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TNM Staging of Common Cancers


Breast Cancer

T stage
Tx The primary tumour is not assessable
T0 There is no evidence of primary tumour
Tis Carcinoma in situ
(DCIS, LCIS, or Paget's disease without a tumour mass)
T1 The tumour measures ≤ 2 cm *
T1mic Micro-invasion ≤ 0.1 cm *
T1a > 0.1 cm but ≤ 0.5 cm *
T1b > 0.5 cm but ≤ 1 cm *
T1c > 1 cm but ≤ 2 cm *
T2 The tumour measures > 2 cm but ≤ 5 cm *
T3 The tumour measures > 5 cm *
T4 A tumour of any size involving the chest wall or skin (including inflammatory breast cancer)
T4a Chest wall extension
T4b Oedema ▸ breast skin ulceration ▸ satellite skin nodules to the same breast
T4c Combined T4a and T4b features
T4d An inflammatory carcinoma

* Greatest dimension

N stage
Nx The nearby lymph nodes are not assessable
N0 There is no spread
N1 There is spread to movable ipsilateral level I and II axillary nodes
N2 There is spread to fixed ipsilateral level I and II axillary nodes, or ipsilateral internal mammary nodes without axillary involvement
N2a There is spread to fixed level I and II ipsilateral axillary nodes
N2b There is spread to ipsilateral internal mammary nodes without axillary node involvement
N3 Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement
N3a Metastases in ipsilateral infraclavicular lymph node(s).
N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)
N3c Metastases in ipsilateral supraclavicular lymph node(s)

M stage
M0 There is no distant spread
M1 There is distant spread

American College of Radiology Bi-Rads

Assessment categories
Taken from ACR BI-RADS ATLAS (5 th Edition) 2013
Incomplete assessment Management Likelihood of cancer
Category 0: incomplete – requires additional imaging evaluation and/or prior mammograms for comparison Recall for additional imaging and/or comparison with prior examination(s) N/A
Final assessment Management Likelihood of cancer
Category 1: Negative Routine mammography screening Essentially 0%
Category 2: Benign Routine mammography screening Essentially 0%
Category 3: Probably Benign Short-interval (6 month) follow-up or continued surveillance mammography > 0% but ≤ 2%
Category 4: Suspicious Tissue diagnosis > 2% but < 95%

  • Category 4A: Low suspicion for malignancy

> 2% to ≤ 10%

  • Category 4B: Moderate suspicion for malignancy

> 10% to ≤ 50%

  • Category 4C: High suspicion for malignancy

≥ 50% to < 95%
Category 5: Highly suggestive of malignancy Tissue diagnosis ≥ 95%
Category 6: Known biopsy-proven malignancy Surgical excision when clinically appropriate N/A
NB: a similar scoring table is used for USS or MRI assessment with the appropriate designation, for example U3 / M3 rather than B3

Lung Cancer

T stage
TX Tumour cannot be assessed (or is not visualized)
T0 There is no evidence of a primary tumour
Tis Carcinoma in situ
T1 A tumour measuring < 3 cm (greatest dimension) ▸ it is surrounded by lung or visceral pleura ▸ there is no bronchoscopic evidence of invasion within the main bronchus
T1(mi)
T1a 		Minimally invasive adenocarcinoma
Tumour measuring ≤ 1 cm (greatest dimension)
T1b
T1c 		Tumour measuring > 1 cm but ≤ 2 cm (greatest dimension)
Tumour measuring > 2 cm but ≤ 3 cm
T2 Tumour measuring >3 cm but ≤ 5 cm, or tumour with any of the following features:

  • Tumour involving the main bronchus regardless of distance from carina, but without involvement of the carina

  • Invades the visceral pleura

  • Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of the lung

T2a Tumour measuring > 3 cm but ≤ 4 cm (greatest dimension) ▸ invasion across a fissure
T2b Tumour measuring > 4 cm but ≤ 5 cm (greatest dimension)
T3 Tumour measuring > 5 cm but not more than 7 cm (greatest dimension) or directly invades any of the following structures:

  • Chest wall (including parietal pleura and superior sulcus tumours), phrenic nerve, parietal pericardium

  • Or associated with separate tumour nodule (s) in the same lobe as the primary

T4 Tumour measuring > 7 cm (greatest dimension) or of any size that invades any of the following structures:

  • Diaphragm, mediastinum heart, great vessels, trachea, recurrent laryngeal nerve, oesophagus, vertebral body, carina

Or associated with separate tumour nodule(s) in a different ipsilateral lobe to that of the primary.

N stage
Nx The lymph nodes are not assessable
N0 There is no regional nodal involvement
N1 There are involved ipsilateral peribronchial (± ipsilateral) hilar and intrapulmonary lymph nodes
N2 There are involved ipsilateral mediastinal (± subcarinal) lymph nodes
N3 There are involved contralateral mediastinal or hilar nodes, ipsilateral or contralateral scalene nodes, or supraclavicular nodes

M stage
M0 There are no distant metastases
M1 There are distant metastases
M1a Separate tumour nodule(s) in a contralateral lobe ▸ tumour with pleural or pericardial nodule(s) or a malignant pleural or pericardial effusion
M1b
M1c		 Single extrathoracic metastasis in a single organ
Multiple extrathoracic metastases in one or several organs

Diagrams illustrating the mediastinal boundaries and junction lines. The visualisation of the junction lines on a plain chest radiograph is variable, depending on how much fat is present in the mediastinum and on how closely the two lungs approximate to one another. (A) Section just above the level of the aortic arch. (B) Section through the aortic arch. (C) Section through the heart. **

Iaslc Lymph Node Map

The International Association for the Study of Lung Cancer (IASLC) lymph node map grouping the lymph node stations into ‘zones’ for purpose of prognostic analysis (from: < http://www.radiologyassistant.nl/en/4646f1278c26f >). Please see explanations in table below. **

The IASLC lymph node map can be applied to clinical staging by computed tomography in axial (A–C) views. The border between the right and left paratracheal region is shown in (A) and (B). Ao = aorta; Az = azygos vein; MB = main bronchus; Eso = oesophagus; IV = innominate vein; LtInV = left innominate vein; LtSCA = left subclavian artery; PA = pulmonary artery; SPV = superior pulmonary vein; RtInV = right innominate vein; SVC = superior vena cava; T = trachea. **

IASLC map for regional lymph nodes *
Zone Side Border Anatomical structure
1 Upper Lower margin of cricoid cartilage
1 Lower Clavicles/manubrium
1 Left/right Midline of trachea
2R Right Upper Apex of right lung/upper border of manubrium
2R Right Lower Intersection of caudal margin of innominate vein with trachea/nodes to left lateral border of trachea
2L Left Upper Apex of left lung/upper border of manubrium
2L Left Lower Superior border of aortic arch
3a Anterior Upper Apex of chest
3a Anterior Lower Level of carina
3a Anterior Anterior Posterior aspect of sternum
3a Anterior Posterior Anterior border of superior vena cava
3a Anterior Upper Apex of chest
3a Anterior Lower Level of carina
3a Anterior Anterior Posterior aspect of sternum
3a Anterior Posterior Left carotid artery
3p Posterior Upper Apex of chest
3p Posterior Lower Carina
4R Right Para-/pretracheal—upper Intersection of caudal margin of innominate vein with trachea
4R Right Right para-/pretracheal—lower Lower border of azygos vein
4L Left Left paratracheal to lig. art.—upper Upper margin of aortic arch
4L Left Left paratracheal to lig. art.—lower Upper rim of left main pulmonary artery
5 Subaortic lateral to lig. art.—upper Lower border of aortic arch
5 Subaortic lateral to lig. art.—lower Upper rim of left main pulmonary artery
6 Anterior and lateral to ascending aorta and aortic—upper Line tangential to upper border of aortic arch
6 Anterior and lateral to ascending aorta and aortic—lower Lower border of aortic arch
7 Mediastinal subcarinal—upper Carina of trachea
7 Right Mediastinal subcarinal—lower Lower border of bronchus intermedius
7 Left Mediastinal subcarinal—lower Upper border of lower lobe bronchus
8 Right Paraoesophageal excluding subcarinal—upper Lower border of bronchus intermedius
8 Left Paraoesophageal excluding subcarinal—upper Upper border of lower lobe bronchus
8 Paraoesophageal excluding subcarinal—lower Diaphragm
9 Within pulmonary ligament incl. inf. pulm. vein—upper Inferior pulmonary vein
9 Within pulmonary ligament incl. inf. pulm. vein—lower Diaphragm
10 Right Hilar—adjacent to mainstem bronchi and hilar vessels—upper Lower rim of azygos vein
10 Left Hilar—adjacent to mainstem bronchi and hilar vessels—lower Upper rim of pulmonary artery
10 Hilar—adjacent to mainstem bronchi and hilar vessels Interlobar region bilaterally
11 Right Interlobar—superior subgroup a#11s: between upper lobe bronchus and bronchus intermedius
11 Right Interlobar—inferior subgroup a#11i: between middle and lower lobe bronchi
11 Left Interlobar Between upper lobe bronchus and lower lobe bronchi
12 Lobar Adjacent to lobar bronchi
13 Segmental Adjacent to segmental bronchi
14 Subsegmental Adjacent to subsegmental bronchi

* International lymph node map in the seventh edition of the TNM classification for lung cancer.

Oesophageal Cancer

T stage
Tx Tumour is not assessable
T0 No primary tumour
Tis Carcinoma in situ; high grade dysplasia
T1 Tumour invades the lamina propria, muscularis mucosae, or submucosa
T1a Lamina propria or muscularis mucosae
T1b Submucosa
T2 Tumour invades the muscularis propria
T3 Tumour invades the adventitia
T4 Tumour invades adjacent structures
T4a Involvement of the pleura, pericardium, diaphragm, or adjacent peritoneum
T4b Unresectable tumour involving other adjacent structures (e.g. aorta, vertebral body, or trachea)

N stage
NX Regional lymph nodes cannot be assessed
N0 There is no regional nodal disease
N1 There are regional nodal metastases
N1 1 to 2 regional lymph nodes
N2 3 to 6 regional lymph nodes
N3 >6 regional lymph nodes

M stage
M0 There are no tumour metastases
M1 There are distant metastases

Oesophagogastric junction

  • Cancers involving the esophagogastric junction (OGJ) that have their epicenter within the proximal 2 cm of the cardia (Siewert types I/II) are to be staged as esophageal cancers.

  • Cancers whose epicenter is more than 2 cm distal from the OGJ, even if the OGJ is involved, will be staged using the stomach cancer TNM

Stomach Cancer

T stage
Tx Primary tumour is not assessable
T0 There is no evidence of primary tumour
Tis Carcinoma in situ
T1 Tumour invades the lamina propria or submucosa
T1a Invasion of the lamina propria or muscularis mucosae
T1b Invasion of the submucosa
T2 Tumour invades the muscularis propria
T3 Tumour invades the subserosa without invading any adjacent structures
T4 Tumour perforates the serosa or invades adjacent structures
T4a Perforation of the serosa (visceral peritoneum)
T4b Invades adjacent structures

N stage
Nx The lymph nodes are not assessable
N0 There is no regional nodal involvement
N1 Tumour spread to 1–2 regional nodes
N2 Tumour spread to 3–6 regional nodes
N3 Tumour spread to ≥ 7 regional nodes
N3a 7–15 nodes
N3b ≥ 16 nodes

M stage
M0 There is no distant spread
M1 There is distant spread

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