Breast Cancer Staging
Anatomy and Breast Cancer Staging. (2018). Plichta, J et al.
Take Aways:
- anatomic staging for breast cancer gives prognostic information
- prognostic staging for breast cancer includes both anatomic factors and tumor-specific factors (receptor status and genomic profiles)
- including tumor biology into new staging system will improve further discrimination of prognosis between tumor stages
----
Traditional Staging System
- UICC (international union against cancer) created the TNM system
> T: Tumor
> N: Nodes
> M: Metastasis
- adopted by the AJCC Cancer Staging Manual
Now there are 2 staging systems: the anatomic stage and prognostic stage
1. Anatomic stage
- TNM from clinical and/or pathological assessments
2. Prognostic Stage
- tumor grade
- receptor status (ER, PR, HER2 status)
- tumor multigene panel testing (oncotype Dx, Genomic Health, etc)
NCCN guidelines for invasive breast cancer staging workup needs:
- H&P
- diagnostic b/l mammogram
- pathologic assessment review
- receptor status (ER/PR/HER2)
- breast MRI (optional)
No consensus on routine use of breast MRI or staging axillary US.
Other studies to consider checking: CBC, CMP, CT abd/pelvis or MRI W, CT chest W, bone scan, FDG PET-CT (optional)
4 types of breast cancer staging
1. clinical staging (denoted with cTNM). Includes PE, imaging, bx of areas
2. pathlogic staging (denoted with pTNM). s/p surgery for tumor and lymph nodes.
3. post tx or post neoadjuvant chemo staging (denoted with yTNM). determines how much cancer remains after preop tx.
4. restaging (denoted with rTNM). if cancer returns after tx and shows extent of disease recurence
On the N category - use "p" and "c" similarly. Also has "sn" for lymph nodes evaluated by sentinal LN bx or "f" for FNA or core needle bx.
- if complete pathologic response (pCR), document initial clinical staging info and pCR
Histologic Grading
- use Nottingham modification of the Scarff-Bloom-Richardson grading system
- three morphologic features: tubule formation, nuclear pleomorphim, mitotic count
- each feature from 1-3 with summation for category
Grade 1 (low): 3-5 points
Grade 2 (intermediate): 6-7 points
Grade 3 (high): 8-9 points
This article includes many key references with their select highlights in the history of breast cancer staging as well.
Ex: larger tumor size is associated with decreased survival, increased recurrence rates, and increased likelihood of + axillary nodes. ER/PR + is associated with increased time to recurrence and improved OS. HER2 gene amplificiation is a stronger discriminant than tumor size. etc.
Biomarkers
- tumor biomarkers were first recognized as prognostic indicators in 1977 by McGuire et al with ER/PR
- Now we are looking at multi gene panel testing like Oncotype Dx.
- the MINDACT trial reported early stage breast cancer + low genomic risk but high clinical risk had a similar 5y survival rate regardless of chemo. Similar for other discordant (high genomic risk but low clinical risk). This suggest chemo may not be beneficial for discordant clinical/genomic risks. Thus, downstage selected tumors in the future.
Thus, including biomarkers into staging will up/downstage large patient population groups.
Take Aways:
- anatomic staging for breast cancer gives prognostic information
- prognostic staging for breast cancer includes both anatomic factors and tumor-specific factors (receptor status and genomic profiles)
- including tumor biology into new staging system will improve further discrimination of prognosis between tumor stages
----
Traditional Staging System
- UICC (international union against cancer) created the TNM system
> T: Tumor
> N: Nodes
> M: Metastasis
- adopted by the AJCC Cancer Staging Manual
Now there are 2 staging systems: the anatomic stage and prognostic stage
1. Anatomic stage
- TNM from clinical and/or pathological assessments
2. Prognostic Stage
- tumor grade
- receptor status (ER, PR, HER2 status)
- tumor multigene panel testing (oncotype Dx, Genomic Health, etc)
NCCN guidelines for invasive breast cancer staging workup needs:
- H&P
- diagnostic b/l mammogram
- pathologic assessment review
- receptor status (ER/PR/HER2)
- breast MRI (optional)
No consensus on routine use of breast MRI or staging axillary US.
Other studies to consider checking: CBC, CMP, CT abd/pelvis or MRI W, CT chest W, bone scan, FDG PET-CT (optional)
4 types of breast cancer staging
1. clinical staging (denoted with cTNM). Includes PE, imaging, bx of areas
2. pathlogic staging (denoted with pTNM). s/p surgery for tumor and lymph nodes.
3. post tx or post neoadjuvant chemo staging (denoted with yTNM). determines how much cancer remains after preop tx.
4. restaging (denoted with rTNM). if cancer returns after tx and shows extent of disease recurence
On the N category - use "p" and "c" similarly. Also has "sn" for lymph nodes evaluated by sentinal LN bx or "f" for FNA or core needle bx.
- if complete pathologic response (pCR), document initial clinical staging info and pCR
Histologic Grading
- use Nottingham modification of the Scarff-Bloom-Richardson grading system
- three morphologic features: tubule formation, nuclear pleomorphim, mitotic count
- each feature from 1-3 with summation for category
Grade 1 (low): 3-5 points
Grade 2 (intermediate): 6-7 points
Grade 3 (high): 8-9 points
This article includes many key references with their select highlights in the history of breast cancer staging as well.
Ex: larger tumor size is associated with decreased survival, increased recurrence rates, and increased likelihood of + axillary nodes. ER/PR + is associated with increased time to recurrence and improved OS. HER2 gene amplificiation is a stronger discriminant than tumor size. etc.
Biomarkers
- tumor biomarkers were first recognized as prognostic indicators in 1977 by McGuire et al with ER/PR
- Now we are looking at multi gene panel testing like Oncotype Dx.
- the MINDACT trial reported early stage breast cancer + low genomic risk but high clinical risk had a similar 5y survival rate regardless of chemo. Similar for other discordant (high genomic risk but low clinical risk). This suggest chemo may not be beneficial for discordant clinical/genomic risks. Thus, downstage selected tumors in the future.
Thus, including biomarkers into staging will up/downstage large patient population groups.
Comments
Post a Comment