evaluation of cancer patient in omfs
TRANSCRIPT
Evaluation of Cancer Patient
Hanan ShanabSBOMFS
TUMOR BIOLOGY• The accepted molecular theory concerning genetic alterations of SCC is
that of a “multihit” tumorigenesis ultimately leading to unregulated cell growth and function.
• It is thought that multiple exogenous insults (tobacco, alcohol, viral) can lead to activation of oncogenes or inactivation of tumor suppressor genes.
• Oncogenes multistep expression of cancer is carried through transformed genes (altered sequence of nucleotides in DNA) called .
• DNA-damaging effects of chemical carcinogens may confer a mutation and transform a normal gene into an oncogene.
• Oncogene dysregulation leads to a gain of function alteration.
• Tumor-suppressor genes are the body's primary cancer surveillance system. These genes produce proteins, such as the well-known p53, p16, and telomerase, that may repair damaged DNA or initiate a self-destruct sequence in a cell with abnormal DNA, causing cell death (apoptosis).
May 01, 2014 | Cancer ManagementBy John Andrew Ridge, MD, PhD, Ranee Mehra, MD, Miriam N. Lango, MD, and Steven Feigenberg, MD
•Oral Cavity 44%•Larymx 31%•Pharynx 25%
EPIDEMIOLOGY
EPIDEMIOLOGYAGE• Oral cancer is predominantly a disease of older age. • More than 92% of oral and pharyngeal cancers occur in individuals older
than 45 years. • Its incidence declines after age of 70.• A recent disturbing trend is the increase in oral cancer in younger adults in
the United States and internationally.
• Young patients:– Lack significant comorbidity. – Tolerate optimal treatment better, which affects prognosis– Have more advanced at presentation.– higher rates of regional and distant metastases.– Recurrent disease is more aggressive, with a fatality rate of 100%.
• GENDER• Once a predominantly male disease, females have experienced a steady
rise in the incidence of oral cancer since the increase in female smokers began in the 1950s.
• percentage of non-smokers with oral cancer was significantly higher in females, especially in women older than 50 years which related to hormonal influence of estrogen deficiency in postmenopausal women, although the data were not conclusive.
• RACE• African American men have the greatest risk for the development of oral
cancer in the United States ,can be attributed to increased alcohol and tobacco consumption.
• For all stages, whites have a relative 5-year survival rate of 61%, whereas only 36% of African Americans are alive after 5 years.
Clinical CorrelationBased on Site
1- LIP. 30% 2- Buccal Mucosa. 2 to 10%.3- Alveolar Ridge /gingival 2 to
18%.4- Retromolar gingiva. 2 to 6%5- Floor of the Mouth. 8 to 25%6- Hard Palate 3 to 6%7- Tongue carcinoma 22 to 49%
1-LIP
• In older white men as a result of chronic sun exposure.
• The rule of 90s applies in lip cancer: 90% of lip cancers are SCC.
• 90% occur on the lower lip, the• 90% 5-year survival rate is, and • 90% of lip cancers have no evidence of
nodal disease.
LIP
• Cancers of the lower lip preferentially drain into level I cervical lymph nodes.
• Subsequent metastases can occur in level II and III lymph nodes.
• cancers of the upper lip and commissure drain to Preauricular, periparotid, and submandibular nodes (level II).
2- Buccal Mucosa
• Central and Southeast Asia the use of “pan” (a combination of tobacco, betel nut, and lime) has been linked to buccal mucosa carcinoma.
• 10 to 27% of cervical metastases • First-echelon lymphatic drainage level I
followed by level II.
3- Alveolar Ridge /gingival • mandibular alveolus (64 to 76%)
with high L.N metastasis.• 1/3 of these tumors exhibit some
bony involvement. • Mainly to levels I and II for both
jaws.• Can be misdiagnosed as
inflammatory lesions, periodontitis or gingivitis, tooth abscesses, or denture sores
4- Retromolar Gingiva(Retromolar Trigone)
• Primary symptomatic complaints with these tumors are sore throat, otalgia, and trismus.
• Lymphatic drainage from this area
is predominantly to level IB& II. • more aggressive in nature with 27
to 56% of cervical metastasis.
5- Floor of the Mouth• Two distinct lymphatic drainage
systems have been identified in the floor of the mouth:– The superficial system drains
bilaterally (level IB) – The deep system drains into the
ipsilateral (levels IB, II, and III). • ½ of pt. have metastatic disease at
presentation. • 60% of individuals with metastatic
disease will have multiple levels involved.
6- Hard Palate • In India and Southeast Asia,
where reverse smoking is popular, the proportion of hard palate lesions is greater.
• 10 to 25% evidence of metastasis, generally to levels I and II.
Anterior Two-Thirds of theTongue (Oral Tongue)
• It has four areas: the tip, the lateral borders, the dorsum, and the ventral surface of the tongue.
Sites:• anterior two-thirds (75%)• posterior one-third (25%).
• Several epidemiologic reviews have shown the unfortunate trend of an increase in tongue cancer.
• Lymphatic drainage of the oral tongue is principally to level II, followed by levels III and I.
• Carcinoma of the lateral border generally metastasizes ipsilaterally, but in tip or body of the tongue may exhibit bilateral metastases.
• 40% of node metastasis at the time of diagnosis.
ETIOPATHOGENESIS/CAUSATIVEFACTORS
• Multiple factors have been associated with increased risk for oral cancer. Although the most compelling evidence implicates tobacco and alcohol, other associated factors:– viruses. – nutritional deficiencies. – previous upper aerodigestive malignancy. – immunocompromised status.
Smoking • Developing oral cancer is five to nine times greater for smokers thanfor nonsmokers.
Oral and Maxillofacial Surgery Knowledge Update, Vol 4, 2006
equation for the development of oral squamous cell carcinomas: P = Kf X C2 X t4
Kerstin M Stenson. Epidemiology and risk factors for head and neck cancer. uptodate
• Secondhand smoke exposure may be a contributing factor. One report evaluated 59 patients with head and neck cancer who did not use tobacco and with rare exceptions did not abuse alcohol. These patients had a significantly higher risk of exposure to environmental tobacco smoke in both the workplace and home than a control population without cancer. This relationship primarily occurred in women and those with tongue cancer
Smokeless Tobacco• In 1981, Winn and co-authors reported a four-fold increase in risk in
women users of smokeless tobacco.• Southeast Asia and India are known for heavy consumption of smokeless
tobacco consisting of various combinations of betel quid (pann)• Associated esophageal, pancreatic, laryngeal, and renal cancer.
• Many of these patients also have submucous fibrosis w/ incidence of cancer from malignant transformation surpassing 7.6%.
• Recent studies suggest that targeting epidermal growth factor receptor (EGFR) may benefit patients with this habit because of overexpression of EGFR.
Epidermal Growth Factor Receptor Inhibitors in Clinical Trials. Review Article | June 01, 2001 | By Janet E. Dancey, MD
ALCOHOL• The role of alcohol as a promoter in the development of oral cancer when
coupled with the use of smoking tobacco. • This may be related to its ability to solubilize carcinogens and enhance
their penetration into oral mucosa.
CO-MORBID CONDITIONS• The identification and analysis of the HNSCC susceptibility syndromes has
contributed to early recognition of patients at risk for young-onset HNSCC.
CO-MORBID CONDITIONS
CO-MORBID CONDITIONS
Viruses • Multiple viruses have been implicated in the etiology of oral
cancer, including:– Epstein-Barr virus, – Human papilloma viruses-16,14,18 (HPVs). – HIV (There is an approximately 2-3 X increase in the incidence of SCC)– Human herpesvirus-8 is recognized as the most important pathogen in
Kaposi sarcoma.
HPVs
• frequently involving oropharynx. significantly higher rates of sexual promiscuity.
• HPV E6 and E7 proteins, have high phenotype oncogenic properties , through disruption of key tumorsuppresor genes (p53).
• The clinical behavior of HPV-positive oropharyngeal SCC’s in terms of response to treatment and prognosis, is clearly superior compared to HPV-negative OPSCCs.
• The higher survival rate among patients with HPV-positive SCC is due in part to greater locoregional control, reflecting higher intrinsic sensitivity to radiation or better radiosensitization by Cisplatin-based chemoradiation strategies.
OTHER• The chronic iron deficiency seen in patients with Plummer-Vinson
syndrome has been associated with a higher incidence of oral and hypopharyngeal cancer.
• A deficiency in vitamins A, C, and E has been associated with oral cancer. Oral cancers have also been associated with low intake of fruits and vegetables, and a protective role may be afforded by diets high in fruits, vegetables, and fiber.
ASSESSMENT OF PRIMARY LESION
PATIENT EVALUATIONHISTORY
• Begins with a thorough history of the disease process, as well as a comprehensive past medical and surgical history.
• Specific focus should be placed on common problems in the oral cancer population, such as alcohol abuse, smoking, and malnutrition.
• level of home or family support available postoperatively. Lack of caregivers often requires the use of home nursing or postoperative placement in a skilled nursing facility.
• Search for symptoms of second primary tumors of the pharynx, esophagus, and lungs, a useful guide for further clinical or radiologic examination.
• include hoarseness,dysphagia, odynophagia, otalgia, stridor, and hemoptysis.
functional capacity of the patient
PHYSICAL EXAMINATION• tumor’s location, size, and relationship to adjacent anatomic structures.• Bimanual palpation is useful to determine the extent of tumor in the floor
of the mouth, buccal mucosa, and lips. • Fixation to the mandible requires consideration of marginal versus
segmental mandibulectomy.• Proximity to the midline often guides the decision for unilateral versus
bilateral neck dissection when indicated. • Trismus or decreased tongue mobility may be an indication of invasion
into deeper structures.
• Cranial nerve deficits suggest tumor involvement, which may increase suspicion for perineural spread.
• The status of the dentition should be assessed in patients in whom radiation therapy may be indicated because of the risk for xerostomia-related caries and osteoradionecrosis.
• Plans should be made for non-viable teeth to be removed at the time of surgery or before radiation therapy.
• The alveololingual sulcus, a “coffin corner” • This area should be thoroughly evaluated in patients with floor of the
mouth or lateral tongue lesions by anterior retraction and digital palpation of the tongue.
• If primary tumors located in areas that are difficult to assess or may be painful to assess, requiring an evaluation under anesthesia along with panendoscopy.
• Panendoscopy, or “triple endoscopy” = the use of a rigid bronchoscope, esophagoscope, and laryngoscope to examine +/- biopsy.
ASSESSMENT OFREGIONAL METASTASIS
• The neck examination is performed by standing behind the patient and using both hands to evaluate for symmetry.
• Palpable nodes should be evaluated for size, location, and fixation to skin or deeper structures.
Regi
onal
Lym
ph N
odes
MANAGEMENT OFNODE-POSITIVE NECKS
• Cancers from the oropharynx,hypopharynx, and larynx levels II to IV.
• Oral cavity cancers levels I to III.
• If involovement of level I, II, or III:
• risk for level IV -- 3% to 17%. • risk for level V -- 1% to 6%.
1-6%3-17%
Regional Lymph Nodes• Other groups:
– Suboccipital.– Retropharyngeal.– Parapharyngeal.– Buccinator (facial).– Preauricular.– Periparotid and intraparotid.
Pt. Evaluation for Rreconstructive purposes
• Ideal donor sites have healthy skin, adequate peripheral pulses, and should lack evidence of poor healing or chronic wounds. – Scars– radial forearm flap - Allen test – A pectoralis flap- mastectomy, – latissimus flap - axillary node dissection– rectus flap- Previous abdominal procedures
NUTRITIONAL STATUS
• Oral cancer patients commonly suffer from malnourishment related to pain, trismus, or dysfunction from their tumor, RTx, alcohol.
• Malnutrition has negative implications on immune function and wound healing, which may be exacerbated if postoperative radiation therapy is planned.
• Consideration should be given to placement of a gastrostomy tube in these patients, depending on the anticipated extent of surgery.
RADIOGRAPHIC ASSESSMENT
(CT), (MRI), (US), (PET).
• - For N0 20% – 45% occult metastasis.• - The presence of neck metastases 50% reduction of 5 Years survival rate • -This has led to the option of performing elective neck dissection (END) in
patients with N0.
Natalie Kelner a, José Guilherme Vartanian a, Clóvis Antônio Lopes Pinto b, Cláudia Malheiros Coutinho-Camillo b, Luiz Paulo Kowalski. Does elective neck dissection in T1/T2 carcinoma of the oral tongue and floor of the mouth influence recurrence and survival rates? British Journal of Oral and Maxillofacial Surgery 52 (2014) 590–597
Plane films• Panoramic and plain film radiography is less useful in the assessment of
bone invasion. • lack of three-dimensional visualization when compared with other
modalities such as CT and MRI. • Early cortical erosion is easily missed on plain films. • Panorex is most useful in planning osteotomies when marginal or
segmental resection is indicated.
Computer Tumography• (+ ):
– Has excellent bone detail, adequate soft tissue enhancement,– Relatively low cost .
• ( -): – Artifact created by metallic dental restorations. This is particularly
problematic when evaluating tumors at the level of the occlusal plane, such as the retromolar trigone or buccal mucosa.
– Irregular tooth sockets or periapical disease seen on CT may be confused with tumor invasion.
• CT is the most common method for assessment of mandibular invasion. • using contrast-enhanced CT with 3-mm cuts ، 100% of sensitivity and a
specificity of 97%. • Necrotic nodes appear on CT with focal hypoattenuation
HEAD AND NECK SYMPOSIUM Year : 2012 | Volume : 22 | Issue : 3 | Page : 195-208 Imaging in oral cancers
Supreeta Arya, Devendra Chaukar, Prathamesh Pai
(A) Axial CECT showing the Puffed Cheek technique in (B) that separates the buccal and gingival surfaces with air depicting that epicenter of lesion (arrows) is in the buccal mucosa .The lesion does not abut mandible as appears in A
• Radiologic findings suggestive of nodal metastasis:1- Enlarged size,
> 1.5 cm in Level II region or 1 cm in other regions of the neck.
2- Rounder shape, metastatic nodes are round or sphere-like.
3- Heterogeneity concerning for necrosis.
Intranodal tumor necrosis is the most reliable criterion, but it is also a late sign. Therefore, nodal size and shape are the predictors commonly used in the assessment of N0 necks.
Extracapsular spread• A retrospective study by Snow and colleagues showed a
surprisingly high rate of extracapsular tumor spread in even small lymph nodes.
– >3 cm had a 73.7%, – 2 to 3 cm a 53.3% chance, – 1 to 2 cm a 44.3%, – < 1 cm a 28.8% chance.
• Below the cricoids
CBCT• These machines are becoming increasingly available in dental offices
and produce images of similar quality to conventional CT with lower cost and radiation exposure.
• CBCT was an accurate method for detecting mandibular invasion better than with MRI and Panorex.
• a sensitivity of 95% and a specificity of 79%.• A study from the Netherlands compared the accuracy of CT, MRI, and
orthopantography in 29 patients. • The authors noted that MRI demonstrated the highest sensitivity
(94%) but had more false-positive results and often overestimated the extent of tumor invasion. Brown and associates also noted the tendency for MRI to overestimate tumor invasion into the mandible.
Magnetic Resonance Imaging
Advantages:– superior soft tissue detail – lack of ionizing radiation.
Disadvantages:– sensitive to motion artifact.* – more expensive than CT. – difficult for patients who suffer from claustrophobia. – Certain implants such as cardiac pacemakers and ferromagnetic
aneurysm clips are absolute contraindications for MRI.
Magnetic Resonance Imaging
• Appropriate investigation in patients with tongue base or retromolar lesions and suspicion of perineural, extrinsic tongue muscle, oropharyngeal, soft palate, or skull base extension.
• T1-weighted, fat-suppressed contrast enhanced image is the optimal sequence to evaluate cervical metastatic disease.
• T2 MRI with hyperintensity and irregular peripheral enhancement.
Axial T2 MRI with enhancement of SCC of the base of tongue .area of central necrotic enlarged lymph nodes.
Positron Emission Tomography• Functional imaging with F -fluorodeoxyglucose PET has been shown to be
an effective tool in the diagnosis of head and neck cancer, although its role is still being defined.
• Higher sensitivity and specificity for FDG-PET (90%, 94%) compared with CT (82%, 85%) and MRI (80%, 79%).
FDG- PET Role
• Evaluation of the clinically N0 neck. • Evaluation of an unknown primary• Evaluation of metastatic disease,
tumor recurrence, and treatment response after chemotherapy or radiation therapy.
Drawbacks of FDG-PET • Inability to differentiate between cancerous and reactive inflammatory
lymph nodes and• the poor anatomic delineation of the primary tumor and neck nodes in
relation to surrounding structures, particularly those of a vascular nature.• Inability to detect micrometastases smaller than 5 mm in diameter due to
the inadequate spatial resolution of PET.
The unit of measurement is the subjective uptake value (SUV); values greater than 2.5 to 3.5 SUV are considered abnormal
Ultrasound
• Quick, non-invasive & inexpensive when compared with CT or MRI. • It may be used as an initial study to help guide the clinician in deciding
whether further imaging studies of the neck may be required.(cN0)• Sensitivity& specificity for lymph node metastasis is 85- 95%.• US-guided FNAC has greatly increases its efficacy and specificity.
• Metastatic nodes are characteristically– round to spherical in shape .– frequently hypoechogenic. – In the presence of extracapsular
spread, loss of border definition.– peripheral or mixed hilar and
peripheral vascular pattern
Normal lymph nodes are frequently difficult to detect because of their high echogenicity mimicking that of the surrounding fatty tissue
• Axial view of a normal lymph node. Note the uniform echogenic parenchyma, smooth borders, and oval shape. (Inset) Duplex view, lymph node identified by dashed line with hilar vascular pattern. CA, carotid artery; IJV, internal jugular vein.
(E) Metastatic disease in lymph node with intranodal cystic necrosis. (Inset) Duplex view, aberrant intranodal vessels. (F) Lymph node metastasis with intranodal cystic necrosis, lack of nodal borders, and diffuse extracapsular infiltration (arrowheads).
Jonathan W. Shum, Eric J. Dierks, Evaluation and Staging of the Neck in Patients with Malignant Disease. Oral Maxillofacial Surg Clin N Am 26 (2014) 209–221
ASSESSMENT OF DISTANT METASTASIS
• Distant metastasis from the oral cavity most frequently involves the lung, followed by liver and bone.
• minimum metastatic work-up for H&N cancer pt.: – PA & Lateral CXR – liver function tests (LFTs) are
• CT of the chest or abdomen and pelvis.• FDG-PET study.
rates in the eventual development of distant metastasis:floor-of-mouth cancer13% carcinoma of the tongue 15%.
DIAGNOSIS
DIAGNOSIS• This delay may be because symptoms develop later in the disease• Low socioeconomic group unable to seek treatment until it has reached an
advanced stage. • 14% of adults in the United States have oral cancer Ex.• These detections occurred in the dental office, whether by a dentist, dental
hygienist, or oral and maxillofacial surgeon.
Toluidine Blue
• It was recognized in the 1960s .Toluidine blue is a metachromic dye that has been used as a nuclear stain.
Unknown mechanism of action:• 1- selectively stains cells with increased DNA synthesis.• 2-It binds to sulfated mucopolysaccharides, found in higher quantities in
actively growing cells.
Toluidine Blue
• Several studies have borne out toluidine blue’s sensitivity (89 to 100%) and specificity (62 to 90%) for oral SCC.
• It should be limited to the screening of high-risk individuals, from a large area of abnormal-appearing tissue.
• In the end, toluidine blue cannot be substituted for a thorough oral examination and biopsies when clinical suspicion is high.
Biopsy• This biopsy can usually be done in an office setting or rarely under general
anesthesia with panendoscopy if the lesion is difficult to access and patient tolerance is low.
• Measuring accurate dimension of the lesion should be acquired prior to biopsy in order to properly stage the lesion.
• For large lesion, several biopsies from different sites in attempt to decrease any sampling error that might be read as dysplasia, necrosis, or inflammation.
Brush cytology • in the dental community as a safe, minimally invasive technique for use in
the screening of clinically suspicious lesions.• Brush cytology differs from exfoliate cytology in that it removes an entire
transepithelial layer for cytologic evaluation as opposed to the sloughing surface layer of the mucosa.
• Commercially available kits exist that include a brush biopsy instrument,
glass slide, and fixative.
• The suspicious lesion is sampled by rubbing or rotating the sampling brush against its surface until pinpoint bleeding at the biopsy site is obtained, indicating sampling to the basement membrane and an adequate specimen.
• This specimen is then transferred to the slide, fixed in the office, and sent.
• Brush biopsy results are classified as– “negative” when no epithelial abnormality is noted, – “positive” when definite cellular evidence of dysplasia or carcinoma is
found, – “atypical” when abnormal epithelial changes of uncertain diagnostic
significance are observed, – “inadequate” when an incomplete transepithelial specimen was submitted.
• The largest study of brush cytology by Sciubba and colleagues found a sensitivity and specificity of 100%. reported sensitivities of approximately 90% but a specificity of only 3%.
• It is our opinion that brush cytology is only a screening tool, and any atypical or positive results must be confirmed by an incisional biopsy.
sentinel node biopsy(SNB) • Indicated for N0 patients who fall under the risk of occult metastasis and
present with a T1 or T2 primary oral cavity.• In head and neck it was first described by Alex and Crag in a case of
Supraglottic Carcinoma in 1996 using lymphoscintigraphy.
Geiger probe
sentinel node biopsy(SNB) • (SNB) has been mostly used in skin melanomas and breast carcinomas.• blue dye, lymphoscintigraphy and gamma probe (e.g1 % Isosulfan Blue
Dye).• Minamikawa et al. performed SLNB in 21 patients of oral cavity SCC
with clinically N0 neck (sensitivity 80.95 % & specificity 94 %).
Purnima Sangwan • Ajith Nilakantan • Uma Patnaik • Awadhesh Mishra • Ashwani Sethi. Sentinel Lymph Node Localization Using 1 % Isosulfan Blue Dye in Cases of Early Oral Cavity and Oropharyngeal Squamous Cell Carcinoma. Indian J Otolaryngol Head Neck Surg2014;56-61
Positioning of the patient under the Gamma camera
Dynamic and static scans captured using gamma cameras
Corresponding sentinel lymph nodes marked on the patient’s skin
STAGING
STAGING• The AJCC/UICC TNM staging system :
– Used to help guide treatment and estimate patients 5-year survivability.– Adequate for classifying the anatomic extent of disease, but not all
prognostic factors.• To group patients into statistical classifications that provide
useful information on treatment and prognosis.• Additionally, this standardized format for research assessment
of outcomes, & communication among clinicians by establishing uniform reporting parameters.
•
AJCC 7th edition 2010 (TNM classification)
American Joint Committee on Cancer • 2010
Jonathan W. Shum, Eric J. Dierks, Evaluation and Staging of the Neck in Patients with Malignant Disease. Oral Maxillofacial Surg Clin N Am 26 (2014) 209–221
1- Presence of ECE as part of tumor staging.2-Proposed changes designate U for upper neck lesions (below the lower level
of cricoid cartilage) and L for lower neck lesions because distant metastasis rates vary depending on level of cervical metastases.
• The 5-year survival rate decreases with lower levels of metastatic nodes, from 37% for level I to 25% for level IV nodal involvement.
• ECS evident on clinical/radiologic examination is designated – E+ – E−
• ECS on histopathologic examination is designated – En (no extranodal extension), – Gross ECS (Eg): Tumor apparent to the naked eye, beyond the
confines of the nodal capsule. – Microscopic ECS (Em): Presence of metastatic tumor beyond the
capsule of the lymph node .
American Joint Committee on Cancer • 2010
Primary Tumor (T)
Note: Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify a tumor as T4.
Snehal G. Patel and Jatin P. Shah. TNM Staging of Cancers of the Head and Neck: Striving for Uniformity Among Diversity. CA Cancer J Clin 2005;55;242-258
Characteristics of lip and oral cavity tumors
• Endophytic. The tumor thickness measurement using an ocular micrometer.
• Exophytic. • Ulcerated.
Tumor thickness was the only independent predictor of nodal metastases, with thin (≤5 mm) and thick (>5 mm) tumors having a 10% and 46% risk, respectively, for the development of nodal metastases
Regional Lymph Nodes (N)
Snehal G. Patel and Jatin P. Shah. TNM Staging of Cancers of the Head and Neck: Striving for Uniformity Among Diversity. CA Cancer J Clin 2005;55;242-258
Distant Metastasis (M)
• M0: No distant metastasis.• M1: Distant metastasis.
• The most common sites of distant spread are in the lungs and bones; hepatic and brain metastases occur less often. •Mediastinal lymph node metastases are considered distant metastases, except level VII lymph nodes (anterior superior mediastinal lymph nodes cephalad to the innominate artery).
AMERICAN JOINT COMMITTEE ONCANCER STAGE GROUPINGS
Special classification/designator rules
• (cTNM) Initial staging• (pTNM) Final staging• (TmNM) multiple primary tumors.• (aTNM) autopsy.• (ycTNM or ypTNM) Post therapy or postneoadjuvant therapy.• (rTNM) Retreatment or recurrence.• (m) suffix Multiple primary tumors. – e.g., T2(m) or T2(5)
American Joint Committee on Cancer • 2010
Histopathological Grading:
• Gx: grade of differentiation can’t be assessed.• G1: Well differentiated• G2: Moderately differentiated.• G3: Poorly differentiated.• G4: Undifferentiated.
Broumand V., Lozano T.E.,Gomez J.A.Evaluation and Staging of Oral Cancer. Oral Maxillofacial Surg Clin N Am 18 (2006) 435-444
R ClassificationThe presence or absence of residual tumor:• Rx: presence of residual tumor cannot be assessed.• R0: No residual tumor.• R1: Microscopic residual tumor.• R2: Macroscopic residual tumor.
Broumand V., Lozano T.E.,Gomez J.A.Evaluation and Staging of Oral Cancer. Oral Maxillofacial Surg Clin N Am 18 (2006) 435-444
• Cancer is a devastating diagnosis for any patient. Careful assessment of the patient and the lesion is required to formulate treatment recommendations aimed at increasing survival and improving or maintaining quality of life.
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