Upload
janice-berry
View
255
Download
2
Tags:
Embed Size (px)
Citation preview
TNM Staging: BreastTONYA 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
Anatomic sites and subsites of the breast.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
Schematic diagram of the breast and regional lymph nodes.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
Common Terms Duct carcinoma, NOS: The largest group of breast cancers.
Duct carcinoma, NOS is not a specific histologic type because it lacks specific features that can be used to better classify the 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 (Paget’s): Paget’s disease of the
nipple without mass
Tis (Paget's) is defined as Paget's disease of the nipple with no tumor.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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
The presence of multiple tumor foci of microinvasion (top of diagram) should be noted in parentheses.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
Elements of Staging: T2-T3
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
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.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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 d’orange) 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 d’orange) 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
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.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
T4b, illustrated here as satellite skin nodules, is defined as edema (including peau d’orange) 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 forinflammatory carcinoma.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
T4b illustrated here as edema (including peau d’orange) of the skin.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
T4c is defined as both T4a and T4b.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
T4d is inflammatory carcinoma.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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
N1 is defined as metastases in movable ipsilateral level I, II axillary lymph node(s).
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
N2a is defined as metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
N3a is defined as metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
N3b is defined as metastases in clinically detected ipsilateral internal mammary lymph node(s) and clinically evident axillary lymph node(s).
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
N3c is defined as metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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
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).
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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”
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
pN1b metastases in internal mammary nodes detected by sentinel lymph node biopsy but not clinically detected.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
pN1c illustrating 3 positive axillary lymph nodes and metastases in internal mammary lymph nodes detected by sentinel lymph node biopsy but not clinically detected.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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
pN2b illustrating metastases in clinically detected internal mammary nodes with no axillary lymph node involvement.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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
pN3b illustrated as metastases in clinically detected internal mammary nodes in the presence of 3 positive axillary lymph nodes.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
pN3c illustrated as metastases in ipsilateral supraclavicular lymph nodes.
Com
pton
, C.C
., Byrd
, D.R
., et al., E
dito
rs. AJC
C C
ance
rSta
gin
g Atla
s, 2
nd E
dition
. New
Yo
rk: Sp
ring
er, 20
12. ©
Am
erican
Join
t Co
mm
ittee
on
C
ance
r
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
Paget’s 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
cT 1b
cN 0
cM 0
Clinical Stage Group
IA
Pathological Staging
pT 1b
pN 0(i-)
pM cM0
Pathologic Stage Group
IA
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
cT 2
cN 0
cM 0
Clinical Stage Group
IIA
Pathological Staging
pT 2
pN 0(i+)
pM cM0
Pathologic Stage Group
IIA
SEER Summary Stage: 1 - Localized