Identification And Measurement Of Itcs And Micrometastases
Our pathologist does H& E staining on all his specimens and uses IHC staining only if nothing is found by H& E staining. Can IHC staining be used to identify micrometastases in lymph nodes?
The distinction between micrometastases and ITCs is now based on size alone. Metastatic cell deposits seen with IHC staining alone are considered to be equivalent to those seen on standard H& E staining.
In defining pN1 vs. pN0, is it appropriate to measure size of the IHC micrometastasis to determine whether it exceeds 0.2 mm in any dimension? A case had negative H& E of a sentinel node and positive IHC with subsequent H& E verification. The maximum size was 0.19 mm on H& E and 0.71 mm on IHC.
This would be staged as pN1mi because we stage by greatest dimension regardless of the method of detection.
A sentinel node had a 1-mm metastatic lesion visible by H& E staining. IHC staining showed three additional small foci in the same lymph node, less than or just about equal to 1 mm. What is the pN designation?
If deeper cuts of the node do not show a contiguous process but confirm four separate foci, the classification would be pN1mi, reflecting the size of the largest lesion.
A sentinel node biopsy showed a single cluster of malignant cells with H& E staining measuring 0.18 mm. Results of IHC staining were unknown. Is this staged as pN1 because the malignant cells were detected by H& E?
ITCs defined as 0.2 mm or less would not upstage the patient.
Stages Of Breast Cancer: What Information Do They Provide
An accurate breast cancer stage provides information about the following:
Broadly, breast cancer can be classified as early breast cancer , locally advanced breast cancer , metastatic breast cancer or recurrent breast cancer . The treatment protocols for different stages are distinct. However, for a more detailed staging, a numeric format has also been developed and is widely accepted. The numeric format can be explained as follows.
What Is Cancer Staging
Staging is a way of describing how extensive the breast cancer is, including the size of the tumor, whether it has spread to lymph nodes, whether it has spread to distant parts of the body, and what its biomarkers are.
Staging can be done either before or after a patient undergoes surgery. Staging done before surgery is called the clinical stage, and staging done after surgery is called the pathologic stage. Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor recommend the best kind of treatment and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.
This page provides detailed information about the system used to find the stage of breast cancer and the stage groups for breast cancer, such as stage IIA or stage IV.
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What Is The Tnm Cancer Staging System
Published by the Union for International Cancer Control, the TNM Classification of Malignant Tumours is a globally recognised standard for classifying the extent of spread of cancer.
The classification of cancer by anatomic disease extent, i.e. stage, is the major determinant of appropriate treatment and prognosis. Stage is an increasingly important component of cancer surveillance and cancer control and an endpoint for the evaluation of the population-based screening and early detection efforts.
The UICC has published the UICC TNM classification of Malignant Tumours for over 50 years. The UICC TNM classification is the internationally accepted standard for cancer staging.
The UICC TNM Classification is an anatomically based system that records the primary and regional nodal extent of the tumour and the absence or presence of metastases.
Diagnostic Tests That Inform The Clinical Stage
Many methods are used to detect and stage cancer. Some of the common tests include:
Biopsy: The doctor uses a needle to extract breast tissue or fluid, which is then sent to a lab. There, various techniques are used to examine different attributes, such as hormone receptor or HER2 status.
Tumor markers: Rapidly dividing cancerous cells interrupt some of the normal mechanisms of cell growth. This causes the cell to overproduce certain molecules. Lab tests detect these compounds, known as tumor markers, in blood or tissue samples.
Imaging techniques: Several different scans are used to examine characteristics of your cancer. Below are some of the noninvasive imaging techniques you might encounter:
- MRI scans use magnets and radio waves to generate detailed pictures of your tissues.
- CT scans use X-rays to look at your organs. Nuclear scans trace the flow of an injected safe radioactive dye in your body.
- PET scans are similar to nuclear scans but specifically examine glucose consumption in the bodysince cancer cells use more glucose than normal cells.
- Ultrasound imaging uses sound waves to see inside your body.
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Classifying Tumors With Dermal Involvement
If there are tumor cells in the dermis without skin ulceration, peau d’orange, edema, or satellite nodules, what is the stage?
Direct skin invasion by AJCC criteria is defined as full-thickness involvement including the epidermis. If the epidermis is intact with only focal dermal involvement, this is not considered T4 but classified by the size of the primary tumor.
Pathology from a lumpectomy revealed a 2 Ã 1.5-cm mass extending into the skin up to the superficial dermis, without invasion of the epidermis. Is it a T1c or a T4?
This would be classified as T1c. As described above, if the epidermis is intact with only focal dermal involvement, classification is based on the size of the primary tumor.
A patient had breast cancer clinically described as a destructive lesion measuring 4 Ã 5 cm with obliteration of most of the nipple areolar complex. Biopsy revealed skin and subcutaneous tissue with infiltrating ductal carcinoma involving dermis and sc subareolar fibrous and muscular tissue. Would this be staged T4b?
Recent Updates To The Tnm Staging Of Breast Cancer
Observed survival rates for more than 200,000 breast cancer cases that were diagnosed between 2001 and 2002 and analyzed by the U.S. National Cancer Data Base to re-evaluate the clinical prognostic value of the AJCC TNM classification categories.
The AJCC, in their 7th Edition of TNM staging of breast cancer, made some changes to the T, N and M categories of breast cancer. The AJCC made the changes and updates as a consequence of new technologies and new clinical outcome data. These changes include:-
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Other Tests On The Breast Cancer Cells
Your doctor also uses other information about your breast cancer. This information helps to work out your overall stage, your outlook and treatment plan. These includes:
- receptors for the female hormones
- HER2 status
- the grade of the cancer
They also look at the levels of the protein HER2. Some breast cancers have large amounts of human epidermal growth factor receptor 2 . They are called HER2 positive cancers. HER2 makes the cancer cells grow and divide. Breast cancers that are HER2 positive generally grow more quickly.
The grade describes how a cancer cell looks under the microscope and whether they are similar or very different to normal cells.
Please remember staging for breast cancer is very complex. Many different factors are considered before doctors can confirm your final stage. Do speak to your breast doctor or nurse if you have any questions about your stage.
Tnm Classification Of Breast Cancer
The TNM definitions for breast cancer from the sixth edition of the AJCC Cancer Staging Manual are shown in Table . In addition to the detailed definitions given in Table , the additional guidelines outlined below should be noted.
AJCC Cancer Staging Manual
- Adapted from Greene, et al., with permission from Springer-Verlag.
- * Clinically apparent is defined as detected by imaging studies or by clinical examination.
- â Classification is based on axillary lymph node dissection with or without sentinel lymph-node dissection. Classification based solely on sentinel lymph-node dissection without subsequent axillary lymph node dissection is designated for âsentinel node,â such as pN0.
- â¡ Isolated tumor cells are defined as single tumor cells or small cell clusters â¤0.2 mm, usually detected only by immunohistochemical or molecular methods but which may be verified on hematoxylin and eosin stains. Isolated tumor cells do not usually show evidence of metastatic activity .
- Â§ Definition of was adapted in 2003 in order to be consistent with the updated International Union Against Cancer classification.
- Â¶ RT-PCR: reverse transcriptase/polymerase chain reaction.
- ** If associated with more than three positive axillary lymph nodes, the internal mammary nodes are classified as pN3b to reflect increased tumor burden.
For Assessment of Tumor Size
For Assessment of Regional Lymph Nodes
For Assessment of Distant Metastasis
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Breast Cancer Staging And Tnm Classifications
NOTE: In January 2018 The American Joint Committee on Cancer updated their 8th Edition of the staging classifications for breast tumors.
You can find a summary of the main changes, including amendments to the TNM categories, for staging breast cancer by clicking HERE. We will also be fully updating our staging articles on this site to include all the new information.
Breast cancer is typically described in stages, according to the presence and size of the tumor and its metastasis in the axillary lymph nodes, and other factors. T refers to the tumor size. For breast tumors, bigger than 2cm changes the T category. N refers to node status, which changes as the tumor spreads into lymph nodes. M refers to metastasis, which indicates that the cancer has spread to places beyond the breast. The TNM classifications were developed by the American Joint Committee on Cancer.
This page is still OK for reading, but it is getting fairly old So we have created a new version of this page with more up-to-date information on TNM classifications.
T Categories For Breast Cancer
T followed by a number from 0 to 4 describes the main tumor’s size and if it has spread to the skin or to the chest wall under the breast. Higher T numbers mean a larger tumor and/or wider spread to tissues near the breast.
TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Carcinoma in situ
T1 : Tumor is 2 cm or less across.
T2: Tumor is more than 2 cm but not more than 5 cm across.
T3: Tumor is more than 5 cm across.
T4 : Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.
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The Ajcc Staging Categories For Breast Cancer
The letters TNM describe three aspects of the staging process:-
- The size of the primary breast tumor
- Presence or absence of metastasis to regional lymph nodes
- The presence or absence of distantmetastases
The TNM scores classify the tumor from Stage 0 to Stage IV . Modifications to this classification can include P factors from the Pathologist.
the American Joint Committee on Cancer reviews and develops the TNM classifications and the latest guidelines are from 2010.
Estimating The Size Of The Primary Tumor
An invasive breast cancer was removed on stereotactic biopsy so no size was available clinically or pathologically. We classified this tumor as cTX/pTX. Is this correct?
Try to obtain a clinical size from the physician’s notation of a palpable size and/or from mammographic or ultrasound imaging of the breast. In addition, because the small invasive tumor was removed entirely by stereotactic biopsy, it must have been less than 2 cm in size, so a classification of T1 would be appropriate.
If there was residual disease found in a relumpectomy or mastectomy specimen, does the patient need to be restaged to include the residual tumor?
If the relumpectomy or mastectomy was considered the definitive operation, then staging needs to be updated to include the findings of both the initial and the subsequent definitive breast cancer surgery.
When multiple tumors are present in the same breast, only the largest is measured to determine the T stage. How far apart do the tumors have to be to be considered separate?
Although various studies have suggested ways to make this determination quantitatively, it remains a judgment call. When the foci appear very close microscopically, a review of imaging studies may be useful in determining whether multiple lesions are present.
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Stage Groups For Breast Cancer
Doctors assign the stage of the cancer by combining the T, N, and M classifications , the tumor grade, and the results of ER/PR and HER2 testing. This information is used to help determine your prognosis . The simpler approach to explaining the stage of breast cancer is to use the T, N, and M classifications alone. This is the approach used below to describe the different stages.
Most patients are anxious to learn the exact stage of the cancer. If you have surgery as the first treatment for your cancer, your doctor will generally confirm the stage of the cancer when the testing after surgery is finalized, usually about 5 to 7 days after surgery. When systemic treatment is given before surgery, which is typically with medications and is called neoadjuvant therapy, the stage of the cancer is primarily determined clinically. Doctors may refer to stage I to stage IIA cancer as “early stage” and stage IIB to stage III as “locally advanced.” Stage 0: Stage zero describes disease that is only in the ducts of the breast tissue and has not spread to the surrounding tissue of the breast. It is also called non-invasive or in situ cancer . Stage IA: The tumor is small, invasive, and has not spread to the lymph nodes . Stage IB: Cancer has spread to the lymph nodes and the cancer in the lymph node is larger than 0.2 mm but less than 2 mm in size. There is either no evidence of a tumor in the breast or the tumor in the breast is 20 mm or smaller .
Stage IIA: Any 1 of these conditions:
Why A Revision Was Needed
AJCC Cancer Staging Manual
â¢ Because of the increasing use of screening mammography, the average size of breast tumors when first detected has decreased significantly. Although many of these small tumors could be treated adequately with surgery alone, a significant percentage of these patients would benefit from adjuvant therapy.
â¢ These smaller tumors are associated with a decreased probability of axillary lymph node metastases. Because of this, clinicians have moved away from the use of axillary lymph node dissection for assessing lymph nodes and have enthusiastically embraced the new technique of sentinel lymph node biopsy . Some issues remain unresolved about the most appropriate candidates and methodology for SLNB.
â¢ The growing use of immunohistochemical staining and molecular biology techniques has led to concerns about the clinical significance of the extremely small metastatic lesions that can be detected by these approaches.
â¢ The clinical importance of total number of positive axillary lymph nodes, now widely recognized by clinicians, has not previously been reflected in breast cancer staging.
â¢ New information about clinical outcomes associated with metastases to supraclavicular, infraclavicular, and internal mammary lymph nodes has led to a reassessment of some classification criteria from the previous edition of the staging manual.
Figure Figure 1
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The Stages Of Breast Cancer
Stage 0: The disease is only in the ducts and lobules of the breast. It has not spread to the surrounding tissue. It is also called noninvasive cancer .
Stage I: The disease is invasive. Cancer cells are now in normal breast tissue. There are 2 types:
- Stage IA: The tumor is up to 2 centimeters . It has not spread to the lymph nodes .
- Stage IB: The tumor is in the breast and is less than 2 cm. Or the tumor is in the lymph nodes of the breast and there is no tumor in the breast tissue.
Stage II describes invasive breast cancer. There are 2 types:
- Stage IIA: A tumor may not be found in the breast, but cancer cells have spread to at least 1 to 3 lymph nodes. Or Stage IIA may show a 2 to 5 cm tumor in the breast with or without spread to the axillary lymph nodes.
- Stage IIB: The tumor is 2 to 5 cm and the disease has spread to 1 to 3 axillary lymph nodes. Or the tumor is larger than 5 cm but has not spread to the axillary lymph nodes.
Stage III describes invasive breast cancer. There are 3 types:
Stage IV : The tumor can be any size and the disease has spread to other organs and tissues, such as the bones, lungs, brain, liver, distant lymph nodes, or chest wall .
Brief Overview Of The 7th Edition
The 7th edition of the AJCC staging system was mainly based on anatomical staging, which used the extent of the primary tumor , status of the regional lymph nodes , and metastasis status . This has remained largely unchanged in the 8th edition. The T stage is based on the size and degree of loco-regional invasion by the primary tumor and is categorized from T1 to T4. The N stage is determined by the extent of nodal involvement including axillary, internal mammary, and ipsilateral supraclavicular lymph nodes. Distant metastases are evaluated to determine the M stage. The 7th edition used nine stages based on different combinations of T, N, and M status .
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