staging help please.

Anonymous

staging help please.

gile987

I need help please. My sister is 32yrs old. she had 2 tumors. Very small 4mm and 5mm but unfortunately spread to lymph nodes (11 removed 3 were positiv) she is Her negative. She has Ki-67 - 10%. So my question is what stage is it? BTW She had surgery and now going thru chemo.

Maryjo000

sounds like stage 1b to me

Kathy044

Sounds like 2a to me but then I was never given my exact number just told I was early stage and I figured it out myself by reading the guidelines.

http://www.breastcancer.org/symptoms/diagnosis/staging

Kathy

gile987

hey, thanks for reply. You can stage I can be with 3 positiv nodes? Even tummor was only 5mm?

exbrnxgrl

What do her doctors say regarding staging

gile987

in my country there is not really about staging. The only important thing is size of tumors and does lymp nodes are positiv or not. This is why i need help here. Thank

Ridley

Gile - while staging still seems to be used re survival stats, I don't think they are that important re treatment. I think the genetic and hormonal characteristics of the Tumorsalong with information of spread (eg lymph nodes) are the important considerations. You noted she is her-, what are her ER and PR characteristics. If ER is +, has she talked to her oncologist about an oncotype test?

gile987

er 8 (70%), pr 6 (20%), Her2 1+ , ki 67 - 10%

This is all what we know

Anonymous

Based on guidelines, your sister is Stage IIa. But I agree with Ridley. Stage isn't as important as lymph node involvement and pathology/oncotype. I saw three doctors who just told me I was 'early stage' until I asked specifically what it was. Since your sister already started chemo, oncotype isn't necessary anymore unless you just want to know for your own information. I wish your sister the best in her treatments.

gile987

Thanks! She already had 3 rounds of chemo ( 1 more left). What is oncotype test? Do i have to ask her doctor for this or this is somewhere wroten in her papers?

Thanks a lot and also i wish good health

BarredOwl

Hi gile987:

She does not need an Oncotype test at this point.

If it was done, she should have received an "Oncotype Recurrence Score".

When it is used, the test is done before chemotherapy and can be used to help make the decision about chemotherapy. (It is ~$4,000.) It is optional for node-positive disease, and is not required.

In the US, in general, we usually follow the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of breast cancer. With hormone-receptor positive, HER2-negative disease that is T1 (size), node positive, M0 (no evidence of distant metastasis), the decision of whether or not to receive chemotherapy can properly be made on the basis of clinicopathologic features alone, and the Oncotype test is not required.

BarredOwl

[EDIT: Revised for clarity. See first two sentences.]

BarredOwl

Hi gile987:

Here is some good information about "TNM" system breast cancer staging typically used in the U.S. for your information:

https://cancerstaging.org/references-tools/quickre...

T = tumor size

N = node status

M = whether there clinical or radiographic evidence of distant metastases

A person who is "T1N1M0" would be Stage IIA (if N1, but not N1mi). See line 6 of the chart "ANATOMIC STAGE/PROGNOSTIC GROUPS."

To be "T1N1M0", the following must be true:

T1 Tumor ≤ 20 mm in greatest dimension

pN1 Micrometastases; or metastases in 1–3 axillary lymph nodes; and/or in internal mammary nodes with metastases detected by sentinel lymph node biopsy but not clinically detected***

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

M0 No clinical or radiographic evidence of distant metastases

EDITED to add "(if N1, but not N1mi)" above and text below:

HOWEVER, the two asterisks (**) in the chart at line 6 (T1**) and the accompanying Note (**) at right state that "T1 tumors with nodal micrometastases only are excluded from Stage IIA and are classified Stage IB" (see line 4 of the chart (T1 N1mi M0 = Stage IB).

pN1mi = Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none greater than 2.0 mm)

BarredOwl

BarredOwl

Hi gile987:

I revised my two posts. Please re-read them.

BarredOwl

gile987

thank you so much! Well, we know everything except how much tumor cells on lymp nodes. All we know is 3 nodes were positiv ( 13 removed). We hope tumors cells were very smal because primary tumor in breast was only 4mm.

Best regards and thanks once again

stotamom

So I have a question I hope someone can answer - my staging looks like this pT1c(m)N1A. I had 1/1 nodes removed and it was macromets.

BarredOwl

Hi stotamom:

What is your exact question?

I note your profile says Stage IIA with a 4 cm tumor.

T1c = Tumor > 10 mm but ≤ 20 mm in greatest dimension

T2 = Tumor > 20 mm but ≤ 50 mm in greatest dimension (<= This includes 4 cm)

What was the actual size of the tumor in largest dimension, determined by surgical pathology in centimeters?

What did your doctor say about your stage? Assuming M0, did they say Stage IIA or Stage IIB?

BarredOwl

stotamom

On my path report it states my first and largest tumor to be 1.7 x 1.3 x1cm my second tumor was 0.8 x 0.5 x 0.5cm. My lymph states that the largest metastatic deposit is 6mm. I guess What I am wondering is if I am a clear cut stage IIA. Thanks BarredOwl, it's all so confusing.

BarredOwl

Hi stotamom:

Here again is a link to the summary and chart based on the 7th edition of the AJCC manual:

https://cancerstaging.org/references-tools/quickre...

The chart and two-page summary is a quick reference only. The underlying reference source is actually full-length manual on the subject (Atlas, Manual, and Pocket Handbook) found here:

https://cancerstaging.org/references-tools/deskref...

I do not have access to the manual or any medical training.

Assuming that you are "M0" (no evidence of metastasis), and if the 4 centimeter size in your profile is an error, I think it is possible that you are Stage IIA. However, to be certain, please confirm it with your MO.

Your profile indicates "Paget's". According to this article,"Paget disease associated with carcinoma in the breast parenchyma should be categorized on the basis of parenchymal disease, although the presence of Paget disease should still be noted."

http://pubs.rsna.org/doi/pdf/10.1148/rg.342135071 (includes clinical photograph)

I believe that means that staging is based on the disease in the breast.

You also said you were: "pT1c(m)N1A".

- The designation "(m)" is not on the little summary chart.

- There is no "N1A", although there is "N1a".

This article discusses some of the changes that came in with the 7th edition of the staging manual and associated pitfalls. According to this paper, the code "m" is used to indicate "multiple" tumors:

http://labmed.ucsf.edu/uploads/210/101_new_ajcc_st...

"Definition of multiple synchronous carcinomas and pT: Occasionally multiple primary carcinomas may be found in one breast specimen (i.e. multiple simultaneous/synchronous ipsilateral primary carcinomas). AJCC defines multiple cancers as those that are grossly or macroscopically distinct. AJCC defines 0.5 cm as the minimum distance required between two macroscopic cancer foci to call them multiple cancers; anything closer than 0.5 cm likely represents a single cancer with a complex shape that appears multi-focal but is probably contiguous if further sampling is performed; in this case, the entire cancer dimension should be used for pT.

AJCC states that tumor size (pT) should be based only on the single largest tumor; do not add the sizes together from the multiple foci. AJCC does advise reporting in the comment of the report the total number of foci and sizes of each one. The code "m" is used to indicate "multiple" tumors. Example: if the largest of multiple tumors is 3.2 cm, the AJCC stage is pT2(m). Alternatively, AJCC states that the "m" can be replaced by the total number of invasive cancers. Example: if the largest of 3 cancers is 3.2 cm, the AJCC stage can be reported as pT2(3).

AJCC states that simultaneous bilateral primary cancers are staged separately (i.e. one pTNM generated for the right breast and another pTNM generated for the left breast).

Clinical significance of multiple tumors within the same pT category remains to be thoroughly studied. There is controversy as to whether multiple cancers may predict for involvement of axillary nodes; much of the controversy is rooted in methodologic issues in defining multiplicity in these studies (reviewed by Jain S et al. Pathology 2009; 41: 57-67). Survival does not appear to be affected by multiple synchronous breast cancers compared to unifocal breast cancer, though it appears that margin positivity may be an issue if breast conservation surgery is chosen. AJCC states that there is not enough compelling evidence to increase stage based on multiple cancers or to base pT on aggregate tumor measurement."

Subject to the accuracy and completeness of the information above (which does not appear to published or peer-reviewed), and if I am reading it correctly, the first paragraph describes when the sizes ought to be combined, because they are likely a single, larger tumor. If they do not fall under that ambit, then the single largest focus controls.

It appears as if your pathologist deemed the 1.7 x 1.3 x1 cm and second 0.8 x 0.5 x 0.5 cm tumors to be separate foci, and used the 1.7 cm (17 mm) size tumor as the largest for pT purposes, to arrive at pT1c(m):

T1c = Tumor > 10 mm but ≤ 20 mm in greatest dimension. That is a kind of "T1" size tumor.

If the pathologist was specifying "pN1a" (by listing it as "N1A"), then it is not pN1mi, the latter which requires there be no nodal metastases greater than 2.0 mm. Consistently, from your reference to "macromet" and a single involved node (1/1 nodes), where the "largest metastatic deposit is 6mm", the nodal metastasis appears to be "N1a" and not "N1mi".

pN1a = Metastases in 1–3 axillary lymph nodes, at least one metastasis greater than 2.0 mm.

Taking it together, it appears to be line 6 of the chart: T1 N1 M0 of Stage IIA, where T1 is pT1c(m) and N1 is pN1a.

However, to be certain, please confirm it with your MO.

BarredOwl

BarredOwl

gile987:

For your information, the discussion I just posted for stotamom does not change what I said to you before.

Even if the two 4mm and 5mm tumors were closer to each other than 0.5 cm, and actually represented a single tumor, I think the largest possible dimension would be 4 mm + 5 mm + ~5 mm maximum of space between, or a total of ~14 mm. So even if combined, I think it would still be T1 size (specifically T1c):

T1c = Tumor > 10 mm but ≤ 20 mm in greatest dimension

If you can ask her doctors, that would be best to be certain.

BarredOwl

stotamom

Thanks BarredOwl!! My typo on the pT1c(m)N1a. The (m) was throwing me off.

gile987

BarredOwl

Thanks! Now we just don't know size of tummors cells on lymph nodes, and as i can see it is very important. Our Doctor just said 3 nodes were positiv and nothing more.

BarredOwl

Hi stotamom:

I was also stumped by the "(m)", until I saw that article. If your node involvement was solely indicated by SNB, the following does not apply. Re nodal status, see the discussion above Jan 19, 2016 09:19AM about "not clinically detected" regarding the nodes (see also, page 2 of the chart re various N statuses). However, special circumstances like "clinically detected" might change things (might be N2)?? These facts are not usually included in profiles.

Hi gile987:

I also wanted to know my stage. But as others said, treatment decisions can be based on particular pathology findings of histology (e.g., ductal, lobular), hormone-receptor status, HER2 status, and node status (and in some cases, the optional Oncotype test discussed above).

My doctors discussed my pathology findings and provided estimates of my risk of recurrence. They did not give me stage information. I think they may see the stage as a broad category that is less relevant to treatment and recurrence risk, than individual pathology findings.

I tried to figure out the stage myself, and then I asked my surgeon for confirmation. From my notes, I didn't have the T status quite right, and so she did not confirm that it was right (nor did she tell me what the correct stage was). So I still don't have an expert determination of stage.

Best,

BarredOwl

BarredOwl

FYI,

A recent article featured in one of cp418's posts included this quote:

Related thread: https://community.breastcancer.org/forum/73/topics...

Quote: "The AJCC [i.e., the group that promulgates the AJCC TNM cancer staging manual] has increasingly recognized the growing need for more accurate and probabilistic individualized outcome prediction for precision medicine that would incorporate additional anatomic and nonanatomic prognostic factors beyond TNM."

A new 8th edition of the staging manual is expected to be published in 2016.

BarredOwl