Clinical Stage Clinical Stage

and Gradeand GradeRumbaoa, Janine R.DMD4-A

IntroductionIntroduction

• 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

Tumor progressionTumor progression

• Tumors may occur spontaneously or

follow a series of cellular and tissue

changes known as epithelial dysplasia

Histologic alterations in Histologic alterations in epithelial dysplasiaepithelial dysplasia

• 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

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

Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2nd ed. St. Louis: Mosby, p. 181

Histologic alterations Histologic alterations observed in epithelial observed in epithelial

dysplasiadysplasia

Architectural changes Architectural changes in epithelial dysplasiain epithelial dysplasia

• 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

Carcinoma Carcinoma in situin situ

• 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: SaundersSapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2nd ed.) St. Louis: Mosby

Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2nd ed. St. Louis: Mosby, p. 188

Malignant cells have

penetrated through

the basement

membrane into the

underlying connective

tissue

Transition of epithelial Transition of epithelial dysplasia to invasive dysplasia to invasive squamous cell carcinomasquamous cell carcinoma

GradingGrading

• Degree of differentiation exhibited by cells

• How closely cells resemble normal tissue structure

G -    Histopathological GradingGX - Grade of differentiation cannot be assessedG1 - Well differentiatedG2 - Moderately differentiatedG3 - Poorly differentiatedG4 - Undifferentiated

StagingStaging• Based upon the size and extent of

metastatic spread of the lesion

• Tumor-node-metastasis (TNM) system used for most cancers

•Stage IThe 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).

The following stages are The following stages are used to describe cancer of used to describe cancer of

the lip and oral cavitythe lip and oral cavity

•Stage IIThe 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.

•Stage IIIEither 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).

•Stage IVAny 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.

RecurrentRecurrent

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.

Staging – TNM systemStaging – TNM system

• Size, in cm, of the tumor (T)

• Involvement of lymph nodes (N)

• Presence or absence of distant metastasis (M)

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

Staging – “T”Staging – “T”

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

Staging – “N”Staging – “N”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

Staging – “M”Staging – “M”

Distant metastasis (M)

MX Distant metastasis not assessed

M0 No distant metastasis

M1 Distant metastasis is present

TNM TNM Staging Staging SystemSystem

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

SummarySummary

• Stage and grade of tumors indicates

prognosis

• Treatment plans based upon stage and

grade, among other factors

• TNM system used with most cancers