Basics of ajcc tnm staging of cancer 8th edition

The basics of AJCC TNM staging of cancer.

1. STAGING OF CANCER DR ALLWIN GEORGE

2. Why staging needed ? Defines prognosis Determining appropriate treatment based on the experience and outcomes of groups of previous patients with similar stage For clinical trials Evaluate the results of treatments and clinical trials Facilitate the exchange and comparison of information across treatment centers and within and between cancer-specific registries, and to serve as a basis for clinical and translational cancer research Conveying clinical experience to others without ambiguity

3. Staging system Tumor, Node, and Metastasis (TNM) staging system Most clinically useful staging system Developed by the American Joint C ommittee on Cancer (AJCC) in collaboration with the union for international cancer control (UICC) (AJCC TNM staging system)

4. AJCC TNM CLASSIFICATION Classifies cancers by Size and extent of the primary tumor (T) Involvement of regional lymph nodes (N) Presence or absence of distant metastases (M) Supplemented in recent years by evidence-based prognostic and predictive factors Exception - pediatric cancers

5. Who assigns the stage of cancer in a patient? Staging requires the collaborative effort of many professionals Managing physician, Pathologist - an accurate microscopic diagnosis Radiologist, Cancer registrar, others. Pathologist and the radiologist provide important staging information, and may provide important t-, n-, and/or m-related information Stage is defined ultimately from the synthesis of an array of patient history and physical examination findings supplemented by imaging and pathology data. Only the managing physician can assign the patient's stage, he routinely has access to all the pertinent information from physical examination, imaging studies, biopsies, diagnostic procedures, surgical findings, and pathology reports.

6. Related Publications to Facilitate Staging World Health Organization Classification of Tumours, Pathology and Genetics WHO International Classification of Diseases for Oncology (ICD-O), 3rd edition . American College of Radiology Appropriateness Criteria ® CAP Cancer Protocols . CAP publishes standards for pathology reporting of cancer specimens for National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines ® ). The National Comprehensive Cancer Network (NCCN) provides practice guidelines for most types of cancer American Society of Clinical Oncology (ASCO) Guidelines. ASCO develops guidelines and technical assessments for an array of clinical situations and tools

7. Evolving use of nonanatomic factors Nonanatomic cancer- and host-related factors Provide critical prognostic information May predict the benefit of specific therapies. Gleason score in early-stage prostate cancer Genomic profiles in women with node-negative breast cancer

8. TNM Staging Classification Stage may be defined at several time points Clinical Classification ( cTNM ) Based on patient history, physical examination, and any imaging done before initiation of treatment. Should not be changed based on: subsequent information obtained from the pathological examination of resected tissue, or information obtained after initiation of definitive therapy Pathological Classification ( pTNM ) Based on clinical stage information - supplemented/modified by operative findings and pathological evaluation of the resected specimens Post-therapy or Post Neoadjuvant Therapy ( ycTNM and ypTNM ) Determined after treatment for patients receiving systemic and/or radiation therapy alone or as a component of their initial treatment, or as neoadjuvant therapy before planned surgery Recurrence or Retreatment ( rTNM ) At the time of retreatment for a recurrence or disease progression Autopsy ( aTNM ) For cancers identified only at autopsy

9. AJCC Prognostic Stage Groups T, N, and M are grouped into prognostic stage groups, commonly referred to as stage groups For the purposes of tabulation and to analyze the care of patients who generally have a similar prognosis, Stage I, II, III, IV

10. ORAL CAVITY AJCC TNM STAGING AND GROUPING

11. ORAL CAVITY On Examination Tumor size – 3 cm in left buccal mucosa, not invading adjacent structures Nodes – single 7 cm in left neck (level 3) No Metastasis What is the TNM staging and prognostic grouping?

12. c T2 N3a M0 - prognostic group IV B

13. ORAL CAVITY After NACT he underwent surgery , Post op HPE - Tumor size – 1 cm residual diseas e, Nodes – absent What is the TNM staging ?

14. yp T1 N0 M0 - prognostic group 1

15. Elements of TNM Classification • c: clinical • p: pathological • yc : post neoadjuvant (radiation or systemic) therapy—clinical • yp : post neoadjuvant (radiation or systemic) therapy—pathological • r: recurrence or retreatment • a: autopsy Category/ Subcategory T Tis, T1 mi, T1 a, T1 b, T1 c N N2a, N2b M M1a, M1b

16. Elements of TNM

17. Elements of TNM

18. Category of TNM T The size and/or contiguous extension o f the primary tumor. The roles o f the size component and the extent of contiguous spread are specifically defined for each cancer site. N Cancer in the regional lymph nodes as defined for each cancer site, including Absence or presence of cancer in regional node(s), and/or Number of positive regional nodes, and/or Involvement of specific regional nodal groups, and/or Size of nodal metastasis or extension through the regional node capsule, and/or In-transit and satellite metastases, somewhat unique manifestations ofnonnodal intralymphatic regional disease, usually found between the primary tumorsite and draining nodal basins. M The absence or presence of distant metastases in sites and/or organs outside the local tumor area and regional nodes as defined for each cancer site

19. Category of TNM - T TX No information about the T category for the primary tumor , or it is unknown or cannot be Assessed T0 No evidence o f a primary tumor Tis Carcinoma in situ T1,2,3,4 Primary invasive tumor , for which a higher category generally means an increasing size an increasing local extension, or both

20. Clinical TNM, c T – COMPONENTS Synchronous primary tumors in a single organ For multiple tumors in a single organ, T is assigned to the highest T category; The preferred designation is: m suffix; for example, pt3(m) NO MO If the number o f tumors is important: suffix number of tumors ; eg , pt3(4) NO MO Note: The (m) suffix applies to multiple invasive cancers. It is not applicable to multiple foci of in situ cancer or a mixed invasive and in situ cancer .

21. c T - COMPONENTS Direct extension of a primary tumor into a contiguous or adjacent organ classified as part of the tumor (T) classification not classified as metastasis (M). Example Direct extension into the liver from a primary colon cancer – T category not in the M category.

22. Category of TNM - N NX No information about the N category for the Regional Lymph node, or it is unknown or cannot be Assessed N0 No Regional lymph node involvement N1,2,3,4 Evidence of regional node(s) containing cancer, with an increasing number, and/or regional nodal group involvement, and/or size o f the nodal metastaticcancer deposit, or non-nodal regional disease asnoted earlier for melanomaand Merkel cell carcinoma, and for colorectal carcinoma

23. N- components N( sn ) , N (f) If SLN biopsy is performed as part of the diagnostic workup: the cN category should have the sn suffix; for example, cNl ( sn ). If an FNA or a core biopsy is performed on lymph nodes as part o f the diagnostic workup the cN category should have the f suffix for example, cN 1 (f). N0( i +) ITCs - single tumor cells or small clusters of cells <0.2 mm in greatest diameter, generally without stromal response in the lymph node N0 (mol+) minimal deposits of cancer in lymph nodes detected using Non-morphologic techniques, including flow cytometry and reverse transcriptase polymerase chain reaction studies, N(mi) 0.2 to 2 mm micrometastasis

24. Category of TNM - M

25. M - components M( i +) Patients with CTCs ( circulating tumor cells), or DTCs ( disseminated tumor cells) in organs and micrometastasis In bone marrow, detected by IHC or molecular techniques, are categorized as cM0( i +). The cM0( i +) category denotes the uncertain prognostic significance of these findings.

26. Classification of TNM – Clinical TNM, c TNM

27. Classification of TNM – Pathological TNM/ pTNM

28. Classification of TNM – Post therapy TNM/ post neoadjuvant TNM / yc TNM, yp TNM

29. Residual Tumor and Surgical Margins