Prostate cancer (staging)

Prostate cancer staging takes into account a TNM staging system (primary site, nodal and distant metastases), pretreatment PSA and histological grading. The Gleason score is used to determine the Grade Group. 

A superseded staging system is the Whitmore-Jewett staging system.

Additionally, there is some overlap with prebiopsy imaging assessment using Prostate Imaging-Reporting and Data System (PI-RADS).

TNM staging

Clinical primary tumor staging (cT)

• TX: primary tumor cannot be assessed

• T0: no evidence of primary tumor

• T1: a clinically inapparent tumor that is not palpable

  • T1a: tumor incidental histologic finding in 5% or less of tissue resected

  • T1b: tumor incidental histologic finding in more than 5% of tissue resected

  • T1c: tumor identified by needle biopsy found in one or both sides, but not palpable

• T2: tumor is palpable and confined within the prostate

  • T2a: tumor involves one-half of one side or less

  • T2b: tumor involves more than one-half of one side but not both sides

  • T2c: tumor involves both sides

• T3: an extraprostatic tumor that is not fixed or does not invade adjacent structures

  • T3a: extraprostatic extension (unilateral or bilateral)

  • T3b: tumor invades seminal vesicle(s)

• T4: tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall

Pathological primary tumor staging (pT)

• T2: organ confined

• T3: extraprostatic extension

  • T3a: extraprostatic extension (unilateral or bilateral) or microscopic invasion of the bladder neck

  • T3b: tumor invades seminal vesicle(s)

• T4: tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall

Regional nodal status (N)

Regional lymph nodes are defined as those of the true pelvis (i.e. pelvic nodes below the bifurcation of the common iliac arteries).

Nodal status is based on PSMA PET-CT, MRI or CT. On MRI/CT a 1 cm short-axis diameter cut-off is used if the size is the sole criterion for adenopathy ¹.

• NX: regional nodes were not assessed

• N0: no positive regional nodes

• N1: metastases in regional node(s)

Distant metastasis (M)

• M0: no distant metastasis

• M1: distant metastasis

  • M1a: non-regional lymph node(s)

    • note that a node along the common iliac arteries would be considered M1a, not N1

  • M1b: bone(s)

  • M1c: other site(s) with or without bone disease

    • e.g. lungs, liver, brain

Histologic grading

Gleason scores are compressed into Grade Groups (table 2) ⁸.

Stage groupings

Prognostic stage groupings (table 1) are determined by TNM, pretreatment serum PSA and histologic Grade Groups ⁷.