Classification of oncological diseases. Stages of cancer: prognosis of survival, how tumors develop, localization

We have already learned. Today we will get to know classification malignant tumors and find out whether all malignant tumors can be called cancer.

All malignant tumors are divided into groups depending on the type of fabric from which they originated:

cancer (carcinoma)- a malignant tumor epithelial tissue. If cells highly differentiated(less malignant), name to be specified by type of fabric: follicular cancer, keratinizing squamous cell carcinoma, adenocarcinoma, etc.
If the tumor has poorly differentiated cells, the cells are called by their shape: small cell carcinoma, cricoid cell carcinoma, etc.

Blood is not epithelial tissue, and one of the types connective tissue. So say " blood cancer» is incorrect. In the 3rd year, while studying pathological anatomy, we were told that such a phrase, spoken aloud in the exam, automatically causes removal from the exam with a deuce. It was remembered. Correct names: leukemia (leukemia, hemoblastosis), is a tumor of hematopoietic tissue that develops throughout circulatory system. Leukemias are acute and chronic. If a tumor from the hematopoietic tissue is localized only in a certain part of the body, it is called lymphoma(Remember in the first part of the photo with Burkitt's lymphoma?).

The lower the cell differentiation, the faster the tumor grows and the earlier it metastasizes. I already wrote about this in the second part of the series.
sarcoma- a malignant tumor of connective tissue, with the exception of blood and hematopoietic tissue. For example, lipoma benign tumor from adipose tissue and liposarcoma- a malignant tumor from the same tissue. Similarly: fibroids and myosarcomas, etc.

Now generally accepted are international classification TNM and clinical classification malignant tumors.

TNM classification

Used all over the world. For a malignant tumor separate characteristic the following options:

1. T (tumor)- the size of the tumor.
2. N (nodes)- the presence of metastases in regional (local) lymph nodes.
3. M (metastasis)- Availability distant metastases.

Then the classification was expanded with two more characteristics:

4. G (gradus, degree)- the degree of malignancy.
5. P (penetration, penetration)- the degree of germination of the wall of a hollow organ (used only for tumors gastrointestinal tract).

Now in order and in more detail.

T (tumor) - tumor.
It characterizes the size of the formation, the prevalence in the departments of the affected organ, the germination of surrounding tissues. Each organ has its own specific gradations of these features.
For example, for colon cancer:
- T o - there are no signs of a primary tumor.
- T is (in situ) - intraepithelial tumor. About her below.
- T 1 - the tumor occupies a small part of the intestinal wall.
- T 2 - the tumor occupies half the circumference of the intestine.
- T 3 - the tumor occupies more than 2/3 or the entire circumference of the intestine, narrowing the lumen.
- T 4 - the tumor occupies the entire intestinal lumen, causing intestinal obstruction and (or) grows into neighboring organs.
For a breast tumor, gradation is carried out by tumor size(in cm), for stomach cancer - according to the degree of wall germination and distribution to the parts of the stomach.

Degree of organ wall invasion and TNM.
Designations (from top to bottom):
mucous - submucosal -
muscular layer - subserous layer -
serous membrane - surrounding organs.

Particular emphasis should be in situ cancer(cancer in situ). At this stage, the tumor is located only in the epithelium (intraepithelial cancer), does not germinate the basement membrane, which means that the blood and lymphatic vessels. At this stage of development, a malignant tumor is still devoid of infiltrating character growth and fundamentally cannot metastasize. That is why in situ cancer treatment gives most favorable results.

Stages of cancer development.
Designations (from left to right): a cell with a gene mutation - hyperplasia -
pathological growth - cancer "in situ" - cancer with infiltrating growth.

It should be noted that morphologically (that is, under a microscope) between normal and malignant cell there are many transitional stages. Dysplasia- violation proper development cells. Hyperplasia- a pathological increase in the number of cells. Not to be confused with hypertrophy(this is a compensatory increase in cell size during their hyperfunction, for example, growth muscle tissue after dumbbell workouts).

Stages of epithelial dysplasia:
normal cell - hyperplasia -
mild dysplasia - cancer "in situ" (severe dysplasia) -
cancer (invasive).
N (nodes) - nodes (lymph nodes).
characterizes changes in regional (local) lymph nodes. As you know, the lymph flowing from the organ first enters the nearest regional lymph nodes (collector of the 1st order), after which the lymph goes to a group of more distant lymph nodes (collectors of the 2nd and 3rd orders). Lymph from the entire organ and even several organs at once gets into them. Groups of lymph nodes have their own name, which is given by their location.

For example, for stomach cancer:
- N x - no data on the presence of metastases in regional lymph nodes (the patient is underexamined).
- N o - there are no metastases in regional lymph nodes.
- N 1 - metastases in the collector of the 1st order (along the greater and lesser curvature of the stomach).
- N 2 - metastases in the collector of the 2nd order (prepyloric, paracardial, lymph nodes of the greater omentum).
- N 3 - metastases affect the para-aortic lymph nodes (collector of the 3rd order, near the aorta), which cannot be removed during surgery. At this stage, it is impossible to completely remove the malignant tumor.
So, the gradations N o and N x are common for all localizations, N 1 - N 3 are different.
M (metastasis).
Characterizes the presence distant metastases.
- M o - no distant metastases.
- M 1 - there is at least one distant metastasis.

Additional TNM classification options:

G (gradus) is the degree of malignancy.
Determined histologically (under a light microscope) by degree of differentiation cells.
- G 1 - low-grade tumors (highly differentiated).
- G 2 - medium malignancy (poorly differentiated).
- G 3 - high degree of malignancy (undifferentiated).
P (penetration) - penetration.
Only for tumors hollow organs. Shows degree germination of their walls.
- P 1 - within the mucosa.
- P 2 - grows into the submucosa.
- P 3 - grows into the muscle layer (to serous).
- P 4 - germinates serosa and out of the body.

According to the TNM classification, the diagnosis may sound, for example, like this: caecal cancer T 2 N 1 M 0 G 1 P 2. This classification is convenient, as it characterizes the tumor in detail. On the other hand, it does not provide generalized data on the severity of the process and the possibility of a cure. Therefore, the clinical classification of tumors is also used.

Clinical classification of tumors

Here are all the options malignant neoplasm(the size of the primary tumor, the presence of regional and distant metastases, germination in surrounding organs) taken together.

Allocate 4 stages of cancer:

1st stage: the tumor is small, occupies a limited area, does not germinate the wall of the organ, there are no metastases.
2nd stage: tumor large sizes, does not spread outside the organ, single metastases to regional lymph nodes are possible.
3rd stage: a large tumor, with decay, germinates the entire wall of the organ or a smaller tumor with multiple metastases to regional lymph nodes.
4th stage: germination of the tumor in the surrounding tissues, including non-removable (aorta, vena cava, etc.) or any tumor with distant metastases.

The possibility of curing a malignant tumor depends on the stage: the higher the stage, the less likely be cured. That's why you need to detect a malignant tumor as soon as possible, and for this, do not be afraid to go to be examined, especially if there are suspicions, which will be discussed in the 4th part of this cycle.

Relative 10-year survival rate for cancer patients
mammary gland depending on the stage of cancer.

The need for classification oncological diseases is dictated by the variety of tumors, which differ in cytological and histological characteristics, primary localization and metastasis features, clinical course and forecast. The manual “Pathological anatomical diagnosis of human tumors” by N. A. Kraevsky and A. V. Smolyannikov (1976) lists about 500 tumors. In the ovaries alone, the histological classification distinguishes 9 histiotypes and 81 types of tumors.

The traditional division of tumors into benign and malignant morphological features sometimes contradicts clinical characteristics. So, colloid goiter, which is considered benign, metastasizes, and skin basalioma that gives local destructive growth does not metastasize. highly differentiated papillary cancer thyroid gland not always distinguishable from benign adenoma. In a malignant tumor with a low degree of tissue differentiation, even an experienced pathologist will not always determine histogenesis, since undifferentiated cancer, according to histological examination, is difficult to distinguish from sarcoma. Similar to sarcoma shows small cell lung cancer.

In 1959, WHO published a universal nomenclature of human tumors. It corresponds to the level of modern oncomorphology, but is inconvenient for practical use. Mutual understanding between pathologists and clinicians can only be achieved on the basis of common views on the essence pathological process and nomenclature. This necessitates the use of generally accepted, informative and concise nomenclature in the classification, understandable to all participants in the diagnostic and treatment process, pathologists, medical statisticians and experimenters.

These requirements are met by the International TNM classification of malignant tumors. The formation of groups according to the TNM system is focused on the prognosis of the disease, which depends mainly on the prevalence of the neoplasm at the time of diagnosis. The first edition of the International TNM-classification was published in 1968, the second - in 1974, the third - in 1978, the fourth - in 1987. At present, the criteria defined by the edition of the fifth edition (1997) have been adopted. All changes, additions and clarifications, consistently adopted by the TNM-classification committee of the International Anti-Cancer Union, were aimed at ensuring that the categories that determine the stage of the disease form the most homogeneous group of patients in terms of prognosis.

The TNM classification adopted to describe the anatomical extent of a tumor, according to the fifth edition, operates with three main categories: T (tumor) - characterizes the prevalence of the primary tumor, N (nodus) - reflects the state of regional tumors. lymph nodes, M (metastasis) - indicates the presence or absence of distant metastases. Category G (gradus), which characterizes the degree of tumor tissue differentiation, has the value of an additional criterion of tumor malignancy.

Each tumor location can be classified according to clinical (clinical classification) and pathological (pathological classification) data. Here are set out general principles TNM classification. Particular questions of the classification of individual localizations of tumors are given in the relevant chapters.

Clinical classification

carried out before treatment based on the results of physical, radiation, endoscopic and laboratory methods, cytological and (or) histological examination of biopsy specimens, surgical revision.

The primary tumor (T) within the clinical classification is characterized by the symbols TX, T0, Tis, T1, T2, T3, T4.

TX is used when the size and local extent of the tumor cannot be assessed. This situation occurs with tumors internal organs in patients in whom surgical revision cannot be performed due to strong contraindications or the patient's refusal to undergo surgery. Without surgical revision, it is impossible to clarify the category T in tumors of the kidney, pancreas, stomach, ovaries, etc.

T0 - the primary tumor is not determined. This is an uncommon situation in clinical oncology. According to G. F. Falileev (1978), among patients with metastases in the lymph nodes of the neck, in 8% of them it is not possible to identify the primary localization. In some patients, breast cancer manifests as metastasis to the axillary lymph node of Sorgius, and lung cancer manifests as metastasis to the supraclavicular lymph nodes; primary localization may appear much later, but sometimes neither surgeons nor pathologists find it. In patients with carcinomatosis abdominal cavity in advanced cases the primary localization of the tumor can only be assumed. The diagnosis in such cases is formulated as "a common malignant tumor with an unspecified primary localization."

Tis - preinvasive carcinoma, carcinoma in situ, intraepithelial form of cancer, First stage development of a malignant tumor without signs of invasion through the basement membrane. It usually turns out to be a find of a pathohistologist who examines a polyp, ulcer, erosion, etc.

Т1, Т2, ТЗ, Т4 - designations of sizes, nature of growth, relationship with border tissues and (or) organs of the primary tumor. The criteria by which the digital symbols of category T are determined depend on the location of the primary tumor. For tumors of the breast, thyroid gland, soft tissues, such a criterion is the maximum size of the tumor. So, a breast tumor with a maximum size of not more than 2 cm is designated T1, more than 2 cm, but not more than 5 cm corresponds to T2, more than 5 cm is designated TK. Primary soft tissue tumor less than 5 cm is designated T1, more than 5 cm - T2. In patients with tumors digestive tract category T is determined not by the size of the tumor, but by the depth of invasion into the wall of the affected organ. In gastric cancer, invasion of the mucosa and submucosa is designated T1, invasion of the muscular layer corresponds to T2, invasion of the serosa - T3. The maximum size of the tumor is not taken into account.

This approach is due to the fact that the TNM classification is focused on the prognosis of the disease, which in neoplasms of the digestive tract depends not on the size of the tumor, but on the depth of invasion. A small gastric endophytic tumor that infiltrates all layers, including the serosa, has a worse prognosis than a large exophytic tumor that only reaches the muscle layer. The characteristics of the primary tumor in patients with skin melanoma are established only after a histological examination of the removed preparation (RT) and it depends on the level of invasion according to Clark. Determination of category T digital symbols in patients with a malignant tumor of the pancreas, cervix or body of the uterus, ovaries, prostate depends on whether the neoplasm is limited to the affected organ or extends to surrounding tissues and, if it extends, how far the external invasion has gone. For example, in cancer of the body of the uterus, a tumor limited to the body is designated T1, its spread to the cervix - T2, invasion of the appendages or vagina - T3, germination into the bladder or rectum - T4. Category T4 in almost all localizations is associated with the release of the primary tumor outside the affected organ. Category T4 also includes an inflammatory erysipelas-like form of breast cancer, which predetermines a poor prognosis, regardless of the size of the lesion.

The state of regional lymph nodes (N) is designated by the categories NX, N0, N1, 2, 3. The TNM classification clearly defines the groups of lymph nodes included in the lymph collector of any localization of the primary tumor. So, for breast tumors, these are axillary, subclavian, interpectoral and internal mammary lymph nodes on the side of the lesion. Category N includes only regional lymph nodes. In breast cancer, supraclavicular and cervical lymph nodes, as well as all lymph nodes on opposite side, are not classified as regional, metastases in them are classified as distant - M1.

NX Insufficient data to assess regional lymph node involvement. It is impossible, for example, a reliable preoperative assessment of the state of regional lymph nodes in patients lung cancer, stomach, colon, uterus, Bladder, prostate, etc. Data ultrasound, computed tomography, indicating an increase in lymph nodes in the regional collectors of the listed localizations, can only suspect their metastatic lesion, and normal sizes lymph nodes do not reject the possibility of metastases.

N0 - no clinical signs of metastases in regional lymph nodes. Category 0, determined prior to surgery for clinical signs or after surgery on the basis of a visual assessment of the removed preparation, clarified by the results of a histological examination. In a macroscopically unchanged lymph node with microscopic examination a metastasis can be detected, clarifying the classification score, and then the clinical category M0 is replaced by the pathological category pN1.

N1, N2, N3 reflect varying degrees metastatic lesions of regional lymph nodes. The criteria that define the numerical symbols of the category depend on the location of the primary tumor. In case of cancer of the esophagus, gallbladder, pancreas, cancer of the cervix and body of the uterus, ovaries, malignant tumors of soft tissues, bones, skin cancer, only the fact of metastatic lesions of regional lymph nodes is taken into account, which is classified by category N1; categories 2 and 3 do not exist for these localizations. In case of stomach cancer, the number of lymph nodes affected by metastases is taken into account: from 1 to 6 - N1, from 7 to 15 - N2, more than 15 - NЗ. In colon cancer, the number of affected lymph nodes is also taken into account: from 1 to 3 lymph nodes corresponds to N1, more than 4 lymph nodes - N2. In patients with breast cancer, mobile metastases in the axillary lymph nodes on the side of the lesion are classified as N1, limitedly mobile, fixed to each other metastases in the axillary lymph nodes on the side of the lesion are classified as N2, metastases in the internal mammary lymph nodes on the side of the lesion - N3. Supraclavicular and cervical lymph nodes, as well as all lymph nodes on the opposite side, are not classified as regional, and metastases in them are classified as distant - M1.

Distant metastases (M) are characterized by the categories MX, M0, M1.

MX - insufficient data to determine distant metastases. This situation occurs when the assumption of distant metastases in a cancer patient cannot be verified. special methods research, either due to the impossibility of applying these methods, or because of their insufficient resolution. X-ray and even CT of organs chest may not always be a reliable confirmation or denial of metastases in the lungs, ultrasound does not provide grounds for a categorical judgment about the state of the para-aortic lymph nodes or about the nature focal lesion liver.

M0 - no signs of distant metastases. This category may be refined and modified if distant metastases are detected during surgical exploration or post-mortem examination. Then the M0 category is changed to the M1 category if no pathological examination was performed, or to the pM1 category if the presence of distant metastases is confirmed by the pathohistological examination data.

M1 - there are distant metastases. Depending on the location of metastases, the M1 category can be supplemented with symbols specifying the target of metastasis: PUL. - lungs, OSS - bones, HEP - liver, BRA - brain, LYM - lymph nodes, MAR - Bone marrow, PLE - pleura, PER - peritoneum, SKI - skin, OTN - others.

Pathological classification (pTNM) is carried out according to the results of a histological examination of surgical preparations or preparations obtained in the course of a pathoanatomical autopsy.

Primary tumor (pT) within pathological classification denoted by the symbols pTX, pT0, pTis, pT1, pT2, pT3, pT4.

pTX - the primary tumor cannot be assessed histologically.

рТ0 – histological examination did not reveal any signs of the primary tumor.

pTis is pre-invasive carcinoma.

pT1, pT2, pT3, pT4 - histologically proven increase in the prevalence of the primary tumor.

The state of regional lymph nodes according to histological examination (pN) is characterized by the symbols pNX, pN0, pN1, pN2, pN3.

pNX - regional lymph nodes cannot be assessed by histological examination.

pN0 - metastases in regional lymph nodes were not detected histologically.

pN1, pN2, pN3 - histologically confirmed increase in the degree of damage to regional lymph nodes.

Distant metastases (pM) according to histological examination are represented by the symbols pMX, pM0, pM1.

pMX - distant metastases cannot be histologically verified.

pM0 – histological examination did not reveal distant metastases.

рМ1 – distant metastases are confirmed by the results of histological examination.

Histopathological differentiation of tumor tissue (G), which characterizes the degree of malignancy of the tumor, is denoted by the symbols GX, G1, G2, G3, G4.

GX - the degree of tissue differentiation cannot be established.

G1 - high degree of differentiation.

G2- average degree differentiation.

G3 - low degree differentiation.

G4 - undifferentiated tumor.

The lower the degree of differentiation, the more malignant the tumor, the higher its invasiveness and ability to metastasize, the worse the prognosis. In addition, the lower the degree of differentiation, the more sensitive the tumor to radiation and cytostatic drug effects. Thus, the degree of tumor tissue differentiation significantly affects the treatment program for a cancer patient and serves as one of the prognosis criteria. For some localizations of the primary tumor, category G determines the stage of the disease (tumors of soft tissues, bones, thyroid, prostate).

The TNM system allows you to accurately and concisely characterize a malignant tumor of any localization. However, 6 degrees of category T, 4 degrees of category N, 3 degrees of category M determine 72 variants of characteristics. Given the 4 degrees of category G, the number of options increases significantly and the practical use of the classification becomes difficult.

In order to reduce the number of classification characteristics, options that are close in prediction are grouped into 5 stages: O, 1, 2, 3, 4.

Stage 0 includes cancer of any localization without regional and distant metastases, when the primary tumor does not extend beyond the epithelium (carcinoma in situ, TisN0M0).

Stage 1 is characterized by the absence of regional and distant metastases in all localizations, except for gastric cancer. Stage 1 primary tumor corresponds to T1 or T2. Gastric cancer T1 with 1 - 6 metastases to the lymph nodes (N1) also belongs to stage 1. Thus, stage 1 includes malignant tumors of all localizations corresponding to T1N0M0 or T2N0M0 and gastric cancer T1N1M0.

Stages 2 and 3 are characterized by progressive growth of the primary tumor (T2, T3, T4) and (or) the appearance of metastases (N1) and progressive (N2, N3) metastasis to regional lymph nodes. common feature the first three stages is the absence of distant metastases (MO).

The presence of distant metastases (M1), regardless of the characteristics of categories T and N, predetermines the 4th stage of a malignant neoplasm. That's why general formula most malignant tumors of the 4th stage looks like this: T any N any M1. However, stage 4 is not limited to malignant tumors with distant metastases. Since the association by stages forms groups that are homogeneous in terms of prognosis, stage 4 also includes primary widespread tumors without distant metastases or tumors with widespread regional metastases (T4 N any M0 for cervical or uterine cancer, kidney cancer; T any N2 M0 for kidney cancer ; T any N1,2,3 M0 for bladder cancer; T4N0M0 or T any N1M0 for prostate cancer). Stage 4 also includes any undifferentiated thyroid tumor (G4), regardless of the characteristics of categories T, N, M.

What do the numbers mean in TNM?

Primary tumor (T):

Tx - the size of the primary tumor cannot be estimated.
T0 - data on the primary tumor are absent.
Tis - the letters is mean "carcinoma in situ" - "cancer in situ". it small tumor that does not grow into adjacent tissues. It is, as it were, in balance - at each moment of time, the same number of tumor cells die and form again.
T1, T2, T3, T4 - denote various sizes tumors.

Spread to regional lymph nodes (N):

Nx - metastases in regional lymph nodes cannot be assessed.
N0 - metastases in regional lymph nodes are not detected.
N1, N2, N3 - indicate the degree of involvement of the lymph nodes in the tumor process.

Distant metastases (M):

Mx - Unable to evaluate distant metastases.
M0 - no distant metastases.
M1 - distant metastases present.

What are the stages of a malignant tumor?

Obviously, combinations of the letters T, N and M with different indexes there may be a lot. Keeping everything in mind is difficult even for a doctor with great experience. Therefore, they are combined into 5 groups (stages). Knowing the stage gives a clear idea of what treatment methods should be used, how the tumor may behave in the future.

The criteria according to which a tumor is assigned to one stage or another differ for different types cancer. For example, bladder cancer T3N0M0 is classified as stage III, and T3N0M0 as stage II.

General characteristics of the stages of malignant tumors:

Stage 0 - "cancer in situ".
Stages I, II, and III: the higher the stage number, the larger the size of the primary tumor, its spread to regional lymph nodes and neighboring organs.
characterized by the presence of distant metastases.

The stage of the tumor can only be determined after a comprehensive examination. For this, the European clinic uses modern equipment. Studies allow you to clarify the localization of cancer, the degree of germination in nearby organs and tissues. It helps to assign the most effective treatment and significantly improve the prognosis for patients.

All tumors are divided into benign and malignant. We have already learned their differences. Today we will get to know classification of malignant tumors and find out whether all malignant tumors can be called cancer.

All malignant tumors are divided into groups depending on the type of fabric. from which they originated:

cancer (carcinoma) is a malignant tumor of epithelial tissue. If cells highly differentiated(less malignant), the name is specified by the type of tissue. follicular cancer, keratinizing squamous cell carcinoma, adenocarcinoma, etc.
If the tumor has poorly differentiated cells, the cells are named according to their shape. small cell carcinoma, ring cell carcinoma, etc.

Blood is not an epithelial tissue, but a type of connective tissue. Therefore, to say "blood cancer" is incorrect. In the 3rd year, during the study of pathological anatomy, we were told that such a phrase, spoken aloud at the exam, automatically causes removal from the exam with deuce. It was remembered. Correct names: leukemia ( leukemia. hemoblastosis), this is a tumor from the hematopoietic tissue that develops throughout the circulatory system. Leukemias are acute and chronic. If a tumor from the hematopoietic tissue is localized only in a certain part of the body, it is called lymphoma (remember the photo with Burkitt's lymphoma in the first part?).

The lower the cell differentiation, the faster the tumor grows and the earlier it metastasizes. I already wrote about this in the second part of the series.
sarcoma - a malignant tumor of connective tissue, with the exception of blood and hematopoietic tissue. For example, lipoma is a benign tumor from adipose tissue, and liposarcoma is a malignant tumor from the same tissue. Similarly: fibroids and myosarcomas, etc.

Now generally accepted are international TNM classification and clinical classification malignant tumors.

TNM classification

Used all over the world. For a malignant tumor, a separate characteristic of the following parameters is given:

1. T (tumor, tumor) - the size of the tumor.
2. N (nodes, nodes) - the presence of metastases in regional (local) lymph nodes.
3. M (metastasis) - the presence of distant metastases. Then the classification was expanded with two more characteristics:

4. G (gradus, degree) - the degree of malignancy.
5. P (penetration, penetration)- the degree of germination of the wall of a hollow organ (used only for tumors of the gastrointestinal tract). Now in order and in more detail.

T (tumor) - tumor.
It characterizes the size of the formation, the prevalence in the departments of the affected organ, the germination of surrounding tissues. Each organ has its own specific gradations of these features.

For example, for colon cancer:

T o - there are no signs of a primary tumor.
T is (in situ) - intraepithelial tumor. About her below.
T 1 - the tumor occupies a small part of the intestinal wall.
T 2 - the tumor occupies half the circumference of the intestine.
T 3 - the tumor occupies more than 2/3 or the entire circumference of the intestine, narrowing the lumen.
T 4 - the tumor occupies the entire lumen of the intestine, causing intestinal obstruction and (or) grows into neighboring organs.

For a breast tumor, gradation is carried out by tumor size(in cm), for stomach cancer - according to the degree of wall germination and distribution to the parts of the stomach.

Degree of organ wall invasion and TNM.
Designations (from top to bottom):
mucous - submucosal -
muscular layer - subserous layer -
serous membrane - surrounding organs.

Of particular note is cancer "in situ" (cancer in situ). At this stage, the tumor is located only in the epithelium (intraepithelial cancer), does not germinate the basement membrane, which means that the blood and lymphatic vessels do not germinate. At this stage of development, a malignant tumor is still devoid of infiltrating character growth and fundamentally cannot metastasize. That is why in situ cancer treatment gives most favorable results .

Stages of cancer development.
Designations (from left to right): a cell with a gene mutation - hyperplasia -
pathological growth - cancer "in situ" - cancer with infiltrating growth.

It should be noted that morphologically (that is, under a microscope) there are many transitional stages between a normal and a malignant cell. Dysplasia is a violation of the proper development of cells. Hyperplasia is a pathological increase in the number of cells. Not to be confused with hypertrophy (this is a compensatory increase in cell size during their hyperfunction, for example, the growth of muscle tissue after exercising with dumbbells).

Stages of epithelial dysplasia:
normal cell - hyperplasia -
mild dysplasia - cancer "in situ" (severe dysplasia) -
cancer (invasive).

N (nodes) - nodes (lymph nodes).
characterizes changes in regional (local) lymph nodes. As you know, the lymph flowing from the organ first enters the nearest regional lymph nodes (collector of the 1st order), after which the lymph goes to a group of more distant lymph nodes (collectors of the 2nd and 3rd orders). Lymph from the entire organ and even several organs at once gets into them. Groups of lymph nodes have their own name, which is given by their location.
For example, for stomach cancer:
- N x - no data on the presence of metastases in regional lymph nodes (the patient is underexamined).
- N o - there are no metastases in regional lymph nodes.
- N 1 - metastases in the collector of the 1st order (along the greater and lesser curvature of the stomach).
- N 2 - metastases in the collector of the 2nd order (prepyloric, paracardial, lymph nodes of the greater omentum).
- N 3 - metastases affect the para-aortic lymph nodes (collector of the 3rd order, near the aorta), which cannot be removed during surgery. At this stage, it is impossible to completely remove the malignant tumor.
So, the gradations N o and N x are common for all localizations, N 1 - N 3 are different.
M (metastasis).
Characterizes the presence distant metastases.
- M o - no distant metastases.
- M 1 - there is at least one distant metastasis.
Additional TNM classification options:
G (gradus) - the degree of malignancy.
Determined histologically (under a light microscope) by degree of differentiation cells.
- G 1 - low-grade tumors (highly differentiated).
- G 2 - medium malignancy (poorly differentiated).
- G 3 - high degree of malignancy (undifferentiated).
P (penetration) - penetration.
Only for tumors of hollow organs. Shows degree germination of their walls.
- P 1 - within the mucosa.
- P 2 - grows into the submucosa.
- P 3 - grows into the muscle layer (to serous).
- P 4 - sprouts the serous membrane and goes beyond the organ.

According to the TNM classification, the diagnosis may sound, for example, like this: caecal cancer T 2 N 1 M 0 G 1 P 2. This classification is convenient, as it characterizes the tumor in detail. On the other hand, it does not provide generalized data on the severity of the process and the possibility of a cure. Therefore, the clinical classification of tumors is also used.

Clinical classification of tumors

Here are all the parameters of a malignant neoplasm (the size of the primary tumor, the presence of regional and distant metastases, germination in surrounding organs) taken together .

Allocate 4 stages of cancer.

1st stage. the tumor is small, occupies a limited area, does not germinate the wall of the organ, there are no metastases.
2nd stage. the tumor is large, does not spread outside the organ, single metastases to regional lymph nodes are possible.
3rd stage. a large tumor, with decay, germinates the entire wall of the organ or a smaller tumor with multiple metastases to regional lymph nodes.
4th stage. germination of the tumor in the surrounding tissues, including non-removable (aorta, vena cava, etc.) or any tumor with distant metastases.

The possibility of curing a malignant tumor depends on the stage: the higher the stage, the less likely be cured. That's why you need to detect a malignant tumor as soon as possible. and for this, do not be afraid to go to be examined, especially if there are suspicions, which will be discussed in the 4th part of this cycle.

Relative 10-year survival rate for cancer patients
mammary gland depending on the stage of cancer.

When deciding on the choice of the optimal treatment plan for a patient, specialists are interested in how far the neoplasm is spread. For this, the international classification of malignant tumors is used. Its main indicators are:

T - means that the tumor is primary, its stages are indicated;
N - the presence of metastases in neighboring lymph nodes;
M - the presence of distant metastases - for example, in metastases in the lungs, liver or other organs.

To clarify the stage of the tumor, the following indexing is used: T1 indicates that the tumor is small, and T4 is already significant (in each case, the growth of the tumor into different layers of the organ and its spread to neighboring ones is taken into account). If the nearest lymph nodes are unchanged, then N0 is set. In the presence of metastases in them - N1. In the same way, the absence (MO) or presence (Ml) of metastases to other organs is noted. Next, a more specific description of the stages of cancer of each organ will be given. Thus, if cancer is detected on early stage and without metastases, then T1 N0 MO is displayed in the medical history.

Classification of tumors according to the TNM system

The TNM System for describing the anatomical extent of a neoplasm is based on 3 components:
T Prevalence of the primary tumor N Presence, absence and prevalence of metastases in the lymph nodes M Presence or absence of distant metastases.
The number next to the component indicates the extent of the malignancy:
TO, T1, T2, TZ, T4 N0, N1, N2, N3 MO, M1
Thus, the TNM System is quick guide to describe the prevalence of specific malignancies.
Basic rules for the classification of neoplasms of any localization
1. In all cases, histological confirmation of the diagnosis is required. Cases where confirmation is not possible should be described separately.
2. For each of the localizations, there are two classifications, namely:
a) clinical classification (cTNM or TNM): classification before treatment, which is used to select and evaluate the effectiveness of treatment. It is based on pre-treatment findings by physical examination, as well as the results of radiological and endoscopic methods research, preoperative biopsies and diagnostic interventions;
b) pathoanatomical classification (pTNM); classification after surgical intervention for selection additional therapy, receiving additional information about the prognosis of treatment, as well as statistical accounting of treatment results. This classification is based on data obtained before the start of treatment, which are further supplemented or modified based on the results of surgical intervention and post-mortem examination. Morphological assessment of the prevalence of the primary tumor is carried out after resection or biopsy of the neoplasm. The defeat of regional lymph nodes (category pN) is assessed after their removal. In this case, the absence of metastases is designated as pNO, and the presence is denoted by one or another pN value. Excisional lymph node biopsy without histological examination of the primary tumor is not a sufficient basis for establishing a pN category and belongs to the clinical classification. The presence of distant metastases (rM) is determined by microscopic examination.
3. After determining the categories T, N and M and / or pT, pN and pM they are grouped into one or another stage of the disease. Established TNM categories as well as disease stage should remain within medical records unchanged. The data of clinical and pathoanatomical classifications can be combined in cases where the information presented in them complements each other.
4. If in a particular case there are doubts in determining exact value category T, N or M, you must choose the category with a lower value. The same rule applies when choosing the stage of cancer.
5. In cases of multiple primary tumors of one organ, category T is assigned the maximum value among these tumors. In this case, the multiple nature of the formation or the number of primary tumors should be indicated in brackets after the T value, for example, T2(t) or T2(5). In the case of simultaneous bilateral (bilateral) primary neoplasms of paired organs, each of them should be classified separately. In tumors of the liver, ovary, and fallopian (fallopian) tubes, multiplicity is a criterion for category T, while in lung cancer, multiplicity can be a criterion for both category T and M.

Classification of tumors clinical TNM

T - Primary tumor
TX Primary tumor cannot be assessed
TO No evidence of primary tumor
Tis Carcinoma in situ
T1-T4 Increased size and/or spread of the primary tumor
N - Regional lymph nodes
NX Regional lymph nodes cannot be assessed
N0 No metastases in regional lymph nodes
N1-N3 Increased involvement of regional lymph nodes
M - Distant metastases*
MO No distant metastases M1 Distant metastases present
* Category MX is considered inappropriate, because evaluation of distant metastases can only be based on physical examination data (MX category cannot be determined).
Subcategories in TNM classifications
Subcategories of some of the main categories are used when further clarification is needed (eg Ha, T1b or N2a, N2b).

Classification of tumors pathoanatomical

The germination of the primary tumor in the lymph nodes is regarded as a metastasis in the lymph nodes.
Tumor deposits (satellites), such as macro- and microscopic nests or nodules in the zone of lymphatic vessels draining the primary tumor without histological signs of residual lymph node tissue in such formations, may be a continuation of the primary tumor, unrelated nodes, the result of venous invasion (V1/ 2) or complete replacement of lymph node tissue tumor tissue. If the pathologist suspects that such a nodule is a lymph node tissue replaced by tumor cells (usually it has smooth contours), he must designate this phenomenon as a metastasis in the lymph node. In this case, each nodule must be recorded as a separate lymph node in the final value of the pN category.
Metastasis in any non-regional lymph node should be considered as distant metastasis.
If the pN category criterion is size, then only the metastasis is measured, not the entire lymph node.
In the presence of only micrometastases in regional lymph nodes, i.e. metastases, the maximum size of which does not exceed 0.2 cm, add (mi) to the pN value in brackets, for example, pN1(mi). It is necessary to indicate the number of removed and metastasized lymph nodes.

sentinel lymph node

The sentinel lymph node is the first lymph node that receives lymph from the primary tumor. If there are tumor cells in the tissue of this node, then they can be in other lymph nodes. If there are no tumor cells in the sentinel node, then most likely they are absent in other lymph nodes (rarely there are several sentinel lymph nodes).
When taking into account the state of the "sentinel" lymph node, the following designations are used:
pNX(sn) Sentinel lymph node cannot be assessed,
pNO(sn) No sentinel node metastasis,
pN 1 (sn) Metastasis in the "sentinel" lymph node.

Histological classification of tumors

The histological grade of malignancy (Grade, G) for neoplasms of most localizations is indicated as follows:
GX Tumor grade cannot be determined;
G1 Highly differentiated tumor;
G2 Moderately differentiated tumor;
G3 Poorly differentiated tumor;
G4 Undifferentiated tumor.
Note: Under certain conditions, categories G3 and G4 can be combined as G3-4, i.e. Poorly differentiated - undifferentiated tumor. In the classifications of bone and soft tissue sarcomas, the terms "high grade" and "low grade" are used. Special systems for assessing the degree of malignancy have been developed for diseases: breast cancer, uterine cancer, prostate cancer and liver cancer.

Additional criteria for classifying tumors

For some special occasions in the TNM and pTNM Systems there are additional criteria, denoted by the symbols T, Y, V and A. Although their use does not change the established stage of the disease, they indicate cases that require separate additional analysis.
Symbol T Used to indicate the presence of multiple primary tumors in the same area.
Y symbol. In cases where the tumor is evaluated during or immediately after complex treatment, the values of the cTNM or pTNM categories are accompanied by the Y prefix. The values of ycTNM or ypTNM characterize the prevalence of the tumor at the time of the study. The Y prefix takes into account the spread of the tumor before the start of complex treatment.
V symbol. Recurrent tumors evaluated after a relapse-free period is denoted by the prefix V.
The character "a". This prefix indicates that the tumor was classified after autopsy.
L - Invasion of the lymphatic vessels
LX Invasion of lymphatic vessels cannot be assessed
L0 No invasion of lymphatics L1 Invasion of lymphatics
V - Venous invasion
VX Venous invasion cannot be assessed
V0 No venous invasion
VI Microscopically detected venous invasion V2 Macroscopically detected venous invasion
Note: macroscopically detected tumor invasion of the vein wall, but without tumor invasion into its lumen, belongs to category V2.
Rp - Perineural invasion
RnS Impossible to assess perineural invasion RnO No perineural invasion Pn1 Perineural invasion present
C-factor, or factor of certainty, reflects the reliability and validity of the classification, depending on the used diagnostic methods. Its use is optional.

Classification of tumors and definitions of C-factor

C1 The classification is based on the results of standard diagnostic procedures(examination, palpation, routine radiography and endoscopy lumen of hollow organs in order to detect tumors of some organs).
C2 The classification is based on the results of special diagnostic studies(radiography in special projections, tomographic examination, CT scan, ultrasonography, lympho- and angiography, scintigraphy, magnetic resonance imaging, endoscopy, cytological and histological studies). C3 The classification is based on the results of exploratory surgery with biopsy and cytological examination. C4 Data on the prevalence of the process were obtained after a full surgical intervention with histological examination remote education
C5 Classification based on autopsy data.
Note: A C-factor value can be assigned to any of the categories T, N, and M. For example, an observation can be described as T3C2, N2C1, M0C2.
Thus, the clinical classification of cTNM usually corresponds to the certainty factor C1, C2 and C3, while the pathological classification of pTNM usually corresponds to the value of C4.

Classification of tumors category R

The presence or absence of residual tumor after treatment is indicated in category R.
Some investigators believe that the R category can only be used for primary tumors and their local or regional tumor growth. Others apply this category more broadly, incl. to designate distant metastases, therefore, when using the R category, these features must be noted.
Usually, using the TNM and pTNM classifications, they describe the anatomical extent of the tumor without taking into account the treatment performed. These classifications can be supplemented by the R category, which describes the state of the tumor after treatment. It reflects the effectiveness of therapy, the impact additional methods treatment on the outcome of the disease, and in addition is a prognostic factor.

R category values:
RX Residual tumor cannot be assessed
R0 No residual tumor
R1 Microscopically detected residual tumor
R2 Macroscopic residual tumor

The TNM system is used to describe and document the anatomic extent of a disease. For the purpose of combining and analyzing data, categories can be grouped into stages. The TNM System defines carcinoma in situ as stage 0. Tumors that do not extend beyond the organ from which they originate are in most cases classified as stages I and II. Locally advanced tumors and tumors involving regional lymph nodes are classified as stage III, and tumors with distant metastases - to stage IV. The stages are set in such a way that, as far as possible, each of the resulting groups is more or less homogeneous in terms of survival and that the survival rates in groups for neoplasms different localizations were different.
When grouped into stages using the pTNM pathology classification in cases where the tissue of interest has been removed for postmortem examination to determine maximum value categories T and N, category M can be both clinical (sM 1) and pathoanatomical (pM1). If there is histological confirmation of distant metastases, the pM1 category and stage will be pathologically confirmed.
Although tumor prevalence, as described by the TNM classification, is a significant predictor of cancer, many other factors also play a role. big influence on the outcome of the disease. Some of these are included in grouped disease stages, such as grade (for soft tissue sarcoma) and age of patients (for thyroid cancer). These classifications remain unchanged in the seventh edition of the TNM Classification. In the newly revised classifications of esophageal and prostate cancer, the grouping in stage based on the principle of the prevalence of the tumor is retained, and a system of grouping by prognosis has been added, which includes a number of prognostic factors.