Module 6:
Clinical Stage
and Grade
Introduction
• 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
Tumor progression
• Tumors may occur spontaneously or follow
a series of cellular and tissue changes
known as epithelial dysplasia
Histologic alterations in
epithelial dysplasia
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•
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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
Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2nd ed.) St. Louis: Mosby
Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2nd ed.) Philadelphia: Saunders
Histologic alterations observed
in epithelial dysplasia
Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2 nd ed. St. Louis: Mosby, p.
181
Architectural changes in
epithelial dysplasia
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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
Carcinoma in situ
• 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
Transition of epithelial dysplasia
to invasive squamous cell
carcinoma
Malignant cells
have penetrated
through the
basement
membrane into
the underlying
connective tissue
Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2 nd ed. St. Louis: Mosby, p.
188
Grading
• Degree of differentiation exhibited by cells
• How closely cells resemble normal tissue
structure
• Grade I – low grade
• Grade II – moderately differentiated
• Grade III – poorly differentiated
Neville, B. W., Damm, D. D., Allen, C. M., & Bouquot, J. E. (2002). Oral and maxillofacial pathology (2nd ed.). Philadelphia: W.
B. Saunders.
Staging
• Based upon the size and extent of
metastatic spread of the lesion
• Tumor-node-metastasis (TNM) system
used for most cancers
Staging – TNM
system
• Size, in cm, of the tumor (T)
• Involvement of lymph nodes (N)
• Presence or absence of distant metastasis
(M)
Staging – “T”
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 – “N”
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 – “M”
Distant metastasis (M)
MX
Distant metastasis not assessed
M0
No distant metastasis
M1
Distant metastasis is present
TNM
Staging
System
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
Summary
• Stage and grade of tumors indicates
prognosis
• Treatment plans based upon stage and
grade, among other factors
• TNM system used with most cancers