Download 03.Diagnosis and Staging

Diagnosis and Staging
JoAnne Zujewski, MD
Head, Breast Cancer Therapeutics
Clinical Investigations Branch
Cancer Therapy Evaluation Program
Division of Cancer Diagnostics and Treatment
May 2011
NEJM, November 23, 2000
Early Detections reduces the risk
of dying from breast cancer.
Cancer Diagnosis: Defining the
Cancer
• The first step in designing the treatment plan is
carefully defining the cancer
– Clinical examination
– Radiology tests
– Pathology tests
– Blood tests
Breast Cancer
Signs and Symptoms
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None
Lump or mass
Pain in breast
Tenderness
Thickening
Firmness
Nipple discharge
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Skin redness
Asymmetry
Enlargement
Nipple retraction
Dimpling
Mass in axilla (armpit)
Warmth
BREAST CANCER
Defining the Cancer: Radiology
• Radiologic imaging can help determine the
location and spread of the cancer
– Local extent
– Regional lymph nodes
– Distant spread (metastases)
Mammography Technique
Mammography
Mammography Sensitivity in
Younger Women
• Screening
mammograms
miss up to 25%
of breast
cancers in
women in their
40s, compared
to 10% of
cancers for older
women
Ultrasound
Breast MRI
• Important new tool for imaging the breast
• High sensitivity
• Detection and characterization of otherwiseoccult breast carcinoma
Breast Cancer Diagnosis
• Any breast change or lump needs to be
evaluated
• Breast cancer needs to be diagnosed
by biopsy
– Fine needle aspiration
– Core needle biopsy
– Surgical biopsy
Mammotone & Minimally
Invasive Breast Biopsy (MIBB)
The Mammotone and MIBB are different from the
core needle biopsy in that a needle is inserted
once and multiple specimens are removed through
contiguous sampling. Core needle biopsies require
the needle to be inserted multiple times.
Both the Mammotone and MIBB biopsy utilize a
vacuum system. A probe is inserted and samples
of tissue are collected in a chamber. Tissue
samples are removed by action of a gentle
vacuum.
Advantages of Needle Biopsies
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Simple procedure – does not require surgery
Accurate
Quick – only takes a few minutes
Not painful
Inexpensive
Quick results
Disadvantages of Needle
Biopsies
• Entire lump is not removed
• Open biopsy may be necessary
For Fine Needle Only:
• Specialist needed to read results
• In situ cancer not distinguishable from invasive
cancer
Image Guided Biopsy in Clinical
Practice
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Allows treatment planning
Better cosmesis
Can mark site with clip
Less costly
• Needs specialized equipment
• May still require confirmatory pathology in
minority of cases
Breast Biopsy
A core needle biopsy of the area is recommended
NonSurgical
Surgical
Ultrasound-Guided Breast Biopsy
Ultrasound
Image Guided Biopsy
Wire Localization: Example
Inking the Tumor Specimen in the O.R.
Needle Biopsies
• Fine Needle – A thin, hollow needle is used to
remove a sample of tissue. The procedure is quick
and can be done in a doctor’s office.
• Core Needle – A larger needle is inserted through a
small incision in the skin, and a small core of tissue
is removed. This type of needle biopsy is done with
the assistance of mammography or ultrasound
imaging using stereotactic techniques with the aid
of the computer, which calculates the precise
location of the lump.
Incisional Biopsy
• A surgical procedure where only a portion of a
tumor is removed
• Generally reserved for lumps that are larger
• Performed under local anesthesia in a hospital or
outpatient clinic
Excisional Biopsy
• A surgical procedure that removes the entire
suspected area plus some surrounding normal
tissue.
• Standard procedure for lumps that are smaller than
an inch or so in diameter
• Similar to a lumpectomy
• Performed under local anesthetic or general
anesthesia in a hospital or outpatient clinic
Advantages of Open Biopsies
• Quick – takes only one hour
• More accurate than a needle biopsy
• Larger samples provide information for treatment
plan
Excisional Only:
• Removes entire lump
• May be the only surgical treatment needed
Disadvantages of Open Biopsies
• Surgical procedure
• Expensive
• Side effects such as infection or blood collection
under the skin
Excisional Only:
• Removing tissue can change the look and feel of the
breast
Cancer is diagnosed
in 1 of 5
breast biopsies
Staging
Breast cancer
Spread to lymph nodes
Supraclavicular
Subclavicular
Mediastinal
Distal (upper)
axillary
Internal mammary
Central (middle)
axillary
Interpectoral
(Rotter’s)
Proximal (lower)
axillary
Breast Cancer: Stage I
T1 N0 M0
T1a: T  0.5 cm
T1b: 0.5 cm < T  1 cm
T1c: 1 cm < T  2 cm
T1
T  2 cm
N0 = no regional lymph node metastasis
M0 = no distant metastasis
Breast Cancer: Stage IIA
T0
T1
}
N1 M0
T2 N0 M0
T0 No evidence
of tumor
T2
2 cm < T < 5 cm
N1 = metastasis to movable ipsilateral axillary lymph node(s)
M0 = no distant metastasis
Breast Cancer: Stage IIB
T2 N1 M0
T3 N0 M0
T3
T > 5 cm
N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b
M0 = no distant metastasis
Breast Cancer: Stage IIIA
T3 N1 M0
T0
T1
T2
T3
Metastasis to ipsilateral axillary lymph node(s)
N1 = movable
N2 = fixed to one another or to other structures
M0 = no distant metastasis
N2 M0
Breast Cancer: Stage IIIB
T4 any N M0
Any T N3 M0
T4
Tumor of any size
with direct extension
to chest wall or skin
T4d = inflammatory
carcinoma
N3 = metastasis to ipsilateral internal mammary lymph node(s)
M0 = no distant metastasis
Breast Cancer: Stage IV
Any T any N M1
M1 = distant metastasis (including metastases to cervical, or contralateral
internal mammary lymph nodes)
Staging for Distant Disease:
Breast Cancer
FDG PET scan
Bone Scan
Patient A
Patient B
Multiple bone
metastases
Tumor in the breast, but
not elsewhere
The most common sites of distant disease in breast cancer are the bones,
liver and lungs
BREAST CANCER
5-year survival: Number
of positive axillary lymph nodes
80%
5-Year Survival
60%
40%
20%
0%
0
1
2
3
4
5
6-10 11-15 16-20 >20
Number of Positive Nodes
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
How effective is therapy for breast
cancer?
Relative 5 Year Survival (%)
Site
19741976
19831985
19921997
19962003
Breast
75
78
86
89.8
SEER, 1973-2003, DCP, NCI, 2009
BHGI-DIAGNOSTICS