Pancreatic Cancer

Staging

After you receive a pancreatic cancer diagnosis, your doctor will need to determine the extent of the cancer and whether it has spread to nearby lymph nodes or tissues or to other parts of the body. This process is called cancer staging. Staging helps the doctor to determine the best treatment options for each specific diagnosis.

Some cancers are staged twice. The first staging, called the clinical stage, is based on the results of the physical exam and imaging tests. A pathologist then classifies the tumor according to a pathologic stage, which is based on examination of tissue specimens removed during surgery or a biopsy. This examination provides more details about the cancer.

One staging system used for pancreatic cancer was developed by the American Joint Committee on Cancer (AJCC). This system classifies the cancer by tumor (T), node (N) and metastasis (M), and together this “TNM” classification provides a description for the overall stage of cancer. The T (tumor) category describes the size and location of the primary tumor. The N (node) category describes lymph node involvement, which is whether the lymph nodes have evidence of cancer cells. The location of these lymph nodes is important because it shows how much the disease has spread. The M (metastasis) category describes distant metastasis (spread of cancer to another part of the body), if any. Staging for the M category is mainly clinical. However, a new M subcategory is based on the presence of tumor cells that can only be detected using a microscope or molecular testing. Table 1 lists how TNM classifications are categorized. The results of the TNM analysis are then combined to determine the overall stage of the cancer for each individual (Table 2 & Figure 1).

In addition to the TNM system, doctors often use another method to determine the most appropriate treatment. This method classifies each case into four categories:

  1. Resectable – If doctors catch the disease early and believe they can surgically remove the entire tumor, it is called “resectable.”
  2. Borderline resectable – Doctors believe that surgery is still a viable option for these tumors, even in more advanced cases when the cancer has spread to nearby blood vessels.
  3. Locally advanced – These tumors have not metastasized to other organs but are still too advanced to surgically remove. They are also classified as “unresectable.” Surgery may still be performed to alleviate symptoms, however, but it’s not performed with the intent of curing the cancer.
  4. Metastatic – These tumors have spread to other organs in the body, most commonly the liver, abdomen and lungs. Spread to other sites in the body is rare.
 

Table 1. AJCC system for classifying pancreatic cancer

Classification Definition
Tumor (T)  
Tx The tumor cannot be assessed.
T0 There is no evidence of a primary tumor.
Tis Also known as “carcinoma in situ,” cancer cells are found only inside the pancreatic duct in which they originated.
T1 The tumor is confined to the pancreas and is 2 centimeters or smaller.
T2 The tumor is confined to the pancreas and is larger than 2 centimeters.
T3 The tumor has spread beyond the pancreas but has not yet invaded the major arteries or veins near the pancreas.
T4 The tumor has spread beyond the pancreas and into the major arteries or veins near the pancreas. A T4 tumor is unresectable (unable to be surgically removed).
Nodes (N)  
Nx Nearby lymph nodes cannot be assessed.
N0 Tumor cells have not spread to nearby lymph nodes.
N1 Tumor cells have spread to lymph nodes near the pancreas.
Metastasis (M)  
M0 Tumor cells have not spread to distant lymph nodes or organs.
M1 Tumor cells have spread to distant organs or tissues; pancreatic cancer most commonly spreads to the liver, the peritoneum (lining of the abdominal cavity) and/or the lungs.

Table 2. Stages of pancreatic cancer

Stage T N M
0 Tis N0 M0
IA T1 N0 M0
IB T2 N0 M0
IIA T3 N0 M0
IIB T1, T2, or T3 N1 M0
III T4 Any N M0
IV Any T Any N M1

 

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