AJCC Staging Moments

AJCC TNM Staging 7th Edition

Breast Case #1

Contributors: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 # 1Presentation of New Case

• Newly diagnosed breast cancer patient

• Presentation at Cancer Conference for treatment recommendations and clinical staging

Breast Case # 1History & Physical

• 85 yr old female who presented with an abnormal screening mammogram, no palpable breast masses, axillary nodes not palpable

• No family hx, no HRT (hormone replacement therapy)

Breast Case # 1Imaging Results

• Mammogram-0.5cm area of microcalcifications in centralleft breast mid depth

• Suspicious by magnificationand spot compression views

• Stereotactic core needle biopsyrecommended

• No further imaging performed

Used with permission. Washington University School of Medicine

ML view: magnification mammogram

Breast Case # 1Diagnostic Procedure

• Procedure– Stereotactic core needle biopsy central left breast

• Pathology– Ductal carcinoma in situ, cribriform and solid type– Nuclear grade 2– Estrogen receptor positive– Progesterone receptor positive

Breast Case # 1Clinical Staging

• Clinical staging – Uses information from the physical exam, imaging,

and diagnostic biopsy

• Purpose– Select appropriate treatment– Estimate prognosis

Breast Case # 1Clinical Staging

• Synopsis- elderly patient with 0.5cm DCIS lesion only visible on imaging, axilla is neg on exam and imaging

• What is the clinical stage?– T____– N____– M____– Stage Group______

Breast Case # 1Clinical Staging

• Clinical Stage correct answer– Tis– N0– M0– Stage Group 0

• Based on stage, treatment is selected• Review NCCN treatment guidelines for this

stage

Prognostic FactorsClinically Significant

• Applicable to this case– Paget’s disease: no– Estrogen receptor: positive– Progesterone receptor: positive– HER2 status: n/a– Method of node assessment: radiographic and

physical examination

• There are no prognostic factors required for staging

Breast Case # 1Surgery & Findings

• Procedure– Image-guided wire localized left partial mastectomy

(lumpectomy)– No lymph nodes excised

• Findings– Specimen radiograph reveals microcalcifications and

clip in center of specimen

• Final pathology deferred to permanent pathology

Breast Case # 1Pathology Results

• DCIS, cribriform and solid type, nuclear grade 2

• Invasive ductal carcinoma – 1mm

• Invasive cancer Scarff-Bloom-Richardson (SBR) Grade 1

• Margins of resection free – closest margins inferior at 5mm

• HER2 negative

Breast Case # 1Pathologic Staging

• Pathologic staging – Uses information from the clinical staging

supplemented or modified by information from surgery and the pathology report

• Purpose– Additional precise data for estimating prognosis– Calculating end results (survival data)

Breast Case # 1Pathologic Staging

• Synopsis- patient with 0.5cm DCIS and a 1mm infiltrating duct ca, no nodes removed

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

– T____– N____– M____– Stage Group______

Breast Case # 1Pathologic Staging

• Pathologic Stage correct answer– pT1mi (6th Ed T1mic, designation changed in 7th Ed)– pNx– cM0– Stage Group unknown

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

Breast Case # 1Pathologic Staging

• Rationale for staging choices

– pT1mi is microinvasion <1mm in size

– pNx because sentinel or axillary nodes were not removed, pathologic staging cannot be completed

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

Prognostic FactorsClinically Significant

• Applicable to this case– Paget’s disease: no– SBR on invasive cancer: Grade 1– Estrogen receptor: positive– Progesterone receptor: positive– HER2 status: negative– Method of node assessment: radiographic and

physical examination

• There are no prognostic factors required for staging

AJCC Cancer Staging AtlasT1mi is microinvasion 0.1cm (1mm) or

less in greatest dimension

Multiple simultaneous tumors should be indicated by (m) or the number of tumors (3)

Breast Case # 1Recap of Staging

• Summary of correct answers– Clinical stage Tis N0 M0 Stage Group 0– Pathologic stage T1mi pNX cM0 Stage Group unknown

• The staging classifications have a differentpurpose and therefore can be different. Do notgo back and change the clinical staging basedon pathologic staging information.

Staging Moments Summary

• Review site-specific information if needed

• Clinical Staging– Based on information before treatment– Used to select treatment options

• Pathologic Staging– Based on clinical data PLUS surgery and pathology

report information– Used to evaluate end-results (survival)