TNM/STAGE Flashcards
ANATOMICAL SUBSITES
- Nipple (C50.0)
- Central portion (C50.1)
- Upper inner quadrant (C50.2)
- Lower inner quadrant (C50.3)
- Upper outer quadrant (C50.4)
- Lower outer quadrant (C50.5)
- Axillary tail (C50.6)
Regional Lymph Nodes
The regional lymph nodes are:
Axillary (ipsilateral): interpectoral (Rotter) nodes and lymph nodes along the axillary vein and its tributaries, which may be divided into the following levels:
a. Level I (low axilla): lymph nodes lateral to the lateral border of pectoralis minor muscle
b. Level II (mid axilla): lymph nodes between the medial and lateral borders of the pectoralis minor muscle and the interpectoral (Rotter) lymph nodes
c. Level III (apical axilla): apical lymph nodes and those medial to the medial margin of the pectoralis minor muscle, excluding those designated as subclavicular or infraclavicular
Infraclavicular (subclavicular) (ipsilateral)
Internal mammary (ipsilateral): lymph nodes in the intercostal spaces along the edge
of the sternum in the endothoracic fascia
Supraclavicular(ipsilateral)
TX
T0
Tis
Tis DCIS
Tis LCIS
Tis PAGET
TX Primary tumour cannot be assessed T0 No evidence of primary tumour
Tis Carcinoma in situ
Tis Ductal carcinoma in situ
(DCIS)
Tis Lobular carcinoma in situa (LCIS)
Tis Paget disease of the nipple not associated with invasive carcinoma and/or (Paget) carcinoma in situ (DCIS and/or LCIS) in the underlying breast parenchyma.
Carcinomas in the breast parenchyma associated with Paget disease are categorized based on the size and characteristics of the parenchymal disease, although the presence of Paget disease should still be noted.
T1mi
Microinvasion is the extension of cancer cells beyond the basement membrane into the adjacent tissues with no focus more than 0.1 cm in greatest dimension. When there are multiple foci of microinvasion, the size of only the largest focus is used to classify the microinvasion. (Do not use the sum of all individual foci.) The presence of multiple foci of microinvasion should be noted, as it is with multiple larger invasive carcinomas.
T1
T1 Tumour 2 cm or less in greatest dimension
T1mi Microinvasion 0.1 cm or less in greatest dimensionb
T1a More than 0.1 cm but not more than 0.5 cm in greatest dimension
T1b More than 0.5 cm but not more than 1 cm in greatest dimension
T1c More than 1 cm but not more than 2 cm in greatest dimension
T2
T2 Tumour more than 2 cm but not more than 5 cm in greatst dimension.
T3
T3 Tumour more than 5 cm in greatest dimension
T4
T4 Tumour of any size with direct extension to chest wall and/or to skin (ulceration or
skin nodules)c
T4a Extension to chest wall (does not include pectoralis muscle invasion only)
T4b Ulceration, ipsilateral satellite skin nodules, or skin oedema (including peau d’orange)
T4c Both 4a and 4b
T4d Inflammatory carcinomad
T4a
T4a Extension to chest wall (does not include pectoralis muscle invasion only)
Chest wall includes ribs, intercostal muscles, and serratus anterior muscle but not pectoral muscle.
T4b
T4b Ulceration, ipsilateral satellite skin nodules, or skin oedema (including peau d’orange)
Invasion of the dermis alone does not qualify as T4.
T4c
T4c Both 4a and 4b
T4a Extension to chest wall (does not include pectoralis muscle invasion only)
T4b Ulceration, ipsilateral satellite skin nodules, or skin oedema (including peau d’orange)
T4d
T4d Inflammatory carcinoma
Inflammatory carcinoma of the breast is characterized by diffuse, brawny induration of the skin with an erysipeloid edge, usually with no underlying mass. If the skin biopsy is negative and there is no localized measurable primary cancer, the T category is pTX when pathologically staging a clinical inflammatory carcinoma (T4d). Dimpling of the skin, nipple retraction, or other skin changes, except those in T4b and T4d, may occur in T1, T2, or T3 without affecting the classification.
NX, N0
NX Regional lymph nodes cannot be assessed (e.g., previously removed)
N0 No regional lymph node metastasis
N1
N1 Metastasis in movable ipsilateral level I, II axillary lymph node(s)
N2
N2 Metastasis in ipsilateral level I, II axillary lymph node(s) that are clinically fixed or matted; or in clinically detected* ipsilateral internal mammary lymph node(s) in the absence of clinically evident axillary lymph node metastasis
N2a Metastasis in axillary lymph node(s) fixed to one another (matted) or to other structures
N2b Metastasis only in clinically detected* internal mammary lymph node(s) and in the absence of clinically detected axillary lymph node metastasis
N2a
N2a Metastasis in axillary lymph node(s) fixed to one another (matted) or to other structures
N2b
N2b Metastasis only in clinically detected* internal mammary lymph node(s) and in the absence of clinically detected axillary lymph node metastasis
N3
N3 Metastasis in ipsilateral infraclavicular (level III axillary) lymph node(s) with orwithout level I, II axillary lymph node involvement; or in clinically detected*ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary lymph node metastasis; or metastasis in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement
N3a Metastasis in infraclavicular lymph node(s)
N3b Metastasis in internal mammary and axillary lymph nodes
N3c Metastasis in supraclavicular lymph node(s)
N3a
N3a Metastasis in infraclavicular lymph node(s)
N3b
N3b Metastasis in internal mammary and axillary lymph nodes
N3c
N3c Metastasis in supraclavicular lymph node(s)
Clinically detected T def
Clinically detected is defined as detected by clinical examination or by imaging studies (excluding lymphoscintigraphy) and having characteristics or a presumed pathological macrometastasis based on fine needle aspiration biopsy with cytologic examination. Confirmation of clinically detected metastatic disease by fine needle aspiration without excision biopsy is designated with an (f) suffix, e.g. cN3a(f).
M
M0 No distant metastasis
M1 Distant metastasis
pTNM
pT
The pathological classification requires the examination of the primary carcinoma with no gross tumour at the margins of resection. A case can be classified pT if there is only microscopic tumour in a margin.
The pT categories correspond to the T categories.
Note
When classifying pT the tumour size is a measurement of the invasive component. If there is a large in situ component (e.g., 4 cm) and a small invasive component (e.g., 0.5 cm), the tumour is coded pT1a.
pTNM
pN
The pathological classification requires the resection and examination of at least the low axillary lymph nodes (level I) (see page 152). Such a resection will ordinarily include 6 or more lymph nodes. If the lymph nodes are negative, but the number ordinarily examined is not met, classify as pN0.
pNX Regional lymph nodes cannot be assessed (e.g., previously removed, or not removed for pathological study)
pN0 No regional lymph node metastasis*
Isolated tumour cell clusters (ITC) are single tumour cells or small clusters of cells not more than 0.2 mm in greatest extent that can be detected by routine H and E stains or immunohistochemistry. An additional criterion has been proposed to include a cluster of fewer than 200 cells in a single histological cross section. Nodes containing only ITCs are excluded from the total positive node count for purposes of N classification and should be included in the total number of nodes evaluated. (See Introduction, page 7.)
pN1mi
pN1 Micrometastases; or metastases in 1 to 3 axillary ipsilateral lymph nodes; and/or in internal mammary nodes with metastases detected by sentinel lymph node biopsy but not clinically detected*
pN1mi Micrometastases (larger than 0.2 mm and/or more than 200 cells, but none larger than 2.0 mm)
pN1a
pN1a Metastasis in 1–3 axillary lymph node(s), including at least one larger than 2 mm in greatest dimension
pN1b
pN1b Internal mammary lymph nodes
pN1c
pN1c Metastasis in 1–3 axillary lymph nodes and internal mammary lymph nodes.
pN2
pN2 Metastasis in 4–9 ipsilateral axillary lymph nodes, or in clinically detected*ipsilateral internal mammary lymph node(s) in the absence of axillary lymph node metastasis
pN2a Metastasis in 4–9 axillary lymph nodes, including at least one that is larger than 2 mm
pN2b Metastasis in clinically detected internal mammary lymph node(s), in theabsence of axillary lymph node metastasis
pN2a
pN2a Metastasis in 4–9 axillary lymph nodes, including at least one that is larger than 2 mm
pN2b
pN2b Metastasis in clinically detected internal mammary lymph node(s), in theabsence of axillary lymph node metastasis
pN3a
pN3a Metastasis in 10 or more ipsilateral axillary lymph nodes (at least one larger than 2 mm) or metastasis in infraclavicular lymph nodes
pN3b
pN3b Metastasis in clinically detected* internal ipsilateral mammary lymph node(s) in the presence of positive axillary lymph node(s); or metastasis in more than 3 axillary lymph nodes and in internal mammary lymph nodes with microscopic or macroscopic metastasis detected by sentinel lymph node biopsy but not clinically detected
pN3c
pN3c Metastasis in ipsilateral supraclavicular lymph node(s)
Post- Treatment ypN
Post treatment yp ‘N’ should be evaluated as for clinical (pretreatment) ‘N’ methods (see Section N – Regional Lymph Nodes). The modifier ‘sn’ is used only if a sentinel node evaluation was performed after treatment. If no subscript is attached, it is assumed the axillary nodal evaluation was by axillary node dissection.
The X classification will be used (ypNX) if no yp post treatment SN or axillary dissection was performed
N categories are the same as those used for pN.
pM1
pM1 Distant metastasis microscopically confirmed
STAGE 0
Tis N0 M0
Stage IA
T1 N0 M0
TODOS LOS T1 sin nada más
Stage IB
T0,T1 con N1mi M0
Stage IIA
- T0,T1, N1, M0
- T2,N0,M0
STAGE IIB
- T2 N1 M0
- T3 N0 M0
STAGE IIIA
- T0,T1,T2 N2 M0
- T3 N1 M0
STAGE IIIB
- T4, N0-2,M0
TODOS LOS T4 MENOS LOS T4,N3
STAGE IIIC
- ANY T, N3, M0
TODOS LOS N3, M0
STAGE IV
ANY T, ANY N, M1
TODOS LOS M1
Histological Grade (Scarff-Bloom-Richardson System - Nottingham Modification)
CLINICALLY DEFINED-TREATMENT ORIENTED SUBTYPES OF BREAST CANCER
CHARACTERIZATION OF THE RESPONSE TO NEOADJUVANT THERAPY
SIMULTANEOUS BILATERAL PRIMARY CARCINOMAS
Each carcinoma is classified and staged as a separate primary carcinoma in a separate organ based on its own characteris tics, including T category as specified in the staging rules (see Chapter 1). Each tumor should have a separate bio marker determination (ER, PR, HER2, and grade).
ESTROGEN RECEPTOR EXPRESSION
ER expression is measured primarily by IHC. Any staining of 1% of cells or more is considered positive for both ER and PR.61AJCC Level of Evidence: I
Progesterone Receptor Expression
PR expression is measured primarily by IHC. Any staining of 1% of cells or more is considered positive for both ER and PR. AJCC Level of Evidence: I
Human Epidermal Growth Factor Receptor-2 (HER2)
The measurement of HER2 is primarily by either IHC to assess expression of the HER2 protein or by in situ hybrid- ization (ISH) - most commonly by fluorescent labeled probes (FISH) or chromogenic labeled probes (CISH) to assess gene copy number. The 2013 American Society of Clinical Oncology/College of American Pathologists Guidelines pro vide standards for sequential performance of tests to accu rately and efficiently determine HER2 status, most commonly starting with IHC and progressing to ISH testing if IHC is 2+ (equivocal). Below the standards are summa- rized. Users are referred to the full guideline for detailed information on HER2 testing and reporting.70AJCC Level of Evidence: I
double probe ISH cut points
IHC:
Negative: 0 or 1+ staining
Equivocal: 2+ staining
Positive: 3+ staining
single probe cut points are:
Negative: < than 4 HER2 copies
Equivocal: > to 4 HER2 copies but < 6 HER2 copies Positive: 6 or more HER2 copies
Oncotype Dx
Oncotype Dx® is a genomic test based on the assessment of 21 genes: the result is the outeome of a mathematical for mula of the weighted expression of each gene combined into a single score. It is measured and reported by RT-PCR, with recurrence score of < 11 the most pertinent cutoff valué.14 Oncotype Dx® is required only for assigning prognostic stage group to patients with T l-2 NO MO, ER-positive, HER2-negative cancers. AJCC Level of Evidence: I
Ki-67
Ki-67 is a nuclear protein associated with cellular prolifera tion.55’91 The most prevalent analysis method of Ki-67 anti gen is IHC; to date, however, no standard operating procedure or generally accepted cutoff definition for Ki-67 exists. AJCC Level of Evidence: III
prognostic tools for breast cancer that met AJCC quality criteria
Multigene Signature Scores
IHC4 combines the IHC assessment of ER. PR, HER2, and Ki-67.82-92The developers presented evidence to suggest that it has prognostic valué similar to the Oncotype Dx® assay. The results are based on a multivariate model that uses semi- quantitative information from IHC assessment of ER, PR, HER2, and Ki-67. IHC4 uses a mathematical formula that weighs the semiquantitative expression valúes and combines these into a single risk score. AJCC Level of Evidence: II
Genomic test/Gene expression profiling
Histopatologic Type
- In situ Carcinomas
Ductal carcinoma in situ
Paget disease
- Invasive Carcinomas
Not otherwise specified (NOS) Ductal
inflam m atory
Medullary. NOS
Medullary with lymphoid stroma
M ucinous
Papillary (predominantly micropapillary pattern)
Tubular
Lobular
Paget disease and infiltrating U ndifferentiated
Squamous cell
Adenoid cystic
Secretory
Cribriform
AJCC Progbostic Stage Group
Se requiere:
- T
- N
- M
- G
- Her2 status
- Er status
- PR status
Para dar como resultado un Prognostic Stage Group
The use of this prognostic table provides a marked improvement in grouping patients with similar prognosis. Compared to the anatomic stage groups, the application of the prognostic stage groups assigns 41% of cases to a different group with either a better or worse prognosis.
