes are involved. To get an accurate idea about lymph node involvement, most doctors recommend that at least 12 lymph nodes be removed during surgery and looked at under a microscope.

Nx: No description of lymph node involvement is possible because of incomplete information.

N0: No cancer in nearby lymph nodes.

N1: Cancer cells are found in or near 1 to 3 nearby lymph nodes

  • N1a: Cancer cells are found in 1 nearby lymph node.
  • N1b: Cancer cells are found in 2 to 3 nearby lymph nodes.
  • N1c: Small deposits of cancer cells are found in areas of fat near lymph nodes, but not in the lymph nodes themselves.

N2: Cancer cells are found in 4 or more nearby lymph nodes

  • N2a: Cancer cells are found in 4 to 6 nearby lymph nodes.
  • N2b: Cancer cells are found in 7 or more nearby lymph nodes.

M categories for colorectal cancer

M categories indicate whether or not the cancer has spread (metastasized) to distant organs, such as the liver, lungs, or distant lymph nodes.

M0: No distant spread is seen.

M1a: The cancer has spread to 1 distant organ or set of distant lymph nodes.

M1b: The cancer has spread to more than 1 distant organ or set of distant lymph nodes, or it has spread to distant parts of the peritoneum (the lining of the abdominal cavity).

Stage grouping

Once a person's T, N, and M categories have been determined, usually after surgery, this information is combined in a process called stage grouping. The stage is expressed in Roman numerals from stage I (the least advanced) to stage IV (the most advanced). Some stages are subdivided with letters.

Stage 0

Tis, N0, M0: The cancer is in the earliest stage. It has not grown beyond the inner layer (mucosa) of the colon or rectum. This stage is also known as carcinoma in situ or intramucosal carcinoma.

Stage I

T1-T2, N0, M0: The cancer has grown through the muscularis mucosa into the submucosa (T1) or it may also have grown into the muscularis propria (T2). It has not spread to nearby lymph nodes or distant sites.

Stage IIA

T3, N0, M0: The cancer has grown into the outermost layers of the colon or rectum but has not gone through them (T3). It has not reached nearby organs. It has not yet spread to the nearby lymph nodes or distant sites.

Stage IIB

T4a, N0, M0: The cancer has grown through the wall of the colon or rectum but has not grown into other nearby tissues or organs (T4a). It has not yet spread to the nearby lymph nodes or distant sites.

Stage IIC

T4b, N0, M0: The cancer has grown through the wall of the colon or rectum and is attached to or has grown into other nearby tissues or organs (T4b). It has not yet spread to the nearby lymph nodes or distant sites.

Stage IIIA

One of the following applies.

T1-T2, N1, M0: The cancer has grown through the mucosa into the submucosa (T1) and it may also have grown into the muscularis propria (T2). It has spread to 1 to 3 nearby lymph nodes (N1a/N1b) or into areas of fat near the lymph nodes but not the nodes themselves (N1c). It has not spread to distant sites.

T1, N2a, M0: The cancer has grown through the mucosa into the submucosa (T1). It has spread to 4 to 6 nearby lymph nodes (N2a). It has not spread to distant sites.

Stage IIIB

One of the following applies.

T3-T4a, N1, M0: The cancer has grown into the outermost layers of the colon or rectum (T3) or through the visceral peritoneum (T4a) but has not reached nearby organs. It has spread to 1 to 3 nearby lymph nodes (N1a/N1b) or into areas of fat near the lymph nodes but not the nodes themselves (N1c). It has not spread to distant sites.

T2-T3, N2a, M0: The cancer has grown into the muscularis propria (T2) or into the outermost layers of the colon or rectum (T3). It has spread to 4 to 6 nearby lymph nodes (N2a). It has not spread to distant sites.

T1-T2, N2b, M0: The cancer has grown through the mucosa into the submucosa (T1) or it may also have grown into the muscularis propria (T2). It has spread to 7 or more nearby lymph nodes (N2b). It has not spread to distant sites.

Stage IIIC

One of the following applies.

T4a, N2a, M0: The cancer has grown through the wall of the colon or rectum (including the visceral peritoneum) but has not reached nearby organs (T4a). It has spread to 4 to 6 nearby lymph nodes (N2a). It has not spread to distant sites.

T3-T4a, N2b, M0: The cancer has grown into the outermost layers of the colon or rectum (T3) or through the visceral peritoneum (T4a) but has not reached nearby organs. It has spread to 7 or more nearby lymph nodes (N2b). It has not spread to distant sites.

T4b, N1-N2, M0: The cancer has grown through the wall of the colon or rectum and is attached to or has grown into other nearby tissues or organs (T4b). It has spread to at least one nearby lymph node or into areas of fat near the lymph nodes (N1 or N2). It has not spread to distant sites.

Stage IVA

Any T, Any N, M1a: The cancer may or may not have grown through the wall of the colon or rectum, and it may or may not have spread to nearby lymph nodes. It has spread to 1 distant organ (such as the liver or lung) or set of lymph nodes (M1a).

Stage IVB

Any T, Any N, M1b: The cancer may or may not have grown through the wall of the colon or rectum, and it may or may not have spread to nearby lymph nodes. It has spread to more than 1 distant organ (such as the liver or lung) or set of lymph nodes, or it has spread to distant parts of the peritoneum (the lining of the abdominal cavity) (M1b).

Comparison of AJCC, Dukes, and Astler-Coller stages

If your stage is reported in letters rather than numbers, your doctor is likely referring to one of the other staging systems sometimes used for colorectal cancer. This table can be used to find the matching AJCC/TNM stage. As you can see, the Dukes and Astler-Coller staging systems often combine different AJCC stage groupings and are not as precise.

    AJCC/TNM

    Dukes

    Astler-Coller

    0

    -

    -

    I

    A

    A, B1

    IIA

    B

    B2

    IIB

    B

    B2

    IIC

    B

    B3

    IIIA

    C

    C1

    IIIB

    C

    C1, C2

    IIIC

    C

    C2, C3

    IV

    -

    D

If you have any questions about your stage, please ask your doctor to explain the extent of your disease.

Grade of colorectal cancer

Another factor that can affect the outlook for survival is the grade of the cancer. Grade is a description of how closely the cancer looks like normal colorectal tissue when seen under a microscope.

The scale used for grading colorectal cancers goes from G1 (where the cancer looks much like normal colorectal tissue) to G4 (where the cancer looks very abnormal). The grades G2 and G3 fall somewhere in between. The grade is often simplified as either "low grade" (G1 or G2) or "high grade" (G3 or G4).

Low-grade cancers tend to grow and spread more slowly than high-grade cancers. Most of the time, the outlook is better for low-grade cancers than it is for high-grade cancers of the same stage. Doctors sometimes use this distinction to help decide whether a patient should get additional (adjuvant) treatment with chemotherapy after surgery (discussed in more detail in the section “Chemotherapy for colorectal cancer”).


Last Medical Review: 07/30/2013
Last Revised: 01/31/2014