Module 6:Module 6:

Clinical Stage Clinical Stage and Gradeand Grade

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 observed Histologic alterations observed in epithelial dysplasiain epithelial dysplasia

Architectural changes in Architectural changes in epithelial dysplasiaepithelial 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 dysplasia Transition of epithelial dysplasia to invasive squamous cell to invasive squamous cell carcinomacarcinoma

GradingGrading• 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 (2nd ed.). Philadelphia: W. B. Saunders.

StagingStaging

• Based upon the size and extent of

metastatic spread of the lesion

• Tumor-node-metastasis (TNM) system

used for most cancers

Staging – TNM Staging – TNM systemsystem

• 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”

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