Breast Cancer Staging
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The tumor-node-metastasis (TNM) classification for staging of breast cancer is provided below. [1, 2]
Table. TNM Classification for Breast Cancer (Open Table in a new window)
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
Tis (DCIS)
Ductal carcinoma in situ
Tis (Paget)
Paget disease of the nipple NOT associated with invasive carcinoma and/or carcinoma in situ (DCIS) in the underlying breast parenchyma. Carcinomas in the breast parenchyma associated with Paget disease are categorized on the basis of 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 (round any measurement >1.0-1.9 mm to 2 mm)
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 and/or to the skin (ulceration or skin nodules), not including invasion of dermis alone
T4a
Extension to chest wall, not including only pectoralis muscle adherence/invasion
T4b
Ulceration and/or ipsilateral satellite nodules and/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
Regional lymph nodes (N)
Clinical
cNX
Regional lymph nodes cannot be assessed (eg, previously removed)
cN0
No regional lymph node metastasis (on imaging or clinical examination)
cN1
Metastasis to movable ipsilateral level I, II axillary lymph node(s)
cN1mi
Micrometastases (approximately 200 cells, larger than 0.2 mm, but none larger than 2.0 mm)
cN2
Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted; or in ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases
cN2a
Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures
cN2b
Metastases only in ipsilateral internal mammary nodes and in the absence of axillary lymph node metastases
cN3
Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s), with or without level I, II axillary node involvement, or in ipsilateral internal mammary lymph node(s) with level I, II axillary lymph node metastasis; or metastases in ipsilateral supraclavicular lymph node(s), with or without axillary or internal mammary lymph node involvement
cN3a
Metastasis in ipsilateral infraclavicular lymph node(s)
cN3b
Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)
cN3c
Metastasis in ipsilateral supraclavicular lymph node(s)
Note: (sn) and (f) suffixes should be added to the N category to denote confirmation of metastasis by sentinel node biopsy or fine needle aspiration/core needle biopsy, respectively.
Pathologic (pN)
pNX
Regional lymph nodes cannot be assessed (for example, previously removed, or not removed for pathologic study)
pN0
No regional lymph node metastasis identified histologically, or isolated tumor cell clusters (ITCs) only. Note: ITCs are defined as small clusters of cells ≤ 0.2 mm, or single tumor cells, or a cluster of < 200 cells in a single histologic cross-section; ITCs may be detected by routine histology or by immunohistochemical (IHC) 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
pN0(i)
No regional lymph node metastases histologically, negative IHC
pN0(i+)
pN0(mol-)
No regional lymph node metastases histologically, negative molecular findings (reverse transcriptase polymerase chain reaction [RT-PCR])
pN0(mol+)
Positive molecular findings by RT-PCR; no ITCs detected
pN1
Micrometastases; or metastases in 1-3 axillary lymph nodes and/or in internal mammary nodes; and/or in clinically negative internal mammary nodes with micrometastases or macrometastases by sentinel lymph node biopsy
pN1mi
Micrometastases (200 cells, > 0.2 mm but none > 2.0 mm)
pN1a
Metastases in 1-3 axillary lymph nodes (at least 1 metastasis > 2.0 mm)
pN1b
Metastases in ipsilateral internal mammary lymph nodes, excluding ITCs, detected by sentinel lymph node biopsy
pN1c
Metastases in 1-3 axillary lymph nodes and in internal mammary sentinel nodes (ie, pN1a and pN1b combined)
pN2
Metastases in 4-9 axillary lymph nodes; or positive ipsilateral internal mammary lymph nodes by imaging in the absence of axillary lymph node metastases
pN2a
Metastases in 4-9 axillary lymph nodes (at least 1 tumor deposit > 2.0 mm)
pN2b
Clinically detected* metastases in internal mammary lymph nodes with or without microscopic confirmation; with pathologically negative axillary lymph nodes
pN3
Metastases in ≥ 10 axillary lymph nodes; or in infraclavicular (level III axillary) lymph nodes; or positive ipsilateral internal mammary lymph nodes by imaging in the presence of one or more positive level I, II axillary lymph nodes; or in > 3 axillary lymph nodes and micrometastases or macrometastases by sentinel lymph node biopsy in clinically negative ipsilateral internal mammary lymph nodes; or in ipsilateral supraclavicular lymph nodes
pN3a
Metastases in ≥ 10 axillary lymph nodes (at least 1 tumor deposit > 2.0 mm); or metastases to the infraclavicular (level III axillary lymph) nodes
pN3b
pN1a or pN2a in the presence of cN2b (positive internal mammary nodes by imaging) or pN2a in the presence of pN1b
pN3c
Metastases in ipsilateral supraclavicular lymph nodes
*”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 on the basis of FNA biopsy with cytologic examination.
Distant metastasis (M)
M0
No clinical or radiographic evidence of distant metastasis
cM0(i+)
No clinical or radiographic evidence of distant metastases in the presence of tumor cells or deposits no larger than 0.2 mm detected microscopically or by molecular techniques in circulating blood, bone marrow, or other nonregional nodal tissue in a patient without symptoms or signs of metastase
cM1
Distant metastases detected by clinical and radiographic means
pM1
Any histologically proven metastases in distant organs; or if in non-regional nodes, metastases > 0.2 mm
Table. Histologic grade (Open Table in a new window)
Histologic grade (G)
GX
Grade cannot be assessed
G1
Low combined histologic grade (favorable)
G2
Intermediate combined histologic grade (moderately favorable)
G3
High combined histologic grade (unfavorable)
Table. Anatomic stage/prognostic groups (Open Table in a new window)
Stage
T
N
M
0
Tis
N0
M0
IA
T1
N0
M0
IB
T0
N1mi
M0
T1
N1mi
M0
IIA
T0
N1
M0
T1
N1
M0
T2
N0
M0
IIB
T2
N1
M0
T3
N0
M0
IIIA
T0
N2
M0
T1
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:
[Guideline] NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. V 1.2016. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Version 3.2018 — October 25, 2018; Accessed: December 7, 2018.
American Joint Committee on Cancer. Breast. Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, et al, eds. AJCC Cancer Staging Manual. 8th edition. New York, NY: Springer; 2017.
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
Tis (DCIS)
Ductal carcinoma in situ
Tis (Paget)
Paget disease of the nipple NOT associated with invasive carcinoma and/or carcinoma in situ (DCIS) in the underlying breast parenchyma. Carcinomas in the breast parenchyma associated with Paget disease are categorized on the basis of 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 (round any measurement >1.0-1.9 mm to 2 mm)
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 and/or to the skin (ulceration or skin nodules), not including invasion of dermis alone
T4a
Extension to chest wall, not including only pectoralis muscle adherence/invasion
T4b
Ulceration and/or ipsilateral satellite nodules and/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
Regional lymph nodes (N)
Clinical
cNX
Regional lymph nodes cannot be assessed (eg, previously removed)
cN0
No regional lymph node metastasis (on imaging or clinical examination)
cN1
Metastasis to movable ipsilateral level I, II axillary lymph node(s)
cN1mi
Micrometastases (approximately 200 cells, larger than 0.2 mm, but none larger than 2.0 mm)
cN2
Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted; or in ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases
cN2a
Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures
cN2b
Metastases only in ipsilateral internal mammary nodes and in the absence of axillary lymph node metastases
cN3
Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s), with or without level I, II axillary node involvement, or in ipsilateral internal mammary lymph node(s) with level I, II axillary lymph node metastasis; or metastases in ipsilateral supraclavicular lymph node(s), with or without axillary or internal mammary lymph node involvement
cN3a
Metastasis in ipsilateral infraclavicular lymph node(s)
cN3b
Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)
cN3c
Metastasis in ipsilateral supraclavicular lymph node(s)
Note: (sn) and (f) suffixes should be added to the N category to denote confirmation of metastasis by sentinel node biopsy or fine needle aspiration/core needle biopsy, respectively.
Pathologic (pN)
pNX
Regional lymph nodes cannot be assessed (for example, previously removed, or not removed for pathologic study)
pN0
No regional lymph node metastasis identified histologically, or isolated tumor cell clusters (ITCs) only. Note: ITCs are defined as small clusters of cells ≤ 0.2 mm, or single tumor cells, or a cluster of < 200 cells in a single histologic cross-section; ITCs may be detected by routine histology or by immunohistochemical (IHC) 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
pN0(i)
No regional lymph node metastases histologically, negative IHC
pN0(i+)
pN0(mol-)
No regional lymph node metastases histologically, negative molecular findings (reverse transcriptase polymerase chain reaction [RT-PCR])
pN0(mol+)
Positive molecular findings by RT-PCR; no ITCs detected
pN1
Micrometastases; or metastases in 1-3 axillary lymph nodes and/or in internal mammary nodes; and/or in clinically negative internal mammary nodes with micrometastases or macrometastases by sentinel lymph node biopsy
pN1mi
Micrometastases (200 cells, > 0.2 mm but none > 2.0 mm)
pN1a
Metastases in 1-3 axillary lymph nodes (at least 1 metastasis > 2.0 mm)
pN1b
Metastases in ipsilateral internal mammary lymph nodes, excluding ITCs, detected by sentinel lymph node biopsy
pN1c
Metastases in 1-3 axillary lymph nodes and in internal mammary sentinel nodes (ie, pN1a and pN1b combined)
pN2
Metastases in 4-9 axillary lymph nodes; or positive ipsilateral internal mammary lymph nodes by imaging in the absence of axillary lymph node metastases
pN2a
Metastases in 4-9 axillary lymph nodes (at least 1 tumor deposit > 2.0 mm)
pN2b
Clinically detected* metastases in internal mammary lymph nodes with or without microscopic confirmation; with pathologically negative axillary lymph nodes
pN3
Metastases in ≥ 10 axillary lymph nodes; or in infraclavicular (level III axillary) lymph nodes; or positive ipsilateral internal mammary lymph nodes by imaging in the presence of one or more positive level I, II axillary lymph nodes; or in > 3 axillary lymph nodes and micrometastases or macrometastases by sentinel lymph node biopsy in clinically negative ipsilateral internal mammary lymph nodes; or in ipsilateral supraclavicular lymph nodes
pN3a
Metastases in ≥ 10 axillary lymph nodes (at least 1 tumor deposit > 2.0 mm); or metastases to the infraclavicular (level III axillary lymph) nodes
pN3b
pN1a or pN2a in the presence of cN2b (positive internal mammary nodes by imaging) or pN2a in the presence of pN1b
pN3c
Metastases in ipsilateral supraclavicular lymph nodes
*”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 on the basis of FNA biopsy with cytologic examination.
Distant metastasis (M)
M0
No clinical or radiographic evidence of distant metastasis
cM0(i+)
No clinical or radiographic evidence of distant metastases in the presence of tumor cells or deposits no larger than 0.2 mm detected microscopically or by molecular techniques in circulating blood, bone marrow, or other nonregional nodal tissue in a patient without symptoms or signs of metastase
cM1
Distant metastases detected by clinical and radiographic means
pM1
Any histologically proven metastases in distant organs; or if in non-regional nodes, metastases > 0.2 mm
Histologic grade (G)
GX
Grade cannot be assessed
G1
Low combined histologic grade (favorable)
G2
Intermediate combined histologic grade (moderately favorable)
G3
High combined histologic grade (unfavorable)
Stage
T
N
M
0
Tis
N0
M0
IA
T1
N0
M0
IB
T0
N1mi
M0
T1
N1mi
M0
IIA
T0
N1
M0
T1
N1
M0
T2
N0
M0
IIB
T2
N1
M0
T3
N0
M0
IIIA
T0
N2
M0
T1
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
Joseph A Sparano, MD Professor, Department of Medicine (Oncology), Professor, Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine; Associate Chairman for Clinical Research, Department of Oncology, Montefiore Medical Center; Associate Director for Clinical Research, Albert Einstein Cancer Center
Joseph A Sparano, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Christopher D Braden, DO Hematologist/Oncologist, Chancellor Center for Oncology at Deaconess Hospital; Medical Director, Deaconess Hospital Outpatient Infusion Centers; Chairman, Deaconess Hospital Cancer Committee
Christopher D Braden, DO is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology
Disclosure: Nothing to disclose.
Marie Catherine Lee, MD, FACS Associate Professor, Department of Oncologic Sciences, Department of Surgery (Joint Appointment), University of South Florida Morsani College of Medicine; Associate Member, Comprehensive Breast Program, Moffitt McKinley Outpatient Center
Marie Catherine Lee, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Clinical Oncology, Association for Academic Surgery, Association of Women Surgeons, Florida Society of Clinical Oncology, Society of Surgical Oncology, Society of University Surgeons
Disclosure: Received research grant from: National Cancer Institute/National Institutes of Health; Department of Defense.
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