Oral Cancer Stage and Grade

Clinical staging and grading of Oral Cancer

1. Clinical Stage Clinical Stage
and Gradeand Grade
Rumbaoa, Janine R.
DMD4-A

2. 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

3. Tumor progressionTumor progression
•Tumors may occur spontaneously or follow a
series of cellular and tissue changes known as
epithelial dysplasia

4. 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

5. Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2
nd
ed. St. Louis: Mosby, p.
181
Histologic alterations Histologic alterations
observed in epithelial observed in epithelial
dysplasiadysplasia

6. Architectural Architectural
changes in epithelial changes in epithelial
dysplasiadysplasia
•Bulbous rete pegs
•Basilar hyperplasia
•Hypercellularity
•Altered maturation
pattern of
keratinocytes
Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2
nd
ed.) Philadelphia: Saunders
Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2
nd
ed.) St. Louis: Mosby

7. Carcinoma Carcinoma in in
situsitu
•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: Saunders
Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2nd ed.) St. Louis: Mosby

8. Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2
nd
ed. St. Louis: Mosby, p.
188
Malignant cells have
penetrated through
the basement
membrane into the
underlying connective
tissue
Transition of epithelial Transition of epithelial
dysplasia to invasive dysplasia to invasive
squamous cell carcinomasquamous cell carcinoma

9. GradingGrading
•Degree of
differentiation
exhibited by
cells
•How closely
cells resemble
normal tissue
structure
G - Histopathological
Grading
GX - Grade of differentiation
cannot be assessed
G1 - Well differentiated
G2 - Moderately
differentiated
G3 - Poorly differentiated
G4 - Undifferentiated

10. StagingStaging
•Based upon the size and extent of metastatic
spread of the lesion
•Tumor-node-metastasis (TNM) system used
for most cancers

11. •Stage I
The cancer is less than 2 centimeters in size (about 1
inch), and has not spread to lymph nodes in the area
(lymph nodes are small almond shaped structures
that are found throughout the body which produce
and store infection-fighting cells).
The following stages are The following stages are
used to describe cancer used to describe cancer
of the lip and oral cavityof the lip and oral cavity

12. •Stage II
The cancer is more than 2 centimeters in size, but less
than 4 centimeters (less than 2 inches), and has not
spread to lymph nodes in the area.

13. •Stage III
Either of the following may be true: The cancer is
more than 4 centimeters in size. The cancer is any
size but has spread to only one lymph node on
the same side of the neck as the cancer. The
lymph node that contains cancer measures no
more than 3 centimeters (just over one inch).

14. •Stage IV
Any of the following may be true: The cancer has
spread to tissues around the lip and oral cavity. The
lymph nodes in the area may or may not contain
cancer. The cancer is any size and has spread to more
than one lymph node on the same side of the neck as
the cancer, to lymph nodes on one or both sides of
the neck, or to any lymph node that measures more
than 6 centimeters (over 2 inches). The cancer has
spread to other parts of the body.

15. RecurrentRecurrent
Recurrent disease means that the cancer has come
back (recurred) after it has been treated. It may
come back in the lip and oral cavity or in another
part of the body.

16. Staging – TNM Staging – TNM
systemsystem
•Size, in cm, of the tumor (T)
•Involvement of lymph nodes (N)
•Presence or absence of distant metastasis (M)

17. 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”

18. 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”
N2a- Metastasis in single
ipsilateral lymph node
more than 3 cm but not
more than 6 cm in
greatest dimension
N2b- Metastasis in
multiple ipsilateral lymph
nodes, none more than 6
cm in greatest dimension
N2c- Metastasis in
bilateral or contralateral
lymph nodes, none more
than 6 cm in greatest
dimension

19. Staging – “M”Staging – “M”
Distant metastasis (M)
MX Distant metastasis not assessed
M0 No distant metastasis
M1 Distant metastasis is present

20. 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

21. SummarySummary
•Stage and grade of tumors indicates prognosis
•Treatment plans based upon stage and grade,
among other factors
•TNM system used with most cancers