Grading Of Breast Carcinoma: Dcis And Lcis
After the initial diagnosis, more detailed staging processes are undertaken to learn about the extent of the breast cancer, and to arrive at a prognosis and treatment strategy.
One part of the staging process is to give the breast tumor a grade, with lower grades usually indicative of a good prognosis, while higher grade breast cancers tend to have a poorer prognosis.
Doctors consider DCIS and LCIS to be a stage 0 or non-invasive breast cancer, as the tumor is still confined within the breast ducts or lobules. But even DCIS and LCIS tumors may still receive a grade.
How Is The Stage Determined
The staging system most often used for breast cancer is the American Joint Committee on Cancer TNM system. The most recent AJCC system, effective January 2018, has both clinical and pathologic staging systems for breast cancer:
- The pathologic stage is determined by examining tissue removed during an operation.
- Sometimes, if surgery is not possible right away or at all, the cancer will be given a clinical stage instead. This is based on the results of a physical exam, biopsy, and imaging tests. The clinical stage is used to help plan treatment. Sometimes, though, the cancer has spread further than the clinical stage estimates, and may not predict the patients outlook as accurately as a pathologic stage.
In both staging systems, 7 key pieces of information are used:
- The extent of the tumor : How large is the cancer? Has it grown into nearby areas?
- The spread to nearby lymph nodes : Has the cancer spread to nearby lymph nodes? If so, how many?
- The spread to distant sites : Has the cancer spread to distant organs such as the lungs or liver?
- Estrogen Receptor status: Does the cancer have the protein called an estrogen receptor?
- Progesterone Receptor status: Does the cancer have the protein called a progesterone receptor?
- HER2 status: Does the cancer make too much of a protein called HER2?
- Grade of the cancer : How much do the cancer cells look like normal cells?
In addition, Oncotype Dx® Recurrence Score results may also be considered in the stage in certain situations.
The Breast Cancer Stages: From 0 To 4
The stage of your cancer will appear on your pathology report, a report that details the size, shape and look of the cancer cells under a microscope. . Most cancers, including invasive breast cancer, have four stages.
Stage 0 is abnormal cells that have not spread beyond the ducts or lobules of the breast, such as DCIS or LCIS, respectively.
Stage I cancer is invasive and spreading beyond where it started.
In Stage IA, the cancer is 2 cm or smaller and has not spread into the lymph nodes or outside of the breast.
In Stage IB, small clumps of cancer cells ranging from 0.2 to 2 mm exist in the lymph nodes. There may not be a tumor in the breast, but if there is, it measures no bigger than 2 cm.
Stage II cancer also has two subcategories. Stage IIA describes a cancer that has spread to 1 to 3 lymph nodes under your arms with or without a tumor up to 2 cm large in the breast, or the breast tumor measures 2 to 5 cm without cancer cells in the axillary lymph nodes.
Stage IIB refers to a tumor between 2 and 5 cm along with cancer in 1 to 3 axillary lymph nodes or lymph nodes near the breastbone, or the tumor is larger than 5 cm when no cancer cells exist in the axillary lymph nodes.
In Stage IIIB, the tumor has reached the skin of your breast and/or your chest wall and up to 9 lymph nodes under your arms or near your breastbone.
Inflammatory breast cancer is automatically Stage IIIB or a later stage.
Stage IIIC involves three behaviors of the cancer:
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What Are Breast Cancer Stages
The stage of a cancer describes the size of the cancer and how far it has spread.
Your breast cancer may be described as stage 1, stage 2, stage 3 or stage 4.
An early form of breast cancer called DCIS is sometimes referred to as stage 0 breast cancer.
The stage takes into account:
- The size of the cancer
- Whether the lymph nodes are affected
- If the cancer has spread to other parts of the body
The stage of your cancer may not be fully known until after you have had surgery.
What Is Breast Cancer
Cancer occurs when changes called mutations take place in genes that regulate cell growth. The mutations let the cells divide and multiply in an uncontrolled way.
Breast cancer is cancer that develops in breast cells. Typically, the cancer forms in either the lobules or the ducts of the breast.
Lobules are the glands that produce milk, and ducts are the pathways that bring the milk from the glands to the nipple. Cancer can also occur in the fatty tissue or the fibrous connective tissue within your breast.
The uncontrolled cancer cells often invade other healthy breast tissue and can travel to the lymph nodes under the arms. The lymph nodes are a primary pathway that help the cancer cells move to other parts of the body.
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How Staging Guides Treatment
The type of cancer you have, along with the stage, will help determine your treatment. With stage I, II, or III breast cancer, the main goal is to cure the cancer by treating it and keeping it from coming back. With stage IV, the goal is to improve symptoms and prolong life. In almost all cases, stage IV breast cancer cannot be cured.
Breast Exam By Your Doctor
The same guidelines for self-exams provided above are true for breast exams done by your doctor or other healthcare professional. They wont hurt you, and your doctor may do a breast exam during your annual visit.
If youre having symptoms that concern you, its a good idea to have your doctor do a breast exam. During the exam, your doctor will check both of your breasts for abnormal spots or signs of breast cancer.
Your doctor may also check other parts of your body to see if the symptoms youre having could be related to another condition.
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What Does Breast Cancer Staging Mean For My Prognosis
Most people confronting breast cancer are concerned about what the future will hold their prognosis. Its understandable to be concerned: Will the treatment be effective? Can you expect a shortened lifespan?
Staging the breast cancer can put a number to a tumors characteristics and behavior, but these are only parts of your entire prognosis. Your overall health matters, too.
Its important to remember that breast cancer stage is not fixed. Your breast cancer stage can improve with treatment, Tran says. For instance, if the tumor responds to endocrine therapy or chemotherapy, the grade can actually go down.
Your surgeon, oncologist and primary care provider can discuss each step of your treatment with you and give you an idea of what to expect. Tran says that, whereas generations ago, a particular breast cancer stage was associated with a high or low five-year survival probability, the outlook is vastly different today.
Most people with breast cancer live beyond five years, and with successful treatment, it is possible to live many years and eventually die from other causes. And, continuing advancements in diagnosis and treatment offer hope for the future.
Treatments For Stage 4 Breast Cancer
The following are treatment options for ductal carcinoma and lobular carcinoma. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.
Stage 4 means that the breast cancer has spread to other parts of the body. It is also called advanced breast cancer, or metastatic breast cancer. Treatments cannot completely cure metastatic breast cancer, but they can control it very well, sometimes for many years. Doctors may offer one treatment until it stops working and then give another one.
The treatments offered for stage 4 breast cancer depend on the hormone-receptor status and the HER2 status of the cancer cells. They will also depend on where the cancer has spread, if it is causing any symptoms and your overall health.
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How A Breast Cancers Stage Is Determined
Your pathology report will include information that is used to calculate the stage of the breast cancer that is, whether it is limited to one area in the breast, or it has spread to healthy tissues inside the breast or to other parts of the body. Your doctor will begin to determine this during surgery to remove the cancer and look at one or more of the underarm lymph nodes, which is where breast cancer tends to travel first. He or she also may order additional blood tests or imaging tests if there is reason to believe the cancer might have spread beyond the breast.
The Tnm Staging System
The breast cancer staging system, called the TNM system, is overseen by the American Joint Committee on Cancer . The AJCC is a group of cancer experts who oversee how cancer is classified and communicated. This is to ensure that all doctors and treatment facilities are describing cancer in a uniform way so that the treatment results of all people can be compared and understood.
In the past, stage number was calculated based on just three clinical characteristics, T, N, and M.
The T category describes the original tumor:
HER2 status: are the cancer cells making too much of the HER2 protein?
Oncotype DX score, if the cancer is estrogen-receptor-positive, HER2-negative, and there is no cancer in the lymph nodes
Adding information about tumor grade, hormone-receptor status, HER2 status, and possibly Oncotype DX test results has made determining the stage of a breast cancer more complex, but also more accurate.
In general, according to experts, the new staging system classifies triple-negative breast cancer at a higher stage and classifies most hormone receptor-positive breast cancer at a lower stage.
You also may see or hear certain words used to describe the stage of the breast cancer:
Distant: The cancer is found in other parts of the body as well.
The updated AJCC breast cancer staging guidelines have made determining the stage of a cancer a more complicated but accurate process. So, the characteristics of each stage below are somewhat generalized.
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About Breast Cancer Staging And Grades
Staging means how big the cancer is and whether it has spread. Grading means how abnormal the cancer cells look under a microscope.
Doctors use the stage and grade of a cancer to help them decide which treatment you need.
There are different systems used in the UK to stage breast cancer. The most common one is the TNM system. Another is the number staging system.
Your doctor might also talk about early, locally advanced or secondary breast cancer.
What Is Stage Iii Breast Cancer
In stage III breast cancer, the cancer has spread further into the breast or the tumor is a larger size than earlier stages. It is divided into three subcategories.
Stage IIIA is based on one of the following:
- With or without a tumor in the breast, cancer is found in four to nine nearby lymph nodes.
- A breast tumor is larger than 50 millimeters, and the cancer has spread to between one and three nearby lymph nodes.
In stage IIIB, a tumor has spread to the chest wall behind the breast. In addition, these factors contribute to assigning this stage:
- Cancer may also have spread to the skin, causing swelling or inflammation.
- It may have broken through the skin, causing an ulcerated area or wound.
- It may have spread to as many as nine underarm lymph nodes or to nodes near the breastbone.
In stage IIIC, there may be a tumor of any size in the breast, or no tumor present at all. But either way, the cancer has spread to one of the following places:
- ten or more underarm lymph nodes
- lymph nodes near the collarbone
- some underarm lymph nodes and lymph nodes near the breastbone
- the skin
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What Are The Stages Of Breast Cancer
Breast cancer staging uses Roman numerals 0, I, II, III and IV, with 0 being noninvasive cancer cells in one spot and IV being invasive breast cancer that has spread into other areas of the body. The five numerals have A and B subcategories that look at other factors such as lymph node involvement and metastases .
The American Joint Committee on Cancer uses the letters T, N and M to characterize three different aspects of breast tumors.
This designation looks at the tumor, its size and whether or not the cancer has invaded surrounding tissue.
The T designation has several categories:
- TX means the tumor is not assessed.
- T0 means there is no evidence of invasive breast cancer.
- T1, T2 and T3 refer to the size of the tumor and consider if and how far it has invaded surrounding breast tissue.
- An important aspect of staging breast cancer has to do with whether the cancer has spread to one or more nearby lymph nodes fluid channels in the breast. The N value describes if and how the cancer has infiltrated one or more lymph nodes near the breast. NX means lymph nodes have not been evaluated.
- N0 means there is no cancer detected in the nearby lymph nodes.
- N1, N2 and N3 mean that breast cancer is in the lymph nodes. The higher the number, the more advanced the lymph node involvement. These cancers have an increased risk of spreading beyond the breast to lymph nodes and to other organs within the body, says Tran.
Diagnosis Of Breast Cancer
To determine if your symptoms are caused by breast cancer or a benign breast condition, your doctor will do a thorough physical exam in addition to a breast exam. They may also request one or more diagnostic tests to help understand whats causing your symptoms.
Tests that can help diagnose breast cancer include:
- Mammogram. The most common way to see below the surface of your breast is with an imaging test called a mammogram. Many women ages 40 and older get annual mammograms to check for breast cancer. If your doctor suspects you may have a tumor or suspicious spot, they will also request a mammogram. If an abnormal area is seen on your mammogram, your doctor may request additional tests.
- Ultrasound. A breast ultrasound uses sound waves to create a picture of the tissues deep in your breast. An ultrasound can help your doctor distinguish between a solid mass, such as a tumor, and a benign cyst.
Your doctor may also suggest tests such as an MRI or a breast biopsy.
If you dont already have a primary care doctor, you can browse doctors in your area through the Healthline FindCare tool.
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What Is Stage 0 Breast Cancer
Also called carcinoma in situ, stage 0 is the earliest breast cancer stage. At stage 0, the breast mass is noninvasive, and there is no indication that the tumor cells have spread to other parts of the breast or other parts of the body. Often, stage 0 is considered a precancerous condition that typically requires close observation, but not treatment.
Stage 0 breast cancer is difficult to detect. There may not be a lump that can be felt during a self-examination, and there may be no other symptoms. However, breast self-exams and routine screening are always important and can often lead to early diagnosis of breast cancer, when the cancer is most treatable. Stage 0 disease is most often found by accident during a breast biopsy for another reason, such as to investigate an unrelated breast lump.
There are two types of stage 0 breast cancer:
Ductal carcinoma in situ occurs when breast cancer cells develop in the breast ducts. Today, stage 0 DCIS is being diagnosed more often because more women are having routine mammogram screenings. DCIS can become invasive, so early treatment can be important.
What Is Stage 4 Breast Cancer
Also known as metastatic breast cancer, the cancer in this stage has spread beyond the breast, underarm and internal mammary lymph nodes to other parts of the body near to or distant from the breast. The cancer has spread elsewhere in the body. The affected areas may include the bones, brain, lungs or liver and more than one part of the body may be involved.
At stage 4, TNM designations help describe the extent of the disease. Higher numbers indicate more extensive disease. Most commonly, stage 4 breast cancer is described as:,
- T: T1, T2, T3 or T4 depends on the size and/or extent of the primary tumor.
- N1: Cancer has spread to the lymph nodes.
- M1: The disease has spread to other sites in the body.
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Stage 2 Breast Cancer Treatment Options
Treatment options for stage 2 breast cancers include surgery to remove the tumor , or breast removal , which may or may not require radiation treatments.
Chemotherapy may be used to shrink the tumor before surgery and is commonly recommended to reduce the risk of recurrence.
Lymph nodes will be removed and biopsied, and others may need to be treated with radiation.
You may also get hormone therapy, targeted therapy, or immunotherapy depending on the characteristics of your cancer.
Diagnosis And Staging/grading Of Infiltrating And Invasive Ductal Carcinomas
Staging of invasive and infiltrating ductal and lobular carcinomas refers to the progression of the tumor and any metastasis.
However, grading is more a description of the tumor itself and a prediction of the aggressiveness of a particular breast tumor. Once a breast tumor is thoroughly staged and graded, treatment begins.
There are many different types of breast cancer, some quite rare in fact. Different types of breast cancers have proven to be more or less aggressive and to a certain extent to respond differently to treatments.
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