STAGING

LIP/MAJOR SALIVARY/THYROID
• T1 - < 2 cm
• T2 - > 2 - < 4cm
• T3 - >4cm

• N2c – mets in bilateral cervical LN’s

 STAGING
ESOPHAGUS – no serosa!!! adventitia
• Tis – high grade dysplasia
• T1a – invades lamina propria/muscularis
mucosa
• T1b – invades submucosa
• T2 – invades muscularis propria/externa
 STAGING
GALLBLADDER
-no muscularis mucosa and submucosa

• T1a – invades through lamina propria

• T1b – invades through muscularis externa
 STAGING
GASTRIC/SI/COLON/RECTUM

• Tis – intraepithelial tumor w/out invasion to lamina

propria
• T1- invasion through lamina propria/submucosa
• T2- invasion through muscularis externa and
subserosa
 STAGING
BREAST/ANAL
• T1 - < 2cm
• T2 - >2 - < 5cm
• T3 - > 5cm
 STAGING
SOFT TISSUE
• T1 - < 5cm
• T2 - > 5cm

• a- superficial (above superficial fascia)

• b- invasion of fascia
 HEAD AND NECK
LYMPH NODE Echelon:
LIP/Oral cavity : Levels I –II (Supraomohyoid dissection)

Larynx/Pharynx: Levels II-IV (Anterolateral neck

dissection)

Nasopharynx: Level V (Posterolateral neck dissection)

Thyroid: Level VI-VII (Central neck dissection

LIP:
T1-2 = Excise or EBRT

T3-T4 = Excise + SLND (Supraomohyoid ND) or

EBRT or ChemoRT

• If N(+)= therapeutic LND

• Any T with N(+) = always do adjuvant RT
ORAL CAVITY down to Hypopharynx: Any T:
always do neck dissection, be it prophylactic or
therapeutic, basta laging may neck dissection
kahit N(-)

• Exception: Nasopharynx: No OR!!!!ChemoRT

lang kahit N(+)
ORAL CAVITY down to HYPOPHARYNX:

• T1-2 N0 = excise + SLND

• T3-4 N0 = excise + MRND or ChemoRT

• N1= MRND,
• N2c=bilateral MRND
• N3=RND
• Hypopharynx (supraglottic, glottis, subglottic):
“always do bilateral neck dissection”

• Larynx: “always do ipsilateral thyroid

lobectomy with isthmusectomy”
THYROID:
• For Papillary and Follicular: MRND for N(+)
only!!!

• For Hurthle and Medullary: any T, N(-), always

do prophylactic central neck dissection

• For medullary: If ipsilateral N(+), always do

contralateral neck dissection
COMPLETION THYROIDECTOMY:
• Tumors > 4cm in size
• Positive margins
• Gross extrathyroidal invasion
• Macroscopic multifocal disease
• Lymphovascular invasion
• LN’s mets
• Aggressive variant (tall cell, clear cell…)
RAI Ablation is done to:
• Ablate the thyroid remnant
• Eliminate micromets
• Eliminate known persistent disease
RAI ablation Indications:
• Gross residual
• > 4cm tumor size
• Distant mets
• W/out gross residual but with high risk
features
PAROTID:

• T3-4 or high grade tumor: Always do

ipsilateral prophylactic neck dissection even if
it’s N(-)

• Always do Adjuvant RT for T3-4, close margin,

or with perineural or lymphovascular invasion

• If possible, always preserve Facial Nerve

 BREAST
MUST KNOW…

1. Give adjuvant chemo if:

• > 0.5cm tumor with poor prognostic features
• > 1 cm tumor size
• N(+)
 BREAST
MUST KNOW…

2. Give Post-op RT if:

• (+) margins/ close margins (< 1mm)
• > 4 axillary LN’s as shown on final histopath
• > 5cm tumor size
 BREAST
MUST KNOW…

3. Do not give Tamoxifen if:

• N(-) with tumor size of <0.5cm
• N(-) with tumor size of 0.5-1cm with low risk
features
• All the rest…give TAMOXIFEN!
 BREAST
MUST KNOW…
Pre- menopausal:
• Tamoxifen for 5 yrs

Post-Menopaisal:
• Tamox x 5 years + AI’s for 5 years
• Tamox sequential with AI’s for a total of 5
years
 BREAST
ALLRED SCORING

PROPORTION SCORE
0 No cells are ER +
1 < 1% of cells are ER +
2 1-10% of cells are ER +
3 11-33% of cells are ER +
4 34-66% of cells are ER +
5 67-100% of cells are ER+
 BREAST
ALLRED SCORING

INTENSITY SCORE
0 Negative
1 Weak
2 Intermediate
3 Strong
 BREAST
ALLRED SCORING

ALLRED SCORE

0-1 No effect

2-3 Small-20% chance of benefit

4-6 Moderate- 50% chance of benefit

7-8 Good- 75% chance of benefit

 BREAST
MUST KNOW…
4. Contraindications for BCT
• Had previous radiation
• Pregnant patients
• Diffuse microcalcifications on mammogram
• (+) pathologic margins
• Widespread disease (locally advance)
• Scleroderma/SLE patients
 BREAST
MUST KNOW…
5. Contraindications for SLNB/SLND
• Pregnant patients
• Palpable LN’s
• T3, N0
• Inflammatory breast CA
• Post neoadjuvant chemo
• Prior axillary or non-oncologic breas Sx
 BREAST
MUST KNOW…
6. Unfavorable Prognostic features?
• Angiolymphatic invasion
• High nuclear grade
• High histologic grade
• Her2 (+)
• ER/PR (-)
DCIS
• Lumpectomy + Radiation
• Total mastectomy + reconstruction – for tumor
> 4cm, disease in more than 1 quadrant
(multicentric)
• Lumpectomy + observation – for tumor
<0.5cm
• Tamoxifen as adjuvant Tx for ER/PR (+)
• Trastuzumab?
LCIS (25-35% - develop into IDCA)

• Observe, H & PE every 6 mos, annual

mammogram
• Tamoxifen x 5 yrs only for > 35 years old

• Bilateral mastectomy for selected pxs who are (+)

for BRCA 1/2, PTEN mutation
STAGE I-II (Early Breast CA)

• Mastectomy + reconstruction + ALND +

adjuvant chemo + Trastuzumab (herceptin) +
Tamoxifen/AI’s

• Lumpectomy + ALND + Radiation + Chemo +

Traztuzumab + Tamoxifen/AI’s

• SLNB/SLND can be done only for T1-T2 tumor, N0

STAGE III

• Neoadjuvant chemo + MRM + RT + adjuvant

chemo + trastuzumab and tamoxifen/AI’s

• If her 2 neu +1 – don’t give trastuzumab

• If her 2 neu +2 – request for FISH
• If her 2 neu +3 – give trastuzumab
STAGE IV
Give HORMONAL TX only if: FIRST CHOICE!!!
• ER/PR (+)
• Bone or soft tissue mets only
• Asymptomatic visceral mets

All others…give Chemotx…

Will do surgery only for patients with sepsis

secondary to infected tumor or bleeding…
• Male Breast CA- same management for
women with breast CA, may also give tamox
and herceptin if postive for tumor markers

• Inflammatory Breast CA
-Neoadjuvant chemo + MRM + RT + adjuvant
chemo + Trastuzumab and Tamox/AI’s
Breast CA in Pregnant patients
• Same Tx with non-pregnant pxs except:
• RT cant be given until the fetus is delivered
• NO SLNB/SLND
• No ChemoTX after 35th weeks AOG of 3 weeks
before the planned delivery
Breast CA among Elderly
• If N0: Lumpectomy/Mastectomy + Tamox/AI’s
• If N1: Mastectomy + ALND + Tamox/AI’s

• May have the option to give RT if indicated

• NO GIVING OF SYSTEMIC CHEMOTX!!!
ESOPHAGUS
CERVICAL ESOPHAGUS (W/in 5cm from
cricopharyngeus ms.)
• T1a: EMR
• T1b: ChemoRT
NONCERVICAL ESOPHAGUS (> 5cm from
cricopharyngeus muscle)
• T1(a and b):Esophagectomy
• T2- up or N(+):Neoadjuvant ChemoRT +
Esophagectomy with lymph node dissection
ESOPHAGUS
• Surgical approach?
– Ivor Lewis
– Transhiatal (Oringger)

Reconstruction?
GASTRIC
• <2cm mass, T1a, N0 – EMR
• T1, N0: Resect
• T2-up, N1: Neoadjuvant chemo /chemoRT +
Resect

• EUS (endoscopic UTZ) very important in

staging
• Type of resection?, reconstruction?
COLON
• Resect all even if stage St. IV
• Post-op: if T3 -low risk tumor: observe
If T3 -high risk tumor: adjuvant
chemo
• T4 or N1: adjuvant Chemo

• WALANG ROLE ANG RADIATION SA COLON

AND SMALL BOWEL!!!!!
RECTAL
• T3-4 or N1: neoadjuvant chemoRT/short
course RT for low risk tumor + formal
resection (APR/LAR)

• 0-5cm FAV: APR

• 6-10 FAV: LAR
• 11-15 FAV: anterior resection
ANAL – Squamous cell Ca only

• ANAL MARGIN: T1: wide excision, all the rest

NIGRO PROTOCOL na!!! (Mitomycin + 5FU +
RT)
• ANAL CANAL: NIGRO PROTOCOL only!

• If after Nigro Protocol, (+)recurrence: do APR!