Staging, Grading, and Clinical Investigations PDF

Presentation by Jonathan Staging, grading and clinical Brack Senior lecturer investigations Learning outcomes Understand the diagnostic stage of the patient pathway for common cancers Explore the role of cancer screening programmes...

Presentation by Jonathan Staging, grading and clinical Brack Senior lecturer investigations Learning outcomes Understand the diagnostic stage of the patient pathway for common cancers Explore the role of cancer screening programmes Appreciate the range of diagnostic tools used for cancer diagnosis Appreciate how prompt diagnosis impacts on prognosis Understand common staging and grading mechanisms and their importance in cancer treatment Prevention and Screening Advances have resulted in significantly improved relative survival for all cancers. Prevention: strategies and measures that stop cancer from developing Screening: Tests and investigations to check for disease before signs and symptoms are evident (while patients are asymptomatic)  Screening for cancer Screening = early detection = reduced mortality Screening is useful when: ̶ A disease has a high prevalence in a population ̶ Tests exist that have good sensitivity and specificity UK based screening programmes Detection and diagnosis Sign: an objective finding as perceived by an examiner Symptom: a subjective indication of a disease or a change in condition as perceived by the patient. Diagnosis: The identification of a disease or a condition Physical Patient examinati interview on Diagnostic tests The Patient interview Use to establish the chronological events of the symptoms of the patient’s illness Medical history is reviewed Familial history is noted Possible symptoms American Cancer Society advise C.A.U.T.I.O.N. Change in bowel or bladder habits A sore or ulcer that doesn’t heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in a mole or wart Nagging cough or hoarseness of voice Self-examination Breast cancer self-examination Self-exam of the testicles Spotting cancer early The physical examination Inspection Palpation Vital signs Diagnostic tests- lab studies – Normal FBC levels Diagnostic tests –lab studies Urine tests Stool samples Sputum sample Blood tests for tumour markers: ̶ PSA (prostate specific antigen) ̶ AFP (alpha-fetaprotein) ̶ BTA (bladder tumour antigen) ̶ BRCA1 and BRCA2 ̶ CA15 ̶ CA125 Common tumour markers Diagnostic tests - imaging Nuclear Medicine Plain x-rays Computed Tomography Magnetic Resonance Imaging Diagnostic ultrasound Biopsy Histological evidence is vital in making a diagnosis of cancer Incisional biopsy: Removes a portion of the tumour for diagnosis Excisional biopsy: Removal of the entire tumour for diagnosis Fine Needle Aspiration: Removal of fluid Core Needle Biopsy: Needle inserted into tumour and a core of tissue is removed Biopsy explained Cancer diagnosis pathway Patient Intervie w Physica l exam Lab studies Medical imagin g Biopsy Diagno sis From diagnosis to staging Now that a diagnosis has been made further imaging may be required for staging purposes. Staging: Establishing the anatomic extent of the disease Staging helps to: Determine a treatment plan for the patient (surgery, RT, chemo..) Provides an indication of prognosis Assists in the evaluation of the results of treatment Assists in the exchange of information from one cancer centre to another Staging investigations Sentinel node biopsy: The lymph node that is first to receive draining fluid from the primary site (breast, melanoma) is removed to determine if cancer cells are present. Medical Imaging: Bone scans, PET, CT, MRI.. of areas where the cancer type is known to spread Bone marrow aspiration: biopsy to collect and examine bone marrow Pathology report: can confirm tumour size, growth into other tissues How do cancers spread? Direct invasion Ductal infiltration Blood borne spread Lymphatic spread CNS spread Transcoelomic spread (through pleura; pericardium, peritoneum) Staging: numerical system Stage 0 - Carcinoma in situ (early cancer that is present only in the layer of cells in which it began). Stage I, Stage II, and Stage III - Higher numbers indicate more extensive disease, i.e. greater tumour size, and/or spread of the cancer to nearby tissues, lymph nodes and/or organs adjacent to the primary tumour. Stage IV - The cancer has spread to another organ. Staging systems: TNM TNM staging: Tumour Nodes Metastases Endorsed by UICC (Union for International Cancer Control) and AJCC (American Joint Committee on Cancer) TNM staging: Tumour To = No evidence of primary tumour. Tis = Carcinoma in situ (early cancer that has not spread to neighbouring tissue) T1 = Relatively small primary tumour confined to the organ of origin. T2 = Relatively large tumour, but still confined to the organ of origin. T3 = Primary tumour is invading neighbouring structures. T4 = Large primary tumour with extensive local spread. Tx = Unable to determine extent of primary tumour. TNM staging: Nodes N0 = No lymph nodes palpable. N1 = Moveable nodes palpable on the same side of the body as the primary tumour. N2 = Moveable nodes on the opposite side of the body from the primary tumour. N3 = Fixed nodes anywhere in the body. Nx = Regional lymph node status has not been, or could not be assessed. TNM staging: Metastases M0 = No evidence of distant metastases. M1 = Evidence of distant metastases. MX = Possibility of distant metastases has not yet been determined. Grading tumours A histological grade also needs to be determined and forms a large part of the decision- making process for the treatment plan proposed for the patient. Histological Grade: Refers to the differentiation of the cell. The closer the tumour cell resembles its normal counterpart = better differentiated = slower growing = less aggressive = better prognosis Grading GX - Grade cannot be assessed G1 - Well-differentiated G2 - Moderately differentiated G3 - Poorly differentiated G4 - Undifferentiated Gleason Grading Used to grade prostate cancers Grade Groups of prostate cancer Some practical examples Breast cancer: Screening NHS breast cancer screening Females aged between 50 and 71 are invited for a screening mammogram every 3 years. Breast cancer: diagnosis Patient interview (may have noticed a lump herself or detected at a screening exam) Physical exam of breast and reginal lymph nodes Mammography Ultrasound MRI in younger woman FNA / Core needle biopsy / excisional biopsy Diagnosis: Ductal carcinoma ; Invasive Lobular carcinoma etc and a grade is determined Breast cancer: staging TNM system is used Lab Tests: o Hormone status (blood tests) o FBC o Liver function tests Imaging: o CT chest o CT abdomen o Bone scan Prostate cancer: screening No reliable test is available, and screening is not offered in the UK. An informed choice programme has replaced a national screening programme. Men aged 50 or over can request a PSA test after discussion with a GP. Digital rectal exam can be performed annually in men over 50 Prostate cancer: Diagnosis Patient interview: Increased frequency, decreased urinary stream; dysuria; haematuria Physical exam: hard irregular gland on rectal examination; Lab tests: PSA Biopsy: transrectal ultrasound guided Diagnosis: adenocarcinoma.. Grading is determined Prostate cancer: staging TNM system is used Lab tests: FBC Medical Imaging: MRI pelvis: shows local invasion of bladder; seminal vesicles and rectal wall CT: pelvis and abdomen Bone scan: high incidence of bone mets PET: distant mets Transrectal ultrasound Lung cancer: screening Targeted lung cancer screening is soon to be offered in some parts of the UK People between the ages of 55-74 who smoke or used to smoke may be invited for assessment Until this service is running a lung health check is offered in some parts of England and Wales. High risk patients are offered a CT of the chest. Lung cancer: diagnosis Patient interview: History of smoking, cough, breathlessness, haemoptysis Physical exam: Infection, pleural effusion Lab tests: sputum cytology; spirometry Medical Imaging: Chest x-ray CT chest Bronchoscopy Biopsy: CT guided FNA, bronchoscopy guided biopsy Diagnosis: SCLC ; NSCLC Grading is determined Lung cancer: staging TNM system and numerical system is used is used Lab tests: FBC LDH and alkaline phosphate tests etc may indicate bone and liver involvement Medical Imaging: MRI brain CT/MRI abdomen PET Colorectal cancer: screening A national bowel cancer screening programme is available in the UK Everyone aged 60-74 is sent a bowel cancer screening kit every 2 years. The programme may shortly be expanded to include everyone aged 50-59. Stool sample is collected at home and is then sent for analysis Colorectal cancer: diagnosis Patient interview: rectal bleeding Physical exam: digital rectal exam, pelvic exam, abo exam, lymph node assessment (pelvis and supraclav) Lab tests: stool sample Colonoscopy Biopsy Diagnosis: adenocarcinoma.. Grading is determined Colorectal cancer: staging TNM system is used Lab tests: FBC Liver function tests Carcinoembryonic antigen (CEA) Medical Imaging: Chest x-ray CT / MRI pelvis PET-CT From diagnosis to treatment Treatme Diagnos nt Staging is decision s