Diffuse pleural mesothelioma TNM staging AJCC version 9

Primary tumor (T)^*
Clinical T (cT)
T category	T criteria
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
T1	Tumor limited to the ipsilateral pleura with Psum^¶ ≤12 mm and no involvement of the fissure (Fmax^Δ ≤5 mm)
T2	Tumor involving the ipsilateral pleura with Psum^¶ ≤12 mm, and with any of the following: Involvement of the fissure (Fmax^Δ >5 mm) Mediastinal fat invasion Solitary area of chest wall soft tissue invasion or Tumor involving the ipsilateral pleura with Psum^¶ >12 mm but ≤30 mm, with or without: Involvement of the fissure (Fmax^Δ >5 mm) Mediastinal fat invasion Solitary area of chest wall soft tissue invasion
T3	Tumor involving the ipsilateral pleura with Psum^¶ >30 mm, with or without: Involvement of the fissure (Fmax^Δ >5 mm) Mediastinal fat invasion Solitary area of chest wall soft tissue invasion
T4	Tumor with invasion of any of the following (any Psum^¶): Chest wall bony invasion (rib) Mediastinal organs (heart, spine, esophagus, trachea, great vessels) Diffuse chest wall invasion Direct tumor extension through the diaphragm or pericardium Direct extension to the contralateral pleura Presence of malignant pericardial effusion
¶ Psum = pmax1 + pmax2 + pmax3 (sum of 3 measurements of maximal pleural thickness measured on axial images along the chest wall or mediastinum in each of the 3 divisions of the chest [upper, middle, and lower] divided by 2 lines; one at the top of the aortic arch and the second drawn at the top of the left atrium). Δ Fmax = maximal thickness of pleural tumor along the fissures measured on sagittal images.
Pathological T (pT)
T category	T criteria
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
T1	Tumor limited to the ipsilateral pleura with no involvement of the fissure
T2	Tumor involving the ipsilateral pleura and with any of the following: Involvement of the fissure Ipsilateral lung parenchyma invasion Diaphragm (nontransmural) invasion
T3	Tumor limited to the ipsilateral pleura (with or without fissure involvement) and with invasion of any of the following: Mediastinal fat Surface of pericardium Endothoracic fascia Solitary area of chest wall soft tissue
T4	Tumor with invasion of any of the following: Chest wall bony invasion (rib) Mediastinal organs (heart, spine, esophagus, trachea, great vessels) Diffuse chest wall invasion Transmural invasion of the diaphragm or pericardium Direct extension to the contralateral pleura Presence of malignant pericardial effusion
Primary tumor suffix (m) Multiple synchronous primary tumors
Regional lymph nodes (N)^*
N category	N criteria
NX	Regional lymph nodes cannot be assessed
N0	No tumor involvement of regional lymph node(s)
N1	Tumor involvement of ipsilateral bronchopulmonary, hilar, or mediastinal (including the internal mammary, peridiaphragmatic, pericardial fat pad, or intercostal lymph nodes) regional lymph nodes
N2	Tumor involvement of contralateral mediastinal, ipsilateral, or contralateral supraclavicular lymph nodes
Regional lymph nodes suffix (sn) Sentinel node procedure (f) FNA or core needle biopsy
Distant metastasis (M)^*
M category	M criteria
cM0	No distant metastasis
cM1	Distant metastasis
pM1	Microscopic confirmation of distant metastasis
AJCC prognostic stage group is assigned based on the stage classification and categories chosen.^*
Prognostic stage groups
When T is...	And N is...	And M is...	Then the stage group is...
T1	N0	M0	I
T2	N0	M0	II
T1	N1	M0	II
T2	N1	M0	IIIA
T3	N0-N1	M0	IIIA
T1-T3	N2	M0	IIIA
T4	Any N	M0	IIIB
Any T	Any N	M1	IV

AJCC: American Joint Committee on Cancer; FNA: fine-needle aspiration; TNM: tumor, node, metastasis.

* AJCC data elements required for staging are identified with an asterisk.

Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer Staging System: Diffuse Pleural Mesothelioma, Version 9 (2024).

Graphic 147435 Version 1.0

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Diffuse pleural mesothelioma TNM staging AJCC version 9