1. AJCC Staging Moments AJCC TNM Staging 7th Edition Breast Case #1 Contributors: Stephen B. Edge, MD Roswell Park Cancer Institute, Buffalo, New York David R. Byrd, MD University of Washington Medical Center, Seattle, Washington David J. Winchester, MD NorthShore University Evanston Hospital, Evanston, Illinois David P. Winchester, MD NorthShore University Evanston Hospital, Evanston, Illinois

2. Breast Case # 1 Presentation of New Case Newly diagnosed breast cancer patient Presentation at Cancer Conference for treatment recommendations and clinical staging

3. Breast Case # 1 History & 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)

4. Breast Case # 1 Imaging Results Mammogram-0.5cm area of microcalcifications in central left breast mid depth Suspicious by magnification and spot compression views Stereotactic core needle biopsy recommended No further imaging performed Used with permission. Washington University School of Medicine ML view: magnification mammogram

5. Breast Case # 1 Diagnostic 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

6. Breast Case # 1 Clinical Staging Clinical staging –Uses information from the physical exam, imaging, and diagnostic biopsy Purpose –Select appropriate treatment –Estimate prognosis

7. Breast Case # 1 Clinical 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______

8. Breast Case # 1 Clinical Staging Clinical Stage correct answer –Tis –N0 –M0 –Stage Group 0 Based on stage, treatment is selected Review NCCN treatment guidelines for this stage

10. Prognostic Factors Clinically 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

11. Breast Case # 1 Surgery & 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

12. Breast Case # 1 Pathology 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

13. Breast Case # 1 Pathologic 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)

14. Breast Case # 1 Pathologic 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______

15. Breast Case # 1 Pathologic Staging Pathologic Stage correct answer –pT1mi (6 th Ed T1mic, designation changed in 7 th Ed) –pNx –cM0 –Stage Group unknown Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected

16. Breast Case # 1 Pathologic 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

17. Prognostic Factors Clinically 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

18. AJCC Cancer Staging Atlas T1mi is microinvasion 0.1cm (1mm) or less in greatest dimension Multiple simultaneous tumors should be indicated by (m) or the number of tumors (3)

19. Breast Case # 1 Recap 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 different purpose and therefore can be different. Do not go back and change the clinical staging based on pathologic staging information.

20. 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)