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Official reprint from UpToDate®
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©2010 UpToDate®
Tumor node metastasis (TNM) staging classification for
breast cancer
Author
Susan E Pories, MD, FACS
Section Editor
Daniel F Hayes, MD
Deputy Editor
Susan E Pories, MD, FACS
Last literature review version 18.1: enero 2010 | This topic last updated:
noviembre 23, 2009
INTRODUCTION — The tumor node metastasis (TNM) staging system for breast cancer
is an internationally accepted system used to determine the disease stage. This disease
stage is a measure of the extent of disease, which is used to guide management and
determine prognosis.
The 7th edition of the TNM staging system and the evidence supporting it are described
here (table 1). The 6th edition of the TNM staging system is included for comparison
(table 2). The initial evaluation, clinical manifestations, diagnosis, treatment, and
prognosis of breast cancer are reviewed elsewhere. (See "An overview of breast cancer
and treatment for early stage disease" and "Initial staging work-up for women with a
diagnosis of breast cancer" and "Clinical decisions in systemic adjuvant therapy for early
breast cancer".)
TNM STAGING SYSTEM — The tumor node metastasis (TNM) staging system for
breast cancer is based upon a retrospective analysis of survival in diverse samples of
patients representing all stages of disease. It reflects the clinical evaluation methods
and treatments that are applied to the particular study population. Periodic revisions are
necessary because advanced imaging techniques and treatments evolve and impact
survival. The 7th edition of the TNM staging system is the most recent version (table
1) [1]. It replaces the 6th edition of the TNM staging system (table 2) [2].
REVISIONS IN BREAST CANCER STAGING — Observed survival rates for 211,645
breast cancer cases diagnosed in years 2001-2002 and entered into the National Cancer
Data Base (Commission on Cancer of the American College of Surgeons and the
American Cancer Society) were used to reevaluate the prognostic value of the TNM
descriptors.
Modest adjustments have been made to the T, N and M categories for the seventh
edition of the staging system for breast cancer in an effort to reflect new technologies
and new clinical outcome data since the 6th edition (table 1). The most important
changes in the new staging system include:
Changes in Tumor (T) classification
z The microscopic measurement is considered most accurate for small invasive
cancers that can be entirely submitted in one paraffin block.
z The gross measurement is considered most accurate for larger invasive cancers that
are submitted in multiple paraffin blocks.
z
For patients being treated with neoadjuvant treatment, the most accurate clinical
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measurement should be used to determine the clinical T at presentation.
Posttreatment T size should be estimated based on the best combination of gross and
microscopic histological findings.
Paget disease associated with an underlying cancer should be classified according to
the underlying cancer (Tis, T1 etc.)
z
z Paget disease that is not associated with an underlying cancer should be classified
as Tis (Paget).
The size of noninvasive cancers, ductal carcinoma in situ (DCIS) and lobular
carcinoma in situ (LCIS), should be estimated as this may influence therapeutic decision
making.
z
z Multiple simultaneous ipsilateral carcinomas can occur in the same quadrant or
separate quadrants.
Changes in Nodes (N) classification
More stringent classification of isolated tumor cell clusters and single cells is now
required. Small clusters of cells not greater than 0.2 mm, or nonconfluent or nearly
confluent clusters of cells not exceeding 200 cells in a single histologic lymph node cross
section are classified as isolated tumor cells.
z
Use of the (sn) modifier has been clarified and restricted. When six or more sentinel
nodes are identified on gross examination of pathology specimens the (sn) modifier is
now omitted.
z
Stage I breast tumors have been subdivided into stage IA and stage IB; stage IB
includes small tumors (T1) with exclusively micrometastases in lymph nodes (NM1mi).
z
Changes in Metastases (M) classification
z A new M0(i+) category has been created, defined by the presence of either
disseminated tumor cells detectable in bone marrow or circulating tumor cells or found
incidentally in other tissues if not exceeding 0.2 mm. However, this category does not
change the stage grouping. Assuming patients do not have clinically or radiographically
detectable metastases, staging for patients with M0(i+) is done according to T and N.
Changes in postneoadjuvant therapy (yc or ypTNM) classification — This
nomenclature is used for cases where systemic and/or radiation therapy are given
before surgery (neoadjuvant) or where no surgery is performed. These patients will
have the extent of disease assessed at the conclusion of the therapy by clinical or
pathologic means to provide information about the extent of response to help direct the
extent of any subsequent treatment. T and N are classified using the same categories as
for clinical or pathologic staging for the disease and the findings are recorded with the
appropriate prefix (ycT, ycN, ypT, ypN). The yc prefix is used for the clinical stage after
therapy and the yp prefix is used for the pathologic stage for patients who have surgical
resection after neoadjuvant therapy.
Preneoadjuvant treatment clinical T (cT) should be based on clinical or imaging
findings.
z
Postneoadjuvant treatment T should be based on clinical or imaging (ycT) or
pathologic findings (ypT).
z
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z A subscript is now added to the clinical N for both node negative and node positive
patients to indicate whether the nodal diagnosis was derived from clinical examination,
fine needle aspiration, core needle biopsy or sentinel lymph node biopsy.
z The posttreatment ypT is the largest contiguous focus of invasive cancer as defined
histopathologically with a subscript to indicate the presence of multiple tumor foci.
z Posttreatment nodal metastases no greater than 0.2 mm are classified as ypN0(+).
However patients with this finding are not considered to have achieved a pathologic
complete response (pCR).
z The degree of response to neoadjuvant treatment (complete, partial, no response)
will now be recorded in the tumor registry.
z Patients are considered to have M1 (stage IV) breast cancer if metastases were
detectable before neoadjuvant therapy, regardless of their status after neoadjuvant
treatment.
SEVENTH EDITION OF THE TNM BREAST CANCER STAGING SYSTEM — (table 1)
Primary Tumor Classification
Tx — Primary tumor cannot be assessed
T0 — No evidence of primary tumor
Tis — Carcinoma in situ
- Tis (DCIS) — Intraductal carcinoma in situ
- Tis (LCIS) — Lobular carcinoma in situ
- Tis (Paget) — Paget disease of the nipple is not associated with invasive
carcinoma and/or carcinoma in situ (DCIS and/or LCIS) in the underlying breast
parenchyma. Carcinomas in the breast parenchyma associated with Paget disease are
categorized based on the size and characteristics of the parenchymal disease, although
the presence of Paget disease should still be noted
T1 — Tumor ≤2 mm in greatest dimension
- T1mi — Tumor ≤1 mm in greatest dimension
- T1a — Tumor >1 mm but ≤5 mm in greatest dimension
- T1b — Tumor >5 mm but ≤10 mm in greatest dimension
- T1c — Tumor >10 mm but ≤20 mm in greatest dimension
T2 — Tumor >20 mm but ≤50 mm in greatest dimension
T3 — Tumor >50 mm in greatest dimension
T4 — Tumor of any size with direct extension to the chest wall and/or the skin
(ulceration or skin nodules)*
- T4a — Extension to chest wall, not including only pectoralis muscle
adherence/invasion
- T4b — Ulceration and/or ipsilateral satellite nodules and/or edema (including
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peau d'orange) of the skin which do not meet the criteria for inflammatory carcinoma
- T4c — Both (T4a and T4b)
- T4d — Inflammatory carcinoma**
*Note: Invasion of the dermis alone does not qualify as T4.
**Note: Inflammatory carcinoma is restricted to cases with typical skin changes
involving a third or more of the skin of the breast. While the histologic presence of
invasive carcinoma invading dermal lymphatics is supportive of the diagnosis, it is not
required, nor is dermal lymphatic invasion without typical clinical findings sufficient for a
diagnosis of inflammatory breast cancer.
Regional lymph nodes (N) — (table 1)
NX — Regional lymph nodes cannot be assessed (eg, previously removed)
- pNX — Regional lymph nodes cannot be assessed (eg, previously removed, or not
removed for pathologic study)
N0 — No regional lymph node metastases
- pNO — No regional lymph node metastasis identified histologically
- pNO(i-) — No regional lymph node metastases histologically, negative IHC
- pNo(i+) — Malignant cells in regional lymph node(s) no greater than 0.2 mm
(detected by H&E or IHC including ITC)
- pNO(mol-) — No regional lymph node metastases histologically, negative
molecular findings (RT-PCR)
- pNO(mol+) — Positive molecular findings (RT-PCR), but no regional lymph node
metastases detected by histology or IHC
N1 — Metastasis to movable ipsilateral level I, II axillary lymph nodes(s)
- pN1 — Micrometastases; or metastases in 1 to 3 axillary lymph nodes; and/or in
internal mammary nodes with metastases detected by sentinel lymph node biopsy but
not clinically detected**
- pN1mi — Micrometastases (greater than 0.2 mm and/or more than 200 cells, but
none greater than 2.0 mm)
- pN1a — Metastases in 1 to 3 axillary lymph nodes, at least one metastasis
greater than 2.0 mm
- pN1b — Metastases in internal mammary nodes with micrometastases or
macrometastases detected by sentinel lymph node biopsy but not clinically detected**
- pN1c — Metastases in 1 to 3 axillary lymph nodes and in internal mammary
lymph nodes with micrometastases or macrometastases detected by sentinel lymph
node biopsy but not clinically detected**
N2 — Metastasis to ipsilateral level I, II axillary lymph nodes that are clinically fixed
or matted; or in clinically detected* ipsilateral internal mammary nodes in the absence
of clinically evident axillary node metastases
- pN2 — Metastases in 4-9 axillary lymph nodes; or in clinically detected****
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internal mammary lymph nodes in the absence of axillary lymph node metastases
- N2a — Metastasis to ipsilateral level I, II axillary lymph nodes fixed to one
another (matted) or to other structures
- pN2a — Metastases in 4 to 9 axillary lymph nodes (at least one tumor deposit
greater than 2.0 mm)
- N2b — Metastasis only in clinically detected*** ipsilateral internal mammary
nodes and in the absence of clinically evident axillary node metastases
- pN2b — Metastases in clinically detected*** internal mammary lymph nodes in
the absence of axillary lymph node metastases.
N3 — Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with
or without level I, II axillary lymph node involvement; or in clinically detected*
ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary
lymph node metastases; or metastases in ipsilateral supraclavicular lymph node(s) with
or without axillary or internal mammary lymph node involvement
- pN3 — Metastases in 10 or more axillary lymph nodes; or in infraclavicular (level
III axillary) lymph nodes; or in clinically detected*** ipsilateral internal mammary
lymph nodes in the presence of 1 or more positive level I, II axillary lymph nodes; or in
more than 3 axillary lymph nodes and in internal mammary lymph nodes with
micrometastases or macrometastases detected by sentinel lymph node biopsy but not
clinically detected**; or in ipsilateral supraclavicular lymph nodes
N3a — Metastasis to ipsilateral infraclavicular lymph node(s)
- pN3a — Metastases in 10 or more axillary lymph nodes (at least one tumor
deposit greater than 2.0 mm); or metastases to the infraclavicular (level III axillary
lymph) nodes
N3b — Metastasis to ipsilateral internal mammary lymph node(s) and axillary lymph
nodes
- pN3b — Metastases in clinically detected*** 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 micrometastases or
macrometastases detected by sentinel lymph node biopsy but not clinically detected**
N3c — Metastasis in ipsilateral supraclavicular lymph node(s)
- pN3c — Metastases in ipsilateral supraclavicular lymph nodes
*Classification is based on axillary lymph node dissection with or without sentinel lymph
node biopsy. Classification based solely on sentinel lymph node biopsy without
subsequent axillary lymph node dissection is designated (sn) for "sentinel node," for
example, pN0(sn).
**Note: Not clinically detected is defined as not detected by imaging studies excluding
lymphoscintigraphy) or not detected by clinical examination.
***Note: Clinically detected is defined as detected by imaging studies (excluding
lymphoscintigraphy) or by clinical examination and having characteristics highly
suspicious for malignancy or a presumed pathologic macrometastasis based on fine
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needle aspiration biopsy with cytologic examination. Confirmation of clinically detected
metastatic disease by fine needle aspiration without excision biopsy is designated with
an (f) suffix, for example, cN3a(f). Excisional biopsy of a lymph node or biopsy of a
sentinel node, in the absence of assignment of a pT, is classified as a clinical N, for
example, cN1. Information regarding the confirmation of the nodal status will be
designated in sitespecific factors as clinical, fine needle aspiration, core biopsy, or
sentinel lymph node biopsy. Pathologic classification (pN) is used for excision or sentinel
lymph node biopsy only in conjunction with a pathologic T assignment.
Note: Isolated tumor cell clusters (ITC) are defined as small clusters of cells not greater
than 0.2 mm, or single tumor cells, or a cluster of fewer than 200 cells in a single
histologic cross-section. ITCs may be detected by routine histology or by
immunohistochemical (IHC) methods. Nodes containing only ITCs are excluded from the
total positive node count for purposes of N classification but should be included in the
total number of nodes evaluated
Distant metastasis (M) — (table 1)
M0 — No clinical or radiographic evidence of distant metastases (no pathologic M0;
use clinical M to complete stage group)
cMO(i+) — No clinical or radiographic evidence of distant metastases, but deposits
of molecularly or microscopically detected tumor cells in circulating blood, bone marrow
or other non-regional nodal tissue that are no larger than 0.2 mm in a patient without
symptoms or signs of metastases
M1 — Distant detectable metastases as determined by classic clinical and
radiographic means and/or histologically proven larger than 0.2 mm
STAGE GROUPINGS — (table 1)
Stage 0
Tis N0 M0
Stage IA
T1 N0 M0
Stage IB
TO N1mi MO
T1 N1mi M0
Stage IIA
T0 N1 MO
T1 N1 M0
T2 N0 M0
Stage IIB
T2 N1 M0
T3 N0 M0
Stage IIIA
T0 N2 M0
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T1 N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0
Stage IIIB
T4 N0 M0
T4 N1 M0
T4 N2 M0
Stage IIIC
Any T N3 M0
Stage IV
Any T Any N M1
PREVIOUS STAGING SYSTEM (6th edition) — The most important changes in the
6th edition, published in 2002, as compared to the 1997 classification included [3]:
Dividing the N staging category into three categories based on the number of
axillary lymph nodes involved
z
Size-based discrimination between micrometastases and isolated tumor cells,
identifiers to indicate usage of sentinel lymph node dissection and immunohistochemical
or molecular techniques
z
Reclassification of metastasis to internal mammary nodes, and supraclavicular nodes
(Designated N3 rather than M1 disease) (table 2) [4].
z
INFORMATION FOR PATIENTS — Educational materials on this topic are available for
patients. (See "Patient information: Breast cancer guide to diagnosis and treatment".)
We encourage you to print or e-mail this topic review, or to refer patients to our public
web site, www.uptodate.com/patients, which includes this and other topics.
SUMMARY AND RECOMMENDATIONS
The tumor node metastasis (TNM) staging system for breast cancer classifies tumors
on the basis of the primary tumor (T), the presence or absence of regional lymph node
involvement (N), and the presence or absence of distant metastases (M). The overall
stage of the tumor (stage I through IV) depends upon the particular combination of T,
N, and M characteristics. (See 'TNM staging system' above.)
z
The TNM staging system predicts survival, but should not be used alone to dictate
treatment. Periodic revisions are necessary because advanced imaging techniques and
treatments continue to evolve and impact survival. (See 'Revisions in breast cancer
staging' above.)
z
The most recent version of the TNM staging system is the 7th edition of the "TNM
Classification of Malignant Tumors". It becomes effective January 1, 2010 and includes
new tumor stage groupings and refinements of the T and M descriptors (table 1 and
z
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table 2). (See 'Seventh edition of the TNM breast cancer staging system' above.)
ACKNOWLEDGMENT — Used with the permission of the American Joint Committee on
Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer
Staging Manual, Sixth Edition (2002) and Seventh Edition (2010) published by SpringerVerlag New York, Inc.
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. AJCC (American Joint Committee on Cancer) Cancer Staging Manual, 7th ed, Edge,
SB, Byrd, DR, Compton, CC, et al (Eds), Springer-Verlag, New York, 2010. 347377.
2. AJCC (American Joint Committee on Cancer) Cancer Staging Manual, 6th ed,
Greene, FL, Page, DL, Fleming, ID, et al (Eds), Springer-Verlag, New York, 2002.
Pp. 223-240.
3. Woodward, WA, Strom, EA, Tucker, SL, et al. Changes in the 2003 american joint
committee on cancer staging for breast cancer dramatically affect stage-specific
survival. J Clin Oncol 2003; 21:3244.
4. Singletary, SE, Allred, C, Ashley, P, et al. Revision of the american joint committee
on cancer staging system for breast cancer. J Clin Oncol 2002; 20:3628.
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GRAPHICS
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Tumor node metastases (TNM) staging system for carcinoma of
the breast
Primary tumor (T)*•Δ
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
Tis (DCIS)
Ductal carcinoma in situ
Tis (LCIS)
Lobular carcinoma in situ
Tis
(Paget's)
Paget's disease (Paget disease) of the nipple NOT associated with
invasive carcinoma and/or carcinoma in situ (DCIS and/or LCIS) in
the underlying breast parenchyma. Carcinomas in the breast
parenchyma associated with Paget's disease are categorized based on
the size and characteristics of the parenchymal disease, although the
presence of Paget's disease should still be noted.
T1
Tumor ≤20 mm in greatest dimension
T1mi
Tumor ≤1 mm in greatest dimension
T1a
Tumor >1 mm but ≤5 mm in greatest dimension
T1b
Tumor >5 mm but ≤10 mm in greatest dimension
T1c
Tumor >10 mm but ≤20 mm in greatest dimension
T2
Tumor >20 mm but ≤50 mm in greatest dimension
T3
Tumor >50 mm in greatest dimension
T4◊
Tumor of any size with direct extension to the chest wall and/or to the
skin (ulceration or skin nodules)
T4a
Extension to the chest wall, not including only pectoralis muscle
adherence/invasion
T4b
Ulceration and/or ipsilateral satellite nodules and/or edema (including peau
d'orange) of the skin, which do not meet the criteria for inflammatory
carcinoma
T4c
Both T4a and T4b
T4d
Inflammatory carcinoma§
Posttreatment ypT.¥ The use of neoadjuvant therapy does not change the clinical
(pretreatment) stage. Clinical (pretreatment) T will be defined by clinical and
radiographic findings, while y pathologic (posttreatment) T will be determined by
pathologic size and extension. The ypT will be measured as the largest single focus
of invasive tumor, with the modifier "m" indicating multiple foci. The measurement
of the largest tumor focus should not include areas of fibrosis within the tumor bed.
Regional lymph nodes (N)
Clinical
NX
Regional lymph nodes cannot be assessed (eg, previously removed)
N0
No regional lymph node metastases
N1
Metastases to movable ipsilateral level I, II axillary lymph node(s)
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N2
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Metastases in ipsilateral level I, II axillary lymph nodes that are
clinically fixed or matted; or in clinically detected‡ ipsilateral internal
mammary nodes in the absence of clinically evident axillary lymph
node metastases
N2a
Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another
(matted) or to other structures
N2b
Metastases only in clinically detected‡ ipsilateral internal mammary nodes
and in the absence of clinically evident level I, II axillary lymph node
metastases
N3
Metastases in ipsilateral infraclavicular (level III axillary) lymph node
(s) with or without level I, II axillary lymph node involvement; or in
clinically detected‡ ipsilateral internal mammary lymph node(s) with
clinically evident level I, II axillary lymph node metastases; or
metastases in ipsilateral supraclavicular lymph node(s) with or
without axillary or internal mammary lymph node involvement
N3a
Metastases in ipsilateral infraclavicular lymph node(s)
N3b
Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph
node(s)
N3c
Metastases in ipsilateral supraclavicular lymph node(s)
Pathologic (pN)†**
pNX
Regional lymph nodes cannot be assessed (eg, previously removed,
or not removed for pathologic study)
pN0
No regional lymph node metastasis identified histologically
pN0(i-)
No regional lymph node metastases histologically, negative
immunohistochemistry (IHC)
pN0(i+)
Malignant cells in regional lymph node(s) no greater than 0.2 mm
(detected by H&E or IHC including isolated tumor cell clusters (ITC))
pN0
(mol-)
No regional lymph node metastases histologically, negative molecular
findings (RT-PCR)••
pN0
(mol+)
Positive molecular findings (RT-PCR)••, but no regional lymph node
metastases detected by histology or IHC
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 ΔΔ
pN1mi
Micrometastases (greater than 0.2 mm and/or more than 200 cells, but none
greater than 2.0 mm)
pN1a
Metastases in 1-3 axillary lymph nodes, at least one metastasis greater than
2.0 mm
pN1b
Metastases in internal mammary nodes with micrometastases or
macrometastases detected by sentinel lymph node biopsy but not clinically
detected ΔΔ
pN1c
Metastases in 1-3 axillary lymph nodes and in internal mammary lymph
nodes with micrometastases or macrometastases detected by sentinel lymph
node biopsy but not clinically detected
pN2
pN2a
Metastases in 4-9 axillary lymph nodes; or in clinically detected◊◊
internal mammary lymph nodes in the absence of axillary lymph node
metastases
Metastases in 4-9 axillary lymph nodes (at least one tumor deposit greater
than 2.0 mm)
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pN2b
pN3
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Metastases in clinically detected◊◊ internal mammary lymph nodes in the
absence of axillary lymph node metastases
Metastases in ten or more axillary lymph nodes; or in infraclavicular
(level III axillary) lymph nodes; or in clinically detected◊◊ ipsilateral
internal mammary lymph nodes in the presence of one or more
positive level I, II axillary lymph nodes; or in more than three axillary
lymph nodes and in internal mammary lymph nodes with
micrometastases or macrometastases detected by sentinel lymph
node biopsy but not clinically detected ΔΔ; or in ipsilateral
supraclavicular lymph nodes
pN3a
Metastases in ten or more axillary lymph nodes (at least one tumor deposit
greater than 2.0 mm); or metastases to the infraclavicular (level III axillary
lymph) nodes
pN3b
Metastases in clinically detected◊◊ ipsilateral internal mammary lymph nodes
in the presence of one or more positive axillary lymph nodes; or in more than
three axillary lymph nodes and in internal mammary lymph nodes with
micrometastases or macrometastases detected by sentinel lymph node biopsy
but not clinically detected ΔΔ
pN3c
Metastases in ipsilateral supraclavicular lymph nodes
Posttreatment ypN
- Post-treatment yp "N" should be evaluated as for clinical (pretreatment) "N"
methods above. The modifier "sn" is used only if a sentinel node evaluation was
performed after treatment. If no subscript is attached, it is assumed that the
axillary nodal evaluation was by axillary node dissection (AND).
- The X classification will be used (ypNX) if no yp posttreatment SN or AND was
performed
- N categories are the same as those for pN
Distant metastasis (M)
M0
No clinical or radiographic evidence of distant metastases
cM0(i+)
No clinical or radiographic evidence of distant metastases, but
deposits of molecularly or microscopically detected tumor cells in
circulating blood, bone marrow, or other nonregional nodal tissue that
are no larger than 0.2 mm in a patient without symptoms or signs of
metastases
M1
Distant detectable metastases as determined by classic clinical and
radiographic means and/or histologically proven larger than 0.2 mm
Posttreatment yp M classification. The M category for patients treated with
neoadjuvant therapy is the category assigned in the clinical stage, prior to initiation
of neoadjuvant therapy. Identification of distant metastases after the start of
therapy in cases where pretherapy evaluation showed no metastases is considered
progression of disease. If a patient was designated to have detectable distant
metastases (M1) before chemotherapy, the patient will be designated as M1
throughout.
Anatomic stage/prognostic groups§§
0
Tis
N0
M0
IA
T1 ¥¥
N0
M0
IB
T0
N1mi
M0
T1 ¥¥
N1mi
M0
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IIA
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T0
N1 ‡‡
M0
T1 ¥¥
N1 ‡‡
M0
T2
N0
M0
T2
N1
M0
T3
N0
M0
T0
N2
M0
T1 ¥¥
N2
M0
T2
N2
M0
T3
N1
M0
T3
N2
M0
T4
N0
M0
T4
N1
M0
T4
N2
M0
IIIC
Any T
N3
M0
IV
Any T
Any N
M1
IIB
IIIA
IIIB
* The T classification of the primary tumor is the same regardless of whether it is
based on clinical or pathologic criteria, or both. Designation should be made with the
subscript "c" or "p" modifier to indicate whether the T classification was determined by
clinical (physical examination or radiologic) or pathologic measurements, respectively.
In general, pathologic determination should take precedence over clinical
determination of T size.
• Size should be measured to the nearest millimeter. If the tumor size is slightly less
than or greater than a cutoff for a given T classification, it is recommended that the
size be rounded to the millimeter reading that is closest to the cutoff.
Δ Multiple simultaneous ipsilateral primary carcinomas are defined as infiltrating
carcinomas in the same breast, which are grossly or macroscopically distinct and
measurable. T stage is based only on the largest tumor. The presence and sizes of the
smaller tumor(s) should be recorded using the "(m)" modifier.
◊ Invasion of the dermis alone does not qualify as T4; dimpling of the skin, nipple
retraction, or any other skin change except those described under T4b and T4d may
occur in T1, T2, or T3 without changing the classification. The chest wall includes ribs,
intercostal muscles, and serratus anterior muscle, but not the pectoralis muscles.
§ Inflammatory carcinoma is a clinical-pathologic entity characterized by diffuse
erythema and edema (peau d'orange) involving a third or more of the skin of the
breast. These skin changes are due to lymphedema caused by tumor emboli within
dermal lymphatics. Although dermal lymphatic involvement supports the diagnosis of
inflammatory breast cancer, it is neither necessary nor sufficient, in the absence of
classical clinical findings, for the diagnosis of inflammatory breast cancer.
¥ If a cancer was designated as inflammatory before neoadjuvant chemotherapy, the
patient will be designated to have inflammatory breast cancer throughout, even if the
patient has complete resolution of inflammatory findings.
‡ Clinically detected is defined as detecting by imaging studies (excluding
lymphoscintigraphy) or by clinical examination and having characteristics highly
suspicious for malignancy or a presumed pathologic macrometastasis based on fine
needle aspiration biopsy with cytologic examination. Confirmation of clinically
detected metastatic disease by fine needle aspiration without excision biopsy is
designated with an (f) suffix, for example, cN3a(f). Excisional biopsy of a lymph node
or biopsy of a sentinel node, in the absence of assignment of a pT, is classified as a
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clinical N, for example, cN1. Information regarding the confirmation of the nodal
status will be designated in site specific factors as clinical, fine needle aspiration, core
biopsy, or sentinel lymph node biopsy. Pathologic classification (pN) is used for
excision or sentinel lymph node biopsy only in conjunction with a pathologic T
assignment.
† Classification is based on axillary lymph node dissection with or without sentinel
lymph node biopsy. Classification based solely on sentinel lymph node biopsy without
subsequent axillary lymph node dissection is designated (sn) for "sentinel node," for
example, pN0(sn).
** Isolated tumor cell clusters (ITC) are defined as small clusters of cells not greater
than 0.2 mm, or single tumor cells, or a cluster of fewer than 200 cells in a single
histologic cross-section. ITCs may be detected by routine histology or by
immunohistochemical (IHC) methods. Nodes containing only ITCs are excluded from
the total positive node count for purposes of N classification but should be included in
the total number of nodes evaluated.
•• RT-PCR: reverse transcriptase/polymerase chain reaction.
ΔΔ "Not clinically detected" is defined as not detected by imaging studies (excluding
lymphoscintigraphy) or not detected by clinical examination.
◊◊ "Clinically detected" is defined as detected by imaging studies (excluding
lymphoscintigraphy) or by clinical examination and having characteristics highly
suspicious for malignancy or a presumed pathologic macrometastasis based on fine
needle aspiration biopsy with cytologic examination.
§§ Anatomic stage:
- M0 includes M0(i+).
- The designation pM0 is not valid; any M0 should be clinical.
- If a patient presents with M1 prior to neoadjuvant systemic therapy, the stage is
considered Stage IV and remains Stage IV regardless of response to neoadjuvant
therapy.
- Stage designation may be changed if postsurgical 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.
- Postneoadjuvant therapy is designated with "yc" or "yp" prefix. Of note, no stage
group is assigned if there is a complete pathologic response (CR) to neoadjuvant
therapy, for example, ypT0ypN0cM0.
¥¥ T1 includes T1mi.
‡‡ T0 and T1 tumors with nodal micrometastases only are excluded from Stage IIA
and are classified Stage IB.
Used with the permission of the American Joint Committee on Cancer (AJCC),
Chicago, Illinois. The original source for this material is the AJCC Cancer Staging
Manual, Seventh Edition (2010) published by Springer New York, Inc.
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2002 TNM staging classification for breast cancer
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
Tis (DCIS)
Intraductal carcinoma in situ
Tis (LCIS)
Lobular carcinoma in situ
Tis (Paget)
Paget disease of the nipple with no tumor; tumor-associated Paget disease is
classified according to the size of the primary tumor
T1
Tumor 2 cm or less in greatest dimension
T1mic
Microinvasion 0.1 cm or less in greatest dimension
T1a
Tumor more than 0.1 but not more than 0.5 cm in greatest dimension
T1b
Tumor more than 0.5 cm but not more than 1 cm in greatest dimension
T1c
Tumor more than 1 cm but not more than 2 cm in greatest dimension
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,
only as described below:
T4a
Extension to chest wall
T4b
Edema (including peau d'orange) or ulceration of the breast skin, or satellite
skin nodules confined to the same breast
T4c
Both (T4a and T4b)
T4d
Inflammatory carcinoma
Regional lymph nodes (N)
Clinical classification
NX
Regional lymph nodes cannot be assessed (eg, previously removed)
N0
No regional lymph node metastases
N1
Metastasis to movable ipsilateral axillary lymph node(s)
N2
Metastasis to ipsilateral axillary lymph node(s) fixed or matted, or in
clinically apparent ipsilateral internal mammary nodes in the absence
of evident axillary node metastases
N3
N2a
Metastasis to ipsilateral axillary lymph node(s) fixed to one another (matted)
or to other structures
N2b
Metastasis only in clinically apparent (as detected by imaging studies
[excluding lymphoscintigraphy] or by clinical examination or grossly visible
pathologically) ipsilateral internal mammary nodes in the absence of evident
axillary node metastases
Metastasis to ipsilateral infraclavicular lymph node(s) with or without
clinically evident axillary lymph nodes, or in clinically apparent
ipsilateral internal mammary lymph node(s) and in the presence of
clinically evident axillary lymph node metastases, or metastasis in
ipsilateral supraclavicular lymph nodes with or without axillary or
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internal mammary nodal involvement
N3a
Metastasis to ipsilateral infraclavicular lymph node(s)
N3b
Metastasis to ipsilateral internal mammary lymph node(s) and clinically
apparent axillary lymph nodes
N3c
Metastasis in ipsilateral supraclavicular lymph nodes with or without axillary
or internal mammary nodal involvement
Pathologic classification•
pNX
Regional lymph nodes cannot be assessed (eg, previously removed,
or not removed for pathologic study)
pN0
No regional lymph node metastasis; no additional examination for
isolated tumor cells (ITCs, defined as single tumor cells or small
clusters not greater than 0.2 mm, usually detected only by
immunohistochemical or molecular methods but which may be
verified on hematoxylin and eosin (H&E) stains. ITCs do not usually
show evidence of malignant activity [eg, proliferation or stromal
reaction])
pN0(i-)
No histologic nodal metastases, and negative by immunohistochemistry
(IHC)
pN0
(i+)
No histologic nodal metastases but positive by IHC, with no cluster greater
than 0.2 mm in diameter
pN0
(mol-)
No histologic nodal metastases and negative molecular findings (by reverse
transcriptase polymerase chain reaction, RT-PCR)
pN0
(mol+)
No histologic nodal metastases, but positive molecular findings (by RT-PCR)
pN1
Metastasis in 1 to 3 ipsilateral axillary lymph node(s) and/or in
internal mammary nodes with microscopic disease detected by SLND
but not clinically apparent
pN1mi
Micrometastasis (greater than 0.2 mm, none greater than 2.0 mm)
pN1a
Metastasis in 1 to 3 axillary lymph nodes
pN1b
Metastasis to internal mammary lymph nodes with microscopic disease
detected by SLND but not clinically apparent
pN1c
Metastasis in 1 to 3 ipsilateral axillary lymph node(s) and in internal
mammary nodes with microscopic disease detected by SLND but not clinically
apparent. If associated with more than 3 positive axillary nodes, the internal
mammary nodes are classified as N3b to reflect increased tumor burden.
pN2
Metastasis in 4 to 9 axillary lymph nodes or in clinically apparent
internal mammary lymph nodes in the absence of axillary lymph
nodes
pN2a
Metastases in 4 to 9 axillary lymph nodes (at least one tumor deposit >2
mm)
pN2b
Metastasis in clinically apparent internal mammary lymph nodes in the
absence of axillary lymph nodes
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 one or more positive axillary nodes;
or in more than three axillary lymph nodes with clinically negative
microscopic metastasis in internal mammary lymph nodes; or in
ipsilateral supraclavicular lymph node(s)
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
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the presence of one or more positive axillary nodes; or in more than three
axillary lymph nodes with microscopic metastasis in internal mammary lymph
nodes detected by SLND but not clinically apparent
pN3c
Metastasis in ipsilateral supraclavicular lymph node(s)
Distant metastasis (M)
MX
Distant metastasis cannot be assessed
M0
No distant metastasis
M1
Distant metastasis
Stage groupings
Stage 0
Tis
N0
M0
Stage I
T1 (including T1mic)
N0
M0
Stage IIA
T0
N1
M0
T1 (including T1mic)
N1
M0
T2
N0
M0
T2
N1
M0
T3
N0
M0
T0
N2
M0
T1 (including T1mic)
N2
M0
T2
N2
M0
T3
N1
M0
T3
N2
M0
Stage IIIB
T4
N0-2
M0
Stage IIIC
Any T
N3
M0
Stage IV
Any T
Any N
M1
Stage IIB
Stage IIIA
* Dimpling of the skin, nipple retraction, or any other skin change except those
described for T4b and T4d may occur in T1-3 tumors without changing the
classification.
• Classification is based upon axillary lymph node dissection (ALND) with or without
sentinel lymph node dissection (SLND). Classification based solely on SLND without
ALND should be designated (sn) [eg, pN0(i+)(sn)].
AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New
York, Inc. Used with the permission of the American Joint Committee on Cancer
(AJCC), Chicago, Illinois.
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