About Cancer Staging

Below is a great explanation on Cancer Staging from the National Cancer Institute
1. What is staging?
Staging describes the severity of a persons cancer based on the extent of the original
primary! tumor and whether or not cancer has spread in the body. Staging is important for
several reasons"
# Staging helps the doctor plan the appropriate treatment.
# $he stage can be used to estimate the persons prognosis.
# %nowing the stage is important in identifying clinical trials that may be suitable for a
particular patient.
# Staging helps health care providers and researchers exchange information about
patients& it also gives them a common terminology for evaluating the results of clinical trials
and comparing the results of different trials.
Staging is based on 'nowledge of the way cancer progresses. Cancer cells grow and divide
without control or order( and they do not die when they should. )s a result( they often form a
mass of tissue called a tumor. )s the tumor grows( it can invade nearby tissues and organs.
Cancer cells can also brea' away from the tumor and enter the bloodstream or the lymphatic
system. By moving through the bloodstream or lymphatic system( cancer cells can spread
from the primary site to lymph nodes or to other organs( where they may form new tumors.
$he spread of cancer is called metastasis.
*. What are the common elements of staging systems?
Staging systems for cancer have evolved over time. $hey continue to change as scientists
learn more about cancer. Some staging systems cover many types of cancer& others focus
on a particular type. $he common elements considered in most staging systems are as
follows"
# Site of the primary tumor.
# $umor si+e and number of tumors.
# ,ymph node involvement spread of cancer into lymph nodes!.
# Cell type and tumor grade how closely the cancer cells resemble normal tissue cells!.
# $he presence or absence of metastasis.
-. What is the TNM system?
$he $N. system is one of the most widely used staging systems. $his system has been
accepted by the International /nion )gainst Cancer /ICC! and the )merican 0oint
Committee on Cancer )0CC!. .ost medical facilities use the $N. system as their main
method for cancer reporting. 1234( NCIs comprehensive cancer information database( also
uses the $N. system.
$he $N. system is based on the extent of the tumor (T)( the extent of spread to the lymph
nodes(N)( and the presence of distant metastasis (M). ) number is added to each letter to
indicate the si+e or extent of the primary tumor and the extent of cancer spread.
Primary Tumor (T)
$5 1rimary tumor cannot be evaluated
$6 No evidence of primary tumor
$is Carcinoma in situ CIS& abnormal cells are present but
have not spread to neighboring tissue& although not
cancer( CIS may become cancer and is sometimes
called preinvasive cancer!
$1( $*( $-( $7Si+e and8or extent of the primary tumor

Regional Lymph Nodes (N)
N5 9egional lymph nodes cannot be evaluated
N6 No regional lymph node involvement
N1( N*( N- Involvement of regional lymph nodes number of lymph
nodes and8or extent of spread!

istant Metastasis (M)
.5 2istant metastasis cannot be evaluated
.6 No distant metastasis
.1 2istant metastasis is present
:or example( breast cancer classified as $- N* .6 refers to a large tumor that has spread
outside the breast to nearby lymph nodes but not to other parts of the body. 1rostate cancer
$* N6 .6 means that the tumor is located only in the prostate and has not spread to the
lymph nodes or any other part of the body.
:or many cancers( $N. combinations correspond to one of five stages. Criteria for stages
differ for different types of cancer. :or example( bladder cancer $- N6 .6 is stage III(
whereas colon cancer $- N6 .6 is stage II.
Stage efinition
Stage 6 Carcinoma in situ.
Stage I( Stage
II( and Stage
III
;igher numbers indicate more extensive disease" ,arger tumor si+e and8or
spread of the cancer beyond the organ in which it first developed to nearby
lymph nodes and8or organs ad<acent to the location of the primary tumor.
Stage I= $he cancer has spread to another organs!.
7. !re all cancers staged "ith TNM classifications?
.ost types of cancer have $N. designations( but some do not. :or example( cancers of the
brain and spinal cord are staged according to their cell type and grade. 2ifferent staging
systems are also used for many cancers of the blood or bone marrow( such as lymphomas.
$he Ann Arborstaging classification is commonly used to stage lymphomas and has been
adopted by both the )0CC and the /ICC. ;owever( other cancers of the blood or bone
marrow( including most types of leu'emia( do not have a clear>cut staging system. )nother
staging system( developed by theInternational Federation of Gynecology and Obstetrics( is
used to stage cancers of the cervix( uterus( ovary( vagina( and vulva. $his system uses the
$N. format. )dditionally( childhood cancers are staged using either the $N. system or the
staging criteria of the Childrens ?ncology @roup( which conducts pediatric clinical trials.
.any cancer registries( such as NCIs Surveillance( Apidemiology( and And 9esults 1rogram
SAA9!( use summary staging. $his system is used for all types of cancer. It groups cancer
cases into five main categories"
# #n situ" )bnormal cells are present only in the layer of cells in which they developed.
# Locali$ed" Cancer is limited to the organ in which it began( without evidence of
spread.
# Regional" Cancer has spread beyond the primary site to nearby lymph nodes or
organs and tissues.
# istant" Cancer has spread from the primary site to distant organs or distant lymph
nodes.
# %n&no"n" $here is not enough information to determine the stage.
B. What types of tests are used to determine stage?
$he types of tests used for staging depend on the type of cancer. $ests include the following"
# Physical exams are used to gather information about the cancer. $he doctor
examines the body by loo'ing( feeling( and listening for anything unusual. $he physical exam
may show the location and si+e of the tumors! and the spread of the cancer to the lymph
nodes and8or to other organs.
# Imaging studies produce pictures of areas inside the body. $hese studies are
important tools in determining stage. 1rocedures such as x>rays( computed tomography C$!
scans( magnetic resonance imaging .9I! scans( and positron emission tomography 1A$!
scans can show the location of the cancer( the si+e of the tumor( and whether the cancer has
spread.
# Laboratory tests are studies of blood( urine( other fluids( and tissues ta'en from the
body. :or example( tests for liver function and tumor mar'ers substances sometimes found
in increased amounts if cancer is present! can provide information about the cancer.
# Pathology reports may include information about the si+e of the tumor( the growth of
the tumor into other tissues and organs( the type of cancer cells( and the grade of the tumor.
) biopsy may be performed to provide information for the pathology report. Cytology reports
also describe findings from the examination of cells in body fluids.
# Surgical reports tell what is found during surgery. $hese reports describe the si+e
and appearance of the tumor and often include observations about lymph nodes and nearby
organs.
TNM staging system
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The TNM Classification of Malignant Tumours (TNM) is a cancer staging system that
describes the extent of a persons cancer!
T describes the si"e of the original (primary) tumor and #hether it has invaded
nearby tissue,
N describes nearby (regional) lymph nodes that are involved,
M describes distant metastasis (spread of cancer from one part of the body to
another)!
The T$% staging system for all solid tumors #as devised by &ierre 'enoix bet#een
()*+ and (),-, using the si"e and extension of the primary tumor, its lymphatic
involvement, and the presence of metastases to classify the progression of cancer!
.(/
T$% is developed and maintained by the 0nternational 1nion 2gainst 3ancer (1033) to
achieve consensus on one globally recognised standard for classifying the extent of
spread of cancer! The T$% classification is also used by the 2merican Joint 3ommittee
on 3ancer (2J33) and the 0nternational Federation of 4ynecology and 5bstetrics
(F045)! 0n ()67, the 1033 and 2J33 staging systems #ere unified into a single staging
system!
General outline[edit]
%ost of the common tumors have their o#n T$% classification! $ot all tumors have
T$% classifications, e!g!, there is no T$% classification for brain tumors!
The general outline for the T$% classification is belo#! The values in parentheses give a
range of #hat can be used for all cancer types, but not all cancers use this full range!
Mandatory parameters'edit(
T: si"e or direct extent of the primary tumor
o Tx: tumor cannot be evaluated
o Tis: carcinoma in situ
o T8: no signs of tumor
o T(, T-, T+, T*: si"e and9or extension of the primary tumor
N: degree of spread to regional lymph nodes
o $x: lymph nodes cannot be evaluated
o $8: tumor cells absent from regional lymph nodes
o $(: regional lymph node metastasis present: (at some sites: tumor spread
to closest or small number of regional lymph nodes)
o $-: tumor spread to an extent bet#een $( and $+ ($- is not used at all
sites)
o $+: tumor spread to more distant or numerous regional lymph nodes ($+
is not used at all sites)
M: presence of distant metastasis
o %8: no distant metastasis
o %(: metastasis to distant organs (beyond regional lymph nodes)
.-/
The %x designation #as removed from the 7th edition of the 2J3391033 system!
)ther parameters'edit(
G ((;*): the grade of the cancer cells (i!e! they are <lo# grade< if they appear
similar to normal cells, and <high grade< if they appear poorly differentiated)
S (8=+): elevation of serum tumor markers
R (8=-): the completeness of the operation (resection=boundaries free of cancer
cells or not)
L (8=(): invasion into lymphatic vessels
V (8=-): invasion into vein (no, microscopic, macroscopic)
C ((;,): a modifier of the certainty (>uality) of the last mentioned parameter
Prefi* modifiers'edit(
c: stage given by clinical examination of a patient! The c=prefix is implicit in
absence of the p=prefix
p: stage given by pathologic examination of a surgical specimen
y: stage assessed after chemotherapy and9or radiation therapy: in other #ords, the
individual had neoad?uvant therapy!
r: stage for a recurrent tumor in an individual that had some period of time free
from the disease!
a: stage determined at autopsy!
u: stage determined by ultrasonography or endosonography! 3linicians often use
this modifier although it is not an officially defined one
For the T, $ and % parameters exist subclassifications for some cancer=types (e!g! T(a,
Tis, $(i)
Examples[edit]
@mall, lo#=grade cancer, no metastasis, no spread to regional lymph nodes, cancer
completely removed, resection material seen by pathologist: pT( p$8 %8 A8 4(:
this grouping of T, $, and % #ould be considered @tage 0!
Barge, high grade cancer, #ith spread to regional lymph nodes and other organs,
not completely removed, seen by pathologist: pT* p$- %( A( 4+: this grouping
of T, $, and % #ould be considered @tage 0C! %ost @tage 0 tumors are curable:
most @tage 0C tumors are inoperable!
2 biopsy is a medical test commonly performed by a surgeon or an interventional
radiologist involving sampling of cells or tissues for examination! 0t is the medical
removal of tissue from a living sub?ect to determine the presence or extent of a disease!
The tissue is generally examined under a microscope by a pathologist, and can also be
analy"ed chemically! When an entire lump or suspicious area is removed, the procedure is
called an excisional biopsy! When only a sample of tissue is removed #ith preservation of
the histological architecture of the tissueDs cells, the procedure is called an incisional
biopsy or core biopsy! When a sample of tissue or fluid is removed #ith a needle in such
a #ay that cells are removed #ithout preserving the histological architecture of the tissue
cells, the procedure is called a needle aspiration biopsy!
When cancer is suspected, a variety of biopsy techni>ues can be applied! 2n excisional
biopsy is an attempt to remove an entire lesion! When the specimen is evaluated, in
addition to diagnosis, the amount of uninvolved tissue around the lesion, the surgical
margin of the specimen is examined to see if the disease has spread beyond the area
biopsied! <3lear margins< or <negative margins< means that no disease #as found at the
edges of the biopsy specimen! <&ositive margins< means that disease #as found, and a
#ider excision may be needed, depending on the diagnosis!
aspiration +iopsy biopsy in which tissue is obtained by application of suction through a needle
attached to a syringe.
+rush +iopsy biopsy in which cells or tissue are obtained by manipulating tiny brushes against
the tissue or lesion in Cuestion e.g.( through a bronchoscope! at the desired site.
cone +iopsy biopsy in which an inverted cone of tissue is excised( as from the uterine cervix.
core +iopsy ( core needle +iopsy needle biopsy with a large hollow needle that extracts a core
of tissue.
endoscopic +iopsy removal of tissue by appropriate instruments through an endoscope.
e*cisional +iopsy biopsy of tissue removed by surgical cutting.
incisional +iopsy biopsy of a selected portion of a lesion.
needle +iopsy biopsy in which tissue is obtained by puncture of a tumor( the tissue within the
lumen of the needle being detached by rotation( and the needle withdrawn. Called also
percutaneous b.
percutaneous +iopsy needle b.
punch +iopsy biopsy in which tissue is obtained by a punch.
sha,e +iopsy biopsy of a s'in lesion in which the sample is excised using a cut parallel to the
surface of the surrounding s'in.
stereotactic +iopsy biopsy of the brain using stereotactic surgery to locate the biopsy site.
sternal +iopsy biopsy of bone marrow of the sternum removed by puncture or trephining.
Bone marrow examination refers to the pathologic analysis of samples of bone marro#
obtained by bone marrow biopsy (often called a trephine biopsy) and bone marrow
aspiration! Eone marro# examination is used in the diagnosis of a number of conditions,
including leukemia, multiple myeloma, lymphoma, anemia, and pancytopenia! The bone
marro# produces the cellular elements of the blood, including platelets, red blood cells
and #hite blood cells! While much information can be gleaned by testing the blood itself
(dra#n from a vein by phlebotomy), it is sometimes necessary to examine the source of
the blood cells in the bone marro# to obtain more information on hematopoiesis: this is
the role of bone marro# aspiration and biopsy!
Eone marro# samples can be obtained by aspiration and trepine biopsy! @ometimes, a
bone marro# examination #ill include both an aspirate and a biopsy! The aspirate yields
semi=li>uid bone marro#, #hich can be examined by a pathologist under a light
microscope and analy"ed by flo# cytometry, chromosome analysis, or polymerase chain
reaction (&3A)! Fre>uently, a trephine biopsy is also obtained, #hich yields a narro#,
cylindrically shaped solid piece of bone marro#, -mm #ide and - cm long (68 FB),
#hich is examined microscopically (sometimes #ith the aid of immunohistochemistry)
for cellularity and infiltrative processes! 2n aspiration, using a -8 mB syringe, yields
approximately +88 FB of bone marro#!
.(/
2 volume greater than +88 FB is not
recommended, since it may dilute the sample #ith peripheral blood!
.(/
3omparison
!spiration Biopsy
!d"antages
Fast
4ives relative >uantity of
different cell types
4ives material to further study,
e!g! molecular genetics and
flo# cytometry
4ives cell and stroma
constitution
Aepresents all cells
Gxplains cause of <dry tap<
(aspiration gives no blood
cells)
#rawbac$s 'oes not represent all cells @lo# processing
2spiration does not al#ays represent all cells since some such as lymphoma stick to the
trabecula, and #ould thus be missed by a simple aspiration!
Site of procedure[edit]
Eone marro# aspiration and trephine biopsy are usually performed on the back of the
hipbone, or posterior iliac crest! 2n aspirate can also be obtained from the sternum
(breastbone)! For the sternal aspirate, the patient lies on his back, #ith a pillo# under the
shoulder to raise the chest! 2 trephine biopsy should never be performed on the sternum,
due to the risk of in?ury to blood vessels, lungs or the heart! Eone marro# is also perform
from the tibial (shinbone) site in children up to - years of age! @pinous process aspiration
in this site usually B+ = B* is puncture in a lumber puncture position!
Examples of blood and urine tests used to diagnose cancer include:
Complete blood count (CBC). This common blood test measures the amount of various
types of blood cells in a sample of your blood. Blood cancers may be detected using this test if
too many or too few of a type of blood cell or abnormal cells are found. A bone marrow biopsy
may help confrm a diagnosis of a blood cancer.
Urine cytology. Examining a urine sample under a microscope may reveal cancer cells
that could come from the bladder, ureters or kidneys.
Blood protein testing. A test to examine various proteins in your blood (electrophoresis)
can aid in detecting certain abnormal immune system proteins (immunoglobulins) that are
sometimes elevated in people with multiple myeloma. Other tests, such as a bone marrow biopsy,
are used to confrm a suspected diagnosis.
Tumor marker tests. Tumor markers are chemicals made by tumor cells that can be
detected in your blood. But tumor markers are also produced by some normal cells in your body
and levels may be signifcantly elevated in noncancerous conditions. This limits the potential for
tumor marker tests to help in diagnosing cancer.
The best way to use tumor markers in diagnosing cancer hasn't been determined. And the use of
some tumor marker tests is controversial. Examples of tumor markers include prostate-specifc
antigen (PSA) for prostate cancer, cancer antigen 125 (CA 125) for ovarian cancer, calcitonin for
medullary thyroid cancer, alpha-fetoprotein (AFP) for liver cancer and human chorionic
gonadotropin (HCG) for germ cell tumors, such as testicular cancer and ovarian cancer.
Pap smear
1apanicolaou test( pap test @ynecology ) test in which cells from the uterine cervix and
endocervix are sampled( spread on a glass slide( stained( and interpreted by a cytotechnologist
or pathologist based on the Bethesda System )bnormal values $he 1S is the Dgold standardD
method for early detection of ;1=( herpes( trichomonad infections( CIN8dysplasia( cervical C)
)ccuracy 1S interpretation is a sub<ective art based on experience of the screening
cytotechnologist or pathologist& in good labs( error rateEfalse negative is BFE1BF. See Bethesda
System. Cf 1apanicolaou classification.
Mammogram facts
.ammograms are images of the breast tissue produced on 5>ray film.
.ammograms are the most efficient screening method to detect early breast cancer.
.onthly breast self>examination and regular doctorDs examinations are combined
with mammography for optimal breast cancer screening.
)n abnormal mammogram does not necessarily mean that a cancer is present(
?ther tests( including biopsy( may be performed for further clarification of an abnormal
mammogram.
) normal mammogram does not exclude the presence of cancer.
What is a mammogram?
) mammogram is an 5>ray test that produces an image of the inner breast tissue on film.
$his techniCue( called mammography( is used to visuali+e normal and abnormal structures
within the breasts. .ammography( therefore( can help in identifying cysts( calcifications( and
tumors within the breast. It is currently the most efficient screening method to detect early
breast cancer. Breast self>examination BSA! on a monthly basis and examination by a
doctor are still important( but physical examinations typically find breast cancers when they
are much larger than those detected by mammography.
.ammography can be used to discover a small cancer in a curable stage& however( it is not
foolproof. 2epending a womanDs age and other factors( approximately ten to fifteen percent
of breast cancers are not identified by mammography( and these cancers are often found by
physical examination. It is essential for a woman to perform monthly BSA and have a breast
examination by her doctor in addition to the mammogram in order to most effectively screen
for breast cancer.
radioisotope scan-
a two>dimensional representation of the gamma rays emitted by a radioisotope showing its
concentration in a body site( such as the thyroid gland( brain( or 'idney. 9adioisotopes used in
diagnostic scanning may be administered intravenously or orally.
%istopatology (compound of three 4reek #ords: histos <tissue<, pathos
<disease=suffering<, and = =logia) refers to the microscopic examination of tissue in
order to study the manifestations of disease! @pecifically, in clinical medicine,
histopathology refers to the examination of a biopsy or surgical specimen by a
pathologist, after the specimen has been processed and histological sections have been
placed onto glass slides! 0n contrast, cytopathology examines free cells or tissue
fragments!
Histopathological examination of tissues starts #ith surgery, biopsy, or autopsy! The
tissue is removed from the body or plant, and then placed in a fixative #hich stabili"es
the tissues to prevent decay! The most common fixative is formalin ((8I formaldehyde
in #ater)!
The second method of histology processing is called fro"en section processing! 0n this
method, the tissue is fro"en and sliced thinly using a microtome mounted in a belo#=
free"ing refrigeration device called the cryostat! The thin fro"en sections are mounted on
a glass slide, fixed immediately J briefly in li>uid fixative, and stained using the similar
staining techni>ues as traditional #ax embedded sections! The advantages of this method
is rapid processing time, less e>uipment re>uirement, and less need for ventilation in the
laboratory! The disadvantage is the poor >uality of the final slide! 0t is used in intra=
operative pathology for determinations that might help in choosing the next step in
surgery during that surgical session (for example, to preliminarily determine clearness of
the resection margin of a tumor during surgery)!
#ysplasia (from ancient 4reek KLM= dys!, <difficulty< N OPQMRS plasis, <formation<) is a
term used in pathology to refer to an abnormality of development!
.(/
This generally
consists of an expansion of immature cells (such as cells of the ectoderm), #ith a
corresponding decrease in the number and location of mature cells! 'ysplasia is often
indicative of an early neoplastic process! The term dysplasia is typically used #hen the
cellular abnormality is restricted to the originating tissue, as in the case of an early, in!
situ neoplasm!
'ysplasia, in #hich cell maturation and differentiation are delayed, can be contrasted
#ith metaplasia, in #hich cells of one mature, differentiated type are replaced by cells of
another mature, differentiated type!
The terms hip dysplasia and fibrous dysplasia also refer to abnormal development, but at
a more macroscopic level!
&mmunoterapy is a medical term defined as the <treatment of disease by inducing,
enhancing, or suppressing an immune response<!
.(/
0mmunotherapies designed to elicit or
amplify an immune response are classified as acti"ation immunoterapies' #hile
immunotherapies that reduce or suppress are classified as suppression
immunoterapies
The active agents of immunotherapy are collectively called immunomodulators! They are
a diverse array of recombinant, synthetic and natural preparations, often cytokines! @ome
of these substances, such as granulocyte colony=stimulating factor (4=3@F), interferons,
imi>uimod and cellular membrane fractions from bacteria are already licensed for use in
patients! 5thers including 0B=-, 0B=7, 0B=(-, various chemokines, synthetic cytosine
phosphate=guanosine (3p4), oligodeoxynucleotides and glucans are currently being
investigated extensively in clinical and preclinical studies! 0mmunomodulatory regimens
offer an attractive approach as they often have fe#er side effects than existing drugs,
including less potential for creating resistance in microbial diseases!
.-/
!gent (xample
0nterleukins 0B=-, 0B=7, 0B=(-
3ytokines 0nterferons, 4=3@F, 0mi>uimod
3hemokines 33B+, 33B-T, 3U3B7
5ther cytosine phosphate=guanosine, oligodeoxynucleotides, glucans
Cell based &mmunoterapies are proven to be effective for some cancers! 0mmune
effector cells such as lymphocytes, macrophages, dendritic cells, natural killer cells ($V
3ell), cytotoxic T lymphocytes (3TB), etc!, #ork together to defend the body against
cancer by targeting abnormal antigens expressed on the surface of the tumor due to
mutation!
What is gene therapy?
4ene therapy is an experimental techni>ue that uses genes to treat or prevent disease! 0n
the future, this techni>ue may allo# doctors to treat a disorder by inserting a gene into a
patientDs cells instead of using drugs or surgery! Aesearchers are testing several
approaches to gene therapy, including:
Aeplacing a mutated gene that causes disease #ith a healthy copy of the gene!
0nactivating, or Wknocking out,X a mutated gene that is functioning improperly!
0ntroducing a ne# gene into the body to help fight a disease!
2lthough gene therapy is a promising treatment option for a number of diseases
(including inherited disorders, some types of cancer, and certain viral infections), the
techni>ue remains risky and is still under study to make sure that it #ill be safe and
effective! 4ene therapy is currently only being tested for the treatment of diseases that
have no other cures!