Cancer: Staging and Grading What is meant by the term “biopsy”? How do tumors behave differently from one another ? Examples of the stages of cancer and their meaning. Why is staging important?

How do doctors diagnose cancer? Possible existence of cancer (symptoms or screening) Doctor will perform a biopsy (surgical removal of a small piece of tissue) Microscopic examination (Tells the doctor whether a tumor is actually present) Benign or Malignant

Biopsy Endoscopy Needle Biopsy Surgical Biopsy Excisional biopsy Incisional biospsy

Biopsy Results Tell us: If the tumor is benign or malignant. What “type” of cancer it is. How the tumor behaves. Is it “aggressiveness” or not? (Well differentiated vs. Poorly differentiated)

The three axes of cancer classification Topographic site Location can change patterns of progression Rectal v. colon Head and neck v. lung Histology Kind of cell responds to different treatments Nonsmall cell lung ca v. small cell lung cancer Melanoma v. basal cell cancer of the skin Anatomic extent (Staging) Degree of local and systemic involvement Topographic site (disease site) Histologic type Anatomic extent (TNM) Patient’s Disease

Topographical Site In situ Local Regional Distant

Histologic alterations in epithelial dysplasia Enlarged nuclei and cells Increased nuclear-to-cytoplasmic ratio Hyperchromatic nuclei Pleomorphic (abnormally shaped) nuclei and cells Increased mitotic activity Abnormal mitotic figures Multinucleation of cells Keratin or epithelial pearls Loss of typical epithelial cell cohesiveness

Grading Degree of differentiation exhibited by cells How closely cells resemble normal tissue structure Grade I – low grade Grade II – moderately differentiated Grade III – poorly differentiated Neville, B. W., Damm, D. D., Allen, C. M., & Bouquot, J. E. (2002). Oral and maxillofacial pathology (2nd ed.). Philadelphia: W. B. Saunders.

Why is staging important? Staging tells us the extent of the disease. Treatment depends on the stage of the specific cancer. Staging helps determine the patient’s prognosis (prediction of course and outcome of disease, especially chances of recovery).

Anatomic Staging Based on three components TThe extent of the primary tumor NThe absence or presence and extent of regional lymph node metastasis MThe absence or presence of distant metastasis

Size of primary tumor (T) in cm TXNo information available on primary tumor T0No evidence of primary tumor TisCarcinoma in situ at primary site T1Tumor less than 2 cm T2Tumor 2-4 cm in diameter T3Tumor greater than 4 cm T4Tumor has invaded adjacent structures Staging – “T”

Tumor (T): Breast Cancer >5 cm tumor T1T2T3T4

Lymph node involvement (N) NXNodes not assessed N0No clinically positive nodes (not palpable) N1 Single clinically positive ipsilateral (on same side) node less than 3 cm N2 Single clinically positive ipsilateral node 3 to 6 cm; or Multiple ipsilateral nodes with all less than 6 cm; or bilateral or contralateral nodes with none greater than 6 cm N3Node or nodes greater than 6 cm Staging – “N”

Staging – “M” Distant metastasis (M) MXDistant metastasis not assessed M0No distant metastasis M1Distant metastasis is present

TNM Staging System