Anal cancer (staging)

Last revised by Henry Knipe on 27 Apr 2022

The most recent version of TNM staging of anal cancer is as follows:

Primary tumor (T)
  • TX: primary tumor cannot be assessed
  • T0: no evidence of primary tumor
  • Tis: carcinoma in situ (Bowen disease, high-grade squamous intraepithelial lesion [HSIL], anal intraepithelial neoplasia II-III (AIN II-III)
  • T1: tumor 2 cm or less in greatest dimension
  • T2: tumor >2 cm but <5 cm in greatest dimension
  • T3: tumor >5 cm in greatest dimension
  • T4: tumor of any size invades adjacent organ(s), e.g. vagina, urethra, bladder
    • note that direct invasion of the rectal wall, perirectal skin, subcutaneous tissue, or the sphincter muscle(s) is not classified as T4

The tumor size can be measured on any of the planes and must reflect its longest diameter. 

Regional lymph nodes (N)
  • Nx: regional lymph nodes cannot be assessed
  • N0: no regional lymph node metastasis
  • N1: metastasis in regional lymph nodes
    • N1a: metastases in inguinal, mesorectal, and/or internal iliac lymph nodes
    • N1b: metastases in external iliac lymph nodes
    • N1c: metastases in external iliac and N1a nodes (inguinal, mesorectal, and/or internal iliac lymph nodes)

Size criteria for anal carcinoma have not yet been validated, and MRI morphologic features are usually more helpful in defining nodal involvement: irregular contours/spiculated margins and heterogeneity or necrosis. F-18 FDG PET-CT has higher sensitivity (89-93%) than MRI and CT (~62%) in determining nodal involvement ref

Distant metastasis (M)
  • Mx: distant metastasis cannot be assessed
  • M0: no distant metastasis
  • M1: distant metastasis

Involvement of para-aortic or more distant lymph nodes is considered as M1. Besides para-aortic nodes, the liver and lungs are the other common sites for metastasis ref

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