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Version 2.2010 03/16/2010 © 2010 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

Guidelines IndexBreast Cancer TOC

Staging, Discussion, ReferencesPractice Guidelinesin Oncology – V.2.2010NCCN ®

TXT0TisTis (DCIS)Tis (LCIS)

T1

T2

T3T4

Regional Lymph Nodes (N)ClinicalNX

N0N1N2

N3

Table 1American Joint Committee on Cancer (AJCC)TNM Staging System For Breast CancerPrimary Tumor (T)Definitions for classifying the primary tumor (T) are the same for clinicaland for pathologic classification. If the measurement is made by thephysical examination, the examiner will use the major headings (T1, T2, orT3). If other measurements, such as mammographic or pathologicmeasurements, are used, the subsets of T1 can be used. Tumors shouldbe measured to the nearest 0.1 cm increment.

Primary tumor cannot be assessedNo evidence of primary tumorCarcinoma in situDuctal carcinoma in situLobular carcinoma in situ

Tis (Paget's) Paget's disease of the nipple with no tumorNote: Paget's disease associated with a tumor is classified according to thesize of the tumor.

T1micT1a

T1b

Tumor 2 cm or less in greatest dimensionMicroinvasion 0.1 cm or less in greatest dimensionTumor more than 0.1 cm but not more than 0.5 cm ingreatest dimensionTumor more than 0.5 cm but not more than 1 cm in greatestdimension

T1c

T4a

Tumor more than 1 cm but not more than 2 cm in greatestdimensionTumor more than 2 cm but not more than 5 cm in greatestdimensionTumor more than 5 cm in greatest dimensionTumor of any size with direct extension to (a) chest wall or(b) skin, only as described belowExtension to chest wall, not including pectoralis muscle

T4b

T4cT4d

Edema (including peau d'orange) or ulceration of the skin ofthe breast, or satellite skin nodules confined to the samebreastBoth T4a and T4bInflammatory carcinoma

Regional lymph nodes cannot be assessed (e.g., previouslyremoved)No regional lymph node metastasisMetastasis to movable ipsilateral axillary lymph node(s)Metastases in ipsilateral axillary lymph nodes fixed ormatted, or in clinically apparent* ipsilateral internalmammary nodes in the absence of clinically evident axillarylymph node metastasis

N2a Metastases in ipsilateral axillary lymph nodes fixed to oneanother (matted) or to other structures

N2b Metastasis only in clinically apparent* ipsilateral internalmammary nodes and in the absence of clinically evidentaxillary lymph node metastasis

Metastasis in ipsilateral infraclavicular lymph node(s) withor without axillary lymph node involvement, or in clinicallyapparent* ipsilateral internal mammary lymph node(s) andin the presence of clinically evident axillary lymph nodemetastasis; or metastasis in ipsilateral supraclavicularlymph node(s) with or without axillary or internal mammarylymph node involvement

Staging

ST-1

N3a Metastasis in ipsilateral infraclavicular lymph node(s)

N3b Metastasis in ipsilateral internal mammary lymph node(s)and axillary lymph node(s)

N3c Metastasis in ipsilateral supraclavicular lymph node(s)*Clinically apparent is defined as detected by imaging studies (excludinglymphoscintigraphy) or by clinical examination or grossly visiblepathologically.

Staging continued on next page (ST-2)

Breast Cancer

RT-PCR: reverse transcriptase/polymerase chain reaction.

Classification is based on axillary lymph node dissection with or without

Pathologic (pN)




Table 1 (continued)a

pNX

pN0

pN1

pN2

pN3

Regional lymph nodes cannot be assessed (e.g., previouslyremoved, or not removed for pathologic study)No regional lymph node metastasis histologically, noadditional examination for isolated tumor cells (ITC)

Note: Isolated tumor cells (ITC) are defined as single tumor cells or smallcell clusters not greater than 0.2 mm, usually detected only byimmonohistochemical (IHC) or molecular methods but which may beverified on H&E stains. ITCs do not usually show evidence of malignantactivity e.g., proliferation or stromal reaction.

pN0(i-)

pN0(i+)

pN0(mol-)

Metastasis in 1 to 3 axillary lymph nodes, and/or in internal

pN1mi

pN1apN1b

pN1c

nodes, the internal mammary nodes are classified as pN3bto reflect increased tumor burden)

axillary lymph node metastasispN2a

pN2b

pN3a

pN3b

pN3c Metastasis in ipsilateral supraclavicular lymph nodes

No regional lymph node metastasis histologically, negativeIHCNo regional lymph node metastasis histologically, positiveIHC, no IHC cluster greater than 0.2 mmNo regional lymph node metastasis histologically, negativemolecular findings (RT-PCR)b

pN0(mol+) No regional lymph node metastasis histologically, positivemolecular findings (RT-PCR)b

a

sentinel lymph node dissection. Classification based solely on sentinellymph node dissection without subsequent axillary node dissection isdesignated (sn) for “sentinel node,” e.g., pN0(i+) (sn).b

mammary nodes with microscopic disease detected bysentinel lymph node dissection but not clinically apparent**Micrometastasis (greater than 0.2 mm, none greater than2.0 mm)Metastasis in 1 to 3 axillary lymph nodesMetastasis in internal mammary nodes with microscopic

Metastasis in 1 to 3 axillary lymph nodes and in internalmammary nodes with microscopic disease detected bysentinel lymph node dissection but not clinically apparent.**(If associated with greater than 3 positive axillary lymph

Metastasis in 4 to 9 axillary lymph nodes, or in clinicallyapparent* internal mammary lymph nodes in the absence of

Metastasis in 4 to 9 axillary lymph nodes (at least one tumordeposit greater than 2.0 mm)

Metastasis in clinically apparent* internal mammary lymphnodes in the absence of axillary lymph node metastasisMetastasis in 10 or more axillary lymph nodes, or ininfraclavicular lymph nodes, or in clinically apparent*ipsilateral internal mammary lymph nodes in the presenceof 1 or more positive axillary lymph nodes; or in more than 3axillary lymph nodes with clinically negative microscopicmetastasis in internal mammary lymph nodes; or inipsilateral supraclavicular lymph nodesMetastasis in 10 or more axillary lymph nodes (at least onetumor deposit greater than 2.0 mm), or metastasis to theinfraclavicular lymph nodes

Metastasis in clinically apparent* ipsilateral internalmammary lymph nodes in the presence of 1 or morepositive axillary lymph nodes; or in more than 3 axillarylymph nodes and in internal mammary lymph nodes withmicroscopic disease detected by sentinel lymph nodedissection but not clinically apparent**

* Clinically apparent is defined as detected by imaging studies (excludinglymphoscintigraphy) or by clinical examination.

** Not clinically apparent is defined as not detected by imaging studies(excluding lymphoscintigraphy) or by clinical examination.

ST-2

disease detected by sentinel lymph node dissection but notclinically apparent**

Staging continued on next page (ST-3)

Breast Cancer

Elston CW, Ellis IO. Pathological prognostic factors in breast cancer. I. The




Table 1 (continued)Distant Metastasis (M)MXM0M1

STAGE GROUPING

Distant metastasis cannot be assessedNo distant metastasisDistant metastasis

HISTOPATHOLOGIC TYPEThe histopathologic types are thefollowing:In situ CarcinomasNOS (not otherwise specified)IntraductalPaget's disease and intraductalInvasive CarcinomasNOSDuctalInflammatoryMedullary, NOS

Medullary with lymphoid stromaMucinousPapillary (predominantlymicropapillary pattern)TubularLobularPaget's disease and infiltratingUndifferentiatedSquamous cellAdenoid cysticSecretoryCribriform

Stage 0Stage IStage IIA

Stage IIB

Stage IIIB

Stage IV

Tis

T1*T0

N0N0N1

M0M0M0

T1* N1 M0N0N1

M0M0

T2T2

N0T3 M0N2N2N2N1N2

M0M0M0M0M0

Stage IIIA T0T1*T2T3T3

* T1 includes T1mic

M0M0M0

T4 N0T4 N1T4 N2

Stage IIIC Any T N3 M0Any T Any N M1

Note: Stage designation may bechanged if post-surgical imagingstudies reveal the presence of distantmetastases, provided that the studiesare carried out within 4 months ofdiagnosis in the absence of diseaseprogression and provided that thepatient has not received neoadjuvanttherapy.

HISTOPATHOLOGIC GRADE (G)All invasive breast carcinomas with the exception of medullary carcinoma

for all three categories. A combined score of 3-5 points is grade 1; a combined

Fitzgibbons PL, Page DL, Weaver D et al. Prognostic factors in breast cancer.College of American Pathologists consensus statement 1999. Arch Pathol LabMed 2000;124:966-978.

HISTOLOGIC GRADE (NOTTINGHAM COMBINED HISTOLOGIC GRADE ISRECOMMENDED)GX Grade cannot be assessedG1 Low combined histologic grade (favorable)G2 Intermediate combined histologic grade (moderately favorable)G3 High combined histologic grade (unfavorable)

should be graded. The Nottingham combined histologic grade (Elston-Ellismodification of Scarff-Bloom-Richardson grading system) is recommended.1,2

The grade for a tumor is determined by assessing morphologic features (tubuleformation, nuclear pleomorphism, and mitotic count), assigning a value of 1(favorable) to 3 (unfavorable) for each feature, and adding together the scores

score of 6-7 points is grade 2; a combined score of 8-9 points is grade 3.1

value of histologic grade in breast cancer: experience from a large study withlong-term follow-up. Histopatholology 1991;19:403-410.2.

Used with the permission of the American Joint Committee on Cancer (AJCC),Chicago, Illinois. The original and primary source for this information is theAJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York. (For more information, visit www.cancerstaging.net.) Anycitation or quotation of this material must be credited to the AJCC as its primarysource. The inclusion of this information herein does not authorize any reuse orfurther distribution without the expressed, written permission of Springer-VerlagNew York, Inc., on behalf of the AJCC.

ST-3

Breast Cancer

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