TNM Staging: Breast - University of Kentucky

TNM Staging: Breast - University of Kentucky

TNM Staging: Breast TONYA BRANDENBURG, MHA, CTR KENTUCKY CANCER REGISTRY Overview Anatomy Common Terms

Changes in T,N,M Staging from AJCC 6th edition to 7th edition Elements of Staging: TX-T4, Clinical N, Pathological N and M0-M1 Stage Groups and Prognostic Factors Helpful Hints

Breast Examples Breast Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer Anatomic sites and subsites of the breast. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer

Schematic diagram of the breast and regional lymph nodes. Common Terms Duct carcinoma, NOS: The largest group of breast cancers. Duct carcinoma, NOS is not a specific histologic type because . features that can be used to better classify the it lacks specific tumor In Situ: A tumor that is confined to the duct system (ductular or lobular) and does not invade surrounding stroma

Invasive: A tumor that penetrates beyond the ductal basement membrane into the adjacent stroma of the breast parenchyma Paget Disease: Paget disease of the nipple is a condition where the epidermis of the nipple is Infiltrated with neoplastic cells. ICD-O-3 classifies all mammary Paget disease as a malignant process with a malignant behavior(/3). Under the matrix system, only if the Paget disease is explicitly specified as in situ or non-invasive by the pathologist, code the behavior in situ (/2) Changes in T,N,M Staging for Breast

from 6th edition to 7th edition Identification of specific imaging modalities that can be used to estimate clinical tumor size Recommendations about sizing a tumor grossly and microscopically Recommendations of use of clinical versus pathological tumor size in cases of neoadjuvant treatment

Estimating tumor size Clarification of inflammatory cancer definition Recommended use of Nottingham combined histologic grade Changes continued

Tighter classification of isolated tumor cells and single cells Use of (sn) modifier on when 6 or more sentinel nodes are identified on gross exam Subdivision of Stage 1 tumors into Stage 1a and Stage 1b based on nodal micrometastases

Creation of new M0 (i+) category, for either disseminated cells in bone marrow, or circulating tumor cells, or cells found incidentally (such as ovaries that are removed prophylactically) Elements of Staging: TX, T0, and Tis TX: Primary tumor cannot be assessed T0: No evidence of primary tumor

Tis: Carcinoma in situ (CIS) Tis (DCIS): Ductal carcinoma in situ Tis (LCIS): Lobular carcinoma in situ Tis (Pagets): Pagets disease of the nipple without mass Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,

2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer Tis (Paget's) is defined as Paget's disease of the nipple with no tumor. Elements of Staging: T1 T1: Tumor 2 cm or less T1mi : Tumor 1 mm or less

T1a Tumor > 1 mm but < 5 mm T1b Tumor > 5 mm but < 10 mm T1c Tumor > 10 mm but < 20 mm Elements of Staging: T1mi

T1mi is defined as microinvasion 1 mm or less in greatest dimension No focus more than 1 mm If multiple foci of microinvasion, use largest to classify Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer

The presence of multiple tumor foci of microinvasion (top of diagram) should be noted in parentheses. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer Elements of Staging: T2T3 T2: Tumor > 2.0 cm but not more than 5.0 cm in greatest dimension T3: Tumor more than 5.0 cm in greatest

dimension Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer T2 (above dotted line) is defined as tumor more than 20 mm but not more than 50 mm in greatest dimension, and T3 (below dotted line) is defined as tumor more than 50 mm in greatest dimension. Elements of Staging: T4 (T4a, T4b,T4c, and T4d) T4: Tumor of any size with direct extension to chest wall and/or skin

T4a: Extension to chest wall, NOT including pectoralis muscle adherence/invasion T4b: Ulceration and/or ipsilateral satellite skin nodules and/or edema (including peau dorange) of the skin, which do not meet criteria for inflammatory carcinoma T4c: Both T4a and T4b

T4d: Inflammatory carcinoma Inflammatory Carcinoma Characterized by diffuse erythema and edema (Pea dorange) involving a third or more of the skin of the breast Palpable mass? Maybe, maybe not

Involvement of dermal lymphatics without clinical skin changes do not qualify as inflammatory carcinoma Neither do locally advanced breast cancers directly invading the dermis or ulcerating the skin without clinical skin changes or tumor emboli in dermal lymphatics Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer T4 is defined as a tumor of any size with direct extension to chest wall and/or

to the skin (ulceration or skin nodules). T4a (illustrated here) is extension to the chest wall, not including only pectoralis muscle adherence/invasion. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer T4b, illustrated here as satellite skin nodules, is defined as edema (including peau dorange) of the skin, or ulceration of the skin of the breast, or satellite skin nodules confined to the same breast. These do not meet the criteria for inflammatory carcinoma. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer

T4b illustrated here as edema (including peau dorange) of the skin. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer T4c is defined as both T4a and T4b. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer T4d is inflammatory carcinoma. Elements of Staging: NX, N0,

N1, N2, N2a, and N2b Clinical cNX: Regional LN cannot be assessed cN0: No regional LN metastases cN1: metastases to movable ipsilateral axillary lymph node(s)

cN2: Ipsilateral LNs fixed or matted OR in clinically apparent ipsilateral internal mammary nodes in the absence of clinically evident axilla cN2a: Ipsilateral axillary LNs fixed or matted to each other or other structures cN2b: Clinically apparent ipsilateral internal mammary nodes in the ABSENCE of clinically evident axillary LNs Elements of Staging: N3, N3a, N3b, and N3c Clinical

cN3: Ipsilateral infraclavicular LNs with or without axillary LN involvement, clinically apparent ipsilateral internal mammary LNs and axillary LNs, or Ipsilateral supraclavicular LNs with or without axillary or internal mammary LN involvement cN3a: Ipsilateral infraclavicular LNs with or without axillary LN involvement cN3b: Clinically apparent ipsilateral internal mammary LNs and axillary LNs

cN3c: Ipsilateral supraclavicular LNs with or without axillary or internal mammary LN involvement Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer N1 is defined as metastases in movable ipsilateral level I, II axillary lymph node(s). Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer

N2a is defined as metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer N2b is defined as metastases only in clinically detected ipsilateral internal mammary nodes and in the absence of clinically evident level I, II axillary lymph node metastases. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer

N3a is defined as metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer N3b is defined as metastases in clinically detected ipsilateral internal mammary lymph node(s) and clinically evident axillary lymph node(s). Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer

N3c is defined as metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement. Elements of Staging: NX, N0, Pathological pNX: Regional lymph nodes cannot be assessed pN0: No regional lymph node metastases histologically

pN0 (i-): No regional lymph node metastases histologically, negative IHC pN0 (i+): Malignant cells in regional lymph nodes, no greater than 0.2m (detected by H & E or IHC including ITC) pN0 (mol -): No regional lymph node metastases histologically, negative molecular findings

pN0 (mol +): Positive molecular findings but no regional lymph node metastases histologically or by IHC Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer pN0(i+) is defined as malignant cells in regional lymph node(s) no greater than 0.2 mm (detected by H&E or IHC including ITC). Elements of Staging: N1 Pathological pN1 mi Micrometastases (greater than 0.2 mm and/ or more than 200 cells, but none greater than 2.0

mm) pN1a: metastases in 1 to 3 axillary LNs, at least one metastases greater than 2.0 mm pN1b: metastases in internal mammary nodes with micrometastases or macrometastases detected by sentinel LND but NOT clinically apparent pN1c: metastases in 1 to 3 axillary LNs and internal

mammary LNs with micrometastases or macrometastases detected by sentinel LND but NOT clinically apparent Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer pN1b metastases in internal mammary nodes detected by sentinel lymph node biopsy but not clinically detected. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas,

2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer pN1c illustrating 3 positive axillary lymph nodes and metastases in internal mammary lymph nodes detected by sentinel lymph node biopsy but not clinically detected. Elements of Staging: N2 Pathological pN2a metastases in 4to 9 axillary lymph nodes (at least one tumor deposit greater than 2.0 mm)

pN2b metastases in clinically detected internal mammary lymph nodes in the ABSENCE of axillary lymph node metastases Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer pN2b illustrating metastases in clinically detected internal mammary nodes with no axillary lymph node involvement. Elements of Staging: N3 Pathological pN3a: metastases in 10 or more axillary lymph nodes (at

least one tumor deposit greater than 2.0 mm), OR metastases to the infraclavicular (level III axillary) lymph nodes pN3b: metastases in clinically detected ipsilateral internal mammary LNs in the presence of 1 or more positive axillary LNs, OR in more than 3 axillary LNs and in internal mammary LNs with micrometastases or macrometastases detected by sentinel LND but NOT clinically apparent pN3c metastases to ipsilateral supraclavicular lymph nodes

Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer pN3b illustrated as metastases in clinically detected internal mammary nodes in the presence of 3 positive axillary lymph nodes. Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer pN3b illustrated as metastases in 6 positive axillary lymph nodes and in one internal mammary lymph node with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected.

Compton, C.C., Byrd, D.R., et al., Editors. AJCC CancerStaging Atlas, 2nd Edition. New York: Springer, 2012. American Joint Committee on Cancer pN3c illustrated as metastases in ipsilateral supraclavicular lymph nodes. Elements of Staging: MX, M0, and M1 MX: No longer exists in TNM Staging M0: No distant metastases (Remember: not

possible for pathologic staging) cM0(i+): No clinical or radiographic evidence of distant metastases, but deposits of molecularly or microscopically detected tumor cells in circulating blood, bone marrow, or other nonregional nodal tissue that are no larger than 0.2mm in a patient without symptoms or signs of metastases M1: Distant metastases

Stage Groups Prognostic Factors for Breast Pagets disease Estrogen receptor, Progesterone receptor, and test method (IHC, RT-PCR, other) HER2 status and test method (IHC, FISH, CISH, RT-PCR, other)

Method of lymph node assessment (e.g., clinical, fine needle aspiration; core biopsy; sentinel lymph node biopsy/IHC of regional lymph nodes Molecular studies of regional lymph nodes Distant metastases method of detection (clinical, radiographic, biopsy)

Circulating Tumor Cells (CTC) and method of detection (RT-PCR, immunomagnetic separation, other) Disseminated Tumor Cells (DTC; bone marrow micrometastases) and method of detection (RT-PCR, immunohistochemical, other) Multi-gene signature score Response to neoadjuvant therapy will be collected in the registry, but does not affect the post neoadjuvant stage

Hints for Breast Please see notes on page 362 in TNM 7th edition, under the table for pathologic lymph nodes but above the table for distant metastasis Also read pages 364 through 369 for useful information Breast Case 1 Answers

Topography: C50.2 Histology: 8500/3 This case is one primary per rule M3 Clinical Staging Pathological Staging cT

1b pT 1b cN 0 pN 0(i-) cM

0 pM cM0 Clinical Stage Group IA Pathologic Stage IA Group SEER Summary Stage: 1 - Localized

Breast Case 2 Answers Topography: c50.4 Histology: 8500/3 This case is one primary per rule M3 Clinical Staging

Pathological Staging cT 2 pT 2 cN 0 pN

0(i+) cM 0 pM cM0 Clinical Stage Group IIA Pathologic Stage IIA

Group SEER Summary Stage: 1 - Localized

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