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AJCC 6 TH EDITION STAGING OF BREAST CARCINOMA.

AJCC 6 TH EDITION STAGING OF BREAST CARCINOMA. AJCC NODE STAGING -16 CATEGORIES . pNX – 1 option pN0 – 5 options; null,(i-),(i+),(mol-),(mol+) pN1 – 4 options; mi,a,b,c pN2 -- 3 options; a,b,c pN3 – 3 options; a,b,c. 5 YR SURVIVAL OF 20,547 WOMEN WITH RESPECT TO LYMPH NODE INVOLVEMENT

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AJCC 6 TH EDITION STAGING OF BREAST CARCINOMA.

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  1. AJCC 6TH EDITION STAGING OF BREAST CARCINOMA.

  2. AJCC NODE STAGING -16 CATEGORIES • pNX – 1 option • pN0 – 5 options; null,(i-),(i+),(mol-),(mol+) • pN1 – 4 options; mi,a,b,c • pN2 -- 3 options; a,b,c • pN3 – 3 options; a,b,c

  3. 5 YR SURVIVAL OF 20,547 WOMEN WITH RESPECT TO LYMPH NODE INVOLVEMENT Cancer 45:2917-2924, 1980.

  4. N0 N1 N2 N3 0 1-3 4-9 >10

  5. MORE THAN JUST AXILLA • 1 - LOW AXILLARY • 2 - MID AXILLARY • 3 - HIGH AXILLARY (INFRACLAVICULAR) • 4 - SUPRACLAVICULAR • 5 - INTERNAL MAMMARY • 6 – LOW CERVICAL 6

  6. NEGATIVE NODE STAGING • pNX – status unknown • pN0 – H&E “negative” for carcinoma • pN0 (i+ or i-) – H&E “negative” and IPOX stains ordered • pN0 (mol+ or mol) – H&E “negative” and RT-PCR ordered “NEGATIVE” = Isolated tumor cells = pN0

  7. DEFINITION –ISOLATED TUMOR CELLS (ITC) • Single tumor cells or small clusters of tumor cells which do notaggregate to greater than 0.2 mm andwhich show no evidence of “proliferation or stromal reaction” • Clinical significance unknown • (i+) and (i-) • (mol+) and (mol-)

  8. ISOLATED TUMOR CELLS • pN0(i+) and pN0(mol +) and pN0 (H&E pos for ITC) are not counted as positive nodes eg 0.8 cm tumor with 12 nodes of which 3 “positive by IPOX” only pT1b pN0 pMX Thus “positive” by IPOX but not by N code.

  9. LOW NODE STAGE • pN1a 1-3 nodes positive In zones 1 and 2

  10. DEFINITION OF CLINICALLY APPARENT • Detected by imaging studies (excluding lymphoscintigraphy) • Detected by physical exam Note: No mention of matting of nodes though physical exam detection could represent matting.

  11. Pathologist’s Decision Tree

  12. LOW NODE STAGE • pN1b not clinically apparent but microscopically detected met

  13. LOW NODE STAGE • pN1c 1-3 axillary nodes pos & internal mam. Nodes pos. but not clinically apparent

  14. INTERMEDIATE NODE STAGE pN2a 4-9 axillary nodes pos. with at least one node met > 2 mm

  15. INTERMEDIATE NODE STAGE • pN2b clinical apparent int. mammary node, no positive axillary nodes

  16. HIGH STAGE NODE STAGING • pN3a Two categories of pN3a - axillary only displayed to the left

  17. HIGH STAGE NODE STAGING • pN3a Infraclavicular nodes positive -Second type of pN3a displayed to the left

  18. HIGH STAGE NODE STAGING • pN3b • Category One - metastasis in clinically apparent Int mammary node plus 1 or more axillary nodes

  19. HIGH STAGE NODE STAGING • pN3b • Second type - 3 or more axillary nodes + with int. mam. node positive by microscopy only

  20. HIGH STAGE NODE STAGING • pN3c Ipsilateral supra- clavicular node met.

  21. WHAT NODE FINDINGS NO LONGER CHANGE STAGING? • MACROSCOPIC - MATTING OF NODES • MICROSCOPIC – EXTRACAPSULAR EXTENSION OF TUMOR Both of the above are no longer included in the MSP approved synoptic report format.

  22. SENTINEL NODE CLASSIFICATION • Sentinel node without accompanying axillary dissection: (sn) e.g. – pN1 (sn); pN0 (i+) (sn) • Sentinel node with accompanying axillary dissection: e.g.– pN1; pN0 (i+)

  23. AGGREGATE WITHIN A NODE? • Node has no mass greater than 0.2 mm but has multiple masses. What’s the N code? • Node has no mass > 0.2 but < 2.0 mm but has multiple masses. What’s the N code. I don’t know the answer but it doesn’t happen very often.

  24. AGGREGATE OR NOT TO AGGREGATE, THAT IS THE ? • Each tumor nodule is 0.15 mm. • Each is < 0.2 mm • When aggregated the sum is 0.45 cm pN0 or pN1mic ?

  25. INTERNAL MAMMARY NODES • pN1b - IMN by sentinel node biopsy - mic + by path but notclinically apparent • pN1c – 1-3 + axillary nodes plus IMN mic + by path • pN2b – clinically apparent IMN with neg. axillary nodes • pN3b – IMN clinically apparent with any + axillary nodes

  26. INFRA AND SUPRACLAVICULAR LYMPH NODES • pN3a – infraclavicular node positive or >10 axillary nodes with one met > 2 mm • pN3c – ipsilateral supraclavicular node positive

  27. GRADING OF TUMORS • GX – CANNOT BE ASSESSED • G1 – LOW COMBINED HISTOLOGIC GRADE (FAVORABLE) • G2 – INTERMEDIATE COMBINED HISTOLOGIC GRADE (MODERATELY FAVORABLE) • G3 – HIGH COMBINED HISTOLOGIC GRADE (UNFAVORABLE)

  28. GRADING SYSTEMS IN USE • Scarff-Bloom-Richardson -1,2,3 • Nottingham ( Elston-Ellis modification of the Scarff-Bloom-Richardson ) – 3 to 9 - based on 1,831 pts - prognosis correlation p < 0.0001 - can be applied to most histologic tumor variants (e.g. - not medullary ca)

  29. CAP AND AJCC RECOMMEDED METHOD FOR TUMOR GRADING • Nottingham Combined Histologic Score - Tubule Formation (1,2 or 3) - Nuclear Pleomorphism (1,2,or 3) - Mitotic Count (1,2, or 3) Sum T + N + M = Combined Score Score 3-5 = grade 1 Score 6-7 = grade 2 Score 8-9 = grade 3

  30. TUMOR STAGING 18 CATEGORIES – CLINICAL AND PATHOLOGY STAGING THE SAME pTX (eg – gross tumor at margin of resection) pT0 no tumor pTis (DCIS, LCIS, Paget’s) pT1 (a,b,c) 0.1 cm to 2.0 cm pT2 > 2.0 < 5.0 cm pT3 >5.0 cm pT4 (a,b,c,d) chest wall or skin spread

  31. What about invasion < 0.1cm? • Termed microinvasion. • No T category reserved. • Lumped under pT1 as pT1mic • Number and size of microinvasive sites should be listed by recommendation of AJCC

  32. WHAT ABOUT COMBINED INSITU AND INVASIVE LESIONS? • The staging is by size of only the invasive component. e.g. – 2.5 cm macroscopic tumor mass shows 60% DCIS. Staging is not pT2 (>2 cm) but pT1b or pT1c (0.5 to 2.0 cm).

  33. WHAT ABOUT NEOADJAVANT PRESURGERY CHEMOTHERAPY? • All TNM in such case should be preceded by the prefix “y” e.g. – ypT1a

  34. WHAT ABOUT S/P NEEDLE CORE BIOPSIED LESIONS? • MEASURE RESIDUAL TUMOR • AGGREGATE MEASUREMENT FROM PREVIOUS CORE AND PRESENT LUMPECTOMY / MASTECTOMY e.g. – mammatome biopsy of 0.7 cm and lumpectomy of 0.8 = 1.5 cm or pT1b (if the mammatome biopsy is from the center of the breast mass then aggregating may not be appropriate).

  35. WHAT ABOUT SYNCHRONOUS LESIONS? • Largest mass’ measurement provides T • Smaller tumor does not get assigned a T • Lesions in the same quadrant are not considered synchronous lesions but are “satellite breast nodules” (no change in T) • Synchronous bilateral lesions are staged separately.

  36. METASTATIC STAGING • pMX - unknown • pM0 – no known mets • pM1 – distant mets low cervical nodes pectoralis muscle invasion distant organs malignant effusions (supraclavicular nodes no longer > M1)

  37. WHAT IS THE PATHOLOGIST’S RESPONSIBILITY? • Use a template that has all the required data fields. • Complete the TNM staging at the time of report signing. • Use all available resources, reports, history to accurately provide the TNM staging.

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