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TNM staging and prognosis
Alexandru Eniu, MD, PhD
Medical Oncologist
Department of Breast Tumors
Cancer Institute Ion Chiricuţă
Cluj-Napoca, Romania
The Basics of TNM Staging
 Premises:
– Cancers of the same anatomic site and histology
share similar patterns of growth and similar
outcomes.
– As the size of the primary tumor (T) increases,
regional lymph node involvement (N) and/or
distant metastases (M) become more likely.
Diagnosis
 THE ONLY CERTITUDE = PATHOLOGY
 Always necessary
 Insufficient for planning treatment
 We need
– prognostic factors
– predictive factors
– targeted diagnosis
The Basics of TNM Staging
 TNM records the 3 significant events in
the life history of a cancer:
– Local Tumor Growth (T)

TX, Tis, T0, T1, T2, T3, T4
– Spread to Regional Lymph Nodes (N)

NX, N0, N1, N2, N3
– Distant Metastasis (M)

MX, M0, M1
The Basics of TNM Staging
 Stage Grouping
– After assignment of TNM categories
– Stage 0, I, II, III or IV
 Multiple Simultaneous Tumors
– The tumor with the highest T category is the
one selected for classification and staging
– Simultaneous bilateral cancers in paired organs
are staged separately
 Staging of primary unknown tumors can be
based on clinical suspicion of the primary
origin
Why Use TNM?
 Allows the health professional to determine
appropriate treatment ( primary, adjuvant)
 Allows assessment of prognosis and outcomes
 Enables the reliable evaluation of treatment
results
 Results in quality cancer care
 Enables comparison of results
Primary Tumor (T)
 Same definitions for clinical and pathologic T
 If the measurement is made by physical
examination, the examiner will use the major
headings (T1, T2, or T3).
 If mammographic or pathologic measurements
are used, the subsets of T1 can be used. Tumors
should be measured to the nearest 0.1 cm
increment.
 TX
Primary tumor cannot be assessed
 T0
No evidence of primary tumor
 Tis
Carcinoma in situ (DCIS, LCIS, Paget’s)
Note: Paget’s disease associated with a tumor is classified according to the size of the tumor.
T1
Tumor 2 cm
or less in
greatest
dimension
Primary Tumor (T)
Subdivisions of T1
 T1
Tumor 2 cm or less in greatest dim.
 T1mic
Microinvasion 0.1 cm or less in greatest
dimension
Tumor more than 0.1 cm but not more
than 0.5 cm in greatest dimension
Tumor more than 0.5 cm but not more
than 1 cm in greatest dimension
Tumor more than 1 cm but not more
than 2 cm in greatest dimension
 T1a
 T1b
 T1c
T2
Tumor more than
2 cm but not more
than 5 cm in
greatest
dimension
T3
Tumor more than
5 cm in greatest
dimension
T4
Tumor of any size with
direct extension to (a)
chest wall or (b) skin
T4a Extension to chest wall, not
including pectoralis muscle
T4b Edema (including peau
d’orange) or ulceration of the skin
of the breast, or satellite skin
nodules confined to the same
breast
T4c
Both T4a and T4b
T4d
Inflammatory carcinoma
Inflammatory
carcinoma
vs
neglected T4b
T4d
T4d
T4b
 NX
Regional Lymph Nodes (N)
Clinical
Regional lymph nodes cannot be assessed (e.g.,
previously removed)
 N0
No regional lymph node metastasis
 N1
Metastasis to movable ipsilateral axillary
lymph node(s)
 N2
Metastases in ipsilateral axillary lymph nodes
fixed or matted, or in clinically apparent* ipsilateral
internal mammary nodes in the absence of clinically
evident axillary lymph node metastasis
– N2a
Metastasis in ipsilateral axillary lymph nodes fixed to
one another (matted) or to other structures
– N2b
Metastasis only in clinically apparent* ipsilateral
internal mammary nodes and in the absence of clinically evident
axillary lymph node metastasis
Clinically apparent is defined as detected by imaging studies (excluding lymphoscintigraphy) or
by clinical examination or grossly visible pathologically.
Regional Lymph Nodes (N)
Clinical
 N3
Metastasis in ipsilateral infraclavicular lymph
node(s) with or without axillary lymph node involvement, or
in clinically apparent* ipsilateral internal mammary lymph
node(s) and in the presence of clinically evident axillary
lymph node metastasis; or metastasis in ipsilateral
supraclavicular lymph node(s) with or without axillary or
internal mammary lymph node involvement
 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 (excluding lymphoscintigraphy) or by
clinical examination or grossly visible pathologically.
 pNX
Regional Lymph Nodes (N)
Pathologic (pN)
Regional lymph nodes cannot be assessed (e.g.,
previously removed, or not removed for pathologic study)
 pN0
No regional lymph node metastasis histologically, no
additional examination for isolated tumor cells (ITC)
 pN1
Metastasis in 1 to 3 axillary lymph nodes, and/or in
internal mammary nodes with microscopic disease etected
by sentinel lymph node dissection but not clinically apparent**
 pN2
 pN3
Metastasis in 4 to 9 axillary lymph nodes, or in
clinically apparent* internal mammary lymph nodes in the
absence of axillary lymph node metastasis
Metastasis in 10 or more axillary lymph nodes, or in
infraclavicular lymph nodes, or in clinically apparent* ipsilateral
internal mammary lymph nodes; or in ipsilateral supraclavicular
lymph nodes
Distant Metastasis (M)
 MX
Distant metastasis cannot be assessed
 M0 No distant metastasis
 M1 Distant metastasis
Breast Cancer Staging
Stage I
Stage 1
N0
T1
Breast Cancer Staging
Stage IIA
Stage IIA
N1
N1
T1
N0
T2
Stage IIa may also describe cancer in the axillary lymph nodes with no
evidence of a tumor in the breast
Breast Cancer Staging
Stage IIB
Stage IIB
N1
N1
T2
N0
T3
Breast Cancer Staging
Stage IIIA
Stage IIIA
N1
N2
N1
T3
T1-3
N2
T1-3
Breast Cancer Staging
Stage IIIB, IIIC
Stage IIIB
N0
N1
T4
N1
T4
Stage IIIC
N3
N2
T4
N2
Stage IV Breast Cancer
 Stage IV breast cancer can be any size and
has spread to distant sites in the body,
usually the bones, lungs or liver, or chest wall
AJCC Staging System (anatomic)
T
N
M
Stage
1
0
0
I
0-2
0-1
0
IIa
2-3
0-1
0
IIb
0-3
1-2
0
IIIa
4 or 0-1
1-2
0
IIIb
Any
3
0
IIIc
any
any
1
IV
Survival in relation to presence and extent of
regional LNs
Breast Cancer Survival Rates
Stage
I
2yr
100
5yr%
10yr%
%BC
90
70
60
II
90
70
55
III
70
40
30
2-5
<1
IV (MBC) 25
30
10
The overall median survival for MBC is <2ys.
50% of women with MBC stage IV will live <2ys.
How to Implement
AJCC TNM Staging
 Development of policy and procedure
 Staging form part of the medical record
 Development of a process by which the
staging form is placed in the medical record
– Size of facility and number of analytic cases
– Pathology, medical records, cancer registry…
 Development of Quality Control Methods to
assure compliance
The TNM is imperfect!
 Prognostic factors
– Lymph Node Involvement
– Tumor Size
– Tumor Grade
– Lymphatic/Vascular/Perineural Invasion
– Age of the patient
– Tumor biology Profile
* ER, PR
*Her2neu expression
*Ki 67/ proliferation fraction
Future of Oncology
 Diagnostic: Organ  Molecular Etiology
 Classification: Histology  Molecular Function
 Focus: Therapy  Prevention
 Therapy: Toxic, Complex  Non-Toxic, Targeted
 Outcome prediction: Suboptimal  Precise
 Patients follow-up : Anatomic  Systemic
Backup slides
Regional Lymph Nodes (N)
Pathologic (pN)
a
 pN0(i–)
No regional lymph node metastasis
histologically, negative IHC
 pN0(i+)
No regional lymph node metastasis
histologically, positive IHC, no IHC
greater than 0.2 mm
cluster
 pN0(mol–) No regional lymph node metastasis
findings
histologically, negative molecular
(RTPCR)b
 pN0(mol+) No regional lymph node metastasis
findings
histologically, positive molecular
(RTPCR)b
Regional Lymph Nodes (N)

a

b
Classification is based on axillary lymph
node dissection with or without sentinel
lymph node
dissection. Classification based
solely on sentinel
lymph node dissection
without subsequent
axillary lymph node
dissection is designated (sn) for “sentinel node,”
e.g., pN0(i+) (sn).
RT-PCR: reverse transcriptase/polymerase
chain reaction.
Regional Lymph Nodes (N)
 pN1
 pN1mi
 pN1a
 pN1b
 pN1c
Metastasis in 1 to 3 axillary lymph nodes, and/or in
internal mammary nodes with microscopic disease
detected by sentinel lymph node dissection but not
clinically apparent**
Micrometastasis (greater than 0.2 mm, none
greater than 2.0 mm)
Metastasis in 1 to 3 axillary lymph nodes
Metastasis in internal mammary nodes with
microscopic disease detected by sentinel lymph
node dissection but not clinically apparent**
Metastasis in 1 to 3 axillary lymph nodes and in
internal mammary lymph nodes with microscopic
disease detected by sentinel lymph node dissection
but not clinically apparent.** (If associated with
greater than 3 positive axillary lymph nodes, the
internal mammary nodes are classified as pN3b
to reflect increased tumor burden)
Regional Lymph Nodes (N)
Pathologic (pN) a
 pN2
Metastasis in 4 to 9 axillary lymph
nodes, or in
clinically apparent* internal
mammary lymph
nodes in the absence of
axillary lymph node
metastasis
 pN2a
Metastasis in 4 to 9 axillary lymph nodes (at
least
one tumor deposit greater than 2.0 mm)
 pN2b
Metastasis in clinically apparent* internal
mammary lymph nodes in the absence of axillary
lymph node metastasis
 pN3
Metastasis in 10 or more axillary lymph
nodes, or
in infraclavicular lymph nodes, or in
clinically
apparent* ipsilateral internal
mammary lymph
nodes in the presence of
1 or more positive axillary
lymph nodes; or in more
than 3 axillary lymph
nodes with
clinically negative microscopic
metastasis in internal mammary lymph nodes; or
Regional Lymph Nodes (N)
Pathologic (pN) a
 pN3a
Metastasis in 10 or more axillary lymph nodes
(at
least one tumor deposit greater than 2.0 mm),
or
metastasis to the infraclavicular lymph nodes
 pN3b
Metastasis in clinically apparent* ipsilateral
internal
mammary lymph nodes in the presence
of 1 or
more positive axillary lymph
nodes; or in more
than 3 axillary lymph
nodes and in internal
mammary lymph
nodes with microscopic disease
detected by
sentinel lymph node dissection but not
clinically
apparent**
 pN3c
Metastasis in ipsilateral supraclavicular
lymph
nodes
–
*Clinically apparent is defined as detected by imaging studies (excluding
lymphoscintigraphy) or by clinical examination.
Stage Grouping



Stage 0
Stage I
Stage IIA



Stage IIB


Stage IIIA





Stage IIIB




Stage IIIC
Stage IV
Tis
T1*
T0
T1*
T2
T2
T3
T0
T1*
T2
T3
T3
T4
T4
T4
Any T
Any T
N0
N0
N1
N1
N0
N1
N0
N2
N2
N2
N1
N2
N0
N1
N2
N3
Any N
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M1
 Note: Stage
designation may be
changed if post-surgical
imaging studies reveal the
presence of distant
metastases, provided that
the studies are carried
out within 4 months of
diagnosis in the absence
of disease progression
and provided that the
patient has not received
neoadjuvant therapy.
Schematic Diagram of Breast and
Regional Lymph Nodes
AJCC Cancer Staging Atlas