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STAGING LMS TUMORS

Leiomyosarcoma Staging

How is Leiomyosarcoma Staged?

The process of finding out how far leiomyosarcoma has spread is called staging. In sarcoma staging, doctors also evaluate the appearance of the tumor under the microscope and judge how fast the cancer seems to be growing. The stage of a sarcoma is the most significant factor in determining each patient’s prognosis (the course of the disease and the chances of survival) and in selecting treatment options.
The information needed to stage sarcomas includes biopsies, and imaging tests of the main tumor (usually with CT or MRI scans) other parts of the body where the cancer may have spread.
When examining the biopsy sample, the pathologist (doctor who specializes in diagnosing diseases by looking at the tissue under a microscope) takes into account the number of cells that are actively dividing and how closely the cancer resembles normal tissue. He or she determines the cell type and grade and estimates how rapidly it will grow and spread.
A staging system is a standard way for the cancer care team to summarize the extent of a cancer’s spread. The system often used to stage sarcomas is the TNM system of American Joint Committee on Cancer.
  • T stands for the size of the tumor.
  • N stands for spread to lymph nodes (small bean-shaped collections of immune system cells found throughout the body that help fight infections and cancers).
  • M is for metastasis (spread to distant organs).
In soft tissue sarcomas, an additional factor, called grade (G), is also part of the tumor’s stage. The grade is based on how the sarcoma cells look under the microscope.
Grade (G)
The grade is a sign of how likely it is the cancer will spread. Previously, the grade of a sarcoma was only based on how normal the cells looked under the microscope (called differentiation). This was not very helpful, and under a new system (known as the French or FNCLCC system), grade is based on 3 factors:
  • Differentiation — cancer cells are given a score of 1 to 3, with 1 being assigned when they look similar to normal cells and 3 being used when the cancer cells look very abnormal
  • Mitotic count — how many cancer cells are seen dividing under the microscope; given a score from 1 to 3 (a lower score means fewer cells were seen dividing)
  • Tumor necrosis — how much of the tumor is made up of dying tissue; given a score from 0 to 2 (a lower score means there was less dying tissue present).
The scores for each factor are added to determine the grade for the cancer. Higher-grade cancers tend to grow and spread faster than lower-grade cancers.

STAGING THE TUMOR ONCE IT IS FOUND:

From the NCCN Guidelines for Patients (2018)

  • Case Dependent guidance to discuss with your Oncology Care team. 

Note:  Treatment Planning is important in the first steps of care.  All such planning is customized always case-specific   – it is not a “one size fits all” situation.  Being proactive in your care is important-  which means knowing as much as you can, and asking the right questions along the way.

Stage 1:    (1A / 1B grade)                          Primary Treatment                  

Low-Grade tumor                                      Surgery.  Recommendations for                                                                                   more treatment is based on size of                                                                             margin is 1 cm or less and if the                                                                                  fascia was cut.

                                                                          Clean margins around the tumor                                                                                site
                                                                          (always the goal)

Follow up Care:  Will begin when treatment is completed.

Rehabilitation if needed
Imaging – CT Scan, CT/PET scan
Note:  CT scan for lung surveillance is best
Genetic test of the tumor
Regular imaging of primary tumor site
Follow up appointments with blood work done

STAGE 2:  (2 – 3 Grade)    Treatment options are based on whether surgery is possible.  Location, size of tumor and overall heath
are always taken into consideration in treatment
options to be considered.   

                                                                       Primary Treatment  Options

Surgery
Surgery following radiation therapy
Radiation followed by surgery

                             Follow Up Care:    Rehabilitation if needed
Regular Imaging  – CT scans, CTG/PET Scans
to check for tumor metastasis:  usually 3 –
6 months for 2 – 3 years;  then every 6 months
for 2 years;  then repeat every year.

 

STAGE 3                                                    Primary Treatment Options
(Stage lllA or lllB
grade 2 – 3)                                     Surgery followed by radiation therapy /
Adjuvant chemotherapy.

Chemotherapy or radiation therapy
followed by surgery; then radiation therapy
boost with or without adjuvant chemo.

Chemotherapy followed by surgery, then
Radiation therapy with or without adjuvant
chemotherapy.

 

Follow-Up Care:       Same as Stage 2 indicated above

 

STAGE 4                                                         Primary Treatment Options

        CONFINED                                   
Treatment as indicated for stages 2 or
3  apply.
Surgery to remove metastases with or
without chemotherapy before or after
surgery; with or without radiation
therapy – such as Ablation, SBRT,
embolization, other modalities;
observation

 

                                    Follow-Up Care:

                                                                      Rehabilitation if needed
Imaging tests for surveillance
same cycles as indicated for
Stages 2 and 3.
Consider baseline and regular imaging of
primary tumor site

 

STAGE 4

       WIDESPREAD                             Primary Treatment Options:

                                                             Chemotherapy, radiation therapy /SBRT
surgery.   Observation if no symptoms

                                       Follow-Up Care:

                                                Same as indicated for Stage 4 above

 

 

                                                R E C U R R E N C E

 

Location:                                                                     Treatment Options:

 

Local                                                                              testing; treatment based on
stage (extent of disease)
More treatment as listed above

 

Isolated Regional disease
or lymph nodes                                                            Regional node dissection with
or without radiation therapy,
with or without chemotherapy
SBRT
Isolated limb infusion/per-
fusion plus surgery

                                                                                         

Widespread                                                                 Palliative chemotherapy
Palliative radiation therapy
SBRT, ablation, embolization.
Observation if no symptoms

 

NOTE:  For Quality of Life maintenance/rebuilding:  Discuss Integrative Medicine  & Survivorship Care Planning with your Oncologist –  the sarcoma center may have a wealth of supportive resources available in a dedicated survivorship clinic, with program resources available patients and their families.