Oncology Overview: Cancer Staging Primer

Question 1

A diagnosis of cancer must be based upon….

Answer 1

Pathology: usuaully based upon a biopsy obtained EARLY in the evaluation.

Question 2

What are the basics of cytology?

Answer 2

Cytology: cellular morphology
▪ Aspiration of tumor (fine needle aspiration)
▪ Removal and analysis of abnormal fluid (eg: pleural
fluid, ascites)
▪ Review and analysis of normal fluid (e.g. CSF)
▪ Washings/lavage with saline (e.g., bladder, lung)

Question 3

What are the pros and cons of cytology?

Answer 3

• Advantages: Less invasive; may distinguish malignancy vs. benign disease
  ▪ Disadvantage: CELLULAR samples only (not tissue), so may limit further classification

Question 4

What are the basics of pathologic sampling?

Answer 4

Pathology: tissue morphology

• core needle biopsy
• surgical biopsy
• excisional biopsy

Question 5

What are the pros and cons of pathologic sampling?

Answer 5

Pros: TISSUE collection allows for further classification may be determined
▪ Determination of invasiveness
▪ Evaluation of malignant tissue in relationship to
normal tissue

Cons: more invasive

Question 6

Name the six types of neoplasm

Answer 6

Carcinoma
Melanoma
Lymphoma
Sarcoma
Germ Cell
CNS Tumors

Question 7

Name the 7 types of Carcinoma

Answer 7

Adenocarcinoma (most common)
Squamous Cell (most common)
Neuroendocrine
Hepatocellular
Thyroid
Renal Cell
Other

Question 8

What 3 things do you consider when trying to find out if the cancer is primary or metastatic?

Answer 8

▪ Clinical presentation
▪ Location and number of tumor(s)
▪ Pattern of metastatic spread

Question 9

What 3 factors might you consider when deciding what/where to biopsy?

Answer 9

• Most accessible site
  ▪ Site most likely to yield diagnostic results
  ▪ Site most likely to influence treatment

Question 10

What is cancer staging?

Answer 10

Determining:

• HOW MUCH cancer is in the body
• WHERE the cancer is located.

Describes SEVERITY of the cancer based on:

• Characteristics of the primary tumor
• Extent of the SPREAD around the body.

Question 11

Why do cancer staging?

Answer 11

▪ Indication of PROGNOSIS
▪ Establish the best TREATMENT PLAN
▪ Evaluate EFFECTIVENESS of treatment
▪ COMMUNICATE “the same language” to other clinicians
▪ Provide standardization for valid RESEARCH

Question 12

What are the three parameters of Clinical Staging?

Answer 12

T =Tumor: The extent of the primary tumor

N =Nodes: The absence or presence and extent of REGIONAL lymph node metastasis

M =Mets: The absence or presence of distant METASTASIS

Question 13

Tumor (T) Stage: Which types of cancer are staged by SIZE and which are staged by DEPTH of penetration?

Answer 13

Size: Lung, Breast, Ovarian, Prostate
Depth: Bowel, Bladder, Melanoma

Question 14

Nodal (N) Stage: What do you consider when assigning the nodal stage?

Answer 14

Based on number and location of regional nodes
(distant node is metastasis via hematologic spread)

Nodes can be assessed by

• Clinical evaluation if PALPABLE
• Imaging for size and appearance (CT,MRI,U/S)
• Biopsy or aspiration (IF it will affect treatment!)
• Surgically (at time of primary tumor resection)

Question 15

Metastasis (M) Stage: What do you consider when assigning the metastasis stage?

Answer 15

• History and PE
• Patterns of metastasis
• Consensus guidelines about radiologic evaluation
• Surgical evaluation is rarely used for metastatic staging

Question 16

What do the staging numbers signify for Primary Tumor (T)

Answer 16

TX Primary tumor cannot be evaluated
T0 No evidence of a primary tumor
Tis Carcinoma In Situ
T1, T2, T3, T4 Increasing size and extent of tumor

Question 17

What do the staging numbers signify for Regional Lymph Nodes? (N)

Answer 17

NX Regional lymph nodes cannot be evaluated
N0 No evidence of disease in lymph nodes
N1, N2, N3 Increasing disease involvement in regional lymph nodes

Question 18

What do the staging numbers signify for Distant Metastasis (M)?

Answer 18

MX Distant metastasis cannot be evaluated
M0 No evidence of metastasis
M1 Distant metastasis

Question 19

What is the difference between clinical and pathological staging?

Answer 19

• Clinical Stage: before starting therapy or having surgery
  ▪ Pathological Stage: surgical exploration and tissue histology.
  ▪ Both should be recorded if possible.

Question 20

Based on TNM score, how do you decide whether the cancer is Stage I, II, III or IV?

Answer 20

Depends on the cancer

Question 21

If a patient has M1 cancer, what stages are possible?

Answer 21

Stage IV only

Question 22

Can a patient have N1 and have Stage I cancer?

Answer 22

No. Regardless of cancer, Stage I must have N=0

Question 23

What is the basis of histopathologic grading?

Answer 23

Histology and morphology of cancerous cells seen with a microscope

Question 24

Which is more important: grading or staging?

Answer 24

Equally important: a small but aggressive cancer can be more dangerous than a large, indolent cancer.

Question 25

What are Grades GX through G4?

Answer 25

GX: Grade cannot be evaluated
G1: Well-differentiated
G2: Moderately differentiated
G3: Poorly differentiated
G4: Very poorly differentiated/Anaplastic

Question 26

What is the difference between well-differentiated cells and poorly-differentiated cells?

Answer 26

Well-differentiated: closely resemble the normal cells in architecture (and less aggressive)

Poorly-differentiated: do not resemble the normal cells (more aggressive)

Question 27

What are other kinds of cancer qualifiers in considering prognosis and therapies besides Stage and Grade?

Answer 27

Age
Serum Markers (eg: PSA, CEA-125)
Tumor Genetics (eg: EGFA expression in lung cancer)
Patient Genetics (eg: BRCA)

Question 28

If the patient has a stage I cancer, what is the

effective treatment most likely to be?

Answer 28

Depends on the location: surgical resection (because it is self-contained) with or without chemo or radiation

Question 29

Why are biopsies of tissue so important for

determining cancer treatment?

Answer 29

Staging, histology/grading, treatment, gene therapy

Question 30

At which stage(s) of cancer is radiation therapy the

most likely to be useful?

Answer 30

When it is still localized, so stages I, II and III.

Question 31

If the patient has a stage IV cancer, which treatment

is most likely to be effective?

Answer 31

Chemo and/or radiation to shrink the tumor, then resection if possible