Diagnosis and Staging
description
Transcript of Diagnosis and Staging
Diagnosis and Staging
JoAnne Zujewski, MDHead, Breast Cancer Therapeutics
Clinical Investigations BranchCancer Therapy Evaluation ProgramDivision of Cancer Diagnostics and
TreatmentMay 2011
NEJM, November 23, 2000
Early Detections reduces the
risk of dying from breast
cancer.
Cancer Diagnosis: Defining the Cancer
• The first step in designing the treatment plan is carefully defining the cancer– Clinical examination– Radiology tests– Pathology tests– Blood tests
Breast Cancer Signs and Symptoms
• None• Lump or mass• Pain in breast• Tenderness• Thickening• Firmness• Nipple discharge
• Skin redness• Asymmetry• Enlargement• Nipple retraction• Dimpling• Mass in axilla
(armpit)• Warmth
BREAST CANCER
Defining the Cancer: Radiology
• Radiologic imaging can help determine the location and spread of the cancer– Local extent– Regional lymph nodes– Distant spread (metastases)
Mammography Technique
Mammography
Mammography Sensitivity in Younger Women
• Screening mammograms miss up to 25% of breast cancers in women in their 40s, compared to 10% of cancers for older women
Ultrasound
Breast MRIBreast MRI
• Important new tool for imaging the breast • High sensitivity• Detection and characterization of
otherwise-occult breast carcinoma
Breast Cancer Diagnosis
• Any breast change or lump needs to be evaluated
• Breast cancer needs to be diagnosed by biopsy– Fine needle aspiration– Core needle biopsy– Surgical biopsy
Mammotone & Minimally Invasive Breast Biopsy
(MIBB)The Mammotone and MIBB are different from the core needle biopsy in that a needle is inserted once and multiple specimens are removed through contiguous sampling. Core needle biopsies require the needle to be inserted multiple times.
Both the Mammotone and MIBB biopsy utilize a vacuum system. A probe is inserted and samples of tissue are collected in a chamber. Tissue samples are removed by action of a gentle vacuum.
Advantages of Needle Biopsies
• Simple procedure – does not require surgery• Accurate• Quick – only takes a few minutes• Not painful• Inexpensive• Quick results
Disadvantages of Needle Biopsies
• Entire lump is not removed• Open biopsy may be necessary
For Fine Needle Only:• Specialist needed to read results• In situ cancer not distinguishable from
invasive cancer
Image Guided Biopsy in Clinical Practice
• Allows treatment planning• Better cosmesis• Can mark site with clip• Less costly
• Needs specialized equipment• May still require confirmatory
pathology in minority of cases
Breast BiopsyA core needle biopsy of the area is recommendedA core needle biopsy of the area is recommended
Non-Surgical
Surgical
Ultrasound-Guided Breast Biopsy
Ultrasound
Image Guided Biopsy
Wire Localization: ExampleWire Localization: Example
Inking the Tumor Specimen in the O.RInking the Tumor Specimen in the O.R.
Needle Biopsies
• Fine Needle – A thin, hollow needle is used to remove a sample of tissue. The procedure is quick and can be done in a doctor’s office.
• Core Needle – A larger needle is inserted through a small incision in the skin, and a small core of tissue is removed. This type of needle biopsy is done with the assistance of mammography or ultrasound imaging using stereotactic techniques with the aid of the computer, which calculates the precise location of the lump.
Incisional Biopsy
• A surgical procedure where only a portion of a tumor is removed
• Generally reserved for lumps that are larger• Performed under local anesthesia in a
hospital or outpatient clinic
Excisional Biopsy
• A surgical procedure that removes the entire suspected area plus some surrounding normal tissue.
• Standard procedure for lumps that are smaller than an inch or so in diameter
• Similar to a lumpectomy• Performed under local anesthetic or general
anesthesia in a hospital or outpatient clinic
Advantages of Open Biopsies
• Quick – takes only one hour• More accurate than a needle biopsy• Larger samples provide information for
treatment plan
Excisional Only:• Removes entire lump• May be the only surgical treatment needed
Disadvantages of Open Biopsies
• Surgical procedure• Expensive• Side effects such as infection or blood
collection under the skin
Excisional Only:• Removing tissue can change the look and feel
of the breast
Cancer is diagnosed
in 1 of 5
breast biopsies
Staging
Breast cancerSpread to lymph nodes
Supraclavicular
Subclavicular
Distal (upper)
axillary
Central (middle)
axillary
Proximal (lower)
axillary
Mediastinal
Internal mammary
Interpectoral
(Rotter’s)
Breast Cancer: Stage I
T1a: T T1a: T 0.5 cm 0.5 cm
T1b: 0.5 cm < T T1b: 0.5 cm < T 1 cm 1 cm
T1c: 1 cm < T T1c: 1 cm < T 2 cm 2 cm
T1 N0 M0T1 N0 M0
T T 2 cm 2 cm
T1T1
N0 = no regional lymph node metastasisM0 = no distant metastasis
Breast Cancer: Stage IIA
T2 N0 M0T2 N0 M0
N1 = metastasis to movable ipsilateral axillary lymph node(s)M0 = no distant metastasis
2 cm < T 2 cm < T << 5 cm 5 cm
No evidenceNo evidenceof tumorof tumor
T0T0
T0 T0 T1T1
N1 M0N1 M0}
T2T2
Breast Cancer: Stage IIB
T3 N0 M0T3 N0 M0
N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1bM0 = no distant metastasis
T > 5 cmT > 5 cm
T2 N1 M0T2 N1 M0
T3T3
Breast Cancer: Stage IIIA
Metastasis to ipsilateral axillary lymph node(s) N1 = movableN2 = fixed to one another or to other structuresM0 = no distant metastasis
T3 N1 M0T3 N1 M0 T0T0T1T1T2T2T3T3
N2 M0N2 M0
Breast Cancer: Stage IIIB
Any T N3 M0Any T N3 M0
N3 = metastasis to ipsilateral internal mammary lymph node(s)M0 = no distant metastasis
Tumor of any sizewith direct extensionto chest wall or skin
T4d = inflammatorycarcinoma
T4 any N M0T4 any N M0
T4T4
Breast Cancer: Stage IV
M1 = distant metastasis (including metastases to cervical, or contralateral internal mammary lymph nodes)
Any T any N M1
FDG PET scanFDG PET scanBone Scan Bone Scan
Staging for Distant Disease: Staging for Distant Disease: Breast CancerBreast Cancer
Tumor in the breast, Tumor in the breast, but not elsewherebut not elsewhere
Multiple bone Multiple bone metastasesmetastases
Patient APatient A Patient BPatient B
The most common sites of distant disease in breast cancer are the The most common sites of distant disease in breast cancer are the bones, liver and lungsbones, liver and lungs
BREAST CANCER5-year survival: Number
of positive axillary lymph nodes
0%
20%
40%
60%
80%
5-Y
ear
Sur
viva
l5-
Yea
r S
urvi
val
0 1 2 3 4 5 6-10 11-15 16-20 >20
Number of Positive NodesNumber of Positive Nodes
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
How effective is therapy for breast cancer?
Site1974-1976
1983-1985
1992-1997
1996-2003
Breast 75 78 86 89.8
SEER, 1973-2003, DCP, NCI, 2009
Relative 5 Year Survival (%)
BHGI-DIAGNOSTICS