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Skin Cancer Treatment (PDQ®)

Stage Information for Skin Cancer

There are separate staging systems in the 7th edition of the American Joint Committee on Cancer’s (AJCC) AJCC Cancer Staging Manual for carcinomas of the eyelid versus other skin surfaces.[1,2] The staging system for non-eyelid skin cancers is primarily designed for squamous cell carcinomas (SCCs). The staging system for carcinoma of the eyelid addresses carcinomas of all histologies.

Basal cell carcinoma (BCC) rarely metastasizes, thus, a metastatic work-up is usually not necessary. Regional lymph nodes should be routinely examined in all cases of SCC, especially for high-risk tumors appearing on the lips, ears, perianal and perigenital regions, or high-risk areas of the hand. In addition, regional lymph nodes should be examined with particular care in cases of SCCs arising in sites of chronic ulceration or inflammation, burn scars, or sites of previous radiation therapy treatment.

Table 2 has a separate list of risk features that should be evaluated for non-eyelid carcinomas; the relevant risk features should also be evaluated for SCCs of the eyelid. Even with relatively small tumor size, SCCs that occur in immunosuppressed patients tend to have more aggressive behavior than SCCs in nonimmunosuppressed patients. Although not a formal part of the AJCC staging system, it is recommended that centers prospectively studying SCC record the presence and type of immunosuppression in addition to the risk features listed in Table 2.

Staging for Cutaneous SCC and Other Cutaneous Carcinomas (Excluding Carcinoma of the Eyelid)

The American Joint Committee on Cancer has designated staging by TNM classification.[1] The TNM classification is used to stage both BCC and SCC.

Table 1. Primary Tumor (T) for Non-Eyelid Carcinomaa,b
aReprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
bExcludes cutaneous squamous cell carcinoma of the eyelid.
cHigh-risk features for the primary tumor (T) staging.
TX Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
Tis Carcinoma in situ.
T1 Tumor ≤2 cm in greatest dimension with <2 high-risk features.c
T2 Tumor >2 cm in greatest dimension.
or
Tumor any size with ≥2 high-risk features.c
T3 Tumor with invasion of maxilla, mandible, orbit, or temporal bone.
T4 Tumor with invasion of skeleton (axial or appendicular) or perineural invasion of skull base.
Table 2. High-Risk Features for Primary Tumor (T) Staging for Non-Eyelid Carcinoma
aReprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
Depth/invasion >2 mm thickness (Breslow thickness).
Clark level ≥IV.
Perineural invasion.
Anatomic Primary site ear.
Location Primary site hair-bearing lip.
Differentiation Poorly differentiated or undifferentiated.
Table 3. Regional Lymph Nodes (N) for Non-Eyelid Carcinomaa
aReprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastases.
N1 Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension.
N2 Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, ≤6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, ≤6 cm in greatest dimension.
N2a Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension.
N2b Metastases in multiple ipsilateral lymph nodes, ≤6 cm in greatest dimension.
N2c Metastases in bilateral or contralateral lymph nodes, ≤6 cm in greatest dimension.
N3 Metastasis in a lymph node, >6 cm in greatest dimension.
Table 4. Distant Metastasis (M) for Non-Eyelid Carcinomaa
aReprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
M0 No distant metastases.
M1 Distant metastases.

Patients with a primary cutaneous SCC or other cutaneous carcinoma with no evidence (i.e., clinical, radiologic, or pathologic) of regional or distant metastases are divided into the following two stages:

  • Stage I for tumors measuring 2 cm or less in size.
  • Stage II for tumors measuring more than 2 cm in size.

In instances where there is clinical concern about extension of the tumor into bone and radiologic evaluation has been performed (and is negative), these data may be included to support the stage I versus stage II designation. Tumors that are 2 cm or less in size can be upstaged to stage II if they contain two or more high-risk features.

Stage III patients are those with either of the following:

  • Clinical, histologic, or radiologic evidence of one involved lymph node measuring 3 cm or less in size.
  • Tumor extension into bone; namely, the maxilla, mandible, orbit, or temporal bone.

Stage IV patients are those with any of the following:

  • Tumor with direct or perineural invasion of skull base or axial skeleton.
  • Two or more involved lymph nodes.
  • Single or multiple involved lymph nodes measuring more than 3 cm in size.
  • Distant metastases.
Table 5. Anatomic Stage/Prognostic Groups for Non-Eyelid Carcinomaa
Stage T N M
aReprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
IV T1 N2 M0
T2 N2 M0
T3 N2 M0
Any T N3 M0
T4 Any N M0
Any T Any N M1

Staging for Carcinomas of the Eyelid

The AJCC has designated staging by TNM classification.[2] The TNM classification is used to stage all cell types of eyelid carcinomas.

Table 6. Primary Tumor (T) for Eyelid Carcinomaa
aReprinted with permission from AJCC: Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
TX Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
Tis Carcinoma in situ.
T1 Tumor ≤5 mm in greatest dimension.
Not invading the tarsal plate or eyelid margin.
T2a Tumor >5 mm but not >10 mm in greatest dimension.
Or, any tumor that invades the tarsal plate or eyelid margin.
T2b Tumor >10 mm but not >20 mm in greatest dimension.
Or, involves full thickness eyelid.
T3a Tumor >20 mm in greatest dimension.
Or, any tumor that invades adjacent ocular or orbital structures.
Any T with perineural tumor invasion.
T3b Complete tumor resection requires enucleation, exenteration, or bone resection.
T4 Tumor is not resectable because of extensive invasion of ocular, orbital, craniofacial structures, or brain.
Table 7. Regional Lymph Nodes (N) for Eyelid Carcinomaa
aReprinted with permission from AJCC: Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
NX Regional lymph nodes cannot be assessed.
cN0 No regional lymph node metastasis based upon clinical evaluation or imaging.
pN0 No regional lymph node metastasis based upon lymph node biopsy.
N1 Regional lymph node metastasis.
Table 8. Distant Metastasis (M) for Eyelid Carcinomaa
aReprinted with permission from AJCC: Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
M0 No distant metastasis.
M1 Distant metastasis.
Table 9. Anatomic Stage/Prognostic Groups for Eyelid Carcinomaa
aReprinted with permission from AJCC: Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
Stage 0 Tis N0 M0
Stage IA T1 N0 M0
Stage IB T2a N0 M0
Stage IC T2b N0 M0
Stage II T3a N0 M0
Stage IIIA T3b N0 M0
Stage IIIB Any T N1 M0
Stage IIIC T4 Any N M0
Stage IV Any T Any N M1

References

  1. Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301–14.
  2. Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
  • Updated: February 25, 2015