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What is Staging?

• Staging describes the extent or

severity of an individual’s cancer
• It is base on the extent of the
original (primary) tumor and the
extent of spread in the body.
Staging is important:

– Staging helps the doctor plan a person’s

– The stage can be used to estimate the
person’s prognosis (likely outcome or
course of the disease).
– Knowing the stage is important in
identifying clinical trials (research
studies) that may be suitable for a
particular patient.
Elements of Staging
 Location of the primary tumor
 Tumor size and number of tumors,
 Lymph node involvement
 Cell type and tumor grade
 Presence or absence of metastasis
TNM System:
The TNM system is based on :
• the extent of the tumor (T)
• the extent of spread to the lymph nodes
• the presence of metastasis (M).

– A number is added to each letter to indicate

the size or extent of the tumor and the
extent of spread.
Primary Tumor (T)

 TX - Primary tumor cannot be

 T0 – No evidence of primary tumor
 Tis - Carcinoma in situ (early cancer
that has not spread to neighboring
 T1, T2, T3, T4 - Size and/or extent of
the primary tumor
Regional Lymph nodes

 NX - Regional lymph nodes cannot

be evaluated
 N0 - No regional lymph node
involvement (no cancer found in the
lymph nodes)
 N1, N2, N3 - Involvement of regional
lymph nodes (number and/or extent
of spread)
Distant Metastasis (M)

 MX - Distant metastasis cannot be

 M0 - No distant metastasis (cancer
has not spread to other parts of the
 M1 - Distant metastasis (cancer has
spread to distant parts of the body)

 breast cancer T3 N2 M0
 It refers to a large tumor that has spread
outside the breast to nearby lymph nodes,
but not to other parts of the body.
 Prostate cancer T2 N0 M0
 It means that the tumor is located only in the
prostate and has not spread to the lymph
nodes or any other part of the body.
 Stage I ( T1, N0, MO)- Early Stage
 Stage II (T2, N1, M0) – local Spread
 Stage III ( T3, N2, M0)- extensive
spread but no metastasis.
 Stage IV (T4, N3, M+) Advanced
stage, with distant metastasis
5 Main Categories of
– In situ is early cancer that is present
only in the layer of cells in which it
– Localized is cancer that is limited to the
organ in which it began, without
evidence of spread.
– Regional is cancer that has spread
beyond the original (primary) site to
nearby lymph nodes or organs and

– Distant is cancer that has spread from

the primary site to distant organs or
distant lymph nodes.

– Unknown is used to describe cases for

which there is not enough information to
indicate a stage.
Stages of Cancer
Stage Definition
Stage 0 Carcinoma in situ (early cancer that is
present only in the layer of cells in
which it began).
Stage I, Stage II, Higher numbers indicate more
and Stage III extensive disease: greater tumor size,
and/or spread of the cancer to nearby
lymph nodes and/or organs adjacent to
the primary tumor.

Stage IV The cancer has spread to another

Why Cancer Detection and
Testing Important?

 Detecting cancers early is an important

step in preventing significant health
Four Possible Outcomes.
 True Positive
 False Positive
 True Negative
 False Negative
 When a test is performed to detect a
disease, there are four possible

 True positive - test indicates that a patient

has a disease that the patient does indeed

 False positive - test indicates that a patient

has a disease when they do not
 True negative - test indicates the patient
is disease-free, and this is indeed the

 False negative - test indicates the

patient is healthy when in fact the
patient has the disease
 Sensitivity refers to how accurately a test
identifies people who have the disease.

 Specificity refers to how accurately a test

identifies people who do not have the disease

 The best medical tests have high sensitivity and

high specificity.
Non - Invasive Invasive Techniques Analysis of Biopsy

Complete Blood Count Fine Needle Aspiration Immunohistochemistry

(CBC) Core Needle Biopsy (IHC)
Ultrasound Fluorescent In Situ
MRI Hybridization (FISH)
PET Scan
CT Scan
 Ultrasound uses reflection of sound waves to
create an image of a part of the body

 MRI uses magnetic fields and radio waves to

produce images of the body.

 PET scans use radioactive molecules to create a

dynamic image of internal tissues and organs.
PET scans are able to measure the metabolic
activity of cells, not just their structure.
 CT scans use x-rays to take multiple
image slices in order to create a 3D

 X-rays utilized high energy beams to

create an image.
Non- Invasive: CBC

 It provides information about the number,

parts, shape, and structure of the different
cell types found in blood.
 3 main types of blood cells:
 Platelets
When contrast agent is not When contrast agent is used
used an MRI can show: MRI can show:

• contrast agent is not used an MRI •size and location of benign or

can show: malignant growths
•The shape, size, appearance, and •enlarged lymph nodes
location of organs, bones, and •changes in blood flow
joints extracellular volume
•The presence of abnormal growths
•Signs of inflammation or infection
Positron Emission
Tomography (PET)
 Is an imaging technique that uses radioactive
molecules to create a dynamic image of
internal tissues and organs.
 It produce images that reveal the activity of
living tissue.
 PET scans use radioactively labeled tracers
(radiotracers) that are injected into the
Computed Tomography

 It uses x-rays in the same way as a

conventional x-ray but instead of
taking one image a CT scanner takes
multiple images, or slices.
 It can provide a 3 dimensional image
of an internal structure, it can detect
differences in tissue density.
Fine Needle Aspiration (FNA) Core Needle Biopsy

 Is the removal of cells, tissue, or fluid

for examination.
Types of Biopsy

 Excisional biopsy- removes all

suspicious tissue.
 Incisional biopsy- removes a sample
of tissue from a mass.
 Needle Aspiration- aspiration of small
amount of core tissue from a
suspicious area.
Invasive Techniques

 Fine needle aspiration (FNA) uses a

small needle to collect small samples
of a lesion.

 Core needle biopsy (BPA) uses a

larger needle to collect samples of a
Fine Needle Aspiration Core Needle Biopsy
Sample Removed Removes only a very small portion of the lesion Removes a small portion in most
cases, occasionally removes the
entire lesion
Needle Size 22-27 gauge 11-18 gauge

Pathology Type Cytopathology Histopathology

Interpretation Time Immediately Delayed

Diagnostic Abilities Limited ability to specifically diagnose benign Strong ability to specifically
lesions diagnose benign lesions.
No ability to differentiate between in situ and Some ability to differentiate
invasive breast cancer between in situ and invasive breast
Disadvantages Cannot be used for additional study More invasive, time consuming,
Advantages Inexpensive, quick, readily available, and very Can be used for additional study
safe and has more specific diagnostic
abilities than FNA
Effectiveness Sensitivity: 75.8-98.7% Sensitivity: 91-99.6%%
Specificity: 60-100% Specificity: 98-100%
Positive Predictive Value: 93.5-100% Positive Predictive Value: 10
Analysis of FNA
 Benign - the mass is not of much concern and will
not cause any significant problems as long as it
remains unchanged.
 Atypically indeterminate - a diagnosis cannot be
obtained from the sample. Other tests are needed
to determine the nature of the lesion.
 Suspicious/probably malignant - not a diagnosis of
cancer. This type of diagnosis requires additional
investigation because the sample has abnormal
characteristics. This lesion should be biopsied
with a more complete method to determine
whether a malignancy (cancer) is present.
 Malignant - a diagnosis of cancer;
should be biopsied and tested for exact
tumor makeup to prepare for
 Unsatisfactory - a diagnosis cannot be
determined from the sample because
of insufficient sample size, processing
or other machine or human errors.
Examination of Tissue
 Immunohistochemistry (IHC)

 Fluorescence in Situ
Hybridization (FISH)
Immunohistochemistry (IHC)
 Is a technique used to determine the
presence and level of specific cellular

 An example: Three proteins of particular

interest in breast cancer are HER2, the
estrogen receptor (ER) and the progesterone
receptor (PR).
Fluorescence in Situ
Hybridization (FISH)

 Is a cytogenetic technique used to detect

and localize the presence or absence of
specific DNA sequences on chromosomes.

 FISH uses fluorescent probes that bind to

only those parts of the chromosome with
which they show a high degree of sequence
Cancer Specific Techniques
 Mammography uses low dose x-ray
to create an image of a breast.
 Sigmoidoscopy uses a small tube
containing viewing equipment to
view the colon.
 Virtual Colonoscopy uses an MRI or
CT scan to create an image of the
inside of the colon.
 Pap smears use a sample of cells from the
cervix to detect cervical cancer. Pap smears
may also detect ovarian and uterine cancers
that have migrated to the cervix.

 Prostate specific antigen (PSA) test

measures levels of a glycoprotein in the
blood. Elevated levels of PSA are associated
with prostate cancer
Sentinel Lymph Node
Biopsy (SLN)
 is used to detect metastasis.
Treatment Goal

 Is to cure the client– eradicate the

 When cure is not possible, controlling
or arresting a tumor growth becomes
the goal– to prolong the survival.
 Palliation or alleviation of symptoms.
 Surgery
 Radiation Therapy
 Hormonal Therapy
 Targeted Therapy
 Antibodies
 Cancer Vaccines
 Complimentary and Alternative
 Chemotherapy

 The first line of treatment for many

solid tumors.
 May be sufficient to cure the patient
by removing all cancerous cells.
 Surgery is often used in combination
with radiation and/or chemotherapy
Types of Treatment

 Local Excision- simple surgery with small

margin of normal tissue surrounding tumor.

 En bloc Dissection- removal of tumor, tissues,

and any contiguous structures.
Surgery on Cancer in Situ
 Electrosurgery- application of
electrical current to cancerous cells
 Cryosurgery- deep freezing with
liquid nitrogen
 Chemosurgery- applied
chemotherapeutic agents layer by
layer with surgical incision.
 Co2 laser- use of laser for laser

 May be used in conjunction with

surgery and/or drug treatments.
 The goal of radiation is to kill the
cancer cells directly by damaging
them with high energy beams
Radiation Therapy

 Radiation treatments utilize high-energy

waves to kill cancer cells.

 Use of high energy moving through

space or medium to treat disease.

 It can be used alone or in conjunction

with other treatments (e.g.
chemotherapy and surgery) to cure or
stabilize cancer.

 This treatment seeks to relieve

symptoms of the cancer and to
prolong survival, making life more

 Used to treat tumors- ionizing

radiation transfers energy to
molecules present in cancer cells.

 Different tissues have different radio

sensitivities– rapidly dividing tissues
(testes, ovaries, lymphoid tissues,
and bone marrows) are more
Types of Radiation

 Electromagnetic- radiation in wave form

 Xrays- linear accelerators
 Electrons- delivered by machines
 Gamma- rays – delivered by machines that
contain radioactive sources (Cobalt 60), or
radioactive substances ( seeds, threads)
 Particulate – radiation in the form of heavy
particles. (beta particles- High speed
Pre- operative Radiation
 It can kill tumor cells at margins of
the tumor site.
 It can keep the cancer under control
and prevent metastases, and also
convert technically inoperable
tumors into operable ones.
Postoperative Radiation

 It can destroy cancer cells still

present around the margins after a
tumor has been surgically removed.
Internal Radiation

 Is the process of implanting

radioactive material onto or near the
tumor or placing radioactive sources
into the body.
 Implantation of radioactive
substance within a client.
 It can be temporary or permanent.
 Also called brachytherapy
Types of Internal
 Unsealed sources: Isotopes
 Liquid and administered orally.
 Sealed Sources: Radium needles and
radon seeds.
 Radioactive substance encased in metal
capsule placed in body cavity.
 Delivers radiation directly to tumor
External Radiation

 It utilizes a machine to deliver radiation

to the tumor.
 This therapy is primarily an outpatient
 Most protocols last approximately 4-7
weeks with treatments given 5 days per
 Also called as Teletherapy- external
source of radiation. ( machine is a
distance from client)
2 Types of External
 Natural Radioactive Source - gamma
rays delivered via machine to lesion.

 Machine is the linear accelerator-

high voltage electric current delivers
electrons to client.
Photon Radiation

 It uses high energy rays composed of

particles of energy called photons.
Photon radiation acts by disrupting the molecules of the target cells, interfering with normal cell functions.
There are several types of photon radiation:

 Gamma rays: are produced by the

breakdown of radioactive isotopes of
elements such as Cobalt-60 and
 X-rays: originate from machines that
excite electrons using cathode ray
tubes or linear accelerators.
Administration of Radiation
 Internal
 Seed implants
 Brachytherapy

 External
 External Beam Radiation Therapy
 3-D Conformal Therapy and Intensity
Modulated Radiation Therapy (IMRT)
 Destroys quickly dividing cells at the
margins of tumors. Surgery may miss these
cells leading to recurrence of disease.
 Can successfully eradicate growth without
permanently damaging the adjacent normal
tissue. If these tumors can be treated early before
metastasis, there is a very high rate of curability.
 In conjunction with other treatments, may
cure tumors that are not responsive to any
single agent.
Hormonal Treatments

 It prevent cancer cell growth by

preventing the cells from receiving
signals necessary for their continued
growth and division
Targeted Therapy

 They work by targeting specific

proteins and processes that are
limited primarily to cancer cells or
that are much more prevalent in
cancer cells.
 Inhibition of these processes
prevents cancer cell growth and

 This treatment involves the use of

antibodies to target cancer cells.
 The antibodies may work by several
different mechanisms, either depriving the
cancer cells of necessary signals or causing
the direct death of the cells.
 Because of their specificity, antibodies may
be thought of as a type of specific inhibitor.
Biological Response
 These treatments involve the use of
naturally occurring, normal, proteins
to stimulate the body's own defenses
against cancer.
Cancer Vaccines

 It stimulate the body's defenses

against cancer.

 The treatment aims to increase the

response of the body against the
cancer cells.
 Vaccines usually contain proteins found on
or produced by cancer cells. By
administering these proteins,
Complementary and
Alternative Medicines
 These treatment methods are not
practiced by conventional western
 They can include herbal, animal
derived, and mind-body approaches to
treating cancer.

 It refers to a wide range of drugs

used to treat cancer.
 These drugs generally work by killing
dividing cells.
Goal of Chemotherapy

 Is to cure malignancy
 Control maybe the goal when cure is
not realistic; the aim is to extend
survival and improve the quality of
 Palliation may be the goal when
neither cure nor control maybe
achieved; this goal is directed toward
client comfort.
Types of Chemotherapy
 Antimetabolites
 Genotoxic Drugs
 Spindle Inhibitors
 Other Chemotherapy Agents
Anti- Metabolites

 Drugs that interfere with the

formation of key bio-molecules
within the cell including nucleotides,
the building blocks of DNA.
 These drugs ultimately interfere with
DNA replication and therefore cell
Types of Anti-
 Folate Antagonists

 Purine Antagonists

 Pyrimidine Antagonists
Folate Antagonist

 also known as antifolates

 It inhibit dihydrofolate reductase (DHFR),
an enzyme involved in the formation of
 When this enzyme is blocked,
nucleotides are not formed, disrupting
DNA replication and cell division
 Methotrexate and Pemetrexed
Purine Antagonists
 It function by inhibiting DNA synthesis in two
different ways:
 They can inhibit the production of the purine
containing nucleotides, adenine and guanine. If a
cell doesn't have sufficient amounts of purines,
DNA synthesis is halted and the cell cannot divide.
 They may be incorporated into the DNA molecule
during DNA synthesis. The presence of the
inhibitor is thought to interfere with further cell
 6-Mercaptopurine, Dacarbazine, Fludarabine
 act Antagonists
to block the synthesis of pyrimidine
containing nucleotides (C and T in DNA; C
and U in RNA).
 The drugs used to block the construction of
these nucleotide have structures that are
similar to the natural compound.
 By acting as 'decoys', these drugs can
prevent the production of the finished
nucleotides. They may exert their effects at
different steps in that pathway and may
directly inhibit crucial enzymes.
 5-fluorouracil
 Arabinosylcytosine
 Capecitabine
 Gemcitabine
 Decitabine
Genotoxic Drugs

 Drugs that damage DNA. By causing

DNA damage, these agents interfere
with DNA replication, and cell
 3 Treatments:
 Alkylating Agents
 Intercalating Agents
 Enzyme Inhibitors
The genotoxic chemotherapy
treatments include:
Alkylating agents:
 The first class of chemotherapy
agents used. These drugs modify the
bases of DNA, interfering with DNA
replication and transcription and
leading to mutations
Intercalating agents
 These drugs wedge themselves into the
spaces between the nucleotides in the
DNA double helix. They interfere with
transcription, replication and induce

Enzyme inhibitors
 These drugs inhibit key enzymes, such as
topoisomerases, involved in DNA
replication inducing DNA damage.
Spindle Inhibitors

 These agents prevent proper cell

division by interfering with the
cytoskeletal components that enable
one cell to divide into two.

 Vinca Alkaloids
Paclitaxel (Taxol®)
Docetaxel (Taxotere®)
Ixabepilone (Ixempra®)
 While many of the Chemotherapy
commonly used
chemotherapy agents fit into one of the
three previously described groupings
(Genotoxic, Cytoskeletal, and Anti-
metabolite), some of them work through
mechanisms that do not neatly fit into one of
these categories.
 Arsenic trioxide (Trisenox®)
 Oral
 IM/ SQ
 IV
 Central Venous Catheter
 Venous Access Devices (VAD)
 Intraarterial Route
 Intraperitoneal Route