20 – Oncology Staging

Question 1

What are different ways to determine stage of the cancer?

Answer 1

1. TMN classification
2. Primary
3. Lymph node
4. Distant metastasis
5. Microscopic vs. gross disease

Question 2

TNM classification

Answer 2

• T: Tumor size (primary tumor)
• N: lymph Node
• M: distant Metastasis

Question 3

Tumor size

Answer 3

• Physical examination
  o Measure in 3 directions, if possible
• Advanced imaging: CT and MRI

Question 4

CT: for tumor size

Answer 4

• Sedation, anesthesia
• *soft tissue, bone , lungs

Question 5

MRI: for tumor size

Answer 5

• $$$, anesthesia, lots more time
• *soft tissue, muscle, nerve

Question 6

FNA screening: lymph node

Answer 6

• Normal size does NOT equal no metastasis
  o Metastasis in 20-46%
• Surgical expiration: cytology: Sens 64-100%, Spec 90-96%
  o Therapeutic

Question 7

Ultrasound for internal lymph nodes

Answer 7

• Short/long axis ratio
• Homogenecity
• *hard to tell sometimes=limited

Question 8

Advanced imaging when ultrasound is limited

Answer 8

• CT/MRI: sacral/intrathoracic LN
  o CT sensitivity: 10-12%, specific 91-96%
• FDG-PET/CT-scan

Question 9

Anatomically closet LN and ‘drainage’

Answer 9

• Is not the draining LN in 28-62%
• *make their own lymphatics

Question 10

What is sentinel LN?

Answer 10

• *1st draining LN
• Colour dye, radiopaque agent, near-infrared florescence
• *sued for cancers that commonly METASTASIZE TO LNs
  o Ex. mast cell tumors, oral tumors, anal sac carcinomas

Question 11

Metastasis can be systemic

Answer 11

• Lungs
  o 3-view or 4 view rads OR CT
  o Cancers that travel through blood
• Abdomen (liver, spleen, kidney, etc.)
  o Abdominal ultrasound, CT +/- FNA
• Brain/CNS
  o Neuro exam, CT, MRI
• Skin/bone
  o Physical exam

Question 12

Co-morbidities in senior patients

Answer 12

• can offer various tests to determine
  o abdominal ultrasound
  o systemic CT
  o FDG-PET/CT=most sensitive (28% of seeing 2nd cancer)

Question 13

FDG-PET/CT

Answer 13

• Cancer=likes to have glucose
  o Try and figure which organ/area is taking the most amount of sugar (‘tag’)

Question 14

Microscopic and gross disease: 2 situations of the microscopic disease/limitations

Answer 14

• 1. Recurrence
     o Soft tissue sarcoma Grade I/II: 7-34% of recurrence
     o Mast cell tumor Grade II: 23% of recurrence
• 2. Metastasis
     o Osteosarcoma: 85-90%
• **why do chemo after surgery still

Question 15

What are the factors to consider in staging?

Answer 15

• Risks, cost, BENEFIT
• Accessibility
• Metastasis likelihood
• *monitoring is an option

Question 16

How much staging should be done?

Answer 16

• Localized tumor (ex. plasma cell tumor)
  o Minimum database
• Microscopic metastasis (ex. splenic hemangiosarcoma)
  o Chest IMAGING, abdominal/cardiac ULTRASOUND
• Hematopoietic systemic tumor (ex. lymphoma)
  o Chest imaging, abdominal ultrasound, bone marrow
  o No staging: cause already going to do treatment

Question 17

Why does staging matter?

Answer 17

• Treatment/monitoring plan changes
• Prognosis changes