Minimum Datasets and Clinical Staging

Datasets and clinical staging Dr J Stevenson ST6 Histopathology Whiston Hospital

Outline 

Principles of cancer staging

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Different staging systems in use

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Examples of staging of specific cancers

TNM staging system  



Cancer staging system Developed and maintained by UICC (International Union Against Cancer) The TNM system is an expression of the anatomic extent of disease and is based on the assessment of 3 components   



T- extent of primary tumour N- lymph node M- distant metastases

Latest edition - 8th edition (TNM 7 may still be in use)

TNM staging system     

T: size or direct extent of the primary tumuor Tx – cannot assess primary tumour T0 - no signs of tumour Tis- Carcinoma in-situ T1 to T4- depend on size or extent of primary tumour

TNM staging system 

Prefix used: c- clinical staging; e.g. cT3  p- pathological staging on resection specimen  y- neoadjuvant chemotherapy  r- recurrent tumour after disease free interval  a –classification determined at autopsy 

TNM staging system 

Other prognostic parameters Grade of tumour – G1-3  Completeness of resection 

Rx- residual tumour cannot be assessed  R0- no residual tumour at margins  R1- microscopic residual tumour  R2-macroscopic residual tumour 



Lymphovascular invasion L- lymphatic invasion  V- venous invasion 

Other organisations 

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 

AJCC (American Joint Committee on Cancer)  Skin cancer staging in the UK (although now UICC TNM 8) FIGO (International Federation of Gynaecology and Obstetrics)  Gynaecological tumours Ann Arbor Staging  Lymphoma International Staging System for Neuroblastoma (INSS) and International Neuroblastoma Risk Group (INRG)  Neuroblastoma

EMQ Choose from the options below: 

    

 

FIGO AJCC 8th edition UICC TNM 8th edition UICC ypT3N0M0 pT2N0M0 pT0N0M0 cT3N0M0

EMQ  







System used for staging of endometrial tumour Organisation that develops TNM staging Staging system used for Melanoma staging currently in the UK Colorectal tumour which had received neoadjuvant therapy and on resection infiltrates beyond muscularis propria without lymph node involvement or metastases In MDT, the stage used before resection of breast carcinoma clinically measuring 55mm

EMQ 

System used for staging of endometrial tumour 



Organisation that develops TNM staging 



FIGO UICC

Staging system used for Melanoma staging currently in the UK 

UICC TNM 8th edition

EMQ 



Colorectal tumour which had received neoadjuvant therapy and on resection infiltrates beyond muscularis propria without lymph node involvement or metastases  ypT3N0M0 In MDT, the stage used before resection of breast carcinoma clinically measuring 55mm  cT3N0M0

Datasets 

Published by The Royal College of Pathologists

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Defines minimum standard for reporting of common cancers

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Evidence based

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Consistency in reporting

Datasets 

The Working Group on Cancer Services (WGCS) production of guidelines and datasets for the reporting of cancers

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WGCS recommendations for histopathologists reporting cancer:     

Use of dataset Nominate lead pathologist Participate in EQA Should be a core member of MDT CPA accredited laboratory

Datasets Provide:  communication with clinicians to achieve optimal patient management  clinical audit of pathology services  accurate and consistent data recording for the Cancer Services and Outcomes Dataset (COSD)  comparison between cancer services.

Datasets 

Core-items recorded by Cancer Registries and National Cancer Outcomes and Services Dataset (COSD)  Essential to record these items 



Non-core items 

recorded to improve the clarity of reports, because of particular local interest, for monitoring clinical trials or for research.

Specific examples

Breast   

Tumour size – most important for staging pTis – DCIS, LCIS or Paget’s disease pT1 up to 2cm    

  

pT2 2-5cm, pT3 >5cm pT4 – skin / chest wall involved Grading 

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pT1mi – microinvasion <1 mm pT1a – 1<5 mm pT1b – 5<10 mm pT1c – 10<20 mm

Tubules, pleomorphism, mitoses

Lymph node   

Metastasis - >2mm micrometastasis  >0.2mm to <2mm ITC (isolated tumour cells)  <0.2mm

Reporting categories for breast biopsy  

  

B1 :  Normal breast – breast parenchyma present or not B2:  FA, FCC, Sclerosing Adenosis, Fat necrosis, Abscess, Duct ectasia B3  Papilloma, Radial scar, Phyllodes B4  Suspicious B5  B5a – in-situ; B5b- invasive

MCQ 

Which of these is the most important parameter in breast cancer staging?

1.

2.

3.

4.

Type of tumour Hormone status Tumour size Tumour grade

Answer 

Tumour size

MCQ 

A sentinel lymph node in wide local excision specimen has tumour cells measuring 1.8mm in maximum dimension. Which of the category does this fall into?  

 

Macrometastases Micrometastases Isolated tumour cells No evidence of metastases

Answer 

Micrometastases

MCQ 

A histology mastectomy specimen shows Paget’s disease of nipple but no evidence of invasive carcinoma. How will you stage it  

 

pTx pT0 pT1 pTis

Answer 

pTis

Thyroid   

  

pTX Primary tumour cannot be assessed pT0 No evidence of primary tumour pT1a </=10 mm, limited to thyroid pT1b </=20 mm but >10 mm, limited to thyroid pT2 >20 mm, </=40 mm, limited to thyroid pT3 >40 mm, limited to thyroid or any tumour with minimal extrathyroidal extension, 

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pT4a Tumour invades beyond thyroid capsule and invades any of: subcutaneous soft tissues, 

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E.g. extension to sternothyroid muscles or perithyroid soft tissues

E.g. larynx, trachea, oesophagus, recurrent laryngeal nerve

pT4b Tumour invades prevertebral fascia, mediastinal vessels, or encases carotid artery.

Cont…

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All anaplastic carcinomas are considered pT4 tumours (TNM 7). pT4a Anaplastic carcinoma limited to thyroid pT4b Anaplastic carcinoma extends beyond thyroid capsule.

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For clinical staging of papillary/follicular thyroid carcinoma

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Age important criteria (> 55 years poorer prognosis)

MCQ 

A thyroid tumour has histology of anaplastic carcinoma with infiltration into the recurrent laryngeal nerve. What is the tumour stage     

pT0 pT1 pT2 pT3 pT4

Answer 

pT4a

Gastrointestinal neuroendocrine tumour  



Well-differentiated (poorly differentiated are staged as per carcinoma) Grading Grade

Mitoses (per 10 hpf)

Ki67 index (%)

1

<2

<2

2

2-20

3-20

3

>20

>20

Staging varies depending on site of lesion, size and depth of invasion

Colorectum 

TNM 8 pTis – limited to lamina propria  pT1 – invades submucosa  pT2 – invades muscularis propria  pT3 – invades beyond muscularis propria  pT4a – perforates visceral peritoneum  pT4b – directly invades other organs or structures 

Colorectum (cont…) 

Node staging Nx – not assessed, N0 – no nodal mets  pN1a – 1 node involved  pN1b – 2 or 3 nodes involved  pN1c – subserosal tumour deposits (without nodal mets)  pN2a – 4-6 nodes involved  pN2b – 7 or more nodes involved 

Local excision of polyp 

Kikuchi level  Sessile tumour  1-3 (level of submucosal invasion)



Haggitt’s level  Polypoid tumour  1-4 (Head, neck, stalk, beyond base)

MCQ 

Which of the following stage of tumour can be confirmed on macroscopic examination of colorectal tumour?  

  

pT1 pT2 pT3 pT4a pT4b

Answer 

pT4a

Gastrointestinal stromal tumour 

Lasota and Miettinen    

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CD117, DOG-1 

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Prediction of tumour behaviour Tumour size (<2cm) Mitoses – per 5mm² (<5) Site of tumour – gastric, duodenum Essential

Mutational analysis  

C-kit – exon 9, 11, 13,17 PDGFRA – exon 12,14, 18

MCQ 

A gastric tumour shows spindle cell morphology and is positive for CD117 and DOG-1. The tumour measures 1cm with 3 mitoses per 5mm².

What is the risk of progressive disease according to Lasota and Miettinen criteria?

None  Low  Moderate  High 

Answer 

None

Pancreas 

Kausch-Whipple’s pancreatoduodenectomy 

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Transection margin in Whipple’s resection: 

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

Gastric, Duodenal, CBD, Pancreas

Dissected margin 



Head of pancreas, Duodenum, CBD, 2/3rd of stomach

SMA/SMV (medial) and posterior margin

Minimum number of lymph nodes – 15 Staging differs depending on where the tumour has arisen from

Kausch-Whipple’s pancreatoduodenectomy

Liver biopsy  



pM0 – does not exist pM1= distant metastasis proven microscopically, e.g.needle biopsy If a cM1 (e.g. liver met) is biopsied and is negative, it becomes cM0, not pM0

Tumour at the gastro-oesophageal junction 

Siewert type: 1–5 cm above the gastro-oesophageal junction (Type 1) - oseophageal  at the junction (Type 2) - gastric  2–5 cm below the junction (Type 3) - gastric 

Tumour at the gastro-oesophageal junction – TNM 8th edition 

A tumour in the stomach, the epicenter of which is within 2 cm of the oesophagogastric junction and also extends into the oesophagus is classified and staged according to the oesophageal scheme



All other tumours with an epicenter in the stomach <20 mm without extension into the oesophagus or greater than 2 cm from the oesophagogastric junction are staged using the gastric carcinoma scheme

Cervical carcinoma 

FIGO I 

 



FIGO IA1 -Measured stromal invasion ≤ 3.0 mm and ≤ 7.0 mm FIGO IA2 -Measured stromal invasion of > 3.0 mm and not > 5.0 mm with an extension of not >7.0 mm

FIGO II 



FIGO IA  Invasive carcinoma, diagnosed only by microscopy,  with deepest invasion ≤ 5.0 mm and largest extension ≤ 7.0 mm.

Beyond uterus but not to pelvic wall or lower third vagina

FIGO III 

Causes hydronephrosis

Endometrial carcinoma 

Tumour grade Endometrioid  Grade 1- <5% solid non-squamous component  Grade 2- 6-50%  Grade 3 ->50%  Upgrading on nuclear characteristics – pleomorphism, mitoses, prominent nucleoli 

Endometrial carcinoma 

High grade carcinoma: 



FIGO IA 



No or less than half of myometrial invasion

FIGO IB 



Serous carcinoma, clear cell carcinoma, undifferentiated carcinoma and carcinosarcoma

Invasion equal to or more than half of the myometrium

FIGO 2- cervical stromal involvement

Ovarian carcinoma 

Serous carcinoma 

Low grade <12mitoses/10hpf  No necrosis or multinucleate tumour cells  Mild nuclear atypia 



High grade >12mitoses/10hpf  Necrosis or multinucleate tumour cells  Marked nuclear atypia 

Ovarian Carcinoma 

FIGO I- tumour limited to ovaries IA-one ovary, capsule intact, no tumour on surface or peritoneal fluid  IB-both ovaries 



FIGO IC 

Tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface; malignant cells in ascites or peritoneal washings

Ovarian carcinoma 

FIGO II 



One or both ovaries with pelvic extension

FIGO III- peritoneal deposit outside pelvis IIIA- microscopic  IIIB- macroscopic 2cm  IIIC- macroscopic >2cm 

Uterine Sarcoma 

Leiomyosarcoma  2 of 3 features  Severe

nuclear atypia  Mitosis>10/10 hpf  Coagulative necrosis

Uterine leiomyosarcoma Stage I Tumour limited to uterus IA ≤5 cm, IB >5 cm  Stage II Tumour extends beyond the uterus, within the pelvis IIA Adnexal involvement,IIB Involvement of other pelvic tissues  Stage III Tumour invades abdominal tissues (not just protruding into the abdomen) IIIA One site, IIIB > one site, IIIC Metastasis to pelvic and/or paraaortic lymph nodes  Stage IV IVA Tumour invades bladder and/or rectum, IVB Distant metastasis 

Melanoma 

UICC TNM 8th Edition 



Early melanoma – mitotic rate more important not Clark’s level

Breslow thickness Increase thickness – increased risk of metastasis  Thin melanoma - <1mm  Extension to peri-appendeal sheath and microsatellites are not counted 

Melanoma 

Ulceration  Important  pT

prognostic factor

stage

 full-thickness

epidermal defect (including absence of stratum corneum), evidence of reactive changes(i.e. fibrin deposition and neutrophils), and thinning, effacement or reactive hyperplasia of the surrounding epidermis in the absence of trauma or recent surgical procedure

Melanoma T

Thickness (mm) Ulceration status

1

a: Without ulceration

2

a: <0.8 b: 0.8-1.0 1.01–2.0

3

2.01–4.0

a: without ulceration b: with ulceration

4

>4.0

a: without ulceration b: with ulceration

b: With ulceration a: without ulceration b: with ulceration

Melanoma 

T1a is restricted to melanomas with two criteria <1.0 mm thick  Absence of ulceration 

Melanoma 

Micrometastases 



diagnosed after sentinel lymph node biopsy and completion lymphadenectomy (if performed). They occur in the setting of no clinical abnormality.

Macrometastases 

defined as clinically detectable nodal metastases confirmed by therapeutic lymphadenectomy or when nodal metastasis exhibits gross extracapsular extension. They occur in the setting of a clinical abnormality

Melanoma - metastases 

M0 



M1a 



Metastases to lung

M1c 



Metastases to skin, subcutaneous, or distant lymph nodes

M1b 



No detectable evidence of distant metastases

Metastases to all other non CNS sites

M1d 

CNS mets

MCQ 

A patient has cutaneous melanoma with Breslow thickness of 0.7 mm with Clark level 2, mitotic rate 1mm², brisk tumour infiltrating lymphocytes, no lymphovascular invasion or perineural invasion. No evidence of ulceration. Margins are clear. Which is the most important staging criteria here?   



Clark level Breslow thickness Ulceration Mitoses

Answer 

Ulceration

Skin – Squamous cell carcinoma   

pT1 ≥20mm size pT2 20 ≤ 40 mm pT3 <40 mm 



Or: minor bone erosion or perineural invasion (named nerve or ≥ 0.1 mm) or deep invasion (beyond SC fat or >6 mm)

pT4 axial skeleton invasion including skull base or foraminal involvement

Skin - BCC 

High risk pathological factors  Growth pattern: infiltrating/morphoeic and/or micronodular  Basosquamous carcinoma  Clark level 5 or beyond  Perineural invasion  Lymphovascular invasion present

Adult Kidney 

Staging 

pT1 –less than or equal to 7cm, confined to kidney. pT1a <= 4cm, pT1b >4cm



T2 - >7cm



Adult Kidney 

Staging 

  

T3a –Tumour grossly extends into the renal vein or its segmental (muscle containing) branches, or tumour invades perirenal and/or renal sinus fat.

T3b – Tumour grossly extends into the vena cava below the diaphragm.

T3c – Tumour grossly extends into the vena cava above the diaphragm or invades the wall of the vena cava.

T4 

Tumour invades beyond Gerota fascia (including contiguous extension into the ipsilateral adrenal gland).

Adult Kidney 

WHO/ISUP grading  Nucleoli 1- none  2- 40hpf  3- 10hpf  4-bizarre cells 

Prostate  

Gleason grading Gleason score in radical prostatectomy 

most prevalent and second most common grades and to mention the presence of a tertiary grade

Prostate 

Gleason score in biopsy If only one grade is present, it is doubled (e.g. 3+3);  If two grades are present, both are included by order of prevalence;  If more than two grades are present, the third is included in the sum score if it is of higher grade 

Prostate 

pT1 (on biopsy or TURP)  pT1a Tumour incidental histological finding in 5% or less of tissue resected  pT1b Tumour incidental histological finding in more than 5% of tissue resected  pT1c Tumour identified by needle biopsy (e.g. because of elevated PSA)

Prostate 



pT2  pT2a Tumour involves one half of one lobe or less  pT2b Tumour involves more than half of one lobe, but not both lobes  pT2c Tumour involves both lobes pT3  pT3a Extracapsular extension (unilateral or bilateral)  pT3b Tumour invades seminal vesicle(s)

Bladder tumour  

pT2 – muscularis propria pT3b – gross invasion into perivesical tissue

Lung 

Important parameters for staging   



Tumour size (pT1 <3cm, pT2 3-7cm) Main bronchus involvement Visceral pleura involvement

pT1 mi – minimally invasive adenocarcinoma  a – ≤ 1 cm  b – 1 ≤ 2 cm  c – 2 ≤ 3 cm 



pT2   



a – 3 ≤ 4 cm b – 4 ≤ 5 cm Or: involves main bronchus (not the carina), invades visceral pleura, associated obstructive pneumonitis

pT3  



Cont…

5 ≤ 7 cm Or: separate tumour nodule in same lobe, or invades – parietal pleura, chest wall, phrenic nerve, parietal pericardium

pT4 - >7 cm or invaded anything else

EMQ      

  

 

Gastric cancer Oesophageal cancer pM0 cM0 cM1 High grade Low grade Gleason grade 4 Gleason grade 3 Fuhrman grade 3 Fuhrman grade 4

EMQ 

A tumour at within 5 cm gastroesophageal junction without extension into the oesophagus – 



A liver biopsy with clinical suspicion of metastasis but no evidence of metastasis on histology 



Gastric cancer

cM0

An endometrial tumour shows morphology of serous carcinoma comprising of 20% solid area . What is the tumour grade? 

High grade

EMQ 

An ovarian tumour showing morphology of serous carcinoma with 15 mitoses/10 hpf. 



A prostate carcinoma on needle core biopsy shows cribriform architecture with fused glands 



High grade

Gleason grade 4

A conventional clear cell carcinoma of the kidney shows bizarre tumour cells. What is the grade of the tumour 

Fuhrman grade 4

Thank you