Module 6:

1. Module 6: Clinical Stage and Grade

2. 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

3. Tumor progression • Tumors may occur spontaneously or follow a series of cellular and tissue changes known as epithelial dysplasia

4. Histologic alterations in epithelial dysplasia • 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

5. Histologic alterations observed in epithelial dysplasia Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2nd ed. St. Louis: Mosby, p. 181

6. Architectural changes in epithelial dysplasia • Bulbous rete pegs • Basilar hyperplasia • Hypercellularity • Altered maturation pattern of keratinocytes 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

7. 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

8. 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, 2nd ed. St. Louis: Mosby, p. 188

9. 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.

10. Staging • Based upon the size and extent of metastatic spread of the lesion • Tumor-node-metastasis (TNM) system used for most cancers

11. Staging – TNM system • Size, in cm, of the tumor (T) • Involvement of lymph nodes (N) • Presence or absence of distant metastasis (M)

12. Staging – “T”

13. Staging – “N”

14. Staging – “M”

15. TNM Staging System

16. Summary • Stage and grade of tumors indicates prognosis • Treatment plans based upon stage and grade, among other factors • TNM system used with most cancers