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FRACS > Staging > Flashcards

Staging Flashcards

1
Q

Breast:

  • Staging
  • Key decision points
A

Tumour:
Tis = carcinoma in situ

T1a = <5mm
T1b = 5-10mm
T1c = 10-20mm

T2 = 20 - 50mm

T3 = >50mm

T4a = invades skin
T4b = invades chest wall (not just pec)
T4c = invades both
T4d = inflammatory breast ca

Nodes
N1 = 1-3 nodes on path, mobile palpable nodes clinically

N2 = 4-9 nodes on path
N2a = fixed axillary nodes clinically
N2b = internal mammary
N3 = 10+ nodes on path
N3a = infraclavicular nodes +/- axillary
N3b = internal mammary and axillary
N3c = supraclavicular nodes +/- any others

Up to T2N1 is considered early stage
T3N0 or worse is late/locally advanced

Stage 1
• T1 NO = IA
• T1 N1micro = IB

Stage 2
•	T1 N1 = IIA
•	T2 N0 = IIA
•	T2 N1 = IIB
•	T3 N0 = IIB
Stage 3
•	T0-2, N2 = IIIA
•	T3, N1-2 = IIIA
•	T4, N1-2 = IIIB
•	Any T, N3 = IIIC

Stage 4
• Mets

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2
Q

Oesophageal

A

Tumour:
T1a = mucosal invasion
T1b = submucosa invasion

T2 = muscularis

T3 = adventitia

T4a = invades resectable adjacent organs (diaphragm, pleura
T4b = invades unresectable adjacent organs (airways, aorta)

Nodes:
N1 = 1-2 nodes
N2 = 3-6
N3 = 7 or more

Stage 2 or above -> neoadj
Stage 2 = T3 or greater, or Tany, node +
Locally advanced (T3+) or node positive tumours are candidates for neoadjuvant treatment (CROSS CRTx or FLOT periop CTx)

T1a tumours may be managed with EMR

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3
Q

Gastric

A 
Tumour:
T1a = mucosal (lamina propria or muscularis mucosae)
T1b = submucosa
T2 = muscularis
T3 = subserosa
T4a = perforates serosa
T4b = invades adjacent organs
N1 = 1-2 nodes
N2 = 3-6
N3a = 7-15
N3b = 16+

Stage
IA = T1, N0, MO
IB = T2 N0 or T1 N1 (always adds up to 2)

IIA = T3 N0 or T2 N1 or T1 N2   (always adds up to 3)
IIB = T4a N0 or T3 N1 or T2 N2 (adds up to 4)

IIIA = T4a N1 or T3 N2 or T2 N3 (adds up to 5)

IIIB = T4b N0/1 or T4a N2 or T3 N3

IIIC = T4b N2/3 or T4a N3

IV = M1

Early gastric ca = T1a or b, N any
T1a may be treated with EMR
T2 and above -> neoadj chemo (FLOT or MAGIC)

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4
Q

Melanoma

A

Tumour:
Tis = in situ
T1a = <0.8mm without ulceration
T1b = <0.8mm with ulceration or 0.8-1mm

T2a = 1-2mm without
T2b = 1-2mm with
T3a = 2-4mm without
T3b = 2-4mm with
T4a = >4mm without
T4b = >4mm with
Nodes:
N1 = 1 node
a = on histo
b = palpable
c = in-transit met
N2 = 2-3 nodes
a = on histo
b = palpable
c = includes in-transit met
N3 = 4 + nodes
a = on histo
b = palpable
c = includes in-transit met
M1a = skin/subcut/distant nodes
M1b = lung
M1c = other viscera
M1d = CNS

Stage 1: Tis to T2a, N0
Stage 2: T2b – T4, N0
Stage 3: any positive nodes
Stage 4: mets

Decision points:

  • Do SNB for >0.75mm thick if no clinical nodes
  • Adjuvant therapy for N1b or greater disease (not funded in NZ)
  • Stage 3 unresectable or stage 4 is funded for immunotherapy in NZ
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5
Q

Pancreas

  • Staging
  • Define resectable, borderline resectable and unresectable
A

Tumour
T1a = <5mm
T1b = 5-10mm
T1c = 10-20mm (like breast)

T2 = >20mm

T3 = extends beyond pancreas without involvement of coeliac axis or SMA (ie still resectable)

T4 = involves coeliac trunk or SMA (unresectable)

Nodes:
N1 = 1-3
N2 = 4+

Staging:

  • Stage 1 = T1-2, N0 (small tumour, no nodes)
  • Stage 2 = T3 N0, T1-2 N1 (bad, resectable tumour or nodes)
  • Stage 3 = T4 Nany (unresectable, no mets)
  • Stage 4 = M1

Resectability
- Controversial, changing

Unresectable:
•	>180 degrees SMA/Coeliac contact
•	Tumour contact with first jej branch of SMA
•	Distant nodal/visceral mets
•	Unreconstructable SMV/PV

Borderline:
• <180 degree SMA/coeliac contact
• Reconstructable SMV/PV
• Tumour contact with CHA, IVC, aberrant arteries

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6
Q

Gallbladder

A

Tumour
T1a = lamina propria
T1b = muscular layer

T2a = invades perimuscular connective tissue on serosal side
T2b = invades perimuscular connective tissue on liver side

T3 = perforates serosa and/or invades liver and/or one other organ

T4 = invades 2 or more extrahepatic organs or invades main portal vein or hepatic artery

Nodes
N1 = 1-3 nodes
N2 = 4+

Stages
I = T1
II = T2
IIIA = T3
IIIB = T1-3, N1
IVA = T4, N0-1
IVB = N2 or M1

Decision points:
T1a is cured by cholecystectomy, T1b and above requires extended chole and portal node dissection

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7
Q

Intrahepatic cholangio

  • what proportion of all cholangios?
  • Staging
A

5-10%

Tumour
T1a = <5cm
T1b = >5cm (no vasc invasion)

T2a = solid tumour with vasc invasion
T2b = multiple tumours with or without vasc invasion

T3 = perforates visceral peritoneum

T4 = invades extrahepatic structures

Nodes
N1 = any regional nodes (hilar, portocaval, inferior phrenic, gastrohepatic)

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8
Q

Hilar cholangio

  • what proportion?
  • classification
  • staging
A

50% aka Klatskin

Bismuth-Corlette:
1 = below confluence
2 = at confluence
3a = right hepatic duct
3b = left hepatic duct
4 = both hepatic ducts
5 = stricture at junction of CBD and cystic duct

Tumour
T1 = confined to bile duct

T2a = invades through wall of bile duct
T2b = invades liver

T3 = invades unilateral portal vein or hepatic artery branch

T4 = invades main vessels or second-order biliary radicles

Nodes
N1 = 1-3
N2 = 4+

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9
Q

Distal cholangio

A 
Tumour
T1 = invades <5mm into bile duct wall
T2 = invades 5-12mm into bile duct wall
T3 = invades >12mm
T4 = invades coeliac axis, CHA, SMA

Nodes
N1 = 1-3 nodes
N2 = 4+

Manage like pancreatic head cancer - resect if resectable!

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10
Q

Colon

A 
Tumour
T1 = submucosa
T2 = muscularis
T3 = subserosa
T4 = perforates peritoneum or invades adjacent structures

N1 = 1-3 nodes

  • N1a = 1
  • N1b = 2-3
  • N1c = extranodal deposit

N2 = 4+

  • N2a = 4-6
  • N2b = 7+
M1a = mets in one organ
M1b = mets in 2+ organs

Stage 1 = T1-2 N0
Stage 2 = T3-4 N0
Stage 3 = nodes
Stage 4 = mets

Decision points:

  • Stage 3 gets adjuvant chemo
  • Stage 2 gets adjuvant chemo if high risk features
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11
Q

Rectum

A 
Tumour
T1 = submucosa
T2 = muscularis
T3 = perirectal fat
T4 = invades surrounding structures
N1 = 1-3 nodes
N2 = 4+
Decision points
Give neoadj rads or chemorads for:
- T3-4
- N1
- CRM threatened

(basically stage 2 and above disease)

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12
Q

GIST

A 
Tumour
T1 = <2cm
T2 = 2-5cm
T3 = >5cm
T4 = >10cm
(a bit like breast ca)
N1 = nodes
M1 = mets

Fletcher criteria stratifies into risk category on basis of size and mitotic rate
V. low risk = <2cm, <5 mitoses per HPF
Low = 2-5cm, <5
Intermediate = <5cm, 6-10 mitoses OR 5-10cm, <5 mitoses
High risk = >5cm, >5 mitoses OR >10cm, any mitoses, or any size, >10 mitoses

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13
Q

NET

A

Well-differentiated NETs vs Poorly-differentiated NECs

NETs:
Grade 1 = <2 mitoses, Ki67 <3%
Grade 2 = 2-20 mitoses, Ki67 3-20%
Grade 3 = >20 mitoses, Ki67 >20%

NECs:
All high grade

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14
Q

Thyroid

A

Tumour
T1 = <2cm
T2 = 2-4cm
T3 = >4cm or invades straps

T4 = invades beyond straps

  • T4a = invades adjacent organs or subcut soft tissue
  • T4b = invades spine or encased great vessels

Nodes
N1a = level 6 or 7 nodes
N1b = any other nodes

Mets
M1 = mets

Stage - depends on age!
<55 y/o - M0 = stage 1, M1 = stage 2

>55 y/o
Stage 1 = T1-2 N0
Stage 2 = T1-3, N1
Stage 3 = T4a N0
Stage 4a = T4b
Stage 4b = M1
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15
Q

Adrenal

A 
Tumour
T1 = <5cm
T2 = >5cm
T3 = invades local tissues
T4 = invades renal vein or IVC
N1 = nodes
M1 = mets

Stage 1: T1 N0 M0
Stage 2: T2 N0 M0
Stage 3: Tany N1, T3-4 (=local invasion)
Stage 4: distant mets

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16
Q

HCC

  • Staging
  • How to treat?
A

Barcelona Staging system

Stage 0: single tumour <2cm,
Stage A: single tumour >2cm or up to 3 tumours <3cm
Stage B: multiple tumours >3cm or >3 nodules
Stage C: major vessel invasion, N1, M1
Stage D: CP-C

Single tumours (0 or A) -> resect unless liver disease makes transplant a better option
Multiple small tumours -> transplant if patient fit, otherwise RFA
Multiple unresectable tumours -> TACE
Mets -> sorafenib
Poor status or CP C -> palliate

17
Q

Anal cancer

A 
Tumour
T1 = <2cm
T2 = 2-5 cm
T3 = >5cm
T4 = invades adjacent organs 
N1a = inguinal, mesorectal, internal iliac
N1b = external iliac
N1c = external iliac plus any N1a nodes
18
Q

Sarcoma

A 
T1 = <5cm
T2 = >5cm
T3 = 10-15cm
T4 = >15cm

N1 = nodes (rare - usually haem spread)

M1 = mets

Grade (differentiation, mitotic count and necrosis score)
• 1 = score 2-3
• 2 = score 4-5
• 3 = score 6-8

Stage
•	IA = T1, N0, M0, grade 1
•	IB = T2-4, grade 1
•	II = T1, grade 2-3
•	IIIA = T2, grade 2-3
•	IIIB = T3-4, grade 2-3 or Tany, N1, grade any
•	IV = M1

FRACS (14 decks)

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