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
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