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.

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Schematic diagram of the breast and regional lymph nodes.

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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)

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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.

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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.

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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.

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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.

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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.

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T4b illustrated here as edema (including peau d’orange) of the skin.

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T4c is defined as both T4a and T4b.

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T4d is inflammatory carcinoma.

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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).

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N2a is defined as metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures.

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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.

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N3a is defined as metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement.

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N3b is defined as metastases in clinically detected ipsilateral internal mammary lymph node(s) and clinically evident axillary lymph node(s).

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N3c is defined as metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement.

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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).

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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”

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pN1b metastases in internal mammary nodes detected by sentinel lymph node biopsy but not clinically detected.

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pN1c illustrating 3 positive axillary lymph nodes and metastases in internal mammary lymph nodes detected by sentinel lymph node biopsy but not clinically detected.

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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.

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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.

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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.

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pN3c illustrated as metastases in ipsilateral supraclavicular lymph nodes.

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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