Oral Cancer Stage and Grade
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Stage and grade determine a tumor's prognosis. Staging reflects the extent of spread while grading reflects differentiation. The TNM system stages tumors based on size (T), lymph node involvement (N), and metastasis (M). Together, stage and grade guide treatment planning and prognosis.
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Oral Cancer Stage and Grade
- 1. CClliinniiccaall SSttaaggee aanndd GGrraaddee Rumbaoa, Janine R. DMD4-A
- 2. IInnttrroodduuccttiioonn • Stage and grade determine prognosis • Staging reflects the clinical extent of the tumor • Grading a tumor reflects its histologic subtype • Of the two, staging is the primary indicator of prognosis
- 3. TTuummoorr pprrooggrreessssiioonn • Tumors may occur spontaneously or follow a series of cellular and tissue changes known as epithelial dysplasia
- 4. Histologic aalltteerraattiioonnss iinn eeppiitthheelliiaall ddyyssppllaassiiaa • Enlarged nuclei and cells • Increased nuclear-to-cytoplasmic ratio • Hyperchromatic nuclei • Pleomorphic (abnormally shaped) nuclei and cells • Increased mitotic activity • Abnormal mitotic figures • Multinucleation of cells • Keratin or epithelial pearls • Loss of typical epithelial cell cohesiveness Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2nd ed.) St. Louis: Mosby Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2nd ed.) Philadelphia: Saunders
- 5. Histologic aalltteerraattiioonnss oobbsseerrvveedd iinn eeppiitthheelliiaall ddyyssppllaassiiaa Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2nd ed. St. Louis: Mosby, p. 181
- 6. AArrcchhiitteeccttuurraall cchhaannggeess iinn eeppiitthheelliiaall ddyyssppllaassiiaa • Bulbous rete pegs • Basilar hyperplasia • Hypercellularity • Altered maturation pattern of keratinocytes Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2nd ed.) Philadelphia: Saunders Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2nd ed.) St. Louis: Mosby
- 7. CCaarrcciinnoommaa iinn ssiittuu • When the entire thickness from the basal level to the mucosal surface is affected, the term carcinoma in situ is used • Once dysplastic cells breach the basement membrance and invade the underlying connective tissue, carcinoma in situ becomes squamous cell carcinoma Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2nd ed.) Philadelphia: Saunders Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2nd ed.) St. Louis: Mosby
- 8. Transition ooff eeppiitthheelliiaall ddyyssppllaassiiaa ttoo iinnvvaassiivvee ssqquuaammoouuss cceellll ccaarrcciinnoommaa Malignant cells have penetrated through the basement membrane into the underlying connective tissue Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2nd ed. St. Louis: Mosby, p. 188
- 9. GGrraaddiinngg • Degree of differentiation exhibited by cells • How closely cells resemble normal tissue structure G - Histopathological Grading GX - Grade of differentiation cannot be assessed G1 - Well differentiated G2 - Moderately differentiated G3 - Poorly differentiated G4 - Undifferentiated
- 10. SSttaaggiinngg • Based upon the size and extent of metastatic spread of the lesion • Tumor-node-metastasis (TNM) system used for most cancers
- 11. The following ssttaaggeess aarree uusseedd ttoo ddeessccrriibbee ccaanncceerr ooff tthhee lliipp aanndd oorraall ccaavviittyy •Stage I The cancer is less than 2 centimeters in size (about 1 inch), and has not spread to lymph nodes in the area (lymph nodes are small almond shaped structures that are found throughout the body which produce and store infection-fighting cells).
- 12. •Stage II The cancer is more than 2 centimeters in size, but less than 4 centimeters (less than 2 inches), and has not spread to lymph nodes in the area.
- 13. •Stage III Either of the following may be true: The cancer is more than 4 centimeters in size. The cancer is any size but has spread to only one lymph node on the same side of the neck as the cancer. The lymph node that contains cancer measures no more than 3 centimeters (just over one inch).
- 14. •Stage IV Any of the following may be true: The cancer has spread to tissues around the lip and oral cavity. The lymph nodes in the area may or may not contain cancer. The cancer is any size and has spread to more than one lymph node on the same side of the neck as the cancer, to lymph nodes on one or both sides of the neck, or to any lymph node that measures more than 6 centimeters (over 2 inches). The cancer has spread to other parts of the body.
- 15. RReeccuurrrreenntt Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the lip and oral cavity or in another part of the body.
- 16. SSttaaggiinngg –– TTNNMM ssyysstteemm • Size, in cm, of the tumor (T) • Involvement of lymph nodes (N) • Presence or absence of distant metastasis (M)
- 17. SSttaaggiinngg –– ““TT”” Size of primary tumor (T) in cm TX No information available on primary tumor T0 No evidence of primary tumor Tis Carcinoma in situ at primary site T1 Tumor less than 2 cm T2 Tumor 2-4 cm in diameter T3 Tumor greater than 4 cm T4 Tumor has invaded adjacent structures
- 18. SSttaaggiinngg –– ““NN”” Lymph node involvement (N) NX Nodes not assessed N0 No clinically positive nodes (not palpable) N1 Single clinically positive ipsilateral (on same side) node less than 3 cm N2 Single clinically positive ipsilateral node 3 to 6 cm; or Multiple ipsilateral nodes with all less than 6 cm; or bilateral or contralateral nodes with none greater than 6 cm N3 Node or nodes greater than 6 cm N2a- Metastasis in single ipsilateral lymph node more than 3 cm 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 contralateral lymph nodes, none more than 6 cm in greatest dimension
- 19. SSttaaggiinngg –– ““MM”” Distant metastasis (M) MX Distant metastasis not assessed M0 No distant metastasis M1 Distant metastasis is present
- 20. TTNNMM SSttaaggiinngg SSyysstteemm Stage TNM Classification 0 Tis N0 M0 I T1 N0 M0 II T2 N0 M0 III T3 N0 M0 T1 N1 M0 T2 N1 M0 T3 N1 M0 IV T4 N0 M0 T4 N1 M0 Any T N2 M0 Any T N3 M0 Any T Any N M1
- 21. SSuummmmaarryy • Stage and grade of tumors indicates prognosis • Treatment plans based upon stage and grade, among other factors • TNM system used with most cancers
Editor's Notes
- A system of staging and grading tumors is utilized to determine patient prognosis.
- Cancerous tumors may occur spontaneously or may follow a series of cellular and tissue changes known as epithelial dysplasia
- Changes in tissue that occur in epithelial dysplasia include: Enlarged nuclei and cells Large, prominent nucleoli Altered nuclear:cytoplasmic ratio Hyperchromatic nuclei (excessively dark-staining) Nuclear pleomorphism (abnormally shaped nuclei and cells) Increased mitotic activity (excessive numbers of mitoses) Abnormal mitotic figures (tripolar or star-shaped mitoses, mitotic figures above the basal layer) Multinucleation of cells Dyskeratosis (premature keratinization of individual cells) - Keratin or epithelial pearls Loss of cohesiveness usually seen in epithelial cells
- This slide demonstrates the histologic alterations
- Epithelial dysplasia may be graded as mild, moderate, or severe, depending upon the microscopic features. Grade of epithelial dysplasia can progress with time. The rate of progression among individuals varies and may range from a few months to many years.
- The diagnosis of carcinoma in situ accompanies progression through the entire thickness of the epithelium. The diagnosis of squamous cell carcinoma is given once the basement membrane is breached and the underlying connective tissue is invaded.
- This slide shows malignant cells have penetrated through the basement membrane into the underlying connective tissue, so we now have squamous cell carcinoma
- Well-differentiated (grade I, low-grade) tumors produce keratin, closely resemble the tissue of origin, grow less aggressively and metastasize later. Tumors that produce little or no keratin but are still recognizable as stratified squamous epithelium are called moderately-differentiated or grade II. Poorly-differentiated (high-grade, grade III) tumors produce no keratin, bear little resemblance to stratified squamous epithelium, lack normal architectural structure and often grow aggressively and metastasize early in their course.
- Tumors are staged based upon their size and the metastatic spread. Usually the TNM system is utilized.
- The “T” is the size, in centimeters, of the tumor The “N” represents the extent of the involvement of the lymph nodes. The “M” represents the presence or absence of metastatis
- This table shows the possible definitions of the tumor part of staging.
- Lymph node involvement staging is depicted in this table. “Ipsilateral” means on the same side.
- Metastasis is staged as an Mx, M0 or M1, according to the presence or absence of distant metastasis.
- 5-year survival rates Localized (stage I and II )82% for Caucasians and 72% for African Americans. Regional metastasis 45% for Caucasians and 29% for African Americans Distant 21% for Caucasians and 18% for African Americans
- Now that we’ve discussed the staging system, we will move on to treatment plans.