How to determine stage

stage isn't really diagnosed until after sugeries and LN s are tested. then if you begin at three. stage wont be dx until pet scan. waiting is the hardest

Hi Mom2fourplusmore:

Staging is in the area of expertise of pathologists. Your pathology report (obtain a copy if you don't already have one) should include information about stage or at least "TNM" information such as pTN.

If your medical oncologist is unclear on the number of tumors, please request that he confer with the pathologist. Appropriate recommendations for chemotherapy, HER2-targeted therapy (for HER2-positive disease) and/or endocrine therapy based on NCCN treatment guidelines, depend on an accurate determination of actual tumor size ("T") and lymph node status ("N") under AJCC staging, as well as ER status, PR status, and HER2 status, and other factors, such as tumor grade, the presence of lymphovascular invasion in the breast, and if applicable, multiparameter test results (such as Oncotype Recurrence Score), and personal medical and family history (including age, menopausal status, co-morbidities).

This paper discusses the 7th Edition of the AJCC staging manual (which I do not have access to). It seems to indicate that whether multiple foci are considered one tumor or multiple tumors depends on the distance between them. The paper is unpublished and not peer-reviewed, and may contain errors. It should not be relied upon, but may be helpful as you prepare follow-up questions for the MO and pathologist:

http://labmed.ucsf.edu/uploads/210/101_new_ajcc_staging_of_breast_cancer_what_has_changed.pdf

"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 [added by me: when they have been determined to be separate based on distance]. 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.

Recommendation: If there is suspicion for multiple ipsilateral primary cancers, additional sampling of tissue in between the two foci should be done to confirm that there is no microscopic tumor connecting the two foci together in dimensions not represented in the initial slides. If there is microscopic invasive cancer connecting the two macroscopic foci, this should be managed as a single, unifocal cancer and measured across the entire span of all foci rather than managed as multiple foci.

Whether ER/PR/HER2 should be done on all foci of multiple cancers in a single breast is not clearly defined. A recent study of 32 patients with multicentric breast cancers found equivalent ER/PR/HER2 profiles in all tumor foci, as well as equivalent morphologic features (Middleton et al. Cancer 2002; 94: 1910-6). In general, if the morphology and grade appears similar in all of them, performing prognostic markers on the largest or two largest is reasonable; however if the morphologies or grades are distinctly different, it may be prudent to test each distinct focus."

In a less common situation, you may wish to consider seeking a second opinion regarding treatment plan from a medical oncologist at an independent institution, along with an independent expert pathology review.

BarredOwl

[EDIT: Note that the above does not apply to microinvasive tumors. See the separate section re same.]

Hi Meow13:

Stage I requires T0 or T1 (and N0 or N1mi).

T1 = Tumor ≤ 20 mm (2 cms) in greatest dimension.

https://cancerstaging.org/references-tools/quickreferences/Documents/BreastMedium.pdf

Unfortunately, your case does not make the situation any clearer, because you would be considered stage I in either case: (a) if they were considered separate tumors (largest one is 1 cm = T1); or (b) if they were considered close enough to be a single tumor and were added together (2 cm = T1). So it would be T1 in either case, with no impact on staging in your particular case.

BarredOwl

Hi Meow13:

That makes total sense, and they were clearly separate tumors in your particular case. However, had they been close enough together under AJCC criteria to be considered a single contiguous tumor (rather than multiple tumors), then the entire combined dimensions would have been used to determine "T" status: 1.0 cm + 1.0 cm = 2.0 cm, which is still Stage I, because a 2.0 cm tumor is still a "T1" tumor.

So, the question in Mom's case would be how close together are the various tumors, and are any of them close enough together to be considered a single contiguous tumor, for which the sizes should be added. If not, then it appears that they should be treated separately and not added. This is a question for the pathologist.

BarredOwl

Mom2fourplusmore:

Are there 4 or 5 foci described?

"The ILC is 8mm (1) and the IDC is 5mm (2). The main tumor was IDC and .9cm (3). Then I have a ILC at 5mm (4) and another ILC at 4mm (5)."

(1) 8 mm ILC

(2) 5 mm IDC

(3) 9 mm IDC

(4) 5 mm ILC

(5) 4 mm ILC

2.5 centimeters apart is not close based on the information quoted above. However, with 5 tumors, does that 2.5 cm describe the smallest distance between any two of the 5 tumors or something else. It is not clear.

Ask your medical oncologist to confer with the pathologist about:

(1) What is the actual number of foci? (four or five);

(2) How far apart are they? (is 2.5 centimeters the smallest distance between any two of the five tumors?)

(3) Under the actual circumstances, should each of these foci be considered as separate (multiple) tumors, or given the distances between some of the them, should the sizes of any one or more foci be combined together for the purposes of determing "T" status under AJCC criteria?

BarredOwl

Hi Mom2fourplusmore:

Re your questions, please remember I am a layperson and I don't have access to the staging manual.

(1) How are multiple tumors identified?

As noted above, one internet paper that summarizes aspects of staging, indicates that tumor foci separated by a minimum distance of 0.5 cm are considered "multiple tumors":

"AJCC defines 0.5 cm as the minimum distance required between two macroscopic cancer foci to call them multiple cancers."

However, there may be exceptions to this general rule that were not discussed in the internet paper.

Should a tumor that has distinct sections with different histologies (IDC and ILC), with clearly separate dimensions, be considered multiple tumors, regardless of the distance between them?? The internet paper did not address this scenario. I don't know what the manual says about it. I don't know if your IDC/ILC tumor should be considered as two "multiple tumors" or not based on histology.

With more than two foci, you probably need to consider the distances between each pair (e.g.,1 and 2; 1 and 3; 1 and 4; 2 and 3; 3 and 4).

(2) If foci are considered to be multiple tumors, what is T status for purposes of staging?

Regarding staging, as noted above, the internet paper suggests that if deemed to be "multiple tumors", then single largest tumor determines the "T" component for purposes of staging:

"AJCC states that tumor size (pT) should be based only on the single largest tumor."

This is my understanding: Consider a person who is node-negative, and has one tumor that is 1.5 cm and one that is 1.0 cm, and they are 3 centimeters apart.

T1 Tumor ≤ 20 mm in greatest dimension

T2 Tumor > 20 mm but ≤ 50 mm in greatest dimension

Option A (not added): 1.5 cm would be pT1 N0 (M0) or Stage IA

Option B (added): 1.5 + 1.0 = 2.5 cm, which would be pT2 N0 (M0) or Stage IIA

Given the distance between them, they are considered "multiple tumors." pT for purposes of staging should be based on the single largest tumor (1.5 cm), so it would be pT1 N0 (M0) or Stage IA.

Because the internet paper is a summary, it may contain errors, and there may be exceptions, please have your MO raise your questions with the pathologist.

BarredOwl

I personally think that it's both the distance between tumors and the different hystological types. "My" tumor was actually a 4 cm ILC with multiple IDC, IDC cribriform, as well as DCIS and LCIS inside, with the largest "minitumors" being 4 mm, and the SN had a macrometastasis of 3 mm. My pathology report said pT2N1Mx. I was diagnosed 2B, multifocal. Required chemo, ALND (that I fought and obtained to have just one level removed and was clear), radiation (which I refused) and Aromatase inhibitors because ALL types were ER+, the lowest being 89% the highest 98%.

dtad:

That statement may be correct on the facts in your particular case, but it appears to be an overbroad based on the above article written by Joseph Rabban MD MPH Associate Professor UCSF Pathology Department. For example, I do not think you can extrapolate from your situation to different situations, such as two IDCs that are only 0.3 mm apart.

Again, as I said above, when under AJCC criteria (and there may be more than one criterion), two tumors are deemed to be "multiple tumors", then single largest tumor determines the "T" component for purposes of staging. As indicated above, one may see the designation "(m)" following pT status (e.g., pT2(m)), which indicates that multiple tumors were present, but are considered to be "multiple tumors" such that pT is based on the single largest one. However, there appear to be certain circumstances where two foci are deemed to be a single tumor, and this rule does not apply.

BarredOwl

Hi there:

I was recently dx with multifocal BC with 5 tumors:10 mm, 9.5 mm, 3.0 mm, 1.1 mm, and 1.0 mm. The last three are ILC and the two largest are IDC with DCIS mixed in. It says in my pathology report that the two largest tumors are separated by benign parenchyma by 2 cm. I was told I am stage pTm1b in pathology report. My nodes based on SNB were negative. I am still waiting for full pathology report with hormone and Her2 status. My BS told me all foci can be heterogenously different and act differently - that they are all separate primary cancers but I am still at stage 1 node negative early breast cancer.

Having said this, 13 years ago I had BC on the other side. I had a 7 CM tumor at dx by the BS. I had two surgeries to diagnose this. The first surgery was an excisional biopsy that turned out to be IDC 4.0 cm in size with no clear margins. The second surgery was a mastectomy where the remaining 3.0 cm was found. I was told the 4.0 cm tumor was removed from the middle of the larger tumor by the BS. The oncologist said I had multiple foci that had grown together. So I was staged 2b based on the 4.0 cm tumor. I never saw the actual pathology report at that time. The oncologist said it could be one contigous tumor, and I could be stage 3a, but it didn't matter in terms of treatment. I would have had the same treatment and prognosis regardless.

This cancer has still not recurred, knock on wood.

The cancer I was dx with in January is a new second primary breast cancer on the other side. I see the oncologist this week for full results and treatment plan. I must admit, I am a bit freaked out by these multiple tumors. But, having been there before and then reading on line in research journals about multifocal/multicentric BC, it seems prognosis is not adversely affected by all these tumors. It can affect treatment.

wallan