Over 500,000 people in the United States and over 8 million people worldwide are dying every year from cancer. As people live longer, the incidence of cancer is rising worldwide and the disease is expected to strike over 20 million people annually by 2030. This open course is designed for people who would like to develop an understanding of cancer and how it is prevented, diagnosed, and treated. The course introduces the molecular biology of cancer (oncogenes and tumor suppressor genes) as well as the biologic hallmarks of cancer. The course also describes the risk factors for the major cancers worldwide, including lung cancer, breast cancer, colon cancer, prostate cancer, liver cancer, and stomach cancer. We explain how cancer is staged, the major ways cancer is found by imaging, and how the major cancers are treated. In addition to the core materials, this course includes two Honors lessons devoted to cancers of the liver and prostate. Upon successful completion of this course, you will be able to: - Identify the major types of cancer worldwide. (Lecture 1) - Describe how genes contribute to the risk and growth of cancer. (Lecture 2) - List and describe the ten cellular hallmarks of cancer. (Lecture 3) - Define metastasis, and identify the major steps in the metastatic process. (Lecture 4) - Describe the role of imaging in the screening, diagnosis, staging, and treatments of cancer. (Lecture 5) - Explain how cancer is treated. (Lecture 6) We hope that this course gives you a basic understanding of cancer biology and treatment. The course is not designed for patients seeking treatment guidance – but it can help you understand how cancer develops and provides a framework for understanding cancer diagnosis and treatment.
TNM Staging
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From the course by Johns Hopkins University
Introduction to the Biology of Cancer
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From the lesson
Metastasis: The Real Killer
The lethal agent of cancer is metastasis. This week, we'll take a good look at this deadly event, TNM staging, the metastatic process, and an ecological paradigm.
Meet the Instructors
Kenneth J. Pienta, M.D.The Donald S. Coffey Professor of Urology
The James Buchanan Brady Urological Institute
Now you've been introduced to the concept and definition of metastasis,
I'm going to go over a common method of staging for
cancer, the TNM system, in which metastasis plays a major role.
The TNM staging system in cancer is by far the most commonly used staging system in
cancer diagnosis and is used to determine a patient's prognosis and
the course of treatment to be used for a certain patient.
Most cancers use this system, except blood cancers and some nervous system cancers.
So the T in TNM stands for Tumor.
The N for the N in node in Lymph node.
And the M is for Metastasis.
As you'll see, metastasis plays a big role in determining how
serious a person's cancer is, and how to treat it.
So let's talk about each of these individually.
The T in TNM stands for tumor, and
the stage of a primary tumor depends on its size.
The larger the tumor, the worse the stage.
Usually, tumors are not immediately obvious.
Tumors are found through various imaging techniques, which you'll hear more about
in lecture five, physical and examination and surgery.
You can see here at CAT scan or CT scan of a liver tumor and
ultrasound of a breast tumor and a picture of a colon tumor found during surgery.
Physical exams can lead to these types of imaging studies.
For instance, the digital rectal exam or DRE is use to screen for
prostate cancer and if then are abnormality is felt upon examination,
further examination and imaging studies are performed.
For some cancers such as stomach cancer, there is no way to
access the primary tumor site by physical examination, so sometimes,
lymph nodes are palpated or touched to determine whether a tumor may be present.
But imaging is always necessary to confirm.
Speaking of lymph nodes,
the N in TNM refers to the involvement of lymph nodes in the cancer.
First, lets review the lymphatic system.
The lymphatic system is comprised of lymphatic vessels,
similar to blood vessels, that carry fluid called lymph from tissues throughout
the body to lymph nodes and then deposits the lymph into the blood stream.
The lymphatic system is important because it carries away excess fluid from
in between cell so as to maintain a constant volume and composition of tissue.
It also acts as an immunological defense mechanism by taking away waste and
bacteria and exposing it to immune cells.
Lymph is mostly comprised of water, white blood cells, and
various molecules like proteins, fats, and sugars.
The lymph nodes of the lymphatic system are important in cancer diagnosis and
treatment because cancer cells can get into the lymph and drain into lymph nodes.
Cancer typically spreads to regional lymph nodes,
which means the closest lymph node to the primary tumor.
For instance, prostate cancer cells drain into inguinal lymph nodes,
which you can see on the diagram.
And breast cancer cells drain into lymph nodes nearby the mammary glands,
as well as axillary lymph nodes.
This is why lymph node palpation is a common part of physical examination.
So the TNM system is typically binary when it comes to the end of TNM.
Basically, N0 means cancer has not been found in the lymph node,
whereas N1 means cancer has been found in a regional or nearby lymph nodes.
When cancer is found in lymph nodes beyond the local region,
it represents the worst diagnosis and prognosis.
And this is actually often reflected in the next part of TNM metastasis.
What you see here is histology of a normal lymph node on the left where
all the purple dots represented nuclei of millions of immune cells
that usually comprise most of the lymph node.
On the right, you see large tumor mass that is taking up almost
the entire lymph node, and only a small portion of normal lymph
node tissue is remaining on the upper right portion there.
So the final letter M of TNM represents our topic today, metastasis.
Once a cancer has reached metastatic capability,
it has become quite aggressive and most likely fatal.
Metastasis can be difficult to find via physical examination.
But once cancer has been found, a primary goal of the physician is to determine
whether or not that cancer has spread, so imaging studies are typically ordered.
Here you can see four representative images
of metastatic tumors found in some of the more common sites of metastasis.
On the left is an x ray of a bone metastasis, meaning a tumor from another
organ that became cancerous and metastasized to the bone.
Then you see an x ray of a lung metastasis,
a CT image of a liver metastasis and an MRI of a brain metastasis.
I'd like to go over an example of a specific TNM staging system for
an individual cancer type, prostate cancer.
Each cancer follows similar rules and numbers,
but can vary slightly depending on how the cancer typically behaves.
For prostate cancer, the primary tumor can be classified as T1, T2, or T3,
depending on how large the tumor is, and whether or
not it has become invasive which, if you look in the diagram,
the blue tumor labeled T3 has done that and become invasive in the picture.
For the N, for prostate cancer, it's a binary numbering system, either N0 for
no lymph node involvement or N1 for lymph node involvement.
For our prostate cancer, N1 only refers to nearby lymph nodes,
which you can see in the picture.
If lymph nodes further away are involved, they are classified in the M portion of
TNM, metastases are classified as either M0 for no metastasis, M1a for far away
lymph node involvement, M1b for metastasis to bone tissue, which is the most common
cyto metastasis in prostate cancer, or M1C for metastasis to other tissues.
So an example of a serious tumor stage in prostate cancer would be T3,
N1, M1B, which is a large tumor that is invasive which has gone to
nearby lymph nodes and also metastasized to the bone.
And that would be a more serious tumor than a T1, N0, M0,
which is a smaller tumor that has not gone to either lymph nodes or metastasized.
At this point, we have finished section B, which was T and M staging tumors and
then we're going to move on to section C which is the actual metastatic cascade.
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