AJCC Staging MomentsAJCC TNM Staging 7th Edition

Breast Case #2Contributors:Stephen B. Edge, MD Roswell Park Cancer Institute, Buffalo, New YorkDavid R. Byrd, MD University of Washington Medical Center, Seattle, WashingtonDavid J. Winchester, MD NorthShore University Evanston Hospital, Evanston, IllinoisDavid P. Winchester, MD NorthShore University Evanston Hospital, Evanston, Illinois

Breast Case # 2Presentation of New CaseNewly diagnosed breast cancer patient

Presentation at Cancer Conference for treatment recommendations and clinical staging

Breast Case # 2History & Physical62 yr old woman noticed a non-tender mass in the upper outer quadrant (UOQ) of the left breast

Family hx-breast ca in maternal aunt at age 70

Physical examination reveals a firm, mobile, 4 cm mass in the UOQ with no overlying skin changes and no palpable adenopathy

Breast Case # 2Imaging ResultsMammogram- 3.9cm density UOQ left breast, right breast negative

Ultrasound breast- 3.8cm hypoechoic area UOQ left breast, left axillary nodes negative, right breast negativeUsed with permission

Breast Case # 2Diagnostic ProcedureProcedureUltrasound-guided core needle biopsy UOQ left breast

Pathology ReportInfiltrating duct carcinomaBloom-Scarff-Richardson (BSR) Grade 3Estrogen receptor positiveProgesterone receptor positiveHER2 negative by IHC

Breast Case # 2Clinical StagingClinical staging Uses information from the physical exam, imaging, and diagnostic biopsy

PurposeSelect appropriate treatmentEstimate prognosis

Breast Case # 2Clinical StagingSynopsis- patient with 3.9cm mass, infiltrating duct ca, axilla is negative on exam and imaging

What is the clinical stage?T____N____M____Stage Group______

Breast Case # 2Clinical StagingClinical Stage correct answerT2N0M0Stage Group IIA

Based on stage, treatment is selectedReview NCCN treatment guidelines for this stage

Breast Case # 2Clinical StagingRationale for staging choices

T2 for 3.9cm primary tumor

N0 because nodes were clinically negative on physical exam and imaging

M0 because there was nothing to suggest distant metastases; if there was, appropriate tests would be performed before developing a treatment plan

Prognostic FactorsClinically SignificantApplicable to this casePagets disease: noBSR: Grade 3Estrogen receptor: positiveProgesterone receptor: positiveHER2 status: negativeMethod of node assessment: radiographic, physical examinationThere are no prognostic factors required for staging

Breast Case # 2Surgery & FindingsPatient declined option of neoadjuvant systemic therapy

ProcedureLumpectomy UOQ left breast, sentinel lymph node (SLN) biopsy

Operative findingsSentinel nodes were reported as negative on frozen section, additional stains will be performed

Breast Case # 2Pathology ResultsInfiltrating duct carcinomaSize of invasive cancer: 4.1cm with dermal invasion BSR Grade IIIMargins of resection negative closest margin inferior at 4mmSentinel nodesNegative by H&ESentinel Node 1 cytokeratin immunohistochemistry shows cluster of isolated tumor cells (ITCs),

Breast Case # 2Pathologic StagingPathologic staging Uses information from the clinical staging supplemented or modified by information from surgery and the pathology report

PurposeAdditional precise data for estimating prognosisCalculating end results (survival data)

Breast Case # 2Pathologic StagingSynopsis- patient with 4.1cm infiltrating duct ca, 1 sentinel node with ITCs detected only on IHC

What is the pathologic stage? (remember, clinical M may be used in pathologic staging)T____N____M____Stage Group______

Breast Case # 2Pathologic StagingPathologic Stage correct answerpT2pN0(i+)cM0Stage Group IIA

Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected

Breast Case # 2Pathologic StagingRationale for staging choices

pT2 Skin invasion is defined as full thickness involvement including epidermis. Focal dermal involvement is not considered T4.

pN0(i+) sentinel nodes had ITCs found on IHC only, H&E stains negative. ITCs usually have no histologic evidence of malignant activity.

cM0 - use clinical M with pathologic staging unless there is pathologic confirmation of distant metastases

Prognostic FactorsClinically SignificantApplicable to this casePagets disease: noBSR: Grade 3Estrogen receptor: positiveProgesterone receptor: positiveHER2 status: negative by IHCMethod of node assessment: sentinel node biopsyIHC of nodes: positive

There are no prognostic factors required for staging

AJCC Cancer Staging AtlaspN0(i+) is defined as Positive ITCs found on H&E or IHC, no ITCs >0.2mmNon confluent, or nearly confluent clusters of cells not exceeding 200 cells in a single histologic lymph node cross section

Breast Case # 2Recap of StagingSummary of correct answersClinical stage T2 N0 M0 Stage Group IIAPathologic stage T2 N0(i+) cM0 Stage Group IIA

The staging classifications have a different purpose and therefore can be different. Do not go back and change the clinical staging based on pathologic staging information.

Staging Moments SummaryReview site-specific information & rules

Clinical StagingBased on information before treatmentUsed to select treatment options

Pathologic StagingBased on clinical data PLUS surgery and pathology report informationUsed to evaluate end-results (survival)