STAGING
MCR Staff
Show Me Healthy Women
March 27, 2008
Supported by a Cooperative Agreement between DHSS and the
Centers for Disease Control and Prevention (CDC) and a
Surveillance Contract between DHSS and MU
Staging
Grouping of cancer cases
according to similar degrees of
spread or extent of disease.
Extent of disease is a detailed
description of how far the tumor
has spread from organ or site of
origin (the primary site).
Staging
 PURPOSES
 Determine
appropriate treatment
 Predict prognosis
 Evaluate results of treatment
 Facilitate exchange of information
 Contribute to research of human
cancer
Staging Elements
 Elements to be considered in any
staging system are the
 primary
tumor site,
 tumor size,
 multiplicity (number of tumors),
 depth of invasion and extension to regional
or distant tissues,
 involvement of regional lymph nodes, and
 distant metastases.
Types of Staging Systems
 Summary Staging
 American Joint Committee on Cancer
(AJCC) Staging System
 Collaborative Staging
 Others
 FIGO
(GYN)
 Dukes (colorectal)
 Ann Arbor ( Lymphoma)
FIGO
 Acronym for the French term that
means International Federation for
Gynecology and Obstetrics. The
American Joint Committee on Cancer
has developed the tumor (T) component
of the TNM staging system to
correspond to FIGO staging.
How to?
 Where did the cancer start?
 Where did the cancer go?
 How did the cancer get there?
 What is the stage?
Staging Sources
 Physical Exam
 Radiologic Procedures
 X-rays
 Scans
 Endoscopies
 Tumor markers
 Pathologic exams
 Surgical reports
 Progress Notes and Discharge Summaries
How Cancer Spreads
 Local invasion
 Direct extension
 Lymphatic metastases
 Blood-borne metastases
 Intra-cavitary
Summary Staging
0 – in situ
1 – localized
2 – regional by direct extension only
3 – regional lymph nodes involved only
4 – regional by both direct extension and
lymph node involvement
 5 – regional, NOS (not otherwise specified)
 7 - distant site(s)/node(s) involved
 9 – unknown (unstaged, unknown or
unspecified)
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training.seer.cancer.gov
In Situ Terms
 CIN III
 Confined to epithelium
 Intracystic, non-infiltrating
 Intraductal
 Intraepidermal
 Intra-epithelial
 Intrasquamous
 Stage 0
In Situ Terms
 Involvement up to but not including
the basement membrane
 Lobular neoplasia
 Non-infiltrating
 Non-invasive
 No stromal invasion
 Preinvasive
CIN III
 CIN III (cervical intraepithelial neoplasia
grade iii) must be carefully reviewed,
because this diagnosis includes both
carcinoma in situ and severe dysplasia.
Microinvasion
 Microinvasion implies invasion through
the basement membrane. The stage
would be INVASIVE not insitu.
 Any foci of invasion makes the stage
invasive rather than insitu.
training.seer.cancer.gov
training.seer.cancer.gov
Distant
 Distant mets can be by:
 direct
contiguous extension
 implantation (discontinuous) mets
 lymph node involvement
Unstageable
 Unknown primaries
 Not enough information to stage
 Death certificate only
AJCC (TNM) Staging
Louanne Currence, RHIT, CTR
What is TNM Staging?
 Developed by physicians (AJCC)
 Uniform staging system to determine
treatment, prognosis & end results
 T = Tumor
 N = Nodes
 M = Metastasis
 Group Stage = summary of TNM
Clinical Staging
 Used to select primary treatment
 Each site has specific guidelines of
what is acceptable under cTNM
Physical exam
Radiology
Endoscopy
Biopsy
Pathologic Staging
 Based on pre-treatment evidence
and/or subsequent surgery/path
 Used to
 Determine
adjuvant therapy
 Estimate prognosis
 Report end results
T
 Primary "Tumor" and its contiguous
extension
 Based on size (invasive only)
 Based on penetration
 Extension of primary
T
 T-value increases with worsening
scenario
 Tx - cannot assess
 T0 - no evidence of primary
 Tis - In situ (never sarcomas)
 T1-4
Sample "T"s
 < 1.0 cm breast lesion = T1
 3.0 cm LOQ breast lesion = T2
 Carcinoma confined to uterus = T1
 Cervical carcinoma extends to
pelvic wall = T3
N
 Regional lymph nodes
 Absence
or presence of + LN
 # of + LNs/size of metastasis
 Laterality of + LNs/size of mets
 Named LN chains
N
 Increases in severity
 Nx
- cannot assess
 N0 - no regional LN mets
 N1-3
Sample "N"s
 Breast
 Metastasis
in axillary LNs fixed or
matted = N2
 1 of 15 axillary LNs + (breast) = N1
 Cervix
1
+ pelvic node = N1
M
 Some sites have listing
 Mx - cannot assess
 M0 - no distant mets
 M1 - distant mets found
Group Stage
 Is the general reference point of
comparison
 Tis = Stage 0
 Stage I, Stage II, Stage III, Stage IV
Group Stage Examples (Breast)
Stage 0
Tis
N0
M0
Stage I
T1
N0
M0
Stage IIA
T0
N1
M0
~~~~~
~~~~~
~~~~
~~~
Stage IIIB
T4
N0
M0
Stage IIIC
Any T
N3
M0
Stage IV
Any T
Any N
M1
Group Stage Samples (Cervix)
Stage 0
Tis
N0
M0
Stage I
T1
N0
M0
Stage IIA
T2a
N0
M0
~~~~~
~~~~~
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~~~
Stage IIIB
T1
N1
M0
T2
N1
M0
Any T
Any N
M1
Stage IV
Collaborative Stage
 Collaborative Staging (CS) data items
 CS
Extension
 CS Lymph Nodes
 CS Mets at Dx
Steps for Staging
1) Determine primary site & histology
3) Is histology included?
4) Review list of regional LNs
5) Review rules of classification
6) Find staging information in chart
7) Determine T, N, M and group stage
Exercises
Missouri Cancer Registry
Help Line: 800-392-2829

Help interpreting path report for staging
http://mcr.umh.edu
 For further information, please contact:
Sue Vest, Project Manager,
vests@health.missouri.edu
Nancy Cole, Assistant Project Manager
colen@health.missouri.edu