Cancer staging question

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Bob12345

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Hi all,

Is there any good way of staging cancer recurrence? E.g. how do you fill out the staging paperwork for a woman who originally had a T3N1M0 breast cancer who completed treatment a few years ago but has now developed 2 small skin nodule recurrences at the scar (with full restaging investigations showing no distant mets)?

Or someone with a glottic tumor originally involving both vocal cords i.e. T1bN0M0 who has completed treatment and presents with a recurrence limited to one vocal cord (i.e. would be T1a if it was the original cancer).

Is there a "TNM" or "Stage I-IV" way of doing this?

Thanks,

Bob

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I'll deffer to a resident or attending if I've been missinformed, but I believe once a patient has been completely staged that's it, no changes. a recurrence is a recurrence. i.e. T3N1M0 now with local recurrence. For a local recurrence you could say whether it is in the previously treated field or not, if you know. Of course, a new primary cancer needs a new staging.
 
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As all have said above, you are always staged with your initial cancer staging, unless you have a new primary. That being said, the AJCC does allow for "recurrent staging" by using the letter 'r' to precede the recurrent TNM stage. i.e. you may initially be a T1N0 glottic cancer and 2 years later be a rT3N1 glottic cancer. This of course does not change the initial stage, but does allow for stratification of patients into higher and lower risk groups for recurrent disease.
 
recurrences arent not staged. they're just recurrences.
 
I think one should stage recurrences and classify them.
Some recurrent tumors can still be treated in curative intention with pretty good chances, for example rectal cancer.
Whether it's a rcT2 rcN0 or a rcT4 rcN+ rectal cancer has a lot to do with treatment decisions (for example yes/no to neoadjuvant treatment)
 
Head and neck is kind of a confusing example, because of the 'condemned mucosa' (my favorite oncological description!). How can you really tell what's recurrence and what's a new primary at the 3-6 year mark?

I guess you can just say in your note that it was T1bN0 and now there is a recurrerence vs. a new primary staged T1aN0, but based on the time since treatment you will treat it like a recurrence/new primary.

-S
 
Generally, an infield malignancy of head and neck cancer (of the same histology), in the high dose volume, within 5 years from treatment is considered a recurrence. Of course this is arbitrary cut-off. Clinical judgement (however biased it may be) is often used in questionable situations.


Head and neck is kind of a confusing example, because of the 'condemned mucosa' (my favorite oncological description!). How can you really tell what's recurrence and what's a new primary at the 3-6 year mark?

I guess you can just say in your note that it was T1bN0 and now there is a recurrerence vs. a new primary staged T1aN0, but based on the time since treatment you will treat it like a recurrence/new primary.

-S
 
doesnt matter if they're curable. treatment is still the same. Staging is only useful for the primary. once its recurred, its recurred.
 
From the AJCC Cancer Staging Handbook (6th ed.) p. 3,
Although cancers that recure after therapy may be staged with the same criteria that are used in pretreatment clinical staging, the significance of these criteria may not be the same. Hence, the "restage" classification of recurrent cancer (rTNM) is considered separately for therapeutic guideance, estimation of prognosis, and end-results reporrting at that time in the patient's clinical course.

At our instituion we do not use the rTNM system for recurrences. In fact, I had to look it up to confirm that it existed. We generally present recurrences like this, "67 YOM s/p [therapeutic intrventions w/ dates] for TxNxM0 [tumor type and histology] presents w/ [details of recurrence]."
 
The treatment of recurrent disease totally depends on whether a patient is curable!! With incurable situations, the radiation dose fractionation and volume are designed for palliation (if even offered at all), while with curable disease, full dose radiation (even a 2nd course) may be an option. It also matters for surgical options as well as chemotherapy options.

Though recurrent staging is not widely used, it does offer an objective means to stratify patients into treatment and prognostic groups and perhaps will become more widely used, particularly as the treatment for recurrent disease improves. Nobody I know actually uses it, but nearly all rad. oncs will classify someome as locally recurrent (potentially curable) vs. distantly recurrence (generally not curable outside of the rare "oligomets" situation), and the treatment options for these patients are completely different.

doesnt matter if they're curable. treatment is still the same. Staging is only useful for the primary. once its recurred, its recurred.
 
mike, you misunderstand me. Obviously you need to determine if youre treating definitively or not. I mean that it doesnt matter if you are treating a recurrence definitively or palliative in terms of staging. there is no formal staging typically used in recurrence.
 
Right, I know, but that's the thing - it's arbitrary as all get-out. I mean really - 4 years and 11 months and it's a recurrence but 5 years and 1 month it's a new primary?!? No way to really know, unless you can do some sophisticated molecular techniques and compare to the original specimen. That's the point I was trying to make.


Generally, an infield malignancy of head and neck cancer (of the same histology), in the high dose volume, within 5 years from treatment is considered a recurrence. Of course this is arbitrary cut-off. Clinical judgement (however biased it may be) is often used in questionable situations.
 
I agree with all of the previous posters. Staging describes only the initial extent of the tumor at diagnosis or at the time of surgical treatment/staging. The stage at diagnosis is the stage. Period. It does not change later upon recurrence or metastasis.

This goes to the original purpose of staging which is to compare outcomes (particularly survival) for similar groups of patients. It is not meant simply to describe the extent of disease which has no merit in and of itself.

A women who was treated for T1N0 Stage I breast cancer, then 15 years later develops metastatic disease and dies, reflects the long natural history of Stage I disease, not Stage IV.

Staging is in essence a measure of the biologic behavior of the tumor -- even though it is quite crude and rarely uses actual biologic measures to determine the stage. This is because in the 60s when a system for staging of cancers was first developed, determinates of tumor biology (other than histologic grade, which wasn't all that useful) that affected prognosis were not known.

I imagine that someday we'll abandon anatomic staging and move toward staging based on the true biology of the tumors. We're already doing this in some respect with our classification of prostate cancers into low, intermediate, and high risk groups based on grade and PSA expression, and in a more sophisticated way by determining the biology of breast cancers based on DNA microarrays (e.g, Oncotype DX). You can come up with several other examples for other tumors, like the molecular profiling of gliomas. Still, despite this new knowledge of the molecular fingerprint of tumors, we still find in most cases that the AJCC Stage and nontumor factors (such as the age and KPS of the patient) are the most predictive of survival. I think this is because the water is murky and we still don't really know how to determine which combination of biologic tests is the best to use. This period of discovery is still in its infancy, but I imagine that someday it will lead to big changes in the way we evaluate and treat cancers based on biology.
 
The original question, that initiated this thread, was how you fill up the paperwork.

In terms of that, I would fill it up classifying the disease at all stages that were confirmed.
Example:

Current diagnosis: metastatic breast cancer rcT0 rcN0 rpM1 (BRA)
History of disease:
03/96: First diagnosis of a cT1 cN0 cM0 G2 invasive ductal breast cancer of the left breast, ER +90%, PR +90%
04/96: Lumpectomy and sentinel lymph-node dissection
pT1b pN0 (0/3) cM0 R0 G2 invasive ductal adenocarcinoma of the left breast, ER +90%, PR
+90%
05-06/96: adjuvant radiation therapy of the left breast and breast wall with 50 Gy, local tumour-bed boost of 10 Gy
06/96-06/01: adjuvant antihormonal therapy with tamoxifen
03/06: First diagnosis of a locoregional recurrence with an FDG-PET-positive and FNP-positive lymph node in the left axilla, mammography and ultrasound without any sign of local recurrence in the breast
rcT0 rcN1 rcM0
04/06: local resection of the lymph node in the left axilla
rcT0 rpN1 rcM0 adenocarcinoma lymph node metastasis, G3, ER -, PR -, Her2/neu -
05/06: further systemic treatment denied by patient
11/07: First diagnosis of an solitary intracranial mass left temporal in MRI-scan (2cm) after reported headache, FDG-PET-staging with no evidence of further disease
rcT0 rcN0 rcM1(BRA)
12/07: Excision of the intracranial mass left temporal
adenocarcinoma brain metastasis rcT0 rcN0 rpM1(BRA), G3, ER -, PR -, Her2/neu -


All comments are welcome.
I realise this is an english-speaking board, mainly used by US students/residents while I live and work on the other side of the Atlantic, so please correct me if you think I making mistakes.
Thank you and have a nice day.
 
I can see how that type of detailed recurrent staging system could be useful for clinical studies. I haven't seen it used standardly in the US at this time. Has Europe moved to using recurrent staging regularly?
 
I can see how that type of detailed recurrent staging system could be useful for clinical studies. I haven't seen it used standardly in the US at this time. Has Europe moved to using recurrent staging regularly?

Not everyone does.
In Europe usually radiation oncologists tend to be the ones that know better than anyone else what the exact TNM-classification for any tumour is and persist in classifying everything, including recurrences.

But for example today I saw a patient presented to our department with an rpT2 rpN0 (0/24) cM0 G2 V1adenocarcinoma of the rectum with vascular invasion, treated by abdominoperineal resection and lymph node dissection. The patient had a pT1 cN0 cM0 G2 adenocarcinoma of the rectum 3 years ago.
The recurrency was classified as I mentioned above by the surgeon, I found it pretty neat.
In this particular patient the classification of the tumour as a rcT2 tumour before operation (by MRI), rather than simply classifying it as a "recurrence" had a therapeutic consequence.
Had it been a rcT3-tumour then one would have proposed a neoadjuvant treatment for the patient. Since this was not the case, he was operated and presented to us for adjuvant treatment because of V1 and his wish for maximum treatment.
(For those who may speculate that he may have been off with a neoadjuvant treatment, with the eventuality of preserving his sphincter: this wouldn't have almost definetely not been the case because of the localization on the tumour in the lower rectum on the linea dentata with muscle infiltration.)


I think one important aspect we need to view here is the fact as more and more the "electronic patient file" becomes a daily tool for physicians around the world, classification of all tumour stages at all times becomes very handy.
By classifying "everything" one can very well make database surveys using complicated queries that would have otherwise resulted in one spending hours and hours of digging out files and reading them.
For example, if one has such a electronic file system with classifications you can ask the database to give you a list of all patients with:
"a breast cancer pT1-3 developing a rcM1(BRA) within 3 years of BCT"
This is very useful if you are for example looking into performing retrospective studies of patient groups.

I have seen such tools being used widely by clinics and tumour registering centers here.
 
that's a good radiation and cancer history to docment. but also the story should be filled in in the narrative. this is a good bit to put in as a summary of treatment.
The original question, that initiated this thread, was how you fill up the paperwork.

In terms of that, I would fill it up classifying the disease at all stages that were confirmed.
Example:

Current diagnosis: metastatic breast cancer rcT0 rcN0 rpM1 (BRA)
History of disease:
03/96: First diagnosis of a cT1 cN0 cM0 G2 invasive ductal breast cancer of the left breast, ER +90%, PR +90%
04/96: Lumpectomy and sentinel lymph-node dissection
pT1b pN0 (0/3) cM0 R0 G2 invasive ductal adenocarcinoma of the left breast, ER +90%, PR
+90%
05-06/96: adjuvant radiation therapy of the left breast and breast wall with 50 Gy, local tumour-bed boost of 10 Gy
06/96-06/01: adjuvant antihormonal therapy with tamoxifen
03/06: First diagnosis of a locoregional recurrence with an FDG-PET-positive and FNP-positive lymph node in the left axilla, mammography and ultrasound without any sign of local recurrence in the breast
rcT0 rcN1 rcM0
04/06: local resection of the lymph node in the left axilla
rcT0 rpN1 rcM0 adenocarcinoma lymph node metastasis, G3, ER -, PR -, Her2/neu -
05/06: further systemic treatment denied by patient
11/07: First diagnosis of an solitary intracranial mass left temporal in MRI-scan (2cm) after reported headache, FDG-PET-staging with no evidence of further disease
rcT0 rcN0 rcM1(BRA)
12/07: Excision of the intracranial mass left temporal
adenocarcinoma brain metastasis rcT0 rcN0 rpM1(BRA), G3, ER -, PR -, Her2/neu -


All comments are welcome.
I realise this is an english-speaking board, mainly used by US students/residents while I live and work on the other side of the Atlantic, so please correct me if you think I making mistakes.
Thank you and have a nice day.
 
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