STAGING

Breast (Essential Features, TMN, Grave Signs)
Cervix
Colon 
Endometrial
Gastric
Head and Neck
Lung NSCLC
Ovary
Testicular

BREAST CANCER STAGING

ESSENTIAL FEATURES

I _____ < 2cm and LN-
IIA ____ 2-5cm OR LN+
IIB ____ >5cm OR 2-5cm AND LN+
IIIA ___ >5cm AND LN+ OR Fixed lymph nodes
IIIB ___ Chest/Skin OR Int Mam lymph nodes
IV ____ Distant mets

TNM STAGING

T1 <= 2 cm

mic = < 0.1 cm
a = 0.1-0.5
b = 0.6-1.0
c = 1.1-2.0

T2 2.1 - 5 cm
T3 >5cm
T4 Any size involving chest wall or skin (automatic Stage IIIB min.)

N1 Movable axillary
N2 Fixed axillary
N3 Ipsilateral internal mammary

Staging by TNM (5YS)

I T1N0M0 (95)
IIA T0N1, T1N1, T2N0 (84)
IIB T2N1, T3N0 (66)
IIIA T0123 N2 (49)
IIIB T4 any N, any T, N3 (46)
IV any T any N M1 (15)

GRAVE SIGNS
(Categorically inoperable)

Skin edema up to 1/3 breast
Fixed to chest wall
Axillary LNs > 2.5cm
Fixed axillary LNs

 

CERVIX STAGING

Generally clinically staged, not pathologic

I - Confined to Cervix

Ia1 Minimal microscopic invasion
Ia2 Invasion >4mm, spread >6mm
Ib Bigger than Ia2

II - Beyond cervix, but not to pelvix sidewall

IIa Proximal (upper) 2/3 of vagina
IIb Obvious parametreal involvement

III - Pelvic sidewall, distal vagina, hydronephrosis or non-functioning kidney

IIIa Extends to distal 1/3 vagina
IIIb Pelvic sidewall, hydro, or non-funct kidney

IV - Beyond true pelvis, bladder or rectal mucosa

IVa Bladder or rectum
IVb Distant organs

 

COLORECTAL CA

TNM SYSTEM

T1 Invades submucosa
T2 Invades into muscularis propria
T3 Invades thru muscularis propria into the subserosa
T4 Invades thru serosa into free peritoneum or contiguous organ

N1 1-3 positive LN
N2 4+ positive LN

STAGE (TNM)_________ DUKE`S

I ____T1/2__N0____M0__A/B1
II ____T3/4__N0____MO__ B2
III ____anyT__N123__ M0__ C
IV ____anyT__anyN___M1__D

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5 YR SURVIVAL RATE

Node Neg (Dukes)

T1 -- 97% A
T2 -- 90% B1
T3 -- 78% B2
T4 -- 63% B2

Node Pos (N1)

T2N1 -- 74% C
T3N1 -- 48% C
T4N1 -- 38% C

GITSG

1-4 LN -- 56%
>4 LN -- 26%

Risk of local recurrence:

T1-T2 N0 <10%
T3 N0 15-30
T3 N1 35-50
T3-T4 N+ 60+

Rates sl higher in Rectal ca.

 

ENDOMETRIAL STAGING/Prognosis

I Cancer confined to the corpus (75% cases, 85% 5YS)

Ia Limited to endometrium
Ib Invades < 1/2 endometrium
Ic Invades > 1/2 endometrium

G1: Well-diff (5YS = 95)
G2: Mod diff (5YS = 80)
G3: Solid or undifferentiated (5YS = 70)

II Involves Corpus & cervix but not beyond uterus (11% cases, 5YS = 60%)

IIa Endocervical glandular involvement only
IIb Cervical stromal invasion

III Extends beyond uterus but within true pelvis (11% cases, 35% 5YS)

IIIa Invades serosa &/or adnexa or positive peritoneal cytology
IIIb Vaginal metastases
IIIc Positive pelvic &/or para-aortic LNs

IV Beyond true pelvis or invades mucosa of bladder or rectum (3% cases, 10% 5YS)

IVa Invasion of bladder and/or bowel mucosa
IVb Distant mets including intra-abdominal &/or inguinal LNs

Note: Adenocas with squamous differentiation are graded according to the nuclear grade of the glandular component. In serous adenoca, clear-cell adenocas, and squamous cell cas, nuclear grading takes precedence. Notable nuclear atypia, inappropriate for the architectural grade, raises the grade of a grade 1 or 2 tumor by one.

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ENDOMETRIAL: RISK OF RECURRENCE

Excellent Prognosis (Recurrence risk 1%)

Stage IA, grade 1

Low Risk (Recurrence risk 6%)

Stage I, grade 1-2
Neg cytology
< 1/3 myometrial invasion

Intermed Risk (Recurrence risk 15% Range 4-46)

Stage IA, grade 3
Stage IB-IC, all grades
All Stage II (30% risk)
Pos cytology only (risk ?)

High Risk (Risk 51-85)

All Stage III-IV
Clear cell or serous carcinoma

 

GASTRIC: STAGING / PROGNOSIS

General Factors, TNM Definitions, Stage Definitions, Prognosis)

Most important factors are (in order from worst):

- serosal penetration
- number + LNs (>3)
- distance of LNs from primary (>5cm)
- location of primary (proximal)

Primary tumor (T) Principal factor is degree of penetration of stomach wall by carcinoma

TX: Primary tumor cannot be assessed

T0: No evidence of primary tumor
Tis: Carcinoma in situ: intraepithelial tumor without invasion of the lamina propria
T1: Tumor invades lamina propria or submucosa
T2: Tumor invades the muscularis propria or the subserosa*
T3: Tumor penetrates the serosa (visceral peritoneum) without invading adjacent structures**
T4: Tumor invades adjacent structures**

*Note: A tumor may penetrate the muscularis propria with extension into the gastrocolic or gastrohepatic ligaments or into the greater or lesser omentum without perforation of the visceral peritoneum covering these structures. In this case, the tumor is classified T2. If there is gross or microscopic perforation of the visceral peritoneum covering the gastric ligaments or omenta, the tumor should be classified T3.

**Note: The adjacent structures of the stomach are the spleen, transverse colon, liver, diaphragm, pancreas, abdominal wall, adrenal gland, kidney, small intestine, and retroperitoneum. Intramural extension to the duodenum or esophagus is classified by the depth of greatest invasion in any of these sites, including stomach.

Nodal involvement (N) The regional lymph nodes are the inferior (right) gastric, splenic, superior (left) gastric, periesophageal (to the right and left of the gastroesophageal junction), perigastric NOS, celiac, and hepatic. All other lymph nodes (including the retropancreatic, hepatoduodenal at or above the bifurcation of the hepatic artery, aortic, portal, retroperitoneal, true periesophageal, and mesenteric) are considered distant disease (M1).

NX: Regional lymph node(s) cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in perigastric lymph nodes within 3.0 cm of the edge of the primary tumor
N2: Metastasis in the perigastric lymph node(s) more than 3.0 cm from the edge of the primary tumor or in lymph nodes along the left gastric, splenic, celiac, and common hepatic arteries

Distant metastasis (M)

MX: Presence of distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis

 

GASTRIC STAGE DEFINITIONS (5YS)

Stage 0 -- Tis, N0, M0

Stage I (90% 5YS)

Stage IA = T1, N0, M0
Stage IB = T1, N1, M0 or T2, N0, M0

Stage II (55-60% 5YS)

T1, N2, M0 or T2, N1, M0 or T3, N0, M0

Stage III (15-30%)

Stage IIIA = T2, N2, M0 or T3, N1, M0 or T4, N0, M0
Stage IIIB = T3, N2, M0 or T4, N1, M0

Stage IV (5-15%)

T4, N2, M0 or any T, any N, M1

 

HEAD AND NECK CANCER STAGING

Principles, TNM Definitions, Stage Groupings

STAGING PRINCIPLES

  • Primary of mouth or oropharynx:

T3 = > 4cm
T4 = invades surrounding structures

  • Vocal cord paralysis = T3 for larynx & hypopharynx.
  • Nodal classifications are same for all primary sites
  • Any +LN means at least stage III.
  • For comparable primary site & T stage, positive cervical LNs decreases chance of cure by 50%.

 

HEAD & NECK STAGING

T1 <2cm or confined to origin
T2 2-4cm or extension to adjacent mucosa
T3 >4cm or extension to adjacent tissue. In larynx & hypopharynx, fixation occurs
T4 Massive lesion w deep invasion into bone, soft tissue, or cartilage

N1 Single ipsilat LN <= 3cm
N2A Single ipsilat LN 3-6cm
N2B Multiple ipsilat LNs < 6cm
N2C Bilat OR Contralat LNs < 6cm
N3 LN > 6cm

 

STAGE GROUPINGS

Stage 0 TisN0

Stage I T1N0

Stage II T2N0

Stage III T3N0M0 or T1-3N1

Stage IV T4 or N2-3 or M1

 

LUNG: NSCLC STAGING

General, TNM Definitions, Stage Groupings, Prognosis M0 disease based on T and N stage, Pretreatment Prognostic Factors

GENERAL PRINCIPLES

I = T1-2 N0___Lung only. LN-. 5YS = 60-70%

II = T1-2 N1 or T3N0: Locally invasive primary or nodal metastases to intrapulmonary or ipsilateral hilar nodes only. 5YS = 30-50%.

IIIa= T3 or N2: Locally invasive but still resectable. 5YS for resected disease = 10-30%.

IIIb= T4 or N3: Invades mediastinal organs, malignant effusion, or contralateral lymph nodes, all of which are not operable

IV = Distant metastases

 

TNM DEFINITIONS

T1 <= 3cm surrounded by lung or visceral pleura, not involving main bronchus.
T2 Any of the following:

- More than 3cm in greatest diameter
- Involves main bronchus, at least 2 cm distal from the carina
- Invading visceral pleura
- Partial atelectasis or obstructive pneumonia that extends to the hilar region but does not involve the entire lung

T3 Any size that directly invades chest wall (incl. superior sulcus), diaphragm, mediastinal pleura, or parietal pericardium. May not involve the heart, great vessels, esophagus or vertebral body.

- Tumor in the main bronchus < 2cm distal to the carina
- Complete atelectasis or obstructive pneumonitis of the entire lung

T4 Tumor of any size that invades:

- Mediastinum, great vessels, trachea, esophagus, vertebra, carina; or malignant pleural effusion*

N1 N1 nodes are contained within the visceral pleural envelope. These include the ipsilateral peribronchial nodes and ipsilateral hilar nodes (Interlobar, lobar, segmental, subsegmental)

N2 N2 nodes are mediastinal nodes. These include: subcarinal, upper or lower paratracheal, pre-tracheal, retro-tracheal, paraesophageal, sub-aortic (AP window), para-aortic (ascending aorta or phrenic), pulmonary ligament, tracheobronchial angle, anterior mediastinal)

N3 N3 nodes are any contralateral nodes (including contralateral scalene) or any supraclavicular node.

 

5YS IN 1479 PTS WITHOUT DISTANT METASTASES ANALYZED ACCORDING TO T AND N FACTORS

T1N0 = 75%
T2N0 = 57
T1N1 = 52
T2N1 = 38
T3N0 = 33
T3N1 = 39
T1-3N2 = 15
T1-3N3 = 0
T4NanyM0 = 8

 

PRETREATMENT PROGNOSTIC FACTORS IN ADVANCED STAGE DISEASE

Better:

Previously good response to CDDP
Expression of blood group A antigen in patients with type A or AB
Expression of neuroendocrine markers (chromogranin, L-dopa, decarboxylase, NSE, Leu-7)

Worse:

Bone/liver metastases
High LDH
Aneuploidy (in squamous cell)
Expression of K-RAS

 

OVARIAN STAGING

Stage I: Limited to ovaries

IA One ovary, no ascites. No tumor on external surface. Capsule intact.
IB Both ovaries, no ascites. no tumor on external surface. Capsule intact.
IC IA or IB, but with tumor on surface, malignant ascites, ruptured capsule, or + peritoneal washings.

Stage II: Pelvic extension

IIA One or both ovaries with pelvic extension
IIB Extension &/or mets to uterus &/or tubes
IIC Same as IC, but stage II tumor.

Stage III: Outside pelvis but still in abdomen. Superficial liver metastases. Tumor limited to true pelvis but with histologically verified malignant extension to small bowel or omentum.

IIIA: Limited to true pelvis grossly. Neg LNs. Microscopic seeding of abdominal peritoneal surfaces.
IIIB: Peritoneal implants < 2cm. LNs neg.
IIIC: Implants > 2cm and/or + RP or inguinal LNs.

Stage IV: Distant mets. Malignant pleural effusion. Parenchymal liver mets.