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CLASIFICAREA STADIALA

cancer localizat

cancer avansat locoregional

cancer metastatic

– Necesitate impartire

OBIECTIVE

– indicatiei terapeutice– indicatii asupra prognosticului– aprecierea unitara a rezultatelor diferitelor

metode de tratament– schimbul de informatii : limbaj comun

CLASIFICAREA STADIALA

Reguli generale de clasificare

1. Confirmare HP . Cazurile fara separat2. TNM - Examene minime necesare ; X3. se tine cont de indicatiile privind definirea

teritoriilor limfatice4. T – indici in dreptul simbolului

1. Masurare in 2 diametre (cel mai mare si perpendicular pe primul)

2. Tumora nemasurabila = se folosesc criterii clinice specifice localizarii respective (ex. Col – extensie parametre , vagin)

Trepte de “T”

Tis T0 – nu e decelabila clinic T1,2,3, 4 – trepte progresive T x

daca sunt mai multe tumori : (2)T1, (5)T2 subcategorii a,b,c,d.

Trepte de “N”

• Date clinice (palpare) , paraclinice (limfografie, CT, Eco…)

• N0• N1- regionala mobila; < 2 cm ; consistenta dura, • N2 – bloc adenopatic ; > 2 cm ; fixare supra ;

subjacent• N3 – treapta de gravitate mai mare : ex. Sin,

plamin …..• Nx

Trepte de “M”

M0 M1 Mx M1a : col (hidronefroza, rect, vezica) M1b : meta la distanta

Gruparea pe stadii clinice Combinarea diferitelor trepte T, N, M I – IV I si II – considerate curabile III – greu curabil IV – incurabil nu se schimba niciodata indiferent de constatarile facute

in evolutia ulterioara a bolnavului 3 medici oscilare intre 2 stadii – se alege cel mai putin avansat

(pentru a nu falsifica rezultatele terapeutice) NU stadiu I/II sau III/IV …..

completare cea clinica; chir curativa informatii intraoperator in general pT = cT daca este pT = se alege pT, pN ,pM numarul de ganglioni invadati – indicatie

terapeutica ulterioara capsula intacta / nu ; grupare pe stadii

Clasificarea postoperatorie

Clasificarea postop (cont.)

DEFINIREA : - formei HP - mono / pluricentric - dimensiunea exacta a piesei - descriere macro - tesut peritumoral - elemente specifice pentru fiecare

localizare : tegument, IHC…..

Mastita carcinomatoasa

Meta hepatice

Meta osoase

Cancer bronhopulmonarBronhoscopie

Cancer bronhopulmonarRadiografie

Cancer bronhopulmonarTomografie computerizata

Cancer bronhopulmonarMRI

Cancer bronhopulmonarScintigrafie osoasa

NSCLCAnatomie patologica

NSCLC

NSCLC

NSCLC

Cancer de sanstadiu I

T1a: T T1a: T 0.5 cm 0.5 cm

T1b: 0.5 cm < T T1b: 0.5 cm < T 1 cm 1 cm

T1c: 1 cm < T T1c: 1 cm < T 2 cm 2 cm

T1 N0 M0T1 N0 M0

T T 2 cm 2 cm

T1T1

N0 = no regional lymph node metastasisM0 = no distant metastasis

Cancer de san . Stadiu IIAT2 N0 M0T2 N0 M0

N1 = mobiliM0 = fara metastaze

2 cm < T 2 cm < T << 5 cm 5 cm

Fara tumoraFara tumoraT0T0

T0 T0 T1T1 N1 M0N1 M0}

T2T2

Cancer de sanStadiu IIB

T3 N0 M0T3 N0 M0

T > 5 cmT > 5 cm

T2 N1 M0T2 N1 M0

T3T3

Cancer de sanStadiu IIIA

T0T0T1T1T2T2T3T3

N1 = mobiliN2 = fixati intre ei sau la alte structuriM0 = fara meta la distanta

T3 N1 M0T3 N1 M0 N2 M0N2 M0

Cancer de san Stadiu IIIB

orice T N3 M0orice T N3 M0T4 orice N M0T4 orice N M0

T4T4

Cancer de san Stadiu IV

M1 = metastaze la distanta (fara supraclaviculari ipsilaterali)

orice T orice N M1orice T orice N M1

NSCLC . Stadiu I 2 cm

N0: N0: M0:M0:

Fara invazie lobara

T 3 cm

IaIaT1T1 N0N0 M0M0

IbIbT2T2 N0N0 M0M0

T >3 cm

T + afectare pleura viscerala

T + atelectazie distala

Oricare din :

T= bronsie principala afectata

2 cm distal de carina

2 cmNSCLC. Stadiu II

N1: ipsilateral peribronsici +/- hilariN1: ipsilateral peribronsici +/- hilariM0:M0:

IIaIIaT1T1 N1N1 M0M0

IIbIIbT2T2 N1N1 M0M0

T + atelectazie totala

T3 N0 M0

Oricare din :T+ bronsie principala < 2 cm distal de carina

T (orice dimensiune) invadeaza peretele toracic, diafragm, pleura mediastinala sau pericardul

NSCLC . Stadiu IIIa

T3T3 N1N1 M0M0T3T3 N2N2 M0M0

T1 T1 N2N2 M0M0T2T2 N2N2 M0M0

N1:N1:N2: ipsilateral mediastinal +/- subcarinal N2: ipsilateral mediastinal +/- subcarinal M0: M0:

<2 cm 2 cm

OR

OR

OR

OR

T2

T peretele toracic sau diafragm

T pleura mediastinala sau pericardul

T 3 cm

T + invazie pleura

viscerala

T + atelectazie

T 3 cmFara invazie bronsie

NSCLC . Stadiu IIIbOrice T, N3, M0Orice T, N3, M0 T4, orice N, M0T4, orice N, M0

ScaleneScaleneSupraclavicularSupraclavicular

T (any size) invading mediastinum, heart, T (any size) invading mediastinum, heart, great vessels, trachea, esophagus, great vessels, trachea, esophagus, vertebral body, or carina vertebral body, or carina or T+ malignant pleural effusionor T+ malignant pleural effusion

Any TAny T

Any NAny N

T4T4

N3: contralateral mediastinal, N3: contralateral mediastinal, contralateral hilar, ipsilateral, or contralateral hilar, ipsilateral, or contralateral scaline or supraclavicular contralateral scaline or supraclavicular nodes involvednodes involved

Humphrey EW, et al. The American Cancer Society Textbook of Clinical Oncology. 1995;221-235.

NSCLC. Stadiu IV

orice T, orice N, M1orice T, orice N, M1

Mountain CF. Chest. 1997;111:1710-1717.

M1: distant metastasisM1: distant metastasis

Brain

Draining lymph nodes

PericardiumLungPleuraLiverAdrenalsSkinBone

NSCLC. Diseminarea limfatica

Secventa invaziei Secventa invaziei ganglionare:ganglionare:

First

Subsequent

From upper lobe

From middle lobe

From lower lobe

Cale de diseminare :Cale de diseminare :

Ginsberg RJ, et al. Cancer: Principles and Practices of Oncology. 5th ed. 1997;858-911.

NSCLC. DiseminareBrain

Draining lymph nodesPericardiumLungPleuraLiverAdrenals

Bone

Ginsberg RJ, et al. Cancer: Principles and Practices of Oncology. 5th ed. 1997;858-911.

PROSTATE CANCERLocal extension

PROSTATE CANCERLymphatic spread

Hypogastric nodes

External iliac nodes

Obturator nodes

Iguinal nodes

Ureter

Hypogastric and vesical arteries

Obturator nerve

External iliac artery and vein

Prostate

PROSTATE CANCERDistant metastatic spread

Lung

Bone

Liver

Epidural space

PROSTATE CANCERStage grouping

Used with the permission of the American Joint Committee on Cancer (AJCC®) Chicago, Illinois. The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.

Stage I T1a N0 M0 G1

Stage I T1a N0 M0 G2,3-4T1b N0 M0 Any GT1c N0 M0 Any GT1 N0 M0 Any GT2 N0 M0 Any G

Stage III T3 N0 M0 Any G

Stage IV T4 N0 M0 Any GAny T N1 M0 Any GAny T N2 M0 Any GAny T N3 M0 Any GAny T Any N M1 Any G

PROSTATE CANCERStage IT1 Clinically inapparent tumor not palpable nor visible by imaging

G1 Well differentiated (slight anaplasia) T1a No MO G1

T1a Tumor incidental histologic finding in 5% or less of tissue resected

N0 No regional lymph node metastasis

M0 No distant metastasis


PROSTATE CANCERStage II

T1a N0 M0 G2, 3-4 T1b N0 M0 Any G

T1a Tumor incidental histologic finding in 5% or less of tissue resected

T1b Tumor incidental histologic finding in more than 5% of tissue resected

N0 No regional lymph node metastasisM0 No distant metastasis

T1c N0 M0 Any G

T1c Tumor identified by needle biopsy (e.g., because of elevated PSA)

T1 clinically inapparent tumor not palpable nor visible by imaging


PROSTATE CANCERStage II (cont’d)

T2a N0 M0 Any GT2b N0 M0 Any G T2c N0 M0 Any G

T2a Tumor involves one lobe

T2b Tumor involves both lobes



T2 Tumor confined within prostate*


*Note: Tumor found in one or both lobes by needle biopsy, but not palpable or reliably visible by imaging, classified as T1c.

PROSTATE CANCERStage III

T3a N0 M0 Any GT3b N0 M0 Any G

T3c N0 M0 Any G

T3a Extracapsular extension(unilateral or bilateral)

T3b Tumor invades seminal vesicle(s)



T3 Tumor extends through the prostate capsule*


*Note: Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is not classified as T3, but as T2.

T4 N0 M0 Any GAny T N1 M0 Any GAny T Any N M1 Any G

PROSTATE CANCERStage IV T4 Tumor is fixed or invades adjacent

structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall

M1 Distant metastases

M1a Nonregional lymph node(s)

M1b Bone(s)

M1c Other site(s)

N1 Metastasis in regional lymph node or nodes


Formulare diagnostic se incepe cu forma HP (adenocc, cc, sarcom …) localizare elemente suplimentare despre tumora stadiul clinic + TNM

Adenocarcinom mamar drept, CSE , T2N1Mo (IIB)- daca evolueaza . ……. . Metastaze hep….- daca se prezinta cu stadiu IV- localizarea

metastazei

Grad de diferentiere

G1 = grad crescut de diferentiere G2 = moderat G3 = scazut G4 = nediferentiat Gx

SBR (Scale Bloom Richardson), scor Gleason

Markeri tumorali

2 categorii :– produsi directi ai celulelor tumorale– reactivi – prodisi de organism ca rezultat al

neoplaziei

MkT produsi de tumora

constituienti ai memebranei celulare sintetizati activi

Markerul :– constituient celular normal DAR in exces

(calcitonina)– produs metabolic anormal / ectopic (sindroame

paraneoplazice)

Constituienti ai membranei celulare

Antigenele oncofetale: – CEA : colon, rect, sin, plamin, stomac, vezica , esofag,

pancreas– AFP : hepatice, tumori germinale testiculare, ovariene

Mucinglicoproteinele :– CA 15.3 : sin– CA 19.9 :pancreas– CA 125 : ovar

alte glicoproteine :– PSA : prostata– LASA (acid sialic legat de lipide) : tu. conjunctive si

epiteliale

Produsi metabolici celulari enzime :

– FAP : in formele ce depasesc capsula– FA : meta osoase , hep (indiferent de tu primara) osteosarcom– LDH : limfoame , meta hep– GGT : meta hep– NSE : SCLC

hormoni :– beta-HCG : tu trofoblastice, testiculare– calcitonina, tiroglobulina : tiroidian (bine dif)– VIP, GIP, insulina, glucagon : tu digestive, tumori carcinoide :

serotonina– cataboliti urinari ai acidului vanil mandelic : neuroblastom,

feocromocitom– ACTH , ADH, parathormon : paraneo (BP)

AFP

dozare radioimunologica, ng/ml VN < 15 ng/ml T1/2 serica = 5-7 zile la pacientii cu seminom pur existenta

elementelor neseminomatoase poate fi crescuta

– 10-20 % in stadiile I– 20-40 % in stadiile II cu volum tumoral mic– 40-60 % volum tumoral mare

ß-HCG produsa de sincitiotrofoblast subunitarea alfa – identica cu LH, FS, TSH subunitatea beta – distincta valori crescute in : seminomatos / neseminomatos T1/2 = 18-36 ore Valori crescute :

– 10-20 % stadii I– 20-30 % stadii II– 40-60 % tumori neseminomatoase stadii avansate– 15-25 % stadii avansate seminom pur

false cresteri :– reactii incrucisate cu LH– hipogonadism indus terapeutic– productie pituitara de HCG

LDH

factor de prognostic independent in tumorile avansate

folosit in decizia terapeutica valori crescute :

– 60% in tumorile nonseminomatoase avansate

– 80% din tumorile seminomatoase avansate

PSA PSA : aprobat de FDA

> 50 ani (45 ani la cei cu AHC I) annual la cei cu speranta > 10 ani glicoproteine cu activitate serinproteazica PSA

– boli benigne - prostatita, HBP– tuseu prostatic– retentie urinara

> 10 ng/ml = cc. 2% din cei cu PSA > 10 ng/ml = HBP

combinare PSA + TR+ Eco = 75-80% detectare

oncogene :– factori de crestere : PDGF, EGF, VEGF (leucemii, cancer

mamar..)– proteine membranare :

receptori : erb-B, fms : receptor EGF, insulina si receptorul IGF - cc mamar, limfoame, hepatic

protein kinaze (tk) - src (LMC) , abl (limfom) – proteina C : ras – leucemii, tu epiteliale, sin, neuroblastom– proteine nucleare – myc : sin, leucemie mieloblastica,

neuroblastom markeri tumorali diversi

– imunoglobuline

Produsi metabolici celulari

Aplicatii clinice . DEPISTARE Nu sunt specifici!!!!! cazuri cu risc crescut de cancer – diag. precoce sarcini molare – HCG – coiocarcinom polipoza familiala CEA + informatii

endoscopice calcitonina – familii cu cc tiroidian medular AFP – cirotici, purtatori B,C, coroborarea markerilor cu metode specifice de

investigatie la populatiile cu risc creste valoarea lor diagnostica si le confera o specificitate ridicata

meta cu punct de plecare neprecizat – orientare : PSA , FAP , acid vanilmandelic,

valori : volum tumoral important , prognostic rezervat

prognostic si mai rezervat daca sunt crescuti 2

stabilire origine celulara a diferitelor tumori : tu testicular , HP seminom + AFP - trat neseminom

prognostic redus, intermediar, rezervat stadiu I in testicul – subdivizat in functie de pozitivitatea markerilor :

– I seric– I cu markeri negativ

Aplicatii clinice .

Diag. Clasif. Stad. Valoare prognostica

dozare secventiala tratament eficace (local / general) –

normalizare valori stationare – rezistenta la tratament crestere dupa normalizare – resuta preced recidiva clinica cu 3-6 luni (ovar)

Aplicatii clinice . Monitorizare tratament