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Ca Μαστού

AJCC Stages

Stages

T

N

M

0

Tis

N0

M0

IA

T1¹

N0

M0

IB

T0

N1mi

M0

T1¹

N1mi

M0

IIA

T0

N1²

M0

T1¹

N1²

M0

T2

N0

M0

IIB

T2

N1

M0

T3

N0

M0

IIIA

T0

N2

M0

T1¹

N2

M0

T2

N2

M0

T3

N1

M0

T3

N2

M0

IIIB

T4

N0

M0

T4

N1

M0

T4

N2

M0

IIIC

Any T

N3

M0

IV

Any T

Any N

M1

Notes: M0 includes M0(i+). The designation pM0 is not valid; any M0 should be clinical. If a patient presents with M1 prior to neoadjuvant systemic therapy, the stage is considered IV and remains stage IV regardless of response to neoadjuvant therapy. Stage designation may be changed if postsurgical imaging studies reveal the presence of distant metastases, provided that the studies are carried out within 4 months of diagnosis in the absence of disease progression and provided that the patient has not received neoadjuvant therapy. Post-neoadjuvant therapy is designated with "yc" or "yp" prefix. Of note, no stage group is assigned if there is a complete pathologic response (CR) to neoadjuvant therapy, for example, ypT0ypN0cM0. 
¹T1 includes T1mi. 
²T0 and T1 tumors with nodal micrometastases only are excluded from stage IIA and are classified stage IB.

(T) Primary Tumor

TX

Primary tumor cannot be assessed

T0

No evidence of primary tumor

Tis

Carcinoma in situ

Tis (DCIS)

Ductal carcinoma in situ

Tis (LCIS)

Lobular carcinoma in situ

Tis (Paget)

Paget disease of the nipple not associated with invasive carcinoma &/or carcinoma in situ (DCIS &/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

T1

Tumor ≤ 20 mm in greatest dimension

T1mi

Tumor ≤ 1 mm in greatest dimension

T1a

Tumor > 1 mm but ≤ 5 mm in greatest dimension

T1b

Tumor > 5 mm but ≤ 10 mm in greatest dimension

T1c

Tumor > 10 mm but ≤ 20 mm in greatest dimension

T2

Tumor > 20 mm but ≤ 50 mm in greatest dimension

T3

Tumor > 50 mm in greatest dimension

T4

Tumor of any size with direct extension to the chest wall &/or to the skin (ulceration or skin nodules); invasion of the dermis alone does not qualify as T4

T4a

Extension to the chest wall, not including only pectoralis muscle adherence/invasion

T4b

Ulceration &/or ipsilateral satellite nodules &/or edema (including peau d'orange) of the skin, which do not meet the criteria for inflammatory carcinoma

T4c

Both T4a and T4b

T4d

Inflammatory carcinoma

The T classification of the primary tumor is the same regardless of whether it is based on clinical or pathologic criteria, or both. Size should be measured to the nearest millimeter. If the tumor size is slightly less than or greater than a cutoff for a given T classification, it is recommended that the size be rounded to the millimeter reading that is closest to the cutoff. For example, a reported size of 1.1 mm is reported as 1 mm or a size of 2.01 cm is reported as 2.0 cm. Designation should be made with the subscript "c" or "p" modifier to indicate whether the T classification was determined by clinical (physical examination or radiologic) or pathologic measurements, respectively. In general, pathologic determination should take precedence over clinical determination of T size.

(N) Regional Lymph Nodes

NX

Regional lymph nodes cannot be assessed (e.g., previously removed)

N0

No regional lymph node metastases

N1

Metastases to movable ipsilateral level I, II axillary lymph node(s)

N2

Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted; or in clinically detected* ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases

N2a

Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures

N2b

Metastases only in clinically detected* ipsilateral internal mammary nodes and in the absence of clinically evident level I, II axillary lymph node metastases

N3

Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement; or in clinically detected¹ ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary lymph node metastases; or metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement

N3a

Metastases in ipsilateral infraclavicular lymph node(s)

N3b

Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)

N3c

Metastases in ipsilateral supraclavicular lymph node(s)

*"Clinically detected" is defined as detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination and having characteristics highly suspicious for malignancy or a presumed pathologic macrometastasis based on fine needle aspiration biopsy with cytologic examination. Confirmation of clinically detected metastatic disease by fine need aspiration without excision biopsy is designated with an (f) suffix, for example, cN3a(f). Excisional biopsy of a lymph node or biopsy of a sentinel node, in the absence of assignment of a pT, is classified as a clinical N, for example, cN1. Information regarding the confirmation of the nodal status will be designated in site-specific factors as clinical, fine needle aspiration, core biopsy, or sentinel lymph node biopsy. Pathologic classification (pN) is used for excision or sentinel lymph node biopsy only in conjunction with a pathologic T assignment.

(pN) Pathologic Lymph Node Classification¹

pNX

Regional lymph nodes cannot be assessed (e.g., previously removed, or not removed for pathologic study)

pN0

No regional lymph node metastasis identified histologically

pN0(i-)

No regional lymph node metastases histologically, negative IHC²

pN0(i+)

Malignant cells in regional lymph node(s) ≤ 0.2 mm (detected by H&E or IHC including ITC³)

pN0(mol-)

No regional lymph node metastases histologically, negative molecular findings (RT-PCR)⁴

pN0(mol+)

Positive molecular findings (RT-PCR),⁴ but no regional lymph node metastases detected by histology or IHC

pN1

Micrometastases; or metastases in 1-3 axillary lymph nodes; &/or in internal mammary nodes with metastases detected by sentinel lymph node biopsy but not clinically detected⁵

pN1mi

Micrometastases (> 0.2 mm &/or > 200 cells, but none > 2.0 mm)

pN1a

Metastases in 1-3 axillary lymph nodes, ≥ 1 metastasis > 2.0 mm

pN1b

Metastases in internal mammary nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected⁵

pN1c

Metastases in 1-3 axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected⁵

pN2

Metastases in 4-9 axillary lymph nodes; or in clinically detected⁶ internal mammary lymph nodes in the absence of axillary lymph node metastases

pN2a

Metastases in 4-9 axillary lymph nodes (≥ 1 tumor deposit > 2.0 mm)

pN2b

Metastases in clinically detected⁶ internal mammary lymph nodes in the absence of axillary lymph node metastases

pN3

Metastases in ≥ 10 axillary lymph nodes; or in infraclavicular (level III axillary) lymph nodes; or in clinically detected⁶ ipsilateral internal mammary lymph nodes in the presence of ≥ 1 positive level I, II axillary lymph nodes; or in > 3 axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected⁵; or in ipsilateral supraclavicular lymph nodes

pN3a

Metastases in ≥ 10 axillary lymph nodes (≥ 1 tumor deposit > 2.0 mm); or metastases to infraclavicular (level III axillary lymph) nodes

pN3b

Metastases in clinically detected⁶ ipsilateral internal mammary lymph nodes in the presence of ≥ 1 positive axillary lymph nodes; or in > 3 axillary lymph nodes and internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected⁵

pN3c

Metastases in ipsilateral supraclavicular lymph nodes

¹ Classification is based on axillary lymph node dissection with or without sentinel lymph node biopsy. Classification based solely on sentinel lymph node biopsy without subsequent axillary lymph node dissection is designated (sn) for "sentinel node." 
² IHC: Immunohistochemistry. 
³ Isolated tumor cell clusters (ITC) are defined as small clusters of cells not greater than 0.2 mm, or single tumor cells, or a cluster of fewer than 200 cells in a single histologic cross-section. ITCs may be detected by routine histology or by immunohistochemical methods. Nodes containing only ITCs are excluded from the total positive node count for purposes of N classification but should be included in the total number of nodes evaluated. 
⁴ RT-PCR: Reverse transcriptase/polymerase chain reaction. 
⁵ "Not clinically detected" is defined as not detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination. 
⁶ "Clinically detected" is defined as detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination and having characteristics highly suspicious for malignancy or a presumed pathologic macrometastasis based on fine needle aspiration biopsy with cytologic examination.

(M) Distant Metastasis

M0

No clinical or radiographic evidence of distant metastases

cM0(i+)

No clinical or radiographic evidence of distant metastases, but deposits of molecularly or microscopically detected tumor cells in circulating blood, bone marrow, or other nonregional nodal tissue that are ≤ 0.2 mm in a patient without symptoms or signs of metastases

M1

Distant detectable metastases as determined by classic clinical and radiographic means &/or histologically proven > 0.2 mm

Χαρακτηριστικά Επέκτασης

Primary route of dissemination is via axillary lymphatics

• Reported incidence of axillary lymph node involvement in patients with DCIS with microinvasion averages ≤ 5%
• Lymph node involvement is correlated with tumor size

Other routes of spread

• Supraclavicular node
• Direct tumor extension through chest wall

Common sites of metastasis include

• Bone, Lung, Liver

Lobular carcinoma

• More likely than ductal Ca to spread to abdomen
  • Peritoneum
  • Retroperitoneum
  • Gastrointestinal tract
  • Ovaries
  • Uterus
• Less likely to metastasize to pleura and lungs

Κατηγοριοποίηση (Ιστολογικοί Τύποι)

Ductal carcinoma traditionally classified according to architectural pattern

• Comedo
• Cribriform
• Micropapillary
• Papillary
• Solid

Grade classification

• Reflects potential of lesion to recur within breast or to progress to invasive breast cancer
  • Low grade
  • Intermediate grade
  • High grade

• Architectural and cytologic features
  • Well differentiated (grade 1)
    • Infiltration of stroma as solid nests of glands
    • Nuclei are relatively uniform with little or no evidence of mitotic activity
  • Moderately differentiated (grade 2)
    • Infiltration as solid nests with some glandular differentiation
    • Nuclear pleomorphism and moderate mitotic rate
  • Poorly differentiated (grade 3)
    • Composed of solid nests of neoplastic cells without evidence of gland formation
      • Marked nuclear atypia and considerable mitotic activity