Classification systems (TNM, AJCC, misc) Flashcards
BIRADS
BIRADS
0: Incomplete, need repeat or additional
1: negative, normal, reg surveillance
2: Benign, zero percent probability of malignancy
3: Probably benign MMG, <2% probability, shorter f/u i.e. 6 months
4: Suspicious for malignant 2-94% malignant, further investigation
5: Highly suggestive for malignancy, biopsy
6: Known malignant lesion
How can you classify benign breast disease? What is in each group?
Aberations of normal breast development and involution.
- Non-proliferative
- Cyst
- Mild duct hyperplasia
- Fibroadenoma
- PASH (pseudoangiomatous hyperplasia)
- Simple columnar alteration
- Proliferative without atypia
- Florid ductal hyperplasia
- Complex fibroadenoma
- Columnar hyperplasia
- Mammary adenosis
- Radial scar/complex sclerosing lesion
- Papilloma
- Proliferative with atypia
- Atypical ductal hyperplasia
- Atypical lobular hyperplasia
- Lobular carcinoma insitu
- Flat epithelial atypia
- Atypical papilloma
Mammographic density
- Classification for density
- A: Entirely fibrofatty tissue
- B: scattered fibroglandular density
- C :heterogeneously dense with patches of density that may obscure small lesion
- D: extremely dense breast
- Difficult to detect, independent risk factor
Choledochal cysts
Todani classification
Type 1:
The most common (>80%)
Solitary fusiform cystic dilatation of a portion extrahepatic biliary tree
Type 2:
An isolated diverticulum of the CBD
Type 3:
Choledochocele (cystic dilatation of the intraduodenal CBD)
Type 4: multiple dilatations (2nd most common)
A: Extra & intrahepatic
B: Extrahepatic
Type 5: Intrahepatic dilations (Carolis)
Cholangiocarcinoma classification macroscopic appearance & location
Bismuth-Corlette classification
Type 1: CHD below confluence
Type 2: at the confluence
Type 3: Into a hepatic duct R=A L=B (stupid)
Type 4: Confluence into both hepatic ducts
Morphology (Japanese)
Type 1: Mass forming (exophytic nodule outwards)
Type 2: Periductal infiltrating (most common)
Type 3: Intraductal (papillary within the duct)
Pancreatitis CT severity score
- Combination of 2 scoring systems
- Balthazar CT score A->E
- A normal
- B enlargement
- C inflammatory changes in the pancreas and peripancreatic fat
- D ill defined single peripancreatic fluid collection
- E 2 or more peripancreatic fluid collection
- Pancreatic necrosis score as a %
- None
- <30
- 30-50
- 50+
Hydatid classification (USS)
Severity of pancreatitis
Revised Atlanta classification:
Mild
- No local or systemic complications
- No organ failure
Moderate
- Either local or systemic complication &/or
- Transient organ failure (<48hrs)
Severe
- Either local or systemic complication &
- Persistent organ failure (>48hrs)
Modified glasgow criteria
- Modified Glasgow criteria
- > or = 3 is higher risk of M&M
- measured at 48hours
- PANCREAS
- Pa02 <60mmHg
- Age >55
- Neutrophils >15
- Calcium <2mmol/L
- Renal function – urea >16mmol/l
- Liver enzymes – AST or ALT >200 or LDH >600
- Albumin <32
- Sugar >10 BGL
TNM Pancreatic adenocarcinoma
T
- Tis: high-grade pancreatic intraepithelial neoplasia (PanIn-3), intraductal papillary mucinous neoplasm with high-grade dysplasia, intraductal tubulopapillary neoplasm with high-grade dysplasia, and mucinous cystic neoplasm with high-grade dysplasia.
- T1 <2cm
- T2 2-4cm
- T3 >4cm
- T4 involving CHA, Coeliac or SMA
N
- N0
- N1 1-3
- N2 4 or more
M
- M0
- M1 distant metastasis
- Stage
- 1a: T1
- 1b: T2
- 2a: T3 (+4cm)
- 2b: N1 (nodes)
- 3: N2 or T4
- 4: Metastatic disease
- 7 out of 10 patients do not receive any time of active treatment, 1 in 10 will have potentially curative surgery
- Majority present at late stage – unresectable – 5 year survival 7%
- Resectable disease (<20% of patients)
- Overall, median survival 12-24 months, 10-25% 5 year overall survival
- R0 resection with >1mm margin – median 35 months
- R0 resection with <1mm margin – median 16 months
- R1 resection – median 14 months
- Metastatic disease
- 6 months median without treatment
- 11 months median with treatment
Grade oesophageal varices
Grade 1-3
Small, collapse on insufflation with air
Moderate, don’t collapse on insufflation
Large, occluding lumen
Classification of gastric varices
Sarin classification
- GOV1:
- Extending <5 cm from GOJ into stomach
- Treated with EBL
- GOV2:
- Extending from GOJ into fundus
- IGV1:
- Isolated varices in gastric fundus
- IGV2:
- Isolated non-fundic gastric varices
- GOV2 and IGV1-2 treated with Injection of cyanoacrylate or thrombin
All respond well TIPS
IGV 1 associated with splenic vein thrombosis, consider splenectomy or SAE
(* The splenic artery remains intact and thus enables continued high pressure in the spleen, which forces an abnormal outlet through collaterals.
* Increased blood flow through the short gastric veins to the coronary vein or through the gastroepiploic vein to the pancreaticoduodenal vein creates a localized form of “left-sided” portal hypertension with dilatation of the submucosal veins within the stomach wall, producing the formation of gastric varices along the greater curvature and the fundus of the stomach.
* The oesophageal veins can usually drain through the patent coronary vein, so the development of associated oesophageal varices is prevented)
Childs pugh score
- Childs Pugh
- 5 factors (2 clinical and 3 biochemical)
- 2 clinical
- Ascites
- 1: absent
- 2: managed with medication
- 3: refractory
- Encephalopathy
- Agitation, reverse sleep wake, lethargy, confusion/coma
- 1: None
- 2: grade 1-2 or supressed with medications
- 3: 3+ or refractory
- 3 biochemical
- Bilirubin
- 1: <34
- 2: 34-50
- 3: 50+
- Albumin
- 1: 35+
- 2: 28-35
- 3: <28
- INR
- 1: <1.7
- 2: 1.7-2.2
- 3: 2.2+
- Total score:
- Class A
- 5-6 points
- 100% survival
- Elective laparotomy 90 day mortality <10%
- Emergency laparotomy 90 day mortality 20%
- Class B
- 7-9 points
- 80% survival
- Elective laparotomy 90 day mortality 20%
- Emergency laparotomy 90 day mortality 30%
- Class C
- 10-15 points
- 45% survival
- Elective laparotomy 90 day mortality 50%
- Emergency laparotomy 90 day mortality 80%
- Limitations
- Subjective
- Decompensation can occur in CP A
- Doesn’t predict mortality
- B is very broad!
TNM gallbladder carcinoma
Gallbladder has no submucosa
T1a: invades lamina propria
T1b: invades muscularis propria
T2a: invades perimuscular tissues on peritoneal side
T2b: invades perimuscular tissues on liver side
T3: penetrates the visceral peritoneum (serosa on peritoneal side), or invades the liver +/- 1 adjacent extrahepatic structure
T4: invades main portal vein, hepatic artery, or 2 extrahepatic structures
Cholangitis Toyko guidelines 2018
**Make diagnosis **
* A: Inflammation (systemic)
* Fever >38C
* Bloods
* <4 WCC 10<
* 1< CRP
- B: Cholestasis
- Bilirubin >20
- Raised liver enzymes >1.5
- C: Radiological
- Biliary dilatation
- Aetiology of obstruction
*** Degree of certainty **
Suspected
* One in A plus
* One in B or C
Definite
* One in A, B and C
**Assess severity **
Mild
* Not moderate or severe
Moderate (no organ markers here)
* WCC >12 or <4
* High fever >39
* Age >75
* Bili >50
* Albumin low
Severe
* Cardiovascular (inotropes)
* Respiratory(PaO2/FiO2 ratio <300)
* Neurological disturbance
* Renal (oligouria or creatinine >200)
* Hepatic dysfunction (INR>1.5)
* Haematological dysfunction (platelets <100)
Mirizzi syndrome
- Csendes (pronounce ~sen dez) classification
- Cholecystobiliary fistula
- Type I: No fistula (compression)
- Type II: 1/3 CHD
- Type III: 2/3 CHD
- Type IV: 3/3 CHD
- Cholecystoenteric fistula
- Type V
- Treatment:
- Treat the sepsis, CrRISP principles, IVABx, biliary drainage ERCP/PTC preoperatively
- Depends on type
- Type I:
- Partial or total cholecystectomy, either laparoscopic or open. Common bile duct exploration is typically not required.
- Type II:
- Cholecystectomy plus closure of the fistula,
- Either by suture repair with absorbable material
- T tube placement
- Or choledochoplasty with the remnant gallbladder
- Type III:
- Will need some degree of reconstruction
- Choledochoplasty or bilioenteric anastomosis (choledochoduodenostomy, cholecystoduodenostomy, or choledochojejunostomy) depending on the size of the fistula. Suture of the fistula is not indicated.
- Type IV:
- Bilioenteric anastomosis, typically choledochojejunostomy, is preferred because the entire wall of the common bile duct has been destroyed.
TNM staging colorectal
T; depth of tumour invasion
T1; into submucosa
T2; into muscularis propria
T3; through muscularis propria into surrounding pericolic tissues
T4a; penetrates through the adventitia (retroperitoneal) or visceral peritoneum/serosa (<-same thing)
T4b; into surrounding organs or structure
–
N0
N1; 1-3
N2; 4+
–
M0
M1; distant site or peritoneal surface
Risk of lymph node metastasis in malignant colorectal polyp
- Haggit classification
- Level of invasion into a pedunculated polyp
- Sessile polyps are level 4
- Risk of LN metastasis
- Level1-3: very low
- Level 4 only: 12-25% (need resection)
- Kikuchi level (see diagram below)
- Used for sessile polyps
- Submucosa divided up into thirds (sm1,2,3)
- SM1: 2%
- SM2: 8%
- SM3: 28%
- Note above [2 + 8 = 28] for Kikuchi & Level 4 is the same as Kikuchi, so it depends, but is up to 28%
Scoring tool for severity of lower GI bleed
Oakland score
Recommended by the british gastro and colorectal surgeons
Hydradenitis suppurativa - classification
The Hurley system, the most widely used assessment tool, describes three clinical stages.
Stage I: solitary or multiple isolated abscess formation without sinus tracts or scarring.
Stage II: Recurrent abscesses, single or multiple widely spaced lesions, with sinus tract formation.
Stage III: Diffuse involvement of an area with multiple interconnected sinus tracts and abscesses.
Le Forte fractures
- Must have pterygoid fracture to be a le fort fracture
- 3 is floating midface
Types
• 1:
o Separation of alveolar process from body of maxilla
o Fracture extends to anterolateral margin of nasal fossa
• 2:
o Pyramid shape, teeth being the base and nasofrontal suture the apex
o Cross inferior orbital rim, orbital floor and medial orbital wall
o Anterior and lateral walls of the maxillary sinuses fractures
• 3:
o Separation of the bones of the face from the skull
o Upper posterior maxillary sinuses are fractured along with zygomatic arch, lateral orbital wall and lateral orbital rim
o Fracture at junction of frontal bone and greater wing of the sphenoid, and across the nasofronatal suture
Neck zones
AAST pancreatic injury
1: mild contusion or laceration (not involving duct)
2: major contusion or laceration (not involving duct)
3: transection of the distal* duct
4: transection of the proximal* duct or ampulla
5: massive disruption of the pancreatic head
* proximal/distal to the SMV crossing
AAST aortic injury
AAST liver injury
AAST spleen injury
AAST duodenum
AAST SB injury
AAST renal injury
Pelvic fracture grading (2 systems)
Mechanism = Young & Burgess
Stability = Tile
Urethral injury AAST
Endoscopic grading of oesophagitis
- Oesophagitis LA classification
- Is the patch confined to the top of mucosal folds (the longitudinal ridges of mucosa)?
- Yes – A or B
- Is the longest patch longer than 5mm?
- No – A
- Yes – B
- No - C or D
- Is the patch greater than 75% of the circumference of the oesophagus?
- No – C
- Yes – D
- A <5mm but confined to top of mucosal fold
- B >5mm but confined to top of mucosal fold
- C Not confined to the top of mucosal fold but <75% circumference
- D Not confined to mucosal fold and >75% circumference
Hiatus hernia classifications
- 1; sliding hiatus hernia, cardia and GOJ
- 2; rare, true paraoesophageal hernia, GOJ remains intraabdominal but fundus herniates
- 3; 1+2, GOJ and cardia into thorax + fundus
- 4; Other organs in the sac
- Giant hiatus hernia; type 3 or 4, at least half stomach in the thorax or hiatus >5cm
Classification of acute gastric volvulus
- Classification
- Oranoaxial (adults with HH)
- Stomach rotates around a line drawn along the longitudinal axis from the GOJ to pylorus, associated with strangulation
- Mesentericoaxial (congential HH)
- Stomach rotates around a transverse axis, a line drawn across the mid lesser to mid greater curve, associated with obstructive symptoms
Endoscopic grading of Barretts
- Endoscopic appearance
- Prague classification
- Seattle protocol
- 4 quadrants, 2cm intervals if no previous dysplasia,
- if dysplasia then 1cm intervals, any dodgy bits then do targeted as well
Grading of caustic oesophageal injury
How to classify location of gastroesophageal junction tumours?
- Siewert classification (GOJ tumour) (5cm +/-, one is 1 above, 2 is to 2 below, 3 is from 2 below)
- 1; Lower oesophagus 1-5cm from GOJ, may infiltrate the GOJ from above
- 2; AT the GOJ, cannot extend >2cm into the cardia of stomach
- 3; is a gastric cancer, 2-5cm below the GOJ and infiltrates the GOJ from below
TNM 8th staging for oesophageal cancer adenocarcinoma
T4a: pericardium, pleura, peritoneum, azygos vein, diaphragm
T4b: other structures; i.e. aorta, airway, vertebrae
endoscopy bleeding ulcer
- F1a or b (active bleeding) - combination of adrenaline + secondary measure (clip or cautery)
- F2a (visible vessel) - treat with or without adrenaline
- F2b (adherent clot) - remove the clot
- F2c or 3 (pigmented spot or clean base) - no treatment needed
classification on gastric cancer macro/microscopic
Macroscopic
- 2 types
- Paris classification (see picture)
- Early classifications
- Protruding, non protruding or excavated types
- Boreman classification
- Advanced lesions T2+
- 5 different types
- 1 protruded, polypoidal
- 2 ulcerated with elevated borders
- 3 ulcerated with infiltrating margins
- 4 diffusely infiltrating
- 5 not fitting
Microscopic
- WHO classification of adenocarcinoma
- Histopathological subtypes
- Tubular (intestinal)
- Papillary (intestinal)
- Mucinous
- Signet ring (diffuse)
- Mixed
- Lauren Classification of adenocarcinoma
- Intestinal or diffuse – pathologically different but same treatment
- Intestinal
- Mass forming
- Environmental sporadic tumour
- Well differentiated
- More liver metastasis risk
- Diffuse
- Familial and CDH1 gastric cancer
- More ulcerating and diffuse
- Doesn’t form a mass, infiltrative
- Linitis plastica, non distendable stomach
- Loss of e Cadherin molecules (similar to lobular breast cancer)
- More prone to peritoneal disease
NM 8th staging for gastric cancer
- Insitu
- Intraepithelial
- Not through LP
- T1
- A: LP or MM
- B; into submucosa
- T2
- Muscularis propria
- T3
- Subserosa without the visceral peritoneum
- T4
- Perforating serosa or into surrounding structures
- N
- N1: 1-2 regional
- N2: 3-6 regional
- N3: 7+ regional
- N most important
- Regional =
- Perigastric nodes
- L gastric, common hepatic, coeliac trunk, splenic hilum and splenic, hepatoduodenal nodes
- M
- Distant mets 1 or 0
- Positive peritoneal cytology and omental seeding is classified as metastatic disease (M1)
Complications of sleeve gastrectomy (specific to sleeve)
- Sleeve leak
- Type 1 = phlegmon
- Type 2 = abscess
- 2a at staple line
- 2b lateral away from staple line
- Type 3 = free leak/peritonitis
- Type 4 = chronic fistula
- Stenosis
- Reflux
- Sleeve dilation
GIST TNM 8th staging
- AJCC
- T = Size
- T1 <2cm
- T2 2-<5
- T3 5-10cm
- T4 10cm+
- N1: regional nodes
- M1:
- Distant LNs
- Distant Mets
- Mitotic rate
- Low <5 per 50 HPFs
- High >5 per 50 HPFs
Oncological lymph node levels of neck
- 1a: submental:
- Medial border = midline
- Inferior border = hyoid bone
- Posterior border = anterior belly of digastrics
- 1b: submandibular:
- Anterior border = anterior belly of digastric
- Posterior border = posterior belly of digastric
- Superior border = inferior border of the mandible
- 2: upper jugular group:
- Superior border = base of skull
- Inferior border = line drawn from the hyoid bone
- Medial border = the lateral border of the sternohyoid muscle
- Posterior border = the posterior border of the SCM
- 2a/b is divided by the spinal accessory nerve (which pierces the SCM)
- 3: middle jugular group:
- Superior border = hyoid bone line
- Inferior border = cricoid cartilage
- Anterior border = anterior border of the SCM
- Posterior border = posterior border of the SCM
- 4: lower jugular group:
- Superior border = cricoid cartilage
- Inferior border = clavicle
- Medial border = medial border of the SCM
- Lateral border = lateral border of the SCM
- 5: posterior triangle of the neck:
- Anterior border = lateral border of the SCM
- Posterior border = anterior border of the trapezius
- Inferior border = clavicle
- 6: anterior/central lymph nodes:
- Pre and para tracheal lymph nodes, precricoid node (delphini node), perithyroid nodes
- Lateral borders = carotid sheath
- Superior border = hyoid bone
- Inferior border = sternal notch
- 7 = superior mediastinum
Melanoma TNM
Salivary gland TNM staging
TNM staging thyroid cancer
T
- T1 <2cm
- T1a <1cm
- T1b 1-2cm
- T2 2-4cm
- T3 >4cm or into strap muscles
- T3a >4cm but limited to thyroid
- T3b into strap muscles (any size)
- T4 into surrounding tissues beyond strap muscles
- T4a invasion into surround tissues including RLNx
- T4b invasion into prevertebral fascia, carotid, mediastinal vessels
N
- N1a Level VI orVII
- N1b I-V or retropharyngeal
Differentiated AJCC 8th edition staging
- Because the prognosis is so good for young people the staging is age based
- <55 TxNxM0 = stage 1, TxNxM1 = stage 2
- >55
- Stage 1: T1-2N0M0
- Stage 2: T1-3 N1
- Stage 3: T4a NxM0
- Stage 4a: T4b NxM0
- Stage 4b: TxNx M1
Adrenal TNM
TNM
T1 :<5cm, no invasion
T2: >5cm, no invasion
T3: any size, local invasion
T4: any size, invading adjacent organs
N1: node positive
M1: distant metastasis
-
TIRADS (ACR Thyroid Imaging, Reporting and Data System)
- Composition
* 0 = cystic or spongiform
* 1 = mixed (solid & cystic)
* 2 = solid (or nearly completely solid)- Echogenicity
* 0 = anechoic
* 1 = iso/hyperechoic
* 2 = hypoechoic
* 3 = very hypoechoic
* 3. Shape- 0 = wider than tall
- 3 = taller than wide
* 4. Margin - 0 = smooth/ill defined
- 2 = lobulated/irregular
- 3 = extrathyroidal extension
* 5. Echogenic foci - 0 = none or large comet tail artifact
- 1 = macrocalcifications (can be associated with medullary)
- 2 = peripheral rim calcification (eggshell, can be seen in malignancy)
- 3 = punctate echogenic foci (microcalcifications) (psammoma bodies)
* Total - 0 = TIRADS 1 = Benign
- 2 = TIRADS 2 = Not suspicious
- 3 = TIRADS 3 = Mildly suspicious
- 4-6 = TIRADS 4 = Moderately suspicious
- 7+ = TIRADS 5 = Highly suspicious
- Echogenicity
- Composition
- Remember
- Cancer is more _hypo_echoic (solid component – obviously a hypoechoic cyst is good)
- Hyperechoic is good
- Intact rim calcification is ok, invasion through rim is bad, internal microcalcification bad
ATA nodule USS patterns and risk of malignancy
Bethesda score for thyroid FNA
1: Non diagnostic
- Need 3+ clusters with 20+ cells in each
- 1-4% risk of malignancy
2: Benign
- 0-3% risk of malignancy
- Should we the most common category
- Colloid, hyperplastic adenoma, thyroiditis
- Repeat USS 12 months
3: Atypia of undetermined significance, follicular lesion of undetermined significance
- 5-15% risk of malignancy (should be a minor of results overall)
- Close follow up at 3 months with FNA or if other high risk features maybe repeat sooner or diagnostic hemithyroidectomy
4: Follicular neoplasm or suspicion of follicular neoplasm
- 20-30% risk of malignancy
- Is there capsular invasion or vascular invasion – can only tell on histology
- Typically management is diagnostic hemithyroidectomy
5: Suspicious for malignancy
- 60-75% risk of malignancy
- Usually papillary thyroid cancer
- Nuclear inclusions/grooves, orphan Annie eyes, psammoma bodies
- Surgical option depends on size, lateral neck involvement
6: Malignant
* 97-99% risk of malignancy
Renal trauma grading
Duodenal truama grading
Duodenal truama grading
Splenic injury AAST grading
Grades of haemorrhagic shock
Approximate blood loss = tennis scores
In grade 1, only the BE will be effected
In grade 2, HR and Pulse pressure (2 things) will be start going off
In grade 3, everything is going off
In grade 4, you are dying
Aortic injury AAST grading
1; intimal tear
2; contained mural haematoma
3; pseudoaneurysm
4; rupture
