Module 6 Clinical Stage and Grade Introduction Stage

Module 6: Clinical Stage and Grade

Introduction • 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 progression • Tumors may occur spontaneously or follow a series of cellular and tissue changes known as epithelial dysplasia

Histologic alterations in epithelial 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 Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2 nd ed. ) St. Louis: Mosby Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2 nd ed. ) Philadelphia: Saunders

Histologic alterations observed in epithelial dysplasia Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2 nd ed. St. Louis: Mosby, p. 181

Architectural changes in epithelial dysplasia • • Bulbous rete pegs Basilar hyperplasia Hypercellularity Altered maturation pattern of keratinocytes Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2 nd ed. ) Philadelphia: Saunders Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2 nd ed. ) St. Louis: Mosby

Carcinoma in 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 (2 nd ed. ) Philadelphia: Saunders Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2 nd ed. ) St. Louis: Mosby

Transition of epithelial dysplasia to invasive squamous cell carcinoma Malignant cells have penetrated through the basement membrane into the underlying connective tissue Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2 nd ed. St. Louis: Mosby, p. 188

Grading • Degree of differentiation exhibited by cells • How closely cells resemble normal tissue structure • Grade I – low grade • Grade II – moderately differentiated • Grade III – poorly differentiated Neville, B. W. , Damm, D. D. , Allen, C. M. , & Bouquot, J. E. (2002). Oral and maxillofacial pathology (2 nd ed. ). Philadelphia: W. B. Saunders.

Staging • Based upon the size and extent of metastatic spread of the lesion • Tumor-node-metastasis (TNM) system used for most cancers

Staging – TNM system • Size, in cm, of the tumor (T) • Involvement of lymph nodes (N) • Presence or absence of distant metastasis (M)

Staging – “T” Size of primary tumor (T) in cm TX No information available on primary tumor T 0 No evidence of primary tumor Tis Carcinoma in situ at primary site T 1 Tumor less than 2 cm T 2 Tumor 2 -4 cm in diameter T 3 Tumor greater than 4 cm T 4 Tumor has invaded adjacent structures

Staging – “N” Lymph node involvement (N) NX Nodes not assessed N 0 No clinically positive nodes (not palpable) N 1 Single clinically positive ipsilateral (on same side) node less than 3 cm N 2 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 N 3 Node or nodes greater than 6 cm

Staging – “M” Distant metastasis (M) MX Distant metastasis not assessed M 0 No distant metastasis M 1 Distant metastasis is present

TNM Staging System Stage TNM Classification 0 Tis N 0 M 0 I T 1 N 0 M 0 II T 2 N 0 M 0 III T 3 N 0 M 0 T 1 N 1 M 0 T 2 N 1 M 0 T 3 N 1 M 0 IV T 4 N 0 M 0 T 4 N 1 M 0 Any T N 2 M 0 Any T N 3 M 0 Any T Any N M 1

Summary • Stage and grade of tumors indicates prognosis • Treatment plans based upon stage and grade, among other factors • TNM system used with most cancers