Mesothelioma staging

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2], Sujit Routray, M.D. [3]

## Overview[edit | edit source]

According to the Union for International Cancer Control staging system, there are four stages of pleural mesothelioma based on the primary tumor, lymph nodes, and metastasis: stage I (IA, IB), stage II, stage III, and stage IV. There is no established staging system for peritoneal mesothelioma.

## Staging[edit | edit source]

According to the Union for International Cancer Control staging system, there are four stages of pleural mesothelioma based on the primary tumor, lymph nodes, and metastasis.[1] There is no established staging system for peritoneal mesothelioma.

### TNM Classification for Pleural Mesothelioma[edit | edit source]

TNM stands for tumor, nodes, and metastasis. TNM staging describes:[1]

* Size and extent of the primary tumor
* Number and location of any regional lymph nodes infiltrated by tumor cells
* Extent of cancer metastasis to distant part of the body

TNM Classification | Definition
Primary Tumor (T)
TX  | Primary tumor cannot be assessed
T0  | No evidence of primary tumor
T1  | Tumor involves the ipsilateral parietal pleura, with or without focal involvement of the visceral pleura.

* T1a – Tumor involves the ipsilateral parietal pleura and may also be in the pleura lining the diaphragm or the mediastinum. There is no tumor in the visceral pleura.
* T1b – Tumor involves both the ipsilateral parietal pleura and the visceral pleura.

T2  | Tumor involves any of the ipsilateral pleural surfaces, with at least one of the following:

* Tumor in the visceral pleura, including the fissures of the lung
* Invasion of the diaphragm
* Invasion of the lung parenchyma

T3  | Tumor involves any of the ipsilateral pleural surfaces, with at least one of the following:

* Invasion of the endothoracic fascia
* Invasion into mediastinal fat
* Solitary tumor invading soft tissues of the chest wall
* Non-transmural involvement of the pericardium

T3 describes mesothelioma that is locally advanced, but potentially resectable

T4  | Tumor involves any of the ipsilateral pleural surfaces, with at least one of the following:

* Diffuse or multifocal invasion of soft tissues of the chest wall
* Rib involvement
* Invasion through the diaphragm and into the peritoneum
* Invasion of any organ in the mediastinum
* Extension to the contralateral pleura
* Invasion into the spine
* Extension to the internal surface of the pericardium
* Pericardial effusion with positive cytology
* Invasion of myocardium
* Invasion of nerves of the brachial plexus

T4 describes mesothelioma that is locally advanced, but unresectable

Regional Lymph Nodes (N)
NX  | Regional lymph nodes cannot be assessed
N0  | No regional lymph node metastasis
N1  | Metastasis in either or both the ipsilateral bronchopulmonary lymph nodes and the hilar lymph nodes.

* Bronchopulmonary lymph nodes are within the lungs.
* Hilar lymph nodes are near where the bronchus enters the lung.

N2  | Metastasis in ipsilateral subcarinal lymph nodes and in either the internal mammary lymph nodes or mediastinal lymph nodes on the same side.

Metastasis in subcarinal lymph nodes or in either the internal mammary lymph nodes or mediastinal lymph nodes on the same side of the chest as cancer.

* Subcarinal lymph nodes are below the trachea.
* Internal mammary lymph nodes are around the sternum.
* Mediastinal lymph nodes are in the mediastinum.

N3  | Metastasis in the contralateral mediastinal lymph nodes, internal mammary lymph nodes, or hilar lymph nodes and in either the supraclavicular lymph node or scalene lymph nodes on the ipsilateral or contralateral side.

Metastasis in the contralateral mediastinal, internal mammary, or hilar lymph nodes or in either the supraclavicular or scalene lymph nodes on the ipsilateral or contralateral side.

* Supraclavicular lymph nodes are located above the clavicle.
* Scalene lymph nodes are located at the base of the neck.

Distant Metastasis (M)
M0  | No distant metastasis
M1  | Distant metastasis

### UICC Staging for Pleural Mesothelioma[edit | edit source]

The UICC further groups the TNM data into the stages listed in the table below.[1]

UICC Stage | TNM | Explanation
Stage IA  | T1a  | N0  | M0  | Mesothelioma in the pleural layer that lines the chest wall on ipsilateral parietal pleura.

It does not involve the visceral pleura. It has not spread to lymph nodes or distant organs.

Stage IB  | T1b  | N0  | M0  | Mesothelioma in the parietal pleura with focal tumors on the visceral pleura on one side of the chest.

It has not spread to lymph nodes or distant organs.

Stage II  | T2  | N0  | M0  | Mesothelioma in any of the pleural surfaces (parietal pleura, pleura lining the mediastinum or diaphragm, and visceral pleura) on one side of the chest. It has also grown into at least one of the following:

* the visceral pleura that covers the fissures of the lung
* the diaphragm
* the lung itself It has not spread to lymph nodes or distant organs

It has not spread to lymph nodes or distant organs.

Stage III  | T1,
T2  | N1  | M0  | Mesothelioma in the parietal pleura, the visceral pleural, or both, on one side of the chest. It may or may not have grown into at least one of the following:

* the diaphragm
* the lung itself

It has spread to the lymph nodes on the same side of the chest as the mesothelioma. These lymph nodes that contain cancer may be:

* bronchopulmonary lymph nodes
* hilar lymph nodes
* in both locations

It has not spread to distant organs.

T1,

| N2  | M0  | Mesothelioma in the parietal pleura, the visceral pleural, or both, on one side of the chest. It may or may not have grown into at least one of the following:

* the diaphragm
* the lung itself

It has spread to the lymph nodes on the same side of the chest as the mesothelioma. The lymph nodes that contain cancer may be:

* subcarinal lymph nodes
* internal mammary lymph nodes
* mediastinal lymph nodes
* subcarinal lymph nodes and internal mammary lymph nodes or mediastinal lymph nodes

It has not spread to distant organs.

T3  | N0,

N1,

| M0  | Mesothelioma involves any of the pleura on one side of the chest and has grown into at least one of the following:

* endothoracic fascia
* the fatty part of the mediastinum
* a single area of soft tissue of the chest wall, such as muscle or fat
* pericardium

It may or may not have spread to lymph nodes closest to the ipsilateral lung, trachea, sternum, or mediastinum.
It has not spread to distant organs.

Stage IV  | T4  | any N  | M0  | Mesothelioma involves any of the pleura on one side of the chest and has grown into at least one of the following:

* several areas of soft tissue of the chest wall
* rib
* the diaphragm and into the peritoneum
* mediastinum
* contralateral pleura
* spine
* pericardium
* pericardial effusion positive for cancer cells
* myocardium
* brachial plexus

It may or may not have spread to lymph nodes. It has not spread to distant organs.

any T  | N3  | M0  | Mesothelioma is any size and may or may not have grown into nearby tissues or organs.

It has spread to lymph nodes in one of the following locations:

* contralateral mediastinal, internal mammary, or hilar lymph nodes
* ipsilateral or contralateral supraclavicular or scalene lymph nodes
* contralateral mediastinal, internal mammary, or hilar lymph nodes and to supraclavicular or scalene lymph nodes on either side

It has not spread to distant organs.

any T  | any N  | M1  | Mesothelioma of any size and may or may not have grown into nearby tissues or organs.

It may or may not have spread to the lymph nodes.
It has spread to distant organs.

## Gallery[edit | edit source]

* Anatomy of the chest.[2]

* Lymph nodes in the neck and chest.[2]

## References[edit | edit source]

1. ↑ 1.0 1.1 1.2 Stages of pleural mesothelioma. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/mesothelioma/staging/?region=on. Accessed on February 6, 2016
2. ↑ 2.0 2.1 Anatomy and physiology of the mesothelium. Canadian cancer society 2016. http://www.cancer.ca/en/cancer-information/cancer-type/mesothelioma/anatomy-and-physiology/?region=on. Accessed on February 16, 2016

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