STAGING MCR Staff Show Me Healthy Women March 27, 2008 Supported by a Cooperative Agreement between DHSS and the Centers for Disease Control and Prevention (CDC) and a Surveillance Contract between DHSS and MU

Staging Grouping of cancer cases according to similar degrees of spread or extent of disease. Extent of disease is a detailed description of how far the tumor has spread from organ or site of origin (the primary site).

Staging PURPOSES Determine appropriate treatment Predict prognosis Evaluate results of treatment Facilitate exchange of information Contribute to research of human cancer

Staging Elements Elements to be considered in any staging system are the primary tumor site, tumor size, multiplicity (number of tumors), depth of invasion and extension to regional or distant tissues, involvement of regional lymph nodes, and distant metastases.

Types of Staging Systems Summary Staging American Joint Committee on Cancer (AJCC) Staging System Collaborative Staging Others FIGO (GYN) Dukes (colorectal) Ann Arbor ( Lymphoma)

FIGO Acronym for the French term that means International Federation for Gynecology and Obstetrics. The American Joint Committee on Cancer has developed the tumor (T) component of the TNM staging system to correspond to FIGO staging.

How to? Where did the cancer start? Where did the cancer go? How did the cancer get there? What is the stage?

Staging Sources Physical Exam Radiologic Procedures X-rays Scans Endoscopies Tumor markers Pathologic exams Surgical reports Progress Notes and Discharge Summaries

How Cancer Spreads Local invasion Direct extension Lymphatic metastases Blood-borne metastases Intra-cavitary

Summary Staging 0 – in situ 1 – localized 2 – regional by direct extension only 3 – regional lymph nodes involved only 4 – regional by both direct extension and lymph node involvement 5 – regional, NOS (not otherwise specified) 7 - distant site(s)/node(s) involved 9 – unknown (unstaged, unknown or unspecified)

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In Situ Terms CIN III Confined to epithelium Intracystic, non-infiltrating Intraductal Intraepidermal Intra-epithelial Intrasquamous Stage 0

In Situ Terms Involvement up to but not including the basement membrane Lobular neoplasia Non-infiltrating Non-invasive No stromal invasion Preinvasive

CIN III CIN III (cervical intraepithelial neoplasia grade iii) must be carefully reviewed, because this diagnosis includes both carcinoma in situ and severe dysplasia.

Microinvasion Microinvasion implies invasion through the basement membrane. The stage would be INVASIVE not insitu. Any foci of invasion makes the stage invasive rather than insitu.

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Distant Distant mets can be by: direct contiguous extension implantation (discontinuous) mets lymph node involvement

Unstageable Unknown primaries Not enough information to stage Death certificate only

AJCC (TNM) Staging Louanne Currence, RHIT, CTR

What is TNM Staging? Developed by physicians (AJCC) Uniform staging system to determine treatment, prognosis & end results T = Tumor N = Nodes M = Metastasis Group Stage = summary of TNM

Clinical Staging Used to select primary treatment Each site has specific guidelines of what is acceptable under cTNM Physical examRadiology EndoscopyBiopsy

Pathologic Staging Based on pre-treatment evidence and/or subsequent surgery/path Used to Determine adjuvant therapy Estimate prognosis Report end results

T Primary "Tumor" and its contiguous extension Based on size (invasive only) Based on penetration Extension of primary

T T-value increases with worsening scenario Tx - cannot assess T0 - no evidence of primary Tis - In situ (never sarcomas) T1-4

Sample "T"s < 1.0 cm breast lesion = T1 3.0 cm LOQ breast lesion = T2 Carcinoma confined to uterus = T1 Cervical carcinoma extends to pelvic wall = T3

N Regional lymph nodes Absence or presence of + LN # of + LNs/size of metastasis Laterality of + LNs/size of mets Named LN chains

N Increases in severity Nx - cannot assess N0 - no regional LN mets N1-3

Sample "N"s Breast Metastasis in axillary LNs fixed or matted = N2 1 of 15 axillary LNs + (breast) = N1 Cervix 1 + pelvic node = N1

M Some sites have listing Mx - cannot assess M0 - no distant mets M1 - distant mets found

Group Stage Is the general reference point of comparison Tis = Stage 0 Stage I, Stage II, Stage III, Stage IV

Group Stage Examples (Breast) Stage 0TisN0M0 Stage IT1N0M0 Stage IIAT0N1M0 ~~~~~ ~~~~~~~ Stage IIIBT4N0M0 Stage IIICAny TN3M0 Stage IVAny TAny NM1

Group Stage Samples (Cervix) Stage 0TisN0M0 Stage IT1N0M0 Stage IIAT2aN0M0 ~~~~~ ~~~~~~~ Stage IIIBT1N1M0 T2N1M0 Stage IVAny TAny NM1

Collaborative Stage Collaborative Staging (CS) data items CS Extension CS Lymph Nodes CS Mets at Dx

Steps for Staging 1) Determine primary site & histology 3) Is histology included? 4) Review list of regional LNs 5) Review rules of classification 6) Find staging information in chart 7) Determine T, N, M and group stage

Exercises

Missouri Cancer Registry Help Line: Help interpreting path report for staging For further information, please contact: Sue Vest, Project Manager, Nancy Cole, Assistant Project Manager