Selection of a clinicopathological staging system

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Overview of evidence (non-systematic literature review)

No systematic reviews were undertaken for this topic. Practice points were based on selected published evidence. See Guidelines development process.

The use of either one or both of the above staging systems has been variously advocated by Pathologist organisations in the USA, UK and Australasia. At the time of writing the College of American Pathologists’ published protocol is based on the AJCC/UICC TNM 7th edition.[1] The Royal College of Pathologists of Australasia’s protocol recommends the use of TNM 7th edition while also recognising the use of the ACPS and Dukes’ systems in Australia and recommends that all variables required for staging under these systems be recorded in pathology reports.[2] The Royal College of Pathologists (UK) mandates the use of modified Dukes’ staging in addition to TNM, specifically the 5th edition, to preserve the integrity of staging data for longitudinal analyses.[3]

When using the TNM staging, it is essential that the specific edition of the system be recorded in the pathology report, as significant variations in the numerical coding have occurred between successive editions of the AJCC staging manual.

The ACPS/Concord system embodies the simplicity of Dukes staging. It comprehensively defines known residual tumour, it is based on a small number of key variables (direct spread, lymph node metastases and known residual tumour) and it has been validated by a large prospective series.[4][5]

Whichever staging system is chosen, all parameters used to derive tumour stage should be recorded individually and explicitly in the pathology report to ensure effective communication and comparability between centres and over time. Table 8.5 shows a comparison between the ACPS/Concord and current AJCC staging systems.

Table 8.5. Translation between ACPS/Concord and AJCC staging system

ACPS Concord substage AJCC 8th edition (2017)
Stage grouping T N M R
A0 A1 0 Tis N0 M0 R0
A A2 I T1 N0 M0 R0
A A2 I T1 N0 M0 R0
A3 I T2 N0 M0 R0
B B1 IIA

IIC

T3

T4b

N0 M0 R0
B2 IIB T4a N0 M0 R0
C C1 IIIA-IIIC Any T N1-N2 M0 R0
C2 IIIA-IIIC Any T N1-N2 M0 R0
D D1 0-III Any T Any N M0 R1-R2
D2 IVA-IVC Any T Any N M1a-M1c Any R


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TNM staging, ACPS/Concord staging and the data required to stage the patient should all be recorded to allow national and international comparisons.


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  1. College of American Pathologists. Protocol for Examination of Specimens From Patients With Primary Carcinoma of the Colon and Rectum. Version: ColoRectum 3.4.0.0. CAP; 2016.
  2. Royal College of Pathologists of Australasia. Colorectal Cancer Structured Reporting Protocol (3rd edition). Royal College of Pathologists of Australasia; 2016 Available from: https://www.rcpa.edu.au/Library/Practising-Pathology/Structured-Pathology-Reporting-of-Cancer/Cancer-Protocols/Gastrointestinal/Protocol-colorectal-cancer.
  3. Royal College of Pathologists. Standards and Datasets for Reporting Cancers — Dataset for Colorectal Cancer Histopathology Reports. 3rd edition. London: RCP; 2014.
  4. Chapuis PH, Dent OF, Bokey EL, Newland RC, Sinclair G. Adverse histopathological findings as a guide to patient management after curative resection of node-positive colonic cancer. Br J Surg 2004 Mar;91(3):349-54 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14991638.
  5. Jass JR, Chapuis PH, Dixon MF et al. Symposium on staging of colorectal cancer. Int J Colorect Dis 1987;2:123-38.