Staging of Cancer

Staging of Cancer

·        = Determining the extent of cancer

·        Why stage:

o   Affects prognosis

o   Affects treatment

o   Allows comparison of results between centres (eg audit)

·        Staging Systems:

o   TNM system:

§  Nomenclature:

·        T: Size and invasion eg 1 = small, 4 = large

·        N: which nodes are involved

·        M: no metastases or metastases present

§  Variations applied to many cancers (eg NSC lung cancer, breast, etc)

§  Guides treatment: eg T1N0M0 ® ?wide local excision, T3N1M0 ® may start with chemo/RT

§  TNMs are grouped to give stage groups ranging from IA to IV

o   FIGO System: Gynae malignancies, eg cervix:

§  Stage I: confined to cervix

§  Stage II: Not involving the pelvic wall or lower 1/3 of vagina

§  Stage III: extends to pelvic side wall

§  Treatment:

·        I & IIa: surgery or radiotherapy

·        IIb & III: radiotherapy

o   Ann Arbor classification or lymphoma

o   Dukes Classification for bowel cancer

·        How to stage:

o   History: symptoms suggestive of local extension or distant metastases

o   Exam: nodal involvement, metastatic involvement (bone tenderness, hepatomegaly) 

o   Bloods: FBC (blood loss, marrow involvement), LFT, ALP and albumin (liver involvement), tumour markers

o   Imaging:

§  CXR, mammography

§  CT Scanning – to determine primary disease, nodal involvement

§  MRI: especially CNS and spinal chord tumours

§  Nuclear medicine: bone scan

§  US: good for differentiating cystic from solid, especially in the abdomen

§  Contract studies (barium swallow, enema): largely surpassed by endoscopy

o   Special investigations:

§  Bone marrow: lymphomas, small cell lung

§  FNA: either US or CT guided

§  Laproscopy: node sampling

§  Endoscopy

§  Surgery: role in staging tumours largely over taken

·        Tumour markers:

o   Generally only reliable for monitoring treatment in cancer demonstrated to produce a tumour marker. Generally poor for screening

·        bHCG: germ cell tumours.  Used for diagnosis and monitoring treatment

·        AFP: produced during liver regeneration: hepatocellular cancer, testicular embryonic cancers, yolk sac tumours

·        CEA: produced by epithelial elements (colon, ovary, pancreas). Usually in advanced disease so no use for screening. Also in gastritis and UC

·        CA125:  ovarian cancer (good response marker).  Also in endometriosis, hepatitis

·        PSA: levels correlate well with disease extent.  > 10 Þ 80% chance of cancer