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GRADING AND STAGING OF
TUMORS & PARANEOPLASTIC
SYNDROME
Shiksha Choytoo
Roll No. 12
22 September 2014
Introduction
Grading and staging are systems
developed to quantify the extent of a
neoplasm in a given case and its clinical
aggressiveness and to compare the end
results of various treatment modalities.
GRADING
Grading
• It is done on two basis:
1. level of differentiation
2. Number of mitotic figures per high power field
• It is done by histopathological exam. By pathologist.
Differentiation
• It is the extent to which the
tumor cells represent their
normal counter part both
morphologically and
functionally.
• Lack of differentiation
is anaplasia.
Mitotic Figure per HPF
• Cell under mitosis are easy
to spot
• The chromosomes are
visible as tangled, dark-
staining threads.
• We call these “mitotic
figures”.
• Helps in grading of tumor.
• The malignancy of tumor can be graded into 4 categories.
• Recommended by the American Joint commission on Cancers and other bodies
GRADES DESCRIPTION
GX Grade cannot be assessed
G1 Well differentiated (Low grade)
G2 Moderately differentiated (Intermediate grade)
G3 Poorly differentiated (High grade)
G4 Undifferentiated (High grade-ANAPLASIA)
Gleason Scale
Grading of CA Prostate
Grading of CA Breast
STAGING
• It is based on
1. Tumor size and/or extent reached
2. Lymph node status
3. presence or absence of metastasis
• It is done by detailed clinical examination, usually along with radiological exam. (x-ray, CT scan, MRI, Ultrasonography)
• Sometimes surgical exploration may be required.
• There are two systems of staging
1. Union for international cancer control (UICC)
The TNM system
2. American Joint Committee on Cancer (AJCC)
• Most medical facilities use the TNM system as their main method for cancer reporting.
TNM System
T • TUMOR SIZE
N • NODAL STATUS
M • +/- METASTASIS
Tumor sizeTUMOR (T) DESCRIPTION
TX Primary tumor cannot be evaluated
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor < 2cm
T2 Tumor 2-5cm
T3 Tumor > 5cm
Eg: CA Prostate
• NOTE
CA in situ
abnormal cells are present but have not spread to neighbouring tissue;
although not cancer, CIS may become cancer
sometimes called preinvasive cancer
Lymph Node Status
LYMPH NOTE STATUS (N) DESCRIPTION
NX Regional lymph nodes cannot be evaluated
N0 No regional lymph node involvement
N1 3 Lymph nodes + Axillary
N2 10 Lymph nodes+
Distant Metastasis (+/-)
METASTASIS DESCRIPTION
MX Distant metastasis cannot be evaluated
M0 No distant metastasis
M1 Distant metastasis is present
Eg: CA Breast
System based on AJCC
STAGE DESCRIPTION
Stage 0 Carcinoma in situ
Stage I
Stage II
Stage III
Higher numbers indicate more extensive disease:
Larger tumor size and/or spread of the cancer beyond
the organ in which it first developed to nearby lymph
nodes and/or tissues or organs adjacent to the location
of the primary tumor
Stage IV The cancer has spread to distant tissues or organs
Importance of grading and
staging
• Helps the doctor plan the appropriate treatment
• Estimates patients’ prognosis trials and comparing the
results of different trials.
• Helps health care providers and researchers exchange
information about patients.
• It also gives them a common terminology for
evaluating the results various treatments
NOTES
• Not all cancers have TNM Designation, eg cancers of spinal
cord and brain ( they are staged according to cell type and
grade)
• Most of the cancers of blood and bone marrow does not
have a clear cut staging system
• Ann Arbor staging classification – lymphomas
• Another staging system, developed by the International
Federation of Gynecology and Obstetrics (FIGO), is used to
stage cancers of the cervix, uterus, vagina, ovary and vulva.
PARANEOPLASTIC
SYNDROME
Definition
Paraneoplastic syndromes are defined as
symptoms complexes occurring in cancer
bearing patients which cannot be explained
on the basis of
• Local spread
• Distant spread
• Elaboration of hormone belonging to that
particular site from the tumor arose.
Significance
• May be the 1st manifestation of occult neoplasm
• It may mimic metastatic disease and confuse treatment
• It may be a serious clinical manifestation that prove fatal
Paraneoplastic syndromes can be grouped into the following 4 categories:
• Endocrinopathies
• Neurological
• Musculocutaneous
• Vascular and hematological
Endocrinopathies
CLINICAL SYNDROME
UNDERLYINGCANCER
CAUSAL MECHANISM
Cushing Syndrome •Small cell CA lung•Pancreatic cancer
Production of ACTH or ACTH like substances
SIADH- Syndrome of inappropriate ADHsecretion
•Small cell CA lung•Intracranial neoplasm
Ectopic ADH or atrialNatriuretic hormone
Hyper calcemia •Squamous cell CA lung•CA Breast•Renal cell CA•Ovarian CA•Adult T cell LL
Production of parathomone related peptide, TGF-alpha,TNF-alpha, IL-1
Hypoglycemia •Fibrosarcoma•Hepatocellular CA
Production of insulin and insulin like substance
Carcinoid Syndrome •Bronchial CA•Pancreatic Cancer•Gastric cancer
•Serotonin•Bradykinin
Polycythemia Renal Cell CA Erythropoetin
Nerve and Muscle Syndm.CLINICAL SYNDROME
UNDERLYINGCANCER
CAUSAL MECHANISM
Myesthenia gravis likes syndrome
Bronchogenic CA Immunological
Disorders of CSN & PNS CA Breast
DERMATOLOGICAL DISORDERSAcanthosis Nigricans
•Gastric CA•CA Lung•Uterine CA
Immunological & secretion of epidermal GF
Dermatomyositis CA LungCA Breast
Immunological
OSSEOUS,ARTICULARAND SOFT TISSUE CHANGES
Hypertropic osteoarthritis and clubbing of finger
Bronchogenic CA Unknown
Vascular & Hematological Changes
CLINICAL SYNDROME
UNDERLYINGCANCER
CAUSAL MECHANISM
Venous thrombosis or migratonisthrombophlebitis
•Pancreatic cancer•Bronchogenic CA•Mucin secreting adenocarcimoma
Tumor products and mucin activated clotting pathway
DIC Acute promylocyticleukemia
Muccin activated coagulation cascade
NBTE ( Non bacterial
endocarditis)
Disceminated/ Advanced CA
Anemia Thymic neoplasm Unknown
OTHERSNephrotic syndrome
Various cancers Deposition of tumor antigens & antibodies or immune complexes
References
• Class Notes
• Robbins and Cotran- pathology textbook
• Internet
• Wikipedia
Thank you