GOOD MORNING

TNM STAGING

GRADING AND STAGING OF CANCER

Grading and staging are two systems to determine the prognosis and choice of treatment after a malignant tumour is detected.

GRADING:

1. 2.

Grading is defined as the macroscopic and microscopic degree of differentiation of the tumour. It is the histopathological evaluation of degree to which the tumour resembles their parental tissue & produce their normal product. Grading is largely based on 2 important histologic features: The degree of anaplasia The rate of growth

BRODERS GRADING

Grade 1: well differentiated (less than 25% anaplastic cells) Grade 2: Moderately differentiated (25 to 50% anaplastic cells) Grade 3: Poorly differentiated (50 to 75 % anaplastic cells) Grade 4: Undifferentiated (more than 75% anapalstic cells)

STAGING:

Staging means extent of spread of the tumour within the patient. i.e., quantifying the clinical parameters of tumour size & extent of metastatic spread of tumour which indicates patient prognosis.

The extent of spread of tumour can be assessed by three ways: 1. By clinical examination 2. By investigations 3. By pathologic examination of tissue removed

TNM STAGING
The tumor-node-metastasis (TNM) staging system was first reported by Pierre Denoix in the 1940s. Developed by AMERICAN JOINT COMMITTEE FOR CANCER. International Union Against Cancer (UICC) eventually adapted the system and compiled the first edition of the TNM staging system in 1968. It is important to realize that the TNM staging system is simply an anatomic staging system that describes the anatomic extent of the primary tumor as well as the involvement of regional lymph nodes and distant metastasis.

TNM STAGING
T indicates size of primary tumour N indicates regional nodal involvement M indicates distant metastasis. For each of 3 components, numbers are added to indicate the extent of involvement.

IMPORTANCE OF TNM STAGING:

IT IS AN UNIVERSALLY ACCEPTED SYSTEM OF CLASSIFICATION. Helps to assess the exact stage that the tumour is present. Helps to plan the treatment . To assist in evaluating results of treatment To give some indication of prognosis & Helps in determining prognosis of lesion. To help in documentation. To facilitate exchange of information between treatment centers.

TNM STAGING:
T STAGING:
Tx : Primary lesion cannot be assessed T0 : No evidence of primary lesion T1 : Carcinoma in situ T2 : Lesion 2cm or less in the greatest diameter T3 : Lesion > 2cm but < 4cm in the greatest diameter T4 : T4a : Lesions invades through cortical bone, into deep structures/ extrinsic muscles of tongue, maxillary sinus or skin of face. T4b : Lesions invades massetric space, pterygoid plates, or skull base and/or encases internal carotid artery

N Staging:
Nx : Regional lymph node cannot be assessed N0 : No regional LN metastasis N1 : Metastasis to a single ipsilateral lymph node, < 3cm in greatest dimension N2A : Metastasis to a single ipsilateral lymph node, > 3cm but not more than 6 cm in greatest dimension N2B : Metastasis in multiple ipsilateral lymph nodes none more than 6 cm in greatest dimension N2C : Metastasis in bilateral or contra lateral lymph nodes none more than 6 cm in greatest dimension N3 : Metastasis in a lymph node more than 6 cm in greatest dimension

NODES N STAGING

M STAGE:

Mx : Distant metastasis cannot be assessed M0 : No distant metastasis M1 : Distant metastasis present

The risk of distant metastasis is dependent on nodal disease rather than the size of primary tumour.

STAGING :
STAGE Stage 0 Stage 1 Stage 2 Stage 3 Tis T1 T2 T1 T2 T3 Stage 4 T4 T N0 N0 N0 N1 N1 N0, N1 N0 ,N1 N M0 M0 M0 M0 M0 M0 M0 M

Any T
Any T

N2 ,N3
Any N

M0
M1

LEVELS OF LYMPH NODES:

As per AMERICAN JOINT COMMITTEE staging manual 1998, Level 1A: Nodes in submental triangle Level 1B: Nodes in submandibular triangle Level 2: Upper deep jugular nodes Level 3: Middle jugular group of nodes Level 4: lower jugular group of nodes Level 5: Nodes in posterior triangle

LEVELS OF LYMPH NODES

CERVICAL LYMPHATIC SYSTEM

NODAL METASTASIS:
Involvement of regional lymph nodes by oral cancer depends on: 1. Site & location of primary lesion 2. Size 3. T stage 4. Histomorphologic feature

NODAL METASTASIS:
Tumour close to the midline are at a great risk of developing bilateral / contra lateral cervical node metastasis. Squamous cell carcinoma in the oral cavity & lips tends to metastasis to lymph nodes at the levels 1, 2 & 3. SCC of the tongue has high risk of metastasis directly to lymph node levels 3 or 4. Tumours arising in the oropharynx commonly metastasis to lymph node 2, 3 & 4.

TREATMENT:

Early stage oral cancer (STAGE 1 & 2)

Single modality treatment (Surgery / Radiotherapy)

Locally advanced cancers

OPERABLE CANCERS (STAGE 3& 4A)

INOPERABLE CASES/ METASTATIC CANCER (STAGE 4B & 4C) Palliative chemotherapy followed by radiotherapy Palliative radiotherapy followed by chemotherapy Symptomatic cares

Combined modality treatment

N0 Neck (Node negative)

Early Cancer (T1 &T2) Elective neck dissection = observe Elective neck dissection preferred, if : T2 cancer Poor follow up Poor prognostic variables like poorly differentiated tumour, perineural invasion, lymphovascular invasion, etc. Thick tumour (>4mm)

Locally advanced (T3 & T4) Treatment of neck mandatory because: High chances of lymph node metastasis

Surgery for the neck: Selective neck dissection (13) Modified neck dissection (15) Radical neck surgery is usually not performed.

Survival and prognosis:

Stage 1 & 2: Better prognosis (5yr survival rate 31-100%) Stage 3 & 4: Poor prognosis (5yr survival rate 7 41%)

THANK YOU!!