ERRATA
Workbook for the Staging of Cancer: A Companion Guide to the AJCC
Staging Manual Seventh Edition
Publisher: National Cancer Registrars Association, Alexandria, VA, 2012
See Attached.
Section 4
ANSWERS: PHARYNX
1. Primary site: Soft Palate
Region: Oropharynx
Clinical
T1
Pathologic T1
N0
NX
3. Primary site: Aryepiglottic fold
Region: Hypopharynx
M0 Stage I
cM0 Stage 99 (Unstaged)
Clinical
T3
Pathologic T3
For oropharynx, size of tumor is the primary criterion for the
T category. The laryngoscopy provides a clinical size which
is in the cT1 range. ENT exam states that no nodes are
involved (cN0). The “questionable” nodule with no further
workup can be disregarded because it is not corroborated
as a metastasis by the clinician. A cM0 only requires an
H&P.
M0 Stage III
cM0 Stage III
This is cT3 because there is fixation of the hemilarynx. No
nodes were mentioned on the H&P, or seen on imaging. No
mets were mentioned on the H&P.
The arytenoids cartilage is at the back of the larynx to
which the vocal folds are attached. So this confirms the
hemilarynx involvement for pT3. No nodes were involved,
and cM0 from the H&P.
On the pathology report, the tumor size measures 1.0
centimeter (pT1). The microscopically involved margin
does not change the category. No lymph node dissection
was performed; therefore this case is pNX. cM0 is used to
complete the pathologic stage documentation based on the
H&P. The stage group cannot be assigned due to the NX.
4. Primary site: Superior, lateral and posterior walls
Region: Nasopharynx
Clinical
T3 N3b M0 Stage IVB
Pathologic TX NX cM0 Stage 99 (Unstaged)
Correction:
Pathologic T blank N blank cM blank Stage blank
2. Primary site: Base of tongue
Region: Oropharynx
Clinical
T4a N0
Pathologic T4a NX
N0
N0
The CT scan shows the large nasopharyngeal mass
has extended into the paranasal sinus (cT3). Bilateral
nodes are involved, and on the right extend down
“almost to the clavicle,” in other words, into the
supraclavicular fossa (cN3b). There is an image of this
fossa in the AJCC Cancer Staging Manual Seventh
Edition, page 45, Figure 4.2. The N3 is paired with the
any T and cM0 to make this clinical stage group IVB.
M0 Stage IVA
cM0 Stage IVA
CT information indicates that palatoglossus muscle (is
involved. The palatoglossus muscle elevates the back of
the tongue and is an extrinsic muscle. Extrinsic muscles
originate elsewhere and attach to the tongue. This is
cT4a. No nodes involved clinically (cN0) and no distant
metastases (cM0). A cM0 only requires an H&P.
There was no resective surgery to meet the criteria for
pathologic staging. All of the categories would be blank,
as using an X would indicate the patient was eligible for
pathologic staging, but the information was unknown.
The wide excision path report confirms the deep muscle
invasion (pT4a). We don’t have pathologic information
about the lymph nodes. General rule #5 says that when
there is uncertainty about which stage group to assign
to use the lower category. N0-2 is Stage IVA and N3 is in
Stage IVB. This rule is not to assign unknown (X) to the
lowest category. But since the nodes were not mentioned
on the operative report, we can assume there wasn’t a large
node qualifying as N3. We can assign Stage IVA.
W O R K B O O K F O R T H E S T A G I N G O F C A N C E R : A C O M PA N I O N G U I D E T O T H E A J C C C A N C E R S T A G I N G M A N U A L S E V E N T H E D I T I O N
85
Section 5
ANSWERS: LARYNX
1. Primary site: Epiglottis
Clinical
T1
Pathologic T2
N0
N0
Region: Supraglottis
3. Primary site: Vocal cord
M0 Stage I
cM0 Stage II
Clinical
T2 N0 M0 Stage II
Pathologic TX NX cM0 Stage 99 (Unstaged)
Correction:
Pathologic T blank N blank cM blank Stage blank
On exam, this tumor involved the laryngeal surface of the
epiglottis only (cT1). There is no involvement of the vocal
cords in the glottic region, which is normal vocal cord
mobility. Lymph nodes in the neck are negative on exam
(cN0). There are no signs of distant mets, cM0. This is
Stage I.
The ventricle of the larynx is part of the supraglottis, the
ventricular bands. This lesion extends from the glottis into
the supraglottis (cT2). The 2 mm extension onto the inferior
border of the vocal cord is within the 1 cm anatomic limit of
the true cords, as described in AJCC Chapter 5. No nodes
are palpable on physical exam (cN0), and there is no clinical
evidence of metastases (cM0). This is a clinical stage II.
On the basis of the pathology report, this is a pT2 lesion
because it invades more than one adjacent sub-site of the
supraglottis (epiglottis, arytenoid cartilage and false cord).
The subsites are listed in the AJCC Cancer Staging Manual
Seventh Edition, Chapter 5. The radical node dissection was
negative, a pN0. This case is Stage II.
There was no surgical resection, therefore it cannot be
assigned a pathologic stage. All of the categories would
be blank, as using an X would indicate the patient was
eligible for pathologic staging, but the information was
unknown.
2. Primary site: Aryepiglottic fold Region: Supraglottis
Clinical
T2
Pathologic T2
Region: Glottis
N0 M0 Stage II
N2b cM0 Stage IVA
4. Primary site: Subglottis
Clinical
T4a N0
Pathologic T4a NX
This is a T2 lesion because two adjacent sub-sites of the
supraglottis are involved. The pharyngo-epiglottis fold would
be in the suprahyoid region. On physical examination, there
were no nodes involved, cN0 and no signs of distant mets
cM0. This is clinical stage II.
Region: Subglottis
M0 Stage IVA
cM0 Stage IVA
The subglottis begins at the lower boundary of the glottis
(vocal cord). The scope shows that the tumor extends nearly
to the inferior border of the cricoid cartilage, which is the
lower boundary of the subglottis. The tumor has extended
through the wall between the subglottis and the esophagus
and onto the surface of the anterior wall of the esophagus.
The tumor on the esophagus makes this a cT4a. No mention
of nodes on the H&P can be assigned cN0, and no mention
of distant mets, cM0. This would be Stage IVA.
The pathology report confirms more than one adjacent
supraglottic site involved, pT2. Two nodes less than 3
cm contained metastases. pN2b is assigned to multiple
ipsilateral nodes, none more than 6 cm were involved. No
distant mets on the H&P, cM0. This is Stage IVA.
The pathologic stage starts with the clinical stage which is
supplemented and/or modified by the surgical findings and
pathology assessment of the resected tissue. The patient
had a debulking procedure which removes most of the
tumor. This information meets the criteria for pT4a. There
were no nodes resected, pNX. There were no distant mets
on the H&P, cM0. General rule #5 says that when there
is uncertainty about which stage group to assign to use
the lower category. N0-2 is Stage IVA and N3 is in Stage
IVB. This rule is not to assign unknown (X) to the lowest
category. Since the nodes were not mentioned on the
operative report, we can presume there wasn’t a large node
qualifying as N3. We can assign Stage IVA.
W O R K B O O K F O R T H E S T A G I N G O F C A N C E R : A C O M PA N I O N G U I D E T O T H E A J C C C A N C E R S T A G I N G M A N U A L S E V E N T H E D I T I O N
87
Section 7
ANSWERS: LUNG
1. Clinical
T2a N3 M0 Stage IIIB
PathologicTX NX cM0Stage 99 (Unstaged)
Correction:
Pathologic T blank N blank cM blank Stage blank
3. Clinical
T1b N0
Pathologic T2a N1
A tumor 3cm or less without involvement of other tissues
is cT1b. There were no nodes seen for a cN0. The scans are
negative, and there were no signs of distant mets on H&P
for a cM0. The clinical stage group is IA.
The tumor is in the right upper lobe, and the subpleural
location means it is close to the pleura. The maximum
size is 5 cm. This makes it a T2a. The hilar mass is nodal
involvement. The hilar nodes are N1. The right paratracheal
nodes are N2, since the nodal map in the AJCC Cancer
Staging Manual Seventh Edition, Figure 25.3, shows the
paratracheal nodes are part of the superior mediastinal
nodes. In addition, there was a scalene node biopsy that
was positive which is N3. The remainder of the workup was
negative, and only no signs of distant mets on the H&P is
needed to assign cM0.This is a clinical Stage IIIB.
The lobectomy and lymph node dissection allow for
pathologic staging. The path report shows a larger tumor of
4 cm, pT2a. The positive hilar nodes are pN1. There were no
signs of distant mets on H&P, and that is all that needed for
a cM0. The pathologic stage group is IIA.
4. Clinical
T4 N3 M0 Stage IIIB
Pathologic TX NX cM0 Stage 99 (Unstaged)
Correction:
Pathologic T blank N blank cM blank Stage blank
There was no surgical resection to qualify this case to have
a pathologic stage. All of the categories would be blank,
as using an X would indicate the patient was eligible for
pathologic staging, but the information was unknown.
2. Clinical
T1b N0
Pathologic T2a N0
M0 Stage IA
cM0 Stage IIA
A tumor in the main broncus is in the T2 category, but the
tumor goes on to involve the trachea which is cT4. There
isn’t enough information on the atelectasis or pneumonitis
to include them in the staging. The patient had partial
vocal cord paralysis. According to the AJCC Cancer Staging
Manual Seventh Edition in “Additional Notes Regarding TNM
Descriptors,” it discusses this can be due to involvement
of the recurrent laryngeal nerve, which is a branch of the
vagus nerve, T4. This can be due to either primary tumor
or lymph node involvement. The mediastinal mass is nodal
involvement, cN2. But the positive scalene node biopsy
makes this cN3. There were no signs of distant mets on
H&P so this is a cM0. This case is clinical Stage Group IIIB.
M0 Stage IA
cM0 Stage IB
The solitary 3 cm nodule identified on chest x-ray with no
additional comments about other tissues is cT1b.Since
nodes were not mentioned, they would be cN0. The scans
are negative but are not required, and only no signs of
distant mets on the H&P is needed to assign cM0. This is a
clinical Stage IA cancer.
There was a lobectomy and lymph node dissection, so
the case meets the criteria for pathologic staging. The
pathology report indicates that the tumor is larger than
what was observed radiographically or by the surgeon, so
this is a pT2a tumor. The hilar nodes were negative, pN0.
There were no signs of distant mets on H&P for a cM0. This
case is a pathologic stage IB.
There was no surgical resection to meet the criteria for
pathologic staging. All of the categories would be blank,
as using an X would indicate the patient was eligible for
pathologic staging, but the information was unknown.
W O R K B O O K F O R T H E S T A G I N G O F C A N C E R : A C O M PA N I O N G U I D E T O T H E A J C C C A N C E R S T A G I N G M A N U A L S E V E N T H E D I T I O N
91
Section 10
ANSWERS: PROSTATE
1. Clinical T2cN0 M0 PSA >20 Gleason X Stage IIB
Pathologic TX NX cM0 PSA >20 Gleason X Stage 99 (Unknown)
Correction:
Pathologic T blank N blank cM blank PSA blank Gleason blank Stage 99 blank
The physical examination indicates a mass involving both lobes, making this case a cT2c. CT scan was negative for nodes,
cN0. No signs of distant mets on H&P, cM0. Also, no mets on the CT abd. The Gleason score is unknown. PSA is in the >20
category. Clinical stage is IIB.
There is no surgery to meet the criteria for pathologic staging. All of the categories would be blank, as using an X would
indicate the patient was eligible for pathologic staging, but the information was unknown.
2. Clinical
T1a N0 M0 PSA X Gleason <6 Stage I
Pathologic TX NX cM0 PSA X Gleason X Stage 99 (Unstaged)
Correction:
Pathologic T blank N blank cM blank PSA blank Gleason blank Stage blank
This patient was treated for BPH (benign prostatic hypertrophy) with a TURP. The adenocarcinoma was an incidental finding by
the pathologist in a single area (focal area), that is 3% of the specimen, cT1a. Extensive imaging is not necessary to assign
cN and cM. With this low T, the case can be assigned cN0 since there is no suspicion of nodes. There are no signs of distant
mets on H&P, cM0. The malignancy is a Gleason 2 which would be classified as a Gleason <6. There is no PSA, so it is PSA X.
The only line containing PSA X is T1-2a N0 M0 PSA X Gleason X. This is clinical Stage I.
The transurethral resection of prostate (TURP) is insufficient surgery for pathologic staging. All of the categories would be
blank, as using an X would indicate the patient was eligible for pathologic staging, but the information was unknown.
3. Clinical T2aN0 M0 PSA <10 Pathologic T2a N0 cM0PSA <10 Gleason <6 Stage I
Gleason <6 Stage I
The physical examination describes the tumor as a nodule on the left side of the prostate which would be <one-half of the
lobe, cT2a. All the rest of the workup is negative, no nodes were seen on CT abd/pelvis, cN0. There were no signs of distant
mets on the H&P, cM0.The grade is Gleason 3. PSA is 5. This is clinical Stage I.
The radical prostatectomy and bilateral lymphadenectomy qualify this case for pathologic staging. The prostatectomy
specimen shows a tumor in the posterior left lobe and focal infiltration of the prostatic capsule on the left side with negative
seminal vesicles, pT2a. Infiltration of (but not through) the prostatic capsule is still a T2. The nodes are negative, pN0. There
are no signs of distant mets on H&P, cM0. Gleason score is 5. PSA is 5. Pathologic stage is I.
4. Clinical
T2a N0 M0 PSA >10<20 Gleason <6 Stage IIA
Pathologic TX NX cM0 PSA >10<20 Gleason X Stage 99 (Unstaged)
Correction:
Pathologic T blank N blank cM blank PSA blank Gleason blank Stage blank
The physical examination shows a nodule occupying less than half of the left lobe, cT2a. Abdominal and pelvic CT scan
shows no adenopathy, cN0. There are no signs of distant mets on H&P, cM0. This is a Gleason 4. PSA is 15. This is clinical
Stage IIA.
The TURP does not meet the criteria for pathologic staging. All of the categories would be blank, as using an X would
indicate the patient was eligible for pathologic staging, but the information was unknown.
W O R K B O O K F O R T H E S T A G I N G O F C A N C E R : A C O M PA N I O N G U I D E T O T H E A J C C C A N C E R S T A G I N G M A N U A L S E V E N T H E D I T I O N
97
Section 11
ANSWERS: TESTIS
1. Clinical
TX N3 M0 SX
Pathologic T1 N3 cM0 S1
Corrections:
Clinical
TX N3 M0 S1 Pathologic T1 N3 cM0 S0 Stage II
Stage IIC
3. Clinical
TX N1 M1a
Pathologic T2 NX cM1a Stage IIC
Stage IIC
The criteria for clinical staging does not allow for
assignment of the T category, which is why they are
designated as pT in the AJCC tables. TX is used. The CT
showed retroperitoneal adenopathy less than 2cm, cN1.
Pulmonary nodules compatible with metastases were seen
on the CXR prior to the resection, cM1a. S is assigned by
levels following orchiectomy not available, making this SX.
Clinical stage is III.
The criteria for clinical staging does not allow for
assignment of the T category, which is why they are
designated as pT in the AJCC tables. TX is used. The 8 cm
lymph node mass on CT is cN3. There is no evidence of
distant metastasis on CT, and no signs of distant mets on
H&P, cM0. LDH, hCG, and AFP markers were elevated., but it
is the post-orchiectomy levels used to assign the status of
the serum tumor markers (S). This is clinical stage IIC.
SX
S1
Stage III
Stage IIIA
The pathology report for the orchiectomy showed tumor
with vascular invasion. No nodes were resected, pNX. The
pulmonary mets on imaging are cM1a. The serum tumor
markers are all in the S1 range. This is a pathologic stage
IIIA, since M1a and S1 include the options for any pT and
any N.
A tumor limited to the testis without lymphatic invasion
is pT1. The positive nodes with a tumor >5cm is pN3. No
signs of distant mets on H&P is cM0. The serum tumor
markers were not elevated in the S1 range. The pathologic
stage is IIC.
4. Clinical
TX
Pathologic T1
2. Clinical
TX N0 M0 SX Stage 99 (Unstaged)
Pathologic T2 N1 cM0 S3 Stage IIIC
N1
N1
M0 SX
cM0 S2
Stage II
Stage IIIB
The criteria for clinical staging does not allow for
assignment of the T category, which is why they are
designated as pT in the AJCC tables. TX is used. The small
pelvic nodules on CT are probably nodal involvement,
cN1. There are no signs of distant mets on H&P, cM0. S
is assigned by levels following orchiectomy not available,
making this SX. The clinical stage is II.
The criteria for clinical staging does not allow for
assignment of the T category, which is why they are
designated as pT in the AJCC tables. TX is used. No nodes
seen on CT, cN0. No signs of distant mets on H&P, cM0. S
is assigned by levels following orchiectomy not available,
making this SX. This cannot be assigned a clinical stage.
The pathology report stated the tumor was confined within
the tunica albuginea without vascular invasion, pT1. There
were five positive nodes <2cm, pN1. There were no signs of
distant mets on the H&P, cM0. The AFP was in the S2 range.
This is pathologic stage IIIB.
The radical orchiectomy showed that the tumor had
vascular invasion, which is pT2. There were four positive
nodes with 1cm mets, pN1. There were no signs of distant
mets on H&P, cM0. The hCG was 6200, which is S3. The
pathologic stage is IIIC.
W O R K B O O K F O R T H E S T A G I N G O F C A N C E R : A C O M PA N I O N G U I D E T O T H E A J C C C A N C E R S T A G I N G M A N U A L S E V E N T H E D I T I O N
99
Section 12
ANSWERS: URINARY BLADDER
1. Clinical
Ta N0 M0 Stage 0a
Pathologic TX NX cM0 Stage 99 (Unstaged)
Correction:
Pathologic T blank N blank cM blank Stage blank
3. Clinical
T4a N0 M1 Stage IV
Pathologic TX NX cM1 Stage 99 (Unstaged)
Correction:
Pathologic T blank N blank cM blank Stage blank
This is a papillary tumor that does not invade the basement
membrane of the bladder mucosa. Because it is papillary, it
is a Ta (a flat or sessile tumor of this nature would be a Tis).
No lymph nodes were seen on CT, cN0. There were no signs
of distant mets on H&P, cM0. This is clinical stage 0a.
The CT of the abdomen and pelvis indicates a soft tissue
mass in the bladder that extends to the pelvic wall and
rectum. However, the radiologist uses the ambiguous
terminology “cannot exclude” so this information should
not be considered as definite evidence of involvement. This
would result in assigning a TX, except that the managing
physician confirmed this involvement in a progress note.
This is cT4a. There is a statement “no other abnormalities
noted.” With this statement, or with no mention of regional
nodal involvement on the imaging, this would be cN0. The
chest x-ray shows lung metastases, cM1. This is clinical
stage IV.
There was no cystectomy; therefore, pathologic staging is
not possible. All of the categories would be blank, as
using an X would indicate the patient was eligible for
pathologic staging, but the information was unknown.
2. Clinical T1(m)
Pathologic ypT2a(m)
N0 M0 Stage I
ypN0 cM0 ypStage II
The case did not have a surgical resection to assign a
pathologic stage. All of the categories would be blank,
as using an X would indicate the patient was eligible for
pathologic staging, but the information was unknown.
In the pathology report from the TURB, there is stromal
invasion, and invasion into the submucosa is T1. Multiple
distinct tumors should be assigned the modifier (m).
Multiple tumors of the same histology in the same organ is
classified by the tumor with the highest T, according to AJCC
Cancer Staging Manual Seventh Edition, Chapter 1. CT scan
was negative, cN0. There were no signs of distant mets on
H&P, cM0. This is a clinical stage I.
4. Clinical
T1 N0 M0 Stage I
Pathologic TX NX cM0 Stage 99 (Unstaged)
Correction:
Pathologic T blank N blank cM blank Stage blank
The pathology report of the TURB states that there is no
invasion of the muscular coat, which is the muscularis
propria. This is cT1. CT is negative for any nodal
involvement, cN0. There are no signs of distant mets on the
H&P, cM0. This is clinical stage I.
The cystectomy and pelvic lymphadenectomy qualify this
case for pathologic staging. However, the patient had
neoadjuvant therapy, which was radiation followed by
surgery. The designation for postneoadjuvant therapy is
ypTNM. The superficial muscle invasion (muscularis propria)
plus multifocal tumor in the right distal ureter make this a
pathologic ypT2a(m). The negative nodes would be ypN0.
There were no signs of distant mets on H&P, cM0. This is
y-pathologic stage II.
This case does not meet the criteria for pathologic staging,
since there was not a sufficient surgical resection. The
criteria states a radical or partial cystectomy is needed. All
of the categories would be blank, as using an X would
indicate the patient was eligible for pathologic staging,
but the information was unknown.
W O R K B O O K F O R T H E S T A G I N G O F C A N C E R : A C O M PA N I O N G U I D E T O T H E A J C C C A N C E R S T A G I N G M A N U A L S E V E N T H E D I T I O N
101
Section 13
ANSWERS: HODGKIN AND
NON-HODGKIN LYMPHOMAS
1. Clinical Stage IIIB
Pathologic Stage 99 unstaged
Correction:
Pathologic Stage blank
3. Clinical Stage IIIA Pathologic Stage 99 unstaged
Correction:
Pathologic Stage blank
Mediastinal nodes are above the diaphragm. Para-aortic
and celiac nodes are below the diaphragm. This means the
patient had involvement of lymph node regions on both
sides of the diaphragm. Patient had symptoms of fever and
night sweats, which is denoted as B. This would be a clinical
stage IIIB. Reed Sternberg cells are diagnostic of Hodgkin’s
Disease.
There is lymphoma above the diaphragm (in the axillary
nodes) and below the diaphragm (in the inguinal, pelvic
and periaortic nodes). There were no B symptoms.
Hepatomegaly is not diagnostic of M1 liver metastases
without confirmation by imaging, abnormal liver function
tests or abnormal serum alkaline phosphatase, or other
tests, or physician judgment. This is clinical stage IIIA.
Pathologic staging requires a staging laparotomy. This is no
longer the standard practice. The pathologic stage cannot
be assigned.
Pathologic staging requires a staging laparotomy. This is no
longer the standard practice. The pathologic stage cannot
be assigned.
2. Clinical Stage IIIE,A Pathologic Stage 99 unstaged
Correction:
Pathologic Stage blank
4. Clinical Stage IIB Pathologic Stage 99 unstaged
Correction: Pathologic Stage blank
The tumor in the ileum (small bowel) with involvement
of the nodes adjacent to the ileum would be localized
involvement of a single extra-lymphatic organ or site in
association with regional node involvement would be IIE.
But there was involvement of two nodal groups above the
diaphragm, the axillary and cervical nodes. The patient did
not have any symptoms according to the criteria and would
be denoted as A. This would make this case clinical stage
IIIE,A.
Patient presented with B symptoms of weight loss (meeting
the criteria of more than 10%) and night sweats. There were
enlarged cervical nodes in the neck on exam. Mediastinal
and paratracheal nodes in the thorax on imaging. There was
more than one nodal region involved on the same side of
the diaphragm. Remember, this is not different groups of
lymph nodes but rather lymph node regions. These regions
have been defined and are described in the AJCC, seventh
edition. This is clinical stage IIB.
Pathologic staging requires a staging laparotomy. This is no
longer the standard practice. The pathologic stage cannot
be assigned.
Pathologic staging requires a staging laparotomy. This is no
longer the standard practice. The pathologic stage cannot
be assigned.
W O R K B O O K F O R T H E S T A G I N G O F C A N C E R : A C O M PA N I O N G U I D E T O T H E A J C C C A N C E R S T A G I N G M A N U A L S E V E N T H E D I T I O N
103