Staging System for Malignant Mesothelioma

The following is a technical discussion of staging for malignant mesothelioma written for health professionals.

The American Joint Committee on Cancer (AJCC) staging system for mesothelioma was adopted from that proposed by the IMIG in 1995 and has been validated in a number of surgically based trials.  The system evolved from a greater understanding of the relationships between the tumor (T) status and nodal (N) status and overall survival.  There was a redefinition of the T categories, and the T1 lesions were divided into T1a (involvement of the parietal pleura only) and T1b (involvement of the visceral pleura), which led to a split of stage I into state IA and IB.  T3 is defined as a locally advanced but potentially resectable tumor, and T4 is defined as a locally advanced, technically unresectable tumor.  The Brigham and Woman’s Staging System has also been proposed for pleural mesothelioma and differs from the AJCC by defining intrapleural adenopathy (lymph node involvement near the pleura) as stage II disease and extrapleural adenopathy as stage III disease.  The AJCC system classifies any nodal involvement, either intrapleural or extrapleural as stage III disease.

International Staging System for Diffuse Malignant Pleural Mesothelioma

T-TUMOR STATUS

T1

T1a

Tumor limited to the ipsilateral parietal ± mediastinal ± diaphragmatic pleura

No involvement of the visceral pleura

T1b

Tumor involving the ipsilateral parietal ± mediastinal ± diaphragmatic pleura

Tumor also involving the visceral pleura

T2

Tumor involving each of the ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic, and visceral pleura) with at least one of the following features:

Involvement of diaphragmatic muscle

Extension of tumor from visceral pleura into the underlying pulmonary parenchyma

T3

Describes locally advanced but potentially respectable tumor

Tumor involving all of the ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic, and visceral pleura) with at least one of the following features:

Involvement of the endothoracic fascia

Extension into the mediastinal fat

Solitary, completely resectable focus of tumor extending into the soft tissues of the chest wall.

Nontransmural involvement of the pericardium

T4

Describes locally advanced technically unresectable tumor

Tumor involving all the ipsilateral pleural surfaces (parietal, mediastinal, diaphragmatic, and visceral pleura) with at least one of the following features:

Diffuse extension or multifocal masses of tumor in the chest wall, with or without associated rib destruction

Direct transdiaphragmatic extension of tumor to the peritoneum

Direct extension of tumor to the contralateral pleura

Direct extension of tumor to mediastinal organs

Direct extension of tumor into the spine

Tumor extending through to the internal surface of the pericardium with or without a pericardial effusion; or tumor involving the myocardium

 

N-LYMPH NODES

NX: Regional lymph nodes cannot be assessed

N0: No regional lymph node metastases

N1: Metastases in the ipsilateral bronchopulmonary or hilar lymph nodes

N2: Metastases in the subcarinal or the ipsilateral mediastinal lymph noes, including the ipsilateral internal mammary nodes

N3: Metastases in the contralateral mediastinal, contralateral internal mammary, ipsilateral, or contralateral supraclavicular lymph nodes

M-METASTASES

MX: Presence of distant metastases cannot be assessed

M0: No distant metastasis

M1: Distant metastasis present

 

STAGE

STAGE I

Ia: T1aN0 M0

Ib: T1bN0 M0

STAGE II

T2 N0 M0

STAGE III

Any T3 M0

Any N1 M0

Any N2 M0

STAGE IV

Any T4

Any N3

Any M1

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