staging and grading cancer

8/10/2019 Staging and Grading Cancer

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STAGING

AND

GRADING CANCERPATHOLOGY DEPARTMENT,

FACULTY OF MEDICINE,

GADJAH MADA UNIVERSITY


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The stageof cancer is a measure how much the cancer

has grown and spreadThe gradingof cancer is determined by looking at certain

features of the cancer cells under the microssope

The aim: help to predict how a cancer might behave, howadvanced it is, how well it may respond to treatment.

THE EARLY THE STAGE AND THE

LOWER THE GRADE OF CANCER, THEBETTER THE OUTLOOK (PROGNOSIS)


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GROWING AND SPREADING OF CANCER

A cancer if untreated1. Growing from one celldivides and multiplies

primary tumorinvade surrounding tissue

2. Some cancer cellsget into local lymph channel

lymph node(s)entrappedmultiplyenlargementof lymph node

3. Some cancer cellsget into local small blood vesselinto bloodstreamspread to other areasmultiplysecondary tumor may then grow and invadenearby tissuespread again


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GROWING AND SPREADING OF CANCER

Each type of cancer differs in the speed ofgrowing and spreading

Some cancer may spread easily and quickly,other may grow slowly and remain in the

primary site for a long times


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CANCER STAGING

A way of describing how much a cancer has grown and

spread the stage is based on 3 factors

Primary tumor size and whether or not the tumor has growninto other nearby areas

Whether or not the cancer has spread to the nearby lymphnodes

Whether or not the cancer has spread to distant areas of thebody

Leukemia, and other some cancer of the blood are notformally stagedthey are assumed to be in all parts ofthe body


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CANCER STAGING

TYPE OF STAGING

1. Clinical staging, based on1. Phisical exam

2. Imaging test (x-rays, CT scan, etc.)

3. Sometimes biopsies

4. Blood test (for certain cancers)2. Pathologic staging (only on patient who have had

surgery to remove or explore the extent of the cancer)1. Combines: clinical staging + results from the surgery

2. The pathology stage may be different from the clinicalstaging


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CANCER STAGING

STAGING SYSTEMS

There were many different systems.

Sometimes different systems were used to stage

the same type of cancer.

Although some of the better ones are still

used, many of these systems did not give doctorsvery useful information


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T(tumor)N(nodule)M(metastasis)


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CANCER STAGING

STAGING SYSTEMS

TNM system1. Developed by AJCC (the American Joint Commitee on Cancer)

2. Replaced many of the older systems

TheT category describes the primary tumor

1. Tx: tumor cant be measured2. T0: there is no evidence of primary tumor

3. T1s: the cancer is in situ (has not started growing into the surroundingstructures)

4. T1T4: describes the size and/or level of invasion. The higher the Tnumber, the larger the size and/or the further it have may grown into thenearby structures


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CANCER STAGING

STAGING SYSTEMS

TNM system

The N category describes whether or not the cancer has reached nearby lymphnodes

Nx: the nearby lymph nodes cant be measured or found

N0: nearby lymph nodes do not contain cancer

N1N3: the size, location, and/or the number of lymph nodes involved.The higher N number, the more involved the lymph nodes are

The M category tells whether there are distant metastasis

Mx: metastasis cant be measured or found

M0: there are no known distant metastasis M1: distant metastasis are present


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CANCER STAGING

STAGING SYSTEMS

TNM system

Note:

Each cancer type has its own classification system.

Letters and numbers do not always mean the same thing for everykind of cancer

For example:

Some cancer may have subcategories, s.a. T3a and T3b, while othermay not have an N3 category


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CANCER STAGING

STAGING SYSTEM

STAGE GROUPING

T, N, M are combinedoverall stageI, II, III, IV

Sometimes stages are subdivided s.a. IIIA, IIIB

For example, for breast cancer

T1, N0, M0: primary tumor 2cm -


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BREAST CANCER

Stage I

T1a: T 0.5 cm

T1b: 0.5 cm < T 1 cm

T1c: 1 cm < T 2 cm

T1 N0 M0

T 2 cm

T1

N0 = no regional lymph node metastasis

M0 = no distant metastasis


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BREAST CANCER

Stage IIA

T2 N0 M0

N1 = metastasis to movable ipsilateral axillary lymph node(s)


2 cm < T < 5 cm

No evidenceof tumor

T0

T0

T1N1 M0}

T2


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BREAST CANCER

Stage IIB

T3 N0 M0

N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b


T > 5 cm

T2 N1 M0

T3


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BREAST CANCER

Stage IIIAT0

T1T2

T3

Metastasis to ipsilateral axillary lymph node(s)

N1 = movable

N2 = fixed to one another or to other structures


T3 N1 M0N2 M0


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BREAST CANCER

Stage IIIB

Any T N3 M0

N3 = metastasis to ipsilateral internal mammary lymph node(s)M0 = no distant metastasis

Tumor of any size

with direct extensionto chest wall or skin

T4d = inflammatorycarcinoma

T4 any N M0

T4


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BREAST CANCER

Stage IV

M1 = distant metastasis (including metastases to ipsilateral supraclavicular,

cervical, or contralateral internal mammary lymph nodes)

Any T any N M1


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CANCER STAGING

STAGING SYSTEM

Other Staging System1. Duke system (for colorectal cancer)

Stage A: the cancer is just in the bowel wall

Stage B: the cancer has grown to the outer surface of

the bowel wall Stage C: the cancer has spread to the lymph nodes

near to the bowel

Stage D: the cancer has spread to other parts of the

body (metastases, or secondary tumors hanedeveloped)

2. Other than TNM system used for lymphoma, some

childhood cancers, cancer in some female reproductive

organs


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Modified DukeAThe tumor penetrates into the mucosa of the bowel wall but no further.Modified Duke B

B1: tumor penetrates into, but not through the muscularis propria (themuscular layer) of the bowel wall.

B2: tumor penetrates into and through the muscularis propria of the bowel wall.

Modified Duke CC1: tumor penetrates into, but not through the muscularis propria of the bowelwall; there is pathologic evidence of colon cancer in the lymph nodes.

C2: tumor penetrates into and through the muscularis propria of the bowel wall;there is pathologic evidence of colon cancer in the lymph nodes.

Modified Duke DThe tumor, which has spread beyond the confines of the lymph nodes

(to organs such as the liver, lung or bone).

Modified Duke Staging

System


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Staging system for

renal cancer Stage I:

in the kidney only, < 7.0 cm FYS > 90%

Stage II:

in the kidney only, >7.0 cm

FYS > 75%

Stage III:

in the kidney, may be any

size, does not extend beyondGerota's fascia.

Additionally, cancer hasspread to the renal vein, tothe inferior vena cava, or tothe adjacent adrenal gland

FYS >65 % depending oninvolved sites

Stage IV:

extends beyond Gerota'sfascia, and/orhas spread to> 1 lnn. near the kidney

spread to other organs in thebody: lungs, liver, brain,bones, intestines or pancreas

FYS


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GRADING CANCER

TUMOR GRADE

Degree of abnormality of cancer cells

compared with the normal counterpart cell

Estimate how quickly the tumor is likely to grow

and spread (degree of malignancy andaggresiveness)


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GRADING CANCER

Benign or

malignant

Tumor grade

Degree of cell differentiation

Tissue (biopsy)

Pathologist

DETERMINING THE TUMOR GRADE


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GRADING CANCER

THE SIGNIFICANCY OF CANCER GRADE

Cancer grade is determined based on microscopicappearances of:

1. Degree of resemblance to the normal tissue (degreeof differentiation)

2. Mitotic activity

3. Nuclear size and pleomorphisme


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GRADING CANCER


Cancer grade recommended by AJCC (the AmericanJoint Commission on Cancer)

GX: grade can not be assed (undetermined grade)

G1: well differentiated (low grade)

G2: moderately differentiated (intermediate grade)

G3: poorly differentiated (high grade)G4: undifferentiated (high grade)


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GRADING CANCER


Grade 1: tumor cells resemble normal cells, tend to growand multiply slowlygenerally considered the least

aggressive in behavior

Grade 2 : tumor cells appears between 1 and 3

Grade 34: tumor cells do not look like normal cells,tend to grow rapidly and spread faster than tumor

with a lower grade


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Well grade

squamous cell carcinoma

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Keratin pearl

Keratin pearl


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Moderate to poorly grade

Squamous Cell Carcinoma

Individual keratine


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Well differentiated adenocarcinoma

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Tubular/ glandular pattern


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Poorly grade adenocarcinoma

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Anaplastic tumor

Pleomorphic Rhabdomyosarcoma

Bizzare cell

Multinucleated giant cell


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Cancer grade + other factors (s.a., cancer stage)

treatment plan and to predict the prognosis.

Generally: a lower grade -- a better prognosis

(the likely outcome or course of a disease; the chance ofrecovery or recurrence)

Tumor grade is very important for certain types ofcancers:

soft tissue sarcoma

primary brain tumors

Lymphomas

breast cancer

and prostate cancer
http://www.cancer.gov/dictionary/db_alpha.aspx?expand=phttp://www.cancer.gov/dictionary/db_alpha.aspx?expand=rhttp://www.cancer.gov/dictionary/db_alpha.aspx?expand=shttp://www.cancer.gov/dictionary/db_alpha.aspx?expand=lhttp://www.cancer.gov/dictionary/db_alpha.aspx?expand=lhttp://www.cancer.gov/dictionary/db_alpha.aspx?expand=shttp://www.cancer.gov/dictionary/db_alpha.aspx?expand=rhttp://www.cancer.gov/dictionary/db_alpha.aspx?expand=p


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GRADING CANCER

APPLYING THE GRADING SYSTEM

Grading systems are different for each

type of cancer, for example:

1. Gleason system for prostate cancer

2. Bloom-Richardson (Nottingham)system for breast cancer

3. Furhman system for kidney cancer


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Breast cancer

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DIAGNOSIS LABORATORIK

MORFOLOGIK :

- biopsi - IHC

- Frozen Section - Flowytometry- AJH

BIOKIMIAWI : Tumor marker

MOLEKULAR : DNA microanalysis

TUMOR MARKER / PETANDA TUMOR


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MARKER TUMOR

Hormon

HCG (Human Chorionic Gonadotropin)

Kalsitonin

Katekolamin dan metabolit

Hormon ektopik

Antigen onkofetal

Alfa-fetoprotein

CEA (carcinoma embryonicantigen)

Isoenzim

Prostatic Acid Phosphatase

Neuron specific enolase (NSE)

Protein spesifikImunoglobulin

PSA

Musin & glikoprotein lain

CA-125

CA-19-9CA-15-3

Tumor trofoblastik dan testis non-seminoma

Ca medular tiroid

Feokromositoma dan tumor yang berhubungan

Paraneoplastic syndrome

HCC, tumor testis sel benih non seminomatosa

Ca kolon, pankreas paru, gaster, mama

Ca prostat

Ca sel kecil paru, neuroblastoma

Mieloma multipel dan gamopati lain

Ca prostat

Ca ovarium

Ca kolon, pankreasCa mama

TUMOR MARKER / PETANDA TUMOR


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staging and grading cancer

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