Workup/Staging Flashcards
What components of the Hx are important in assessing a pt with dysphagia?
Appropriate parts of the Hx in assessing dysphagia Sx include onset, duration, severity (dysphagia to normal solids, soft solids, liquids, or aphagia), weight loss, other Sx of retrosternal pain, bone pain, cough, hoarseness, Hx of smoking/alcohol, GERD, and Hx of prior H&N cancer.
What should be included in the workup of suspected esophageal cancer?
Suspected esophageal cancer workup: H&P, labs (LFTs, alk phos, Cr), esophagogastroduodenoscopy with Bx. If cancer, then chest/abdominal ± pelvic CT w/ contrast; if not M1, then PET/CT, EUS + FNA for nodal sampling for tumor and node staging, bronchoscopy (if tumor at or above carina to r/o tracheoesophageal fistula), assign Siewert category, nutritional assessment, smoking cessation, and screen for family Hx. Laparoscopic staging is done in some institutions, with reports of upstaging and sparing the morbidity of more aggressive Tx in 10%–15% of cases. If M1, testing for MSI-H/dMMR including HER2 and PD-L1 if adeno (NCCN 2018).
To what anatomic extent is esophageal cancer being defined?
Esophageal cancer is defined as below hypopharynx (15 cm from the incisors) to the EGJ and the proximal 2 cm of the stomach. A tumor epicenter ≥2 cm distal to the EGJ, even if it involves EGJ, is considered stomach cancer.
What is different about the AJCC 8th edition (2017) of the TNM staging for esophageal cancer?
The AJCC 8th edition redefines tumor location based on location of epicenter rather than proximal border, adds unique tumor, nodes, & metastases clinical staging (cTNM) and tumor, nodes, & metastases pathologic staging post-neoadjuvant therapy (ypTNM) prognostic stage groupings, incorporates pT1a and pT1b into stage grouping, and separates pT2–T3 into pT2 and pT3 for stage grouping.
Tis: high-grade dysplasia and CIS
T1a: invades lamina propria or muscularis mucosae
T1b: invades submucosa
T2: invades muscularis propria
T3: invades adventitia (Note: No serosal layer.)
T4a: invades pleura, pericardium, azygos vein, diaphragm, or peritoneum
T4b: invades other adjacent organs (aorta, vertebral body, airway)
Nx: regional nodes cannot be assessed
N0: no regional node mets
N1: 1–2 regional LN mets, including nodes previously labeled as M1a in AJCC 6th*
N2: 3–6 regional LN mets, including nodes previously labeled as M1a*
N3: ≥7 regional LN mets, including nodes previously labeled as M1a*
*M1a (differ by site): upper T includes Cx LN mets; midthoracic is not applicable; lower T/GE junction includes celiac LN mets. (Note: M1a designation is no longer recognized in the 7th or 8th editions.)
M1: DM (retroperitoneal, P-A LN, lung, liver, bone, etc.)
What are the AJCC 8th edition (2017) stage groupings for esophageal cancer, and what new feature has been added?
Stage IV has been separated to IVA and IVB and there is no longer IIIC; cTNM and ypTNM groups staging has been added for SCC and adeno:
Staging for SCC
cTNM
Stage 0: TisN0M0
Stage I: T1N0–1M0
Stage II: T2N0–1M0; T3N0M0
Stage III: T3N1M0; T1–3N2M0
Stage IVA: T4 or N3
Stage IVB: M1
Tumor, Nodes, & Metastases pathologic staging (pTNM) (Location is “Any” unless specified)
Stage 0: TisN0M0, N/A
Stage IA: T1aN0M0, G1/GX
Stage IB: T1aN0M0, G2–3; T1bN0M0, any G; T2N0M0, G1
Stage IIA: T2N0M0, G2–3/GX; T3N0M0, any G, Lower; T3N0M0, G1, Upper/Middle
Stage IIB: T3N0M0, G2–3, Upper/Middle; T3N0M0, GX; T1N1M0, any G
Stage IIIA: T1N2M0, any G; T2N1M0, any G
Stage IIIB: T2N2M0, any G; T3N1–2M0, any G; T4aN0–1M0, any G
Stage IVA: T4aN2M0, any G; T4b or N3, any G
Stage IVB: M1
ypTNM
Stage I: T0–2N0M0
Stage II: T3N0M0
Stage IIIA: T0–2N1M0
Stage IIIB: T3N1M0; T0–3N2M0; T4aN0M0
Stage IVA: T4aN1–2/NXM0; T4b or N3
Stage IVB: M1
Staging for Adeno:
cTNM
Stage 0: TisN0M0
Stage I: T1N0M0
Stage IIA: T1N1M0
Stage IIB: T2N0M0
Stage III: T2N1M0; T3N0–1M0; T4aN0–1M0
Stage IVA: T4b or N2–3
Stage IVB: M1
pTNM
Stage 0: TisN0M0, N/A
Stage IA: T1aN0M0, G1/GX
Stage IB: T1aN0M0, G2; T1bN0M0, G1–2/GX
Stage IC: T1N0M0, G3; T2N0M0, G1–2
Stage IIA: T2N0M0, G3/GX;
Stage IIB: T1N1M0, any G; T3N0M0, any G
Stage IIIA: T1N2M0, any G; T2N1M0, any G
Stage IIIB: T2N2M0, any G; T3N1–2M0, any G; T4aN0–1M0, any G
Stage IVA: T4aN2M0, any G; T4b or N3, any G
Stage IVB: M1
ypTNM
Stage I: T0–2N0M0
Stage II: T3N0M0
Stage IIIA: T0–2N1M0
Stage IIIB: T3N1M0; T0–3N2M0; T4aN0M0
Stage IVA: T4aN1–2/NXM0; T4b or N3
Stage IVB: M1
Why does SCC have a separate stage grouping from Adeno?
Tumor location is accounted for in the stage grouping for SCC, with lower regions having better prognosis c/w upper and middle regions.
