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Staging of Breast Cancer

TNM Classification

The TNM system describes the anatomical extent of the disease at presentation. “T” refers to the extent of the primary tumor in and around the breast. “N” (node) refers to the absence or presence and extent of regional lymph node metastasis. “M” refers to the absence or presence of distant metastasis. 

The TNM classification differentiates between the clinical classification (TNM) and the pathological classification (pTNM).

The classification is the decisive factor for determining of adjuvant treatment and prognosis.

Primary Tumor (T)

  • TX – Classification is not possible due to lack of information.
  • T0 – Primary tumor not identified.
  • Tis – Carcinoma in situ. 
    • Tis DCIS – Ductal carcinoma in situ 
    • Tis LCIS - Lobular carcinoma in situ
  • T1 – Tumor ≤ 2 cm in the largest dimension
    • T1mic – Tumor ≤ 0.1 cm in the largest dimension
    • T1a – Tumor >0.1≤0.5 cm in the largest dimension
    • T1b – Tumor >0.5 ≤ 1 cm in the largest dimension
    • T1c – Tumor > 1≤ 2 cm in the largest dimension
  • T2 – Tumor > 2 ≤ 5 cm in the largest dimension 

/upload/mammae/bryst_t1_2.gif 

  • T3 – Tumor > 5 cm in the largest dimension
  • T4 – Tumor independent of size, growing into the skin or breast wall
    • T4a - Invasion of the breast wall (the rib, intercostal musculature, serratus anterior)
    • T4b – With edema, infiltration or ulceration of the skin of the breast including peau d’orange, or satellite skin tumors of the same breast
    • T4c – Both T4a and T4b
  • T4d – Inflammatory carcinoma 

/upload/mammae/bryst_t3_4.gif 

  Clinical lymph node status (N)

  •  NX – N-classification not possible due to lack of information
  •  N0 – No apparent regional lymph node metastases
  •  N1 – Movable ipsilateral axillary lymph node metastasis
  •  N2 – Ipsilateral axillary lymph node metastases fused to each other or other structures or clinically or radiological identifiable metastasis to ipsilateral mammary internal lymph nodes and absence of clinically apparent axillary lymph node metastasis 
    • N2a – Ipsilateral axillary lymph node metastases fused to each other or other structures
    • N2b – Clinical or radiological apparent metastases to ipsilateral internal mammary lymph nodes in the absence of clinically visible axillary lymph node metastases 
  • N3 – Ipsilateral spreading of infraclavicular lymph nodes or spreading to clinically or radiologicaly identifiable ipsilateral internal mammary lymph nodes and simultaneously clinically apparent axillary lymph node metastases; or ipsilateral spreading to supraclavicular lymph nodes with or without axillary or internal mammary lymph node metastases   
    • N3a – Clinically identifiable ipsilateral infraclavicular lymph node metastases and axillary lymph node metastases
    • N3b – Clinically or radiologically apparent ipsilateral internal mammary lymph nodes and simultaneous clinically axillary lymph node metastases 
    • N3c – Clinically identifiable ipsilateral supraclavicular lymph node metastases

Histological lymph node status (pN)

  • pNx – N - classification is not possible due to lack of information
  • pN0 – No histologically apparent regional lymph node metastasis, not performed immunohistochemical examination for visualization of tumor cell clusters < 0.2 mm
    •   pN0(i-) – no histologically apparent regional lymph node metastases, negative immunohistochemical analysis
    •   pN0(i+) – No apparent regional lymph node metastases, positive immunohistochemical analysis, but no tumor cell clusters > 0.2 mm
    •    pN0(mol-) – No apparent regional lymph node metastases, negative molecular examination (rt-pcr)
    •   pN0(mol+) – No apparent regional lymph node metastases, positive molecular examination (rt-pcr)
  • pN1(mi) – Micrometastasis > 0.2 ≤ 2.0 mm in the largest diameter
  • pN1 – Metastasis to 1-3 axillary lymph nodes and/or microscopically apparent spread to internal mammary lymph nodes after sentinel node examination (not clinically apparent) 
    • pN1a – Metastasis to 1-3 axillary lymph nodes
    • pN1b – Microscopically identifiable spread to internal mammary lymph nodes after sentinel node examination (not clinically visible)
    • pN1c – Metastasis to 1-3 axillary lymph nodes and microscopically apparent spread to internal mammary lymph nodes after sentinel node examination (not clinically identifiable)
/upload/mammae/bryst_pn1.gif

 

  • pN2 – Metastasis in four to nine axillary lymph nodes, or in clinically or radiologically apparent ipsilateral internal mammary lymph nodes in the absence of axillary lymph node metastasis
    • pN2a- Metastasis to 4-9 axillary lymph nodes (greatest metastasis > 2.0 mm)
    • pN2b – Metastasis to clinical or radiological identifiable ipsilateral internal mammary lymph nodes in the absence of axillary lymph node metastasis

/upload/mammae/bryst_pn2.gif 

  • pN3 – Metastasis in 10 or more axillary lymph nodes, or in infraclavicular lymph nodes, or in clinically identifiable ipsilateral internal mammary lymph nodes in the presence of one or more positive axillary lymph nodes, or in more than 4 axillary lymph nodes with clinically negative microscopic metastasis in internal mammary lymph nodes or in ipsilateral supraclavicular lymph nodes
    • pN3a – Metastasis in 10 or more axillary lymph nodes (at least one tumor deposit greater than 2.0 mm), or metastasis to the infraclavicular lymph nodes
    • pN3b – Metastasis in clinically or radiologically apparent ipsilateral internal mammary lymph nodes in the presence of one or more positive axillary lymph nodes, or metastasis to ≥ 4 axillary lymph nodes in the presence of microscopic disease detected by sentinel lymph nodes dissection but not clinically apparent
    • pN3c – Metastasis in ipsilateral supraclavicular lymph nodes

/upload/mammae/bryst_pn3.gif 

  Metastasis (M)

  • MX – M- assessment not possible due to lack of information
  • M0 – No apparent metastasis 
  • M1 – Metastasis

Staging

Staging is applied for the determination of adjuvant treatment.

The staging for breast cancer has previously not been conformal to the international practice.

The Norwegian has been based on the staging by the Norwegien Cancer Registry. For instance has patients with T2 tumors  been classified as Stage I, in contrast to international staging lassifying them as stage II. This difference is not satisfying. Therefore The Norwegian Breast Cancer Group (NBCG) has adopted the international practice (UICC).  According to the Iast TNM classification patients with supraclavicular lymph node metastases will be classified as N3 and not M1 (6,7). This means that these patients in the future will be classified as stage III.

In the overview below, the staging is categorized according to whether the breast cancer is considered primary operable or inoperable. 

Primary operable cancer
Stage I T1N0M0
Stage II T0-2N1M0
  T2N0M0
Primary inoperable cancer
Stage II T3N0M0
Stage III T0-2N2M0
  T3N1-2M0
  T4N0-2M0
  T0-4N3M0
Stage IV T1-4N0-3M1

 

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