approach to cancer case - prognosis + staging

Communication tips

Uncertainties can be removed

Don’t give prognosis too early

Explain options

When is active monitoring done

Benign

After sx with unlikely recurrence

Which tumours are always at a more advanced stage than can be detected

Osteosarcoma

HSA

Which tumour mets progress slowly

Thyroid carcinoma

Location that MCT spread too

LN, spleen, liver

Stage vs grade

S- extent/ progression

G- histo features

Staging solid tumours - TNM meaning

T= primary

N = local mets

M = distant mets

Staging solid tumours - How is T measured

0-3 = size

Demarcation, fixation, ulceration

Staging solid tumours - How is N measured

0-3= movement

Staging solid tumours - How is M measured

0-1= presence of distant mets

Staging solid tumours - Limitations of TMN

Sometimes no primary dz shown

Paraneoplastic syndromes

Staging solid tumours - T imaging options

Rx

Contrast rx

US

Scope

Sx

CT

MRI

Which imaging best for CNS lesions

MRI

Metastasis - types

Haematogenous

Lymphatic

Metastasis - Types spread via haematogenous

Sarcoma

Malignant melanoma

Metastasis - Types spread via lymphatic

Mast cell tumour

Carcinoma

Malignant melanoma

Metastasis - lymphatic spread direction

To nearest LN towards centre of body

Cr abd → sternal LN

Thyroid carcinoma → retropharyngeal LN

Prostate → popliteal LN

Regional staging - how to dx N

Palp

Imaging - rx, US, lymphangiography

Cytology, histo, biopsy, FNA

Regional staging - Purpsoe of lymphangiogrpahy

Show draining LN of tumour (not if it has metastasised)

Which tumour is considered metastasised by default

Lymphoma

Regional staging - Common sites of M

Lung, parenchyma organs, bone, skin, CNS, distant LN

Regional staging - M dx

CE

Hx

Ausc

Pathology

Scintigraphy

CT, MRI

Regional staging - Mets common radiodensity

Soft tissue

Ddx of this cat abd

Loss of serosal detail = fluid, dec fat in tissues

staging - best dx imaging options (sampling most accurate)

Rx x3

US

Regional staging - Common age related changes confused with mets in parenchyma so need confirming with FNA

Nodular hep hyperplasia

Spleen nodular hyperplasia, lymphoid hyperplasia, haematoma

Highly metastatic tumour examples

Oral/mucosal malignant melanoma

• Visceral and some other soft tissue haemangiosarcoma

• Appendicular osteosarcoma (dog)

• High grade (Patniak grade III/Kiupel high grade or poorly differentiated) MCTs

• Subungual malignant melanoma (dog)

• Poorly differentiated mammary tumours (dog)

• Most mammary carcinomas in cats

• (Anal sac adenocarcinoma)

• (Prostatic carcinoma)

• (Digital squamous cell carcinoma)

Variably metastatic tumour examples

• Oral /axial OSA

• Thyroid carcinoma (dog)

• Patnaik intermediate grade MCTs

• Injection site sarcoma

• Anaplastic sarcoma

• Insulinoma (most do!)

• Mammary carcinomas (dog)

• Apocrine adenocarcinomas

• GIT carcinomas

• Transitional cell carcinoma (TCC) of the bladder

• Liposarcoma

Low metastatic tumour examples

• Oral fibrosarcoma

• Non-tonsillar oral squamous cell carcinoma

• Most ST sarcomas

• Sebaceous adenocarcinoma

• Low grade MCTs

• Multilobular osteoma /osteosarcoma of bone

• Intranasal tumours

Non metastatic tumour examples

Oral acanthomatous ameloblastomas/ basal cell carcinomas/ acanthomatous epulids

• Haemangiopericytoma

• Schwannoma/neurofibroma

• BENIGN TUMOURS

Ideal way to present prognosis

Range of time

When is referral needed

Advanced tx / expertise needed

Uncertain dx

Client

Aggressive tumour