surgical staging

[Furious Curious]

Hi fellow students:

I am studying gynecologic cancers now and I keep running across the phrase "surgical staging" but nowhere can I find it exactly defined. I mean, obviously it involved a surgery of a cancer patient, and somehow figuring out via the surgery what stage they are at, but I want particulars of the process. Do you stage visually? Do you stage by sending all the specimens to pathology? ??

 

[CherryRedDracul]

Surgical staging is essentially pathologic staging in that, yes, you can stage something visually (e.g. seeing a tumor invading other nearby structures), but ultimately, the surgically excised specimen(s) will go to pathology. This includes lymph nodes where micrometastases will not be obvious visually.

 

[operaman]

Yes you stage both ways and the actual stage often evolves during the early workup and treatment phase.

In the TNM system a number of cancers are staged based on what structures they involve. When we do diagnostic explorations one of the things we look for is extent and involvement of additional subsites and invasion into other structures. Imaging and your physical exam can also help establish this. Oftentimes cancers are only treated with chemo and radiation and thus may never be subjected to formal pathalogic evaluation, though obviously their reports can be far more accurate and detailed as they can detect more subtle invasion.

In general I don’t think of surgical staging as it’s own thing but rather as a tool involved in the clinical staging of a cancer. You’ll often see the TNM stages reported cT3cN1 or pT4pN2b to delineate between clinical and pathalogic staging.

So why the heck does this matter? Let me share with you something a chief resident told me as an M3.

Don’t think of cancer staging as one disease with various stages. Think of each individual stage as a separate and distinct disease entity just like you think of diabetes and COPD and coronary artery disease as different things. Obviously you don’t give someone a diabetes treatment for their COPD, so likewise you wouldn’t want to treat T4 tumor with T2 treatment. Thinking of the staging as an absolutely essential part of the diagnosis helped me care more about it and think of it differently. Today it guides my exam and workup when seeing a new cancer patient and also allows me to answer the inevitable questions that arise when you give someone a cancer diagnosis, all of which revolve around next steps and how serious their disease is.

If you want to be a true rockstar on cancer rotations you can download the free NCCN guidelines for whatever cancer you’re working with, quickly memorize the staging and then use those algorithms to formulate your plans based on the staging. Everyone should take a peek at those anyhow just to see how much staging plays into treatment. It’ll hammer home the importance of getting that right. But then when you’re seeing and presenting a new patient, rather than be the “my impression is this guy has larynx cancer and my plan would be chemoRads” you can say “my impression is this guy has a T3N2a squamous cell carcinoma of the supraglottis. Based on NCCN guidelines I’d like to complete his metastic workup with a chest CT or PET scan and then assuming those are negative, offer him chemorads versus primary surgical excision and neck dissection.” I meet students who do both ways and you can guess which ones are impressive. It also leads very quickly to interesting discussions about the nuances of treatment decisions that may not be apparent early on.

 

[Furious Curious]

All this is good; thank you. So what's the difference between "clinical staging" versus "surgical staging"? It doesn't seem like you could really do one without the other. I don't understand why they are considered separate processes. Is it possible to do one without the other?

 

[operaman]

All this is good; thank you. So what's the difference between "clinical staging" versus "surgical staging"? It doesn't seem like you could really do one without the other. I don't understand why they are considered separate processes. Is it possible to do one without the other?

That’s not a nomenclature I see used in my field. We talk of clinical versus pathological staging, but not really of surgical staging as its own entity.

I’ve heard the term mentioned and would think of it as a part of pathologic staging where essentially the surgeon is examining the tumor grossly intraoperatively and determining its size and relation to nearby structures.

Clinical staging is essentially based on history and exam and imaging. I can look and see a tumor and use my exam and CT scan to determine its T stage. I can use the scan and exam to look at lymph nodes and identify any that are suspicious and get a sense for the N stage, and other imaging can point to possible distant metastatic disease. This would all be clinical staging.

Once we go to the OR and resect it, our findings combined with the pathology report will be used to come up with the pathologic stage (this is probably what your book is calling surgical stage). This may show the exact stage as the clinical stage, or it may differ if it turns out the cancer was more or less aggressive than we realized.

For us, the clinical stage is far and away the most important because it drives what we do in terms of treatment. The pathologic stage typically becomes important when it guides whether or not someone needs chemo and radiation in addition to surgery. In our world, that is usually determined by the lymph nodes, though there are other factors as well.

 

[Furious Curious]

That’s not a nomenclature I see used in my field. We talk of clinical versus pathological staging, but not really of surgical staging as its own entity.

I’ve heard the term mentioned and would think of it as a part of pathologic staging where essentially the surgeon is examining the tumor grossly intraoperatively and determining its size and relation to nearby structures.

Clinical staging is essentially based on history and exam and imaging. I can look and see a tumor and use my exam and CT scan to determine its T stage. I can use the scan and exam to look at lymph nodes and identify any that are suspicious and get a sense for the N stage, and other imaging can point to possible distant metastatic disease. This would all be clinical staging.

Once we go to the OR and resect it, our findings combined with the pathology report will be used to come up with the pathologic stage (this is probably what your book is calling surgical stage). This may show the exact stage as the clinical stage, or it may differ if it turns out the cancer was more or less aggressive than we realized.

For us, the clinical stage is far and away the most important because it drives what we do in terms of treatment. The pathologic stage typically becomes important when it guides whether or not someone needs chemo and radiation in addition to surgery. In our world, that is usually determined by the lymph nodes, though there are other factors as well.

 

[Furious Curious]

OK this is making sense now. I had thought that "clinical" staging would somehow be based only on history and physical. That is how I have heard "clinical" used in the past. But when you add imaging and lab tests, then yes, it makes sense that you could arrive at a preliminary staging of the cancer, using that definition of "clinical."

Thanks for lumping "surgical" and "pathological" together. That is helping it makes sense also. I think the surgical staging would be incomplete without the pathology report, but I guess the "surgical" is a necessary term, because after all the surgeon makes notes, from WHERE s/he resected the samples that go to pathology.

Friends, thank you very much for helping this make sense. This is what I'm coming away with:

"clinical" staging: history, physical, imaging, labs altogether make a preliminary assessment of the cancer stage

"surgical" staging: As the cancer and other suspicious tissues are resected during surgery, and then examined by pathology, we arrive at a possibly more refined definition of the stage of the cancer.

Did I get it?