STAGING & GRADING
OF CANCER
HISTOLOGIC GRADING
Tumor grade is the description of a tumor based on how
abnormal the tumor cells and tumor tissue look under a
microscope.
Tumor grade is an indicator of how quickly the tumor is
likely to grow and spread.
Tumor grading systems differ depending on the type of
cancer.
Tumor grade may be one of the factors considered when
planning treatment for a patient.
Grading is classification of tumor cells.
HISTOLOGIC GRADING
GX: Grade cannot be assessed (undetermined grade)
GI: Cells are slightly different than normal,
well differentiated (low grade, mild dysplasia)
GII: Cells are more abnormal, moderately well differentiated
(intermediate grade, moderate dysplasia)
GIII: cells are clearly abnormal, poorly differentiated (high
grade, severe dysplasia)
GIV: Undifferentiated (high grade, anaplastic)
GI – well differentiated; most differentiated, more like the
parent tissue (least malignant)
GII – moderately well-differentiated
G3 – Poorly Differentiated
G4 – poorly differentiated; least differentiated, more unlike
the parent tissue (high degree of malignancy)
Breast Cancer Grading
“Nottingham Grading” or “Elston Grade”
Tubule Formation: how much of the tumor tissue has
normal breast (milk) duct structures
Nuclear Grade: an evaluation of the size and shape of the
nucleus in the tumor cells
Mitotic Rate: how many dividing cells are present, which
is a measure of how fast the tumor cells are growing and
dividing
Glandular (Acinar)/Tubular Differentiation
Score 1: >75% of tumor area forming glandular/tubular structures
Score 2: 10% to 75% of tumor area forming glandular/tubular structures
Score 3: <10% of tumor area forming glandular/tubular structures
Nuclear Pleomorphism
Score 1: Nuclei small with little increase in size in comparison with normal breast
Score 2: Cells larger than normal with open vesicular nuclei, visible nucleoli, and
moderate variability in both size and shape
Score 3: Vesicular nuclei, often with prominent nucleoli, exhibiting marked
variation in size and shape, occasionally with very large and bizarre forms
Mitotic Count
Score 1: less than or equal to 7 mitoses per 10 high power fields
Score 2: 8-14 mitoses per 10 high power fields
Score 3: equal to or greater than 15 mitoses per 10 high power fields
Total score = 3–5: GI (Low grade or well differentiated)
Total score = 6–7: GII (Intermediate grade or moderately
differentiated)
Total score = 8–9: GIII (High grade or poorly differentiated)
Prostate Cancer Grading
“Gleason Scoring System”
The primary pattern represents the most common tissue
pattern seen in the tumor
The secondary pattern represents the next most
common pattern.
Gleason X: Gleason score cannot be determined
Gleason 2–6: The tumor tissue is well differentiated
Gleason 7: The tumor tissue is moderately differentiated
Gleason 8–10: The tumor tissue is poorly differentiated
or undifferentiated
TNM Staging
Determine the existence of metastasis and size of tumor
Define categories for all cases and allow subsequent and more
detailed information
This is very necessary at the time of diagnosis to determine
the extent of disease (local vs. metastatic), prognosis and to
guide in proper management
Elements of Staging System:
Location of the primary tumor
Tumor size and number
Lymph node involvement
Cell type & tumor grade
Presence or absence of metastasis
Tests for Staging:
1. Physical exams
location and size of the tumor(s)
spread of the cancer to the lymph nodes and/or to other organs
2. Imaging studies (X-Ray, CT Scan, MRI, PET Scan)
location of the cancer,
size of the tumor
cancer has spread
3. Laboratory tests (blood, urine, other fluids, tissues)
tests for liver function and tumor markers can provide information
about the cancer
Tests for Staging:
4. Pathology reports
size of the tumor
growth of the tumor into other tissues and organs
type of cancer cells,
grade of the tumor (how closely the cancer cells resemble normal
tissue)
Biopsy - the removal of cells or tissues for examination
Cytology - the examination of cells in body fluids.
5. Surgical reports
size and appearance of the tumor
observations about lymph nodes and nearby organs
The American Joint Committee of Cancer (AJCC) has
developed the TNM classification that can be applied to ALL
tumor types.
❖ T: TUMOR – the extent of the primary tumor (size and
extent of invasion)
❖ N: NODE – the absence or presence and extent of regional
lymph node metastasis
❖ M: METASTASIS – the absence or presence of distant
metastasis
The use of numerical subsets of the TNM components indicates
the progressive extent of the malignant disease.
Terminologies:
In Situ – is early cancer that is present only in the layer of cells
in which it began, without evidence of spread (localized)
Regional – cancer that has spread beyond the original (primary)
site to nearby lymph nodes or organs & tissues
Distant – cancer that has spread from the primary site to distant
organs or distant lymph nodes
Unknown – used to describe cases for which there is not
enough information to indicate a stage
T – PRIMARY TUMOR
STAGE CHARACTERISTICS
Primary tumor cannot be
Tx evaluated
T0 No evidence of primary tumor
Carcinoma in situ
Tis (early cancer that has not
spread to neighboring tissue)
Size and/or extent of the
T1 T2 T3 T4 primary tumor
N – LYMPH NODE INVOLVEMENT
STAGE CHARACTERISTICS
Regional nodes cannot be assessed
Nx clinically
No regional nodes demonstrably
N0 abnormal
Demonstrate regional lymph nodes,
N1a , N2a metastasis not suspected
Demonstrable, progressive regional
N1b , N2b , N3b lymph nodes; metastasis suspected
M – DISTANT METASTASIS
STAGE CHARACTERISTICS
Distant metastasis cannot be
Mx evaluated
M0 No evidence of distant metastasis
Ascending degrees of metastatic
M1 , M2 , M3 involvement of the host including
distant nodes
