AJCC CANCER STAGE. Site-Specific Instructions - BREAST. Reference: AJCC Cancer Staging Manual, 7 th Edition

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1 Slide 1 AJCC CANCER STAGE Site-Specific Instructions - BREAST Reference: AJCC Cancer Staging Manual, 7 th Edition In this presentation, we are going to review the AJCC Cancer Staging criteria for the breast primary site. It is important that you follow along and make notes in your manual. In addition to reading the slides and the instructor s notes, it is important that you stop and read the related sections in your manual as not every point will be discussed in detail. Don t forget the general rules, including the timing rules. These still apply.

2 Slide 2 TOPOGRAPHY Right Breast 1:00 UOQ UIQ LOQ LIQ First let s review the anatomy of the breast. Because staging is based on where the cancer started and what other tissues or organs are involved, it is important to understand where these structures are in relation to the breast. The breast is divided into 4 quadrants. The topography subsites and the corresponding area of the breast are shown here on this slide. This is a picture of the right breast that is divided into four quadrants. The UIQ would be C50.2, etc. The code C50.0 is used to describe the nipple and areola. If the primary site is the central portion of the breast, subareolar, or beneath the areola use primary site code C50.1.

3 Slide 3 TOPOGRAPHY Image Source: SEER Training Website Or, it can be divided into sections like the face of a clock. Note that for the clock positions, the sections are not mirror images of each other. The 1 o clock position on the right breast is in the UIQ where as on the left breast, the 1 o clock position would be the UOQ.

4 Slide 4 TOPOGRAPHY C50.8 Overlaps more than one quadrant Upper, lower, inner, outer, medial, lateral 3:00, 6:00, 9:00, 12:00 C50.2 C50.8 C50.3 C50.4 C50.5 Left Breast C50.9 Involved quadrant unknown Multiple tumors in the same breast one primary tumors in different quadrants C50.2 C50.4 C50.9 C50.3 C50.5 The overlapping lesion code C50.8 is used to describe when one tumor occupies more than one quadrant and the point of origin is unknown. If the primary site is described as being in the upper, or the inner, or the lateral portion of the breast, and the quadrant that the tumor started in cannot be determined, the ICD-O-3 primary site code is C50.8, overlapping lesion of breast, because a more specific subsite cannot be determined with that description alone. The 3 o clock (as well as 6, 9, and 12) are also considered an overlapping location and are assigned a code of C50.8 as well. The code C50.9 is used when you know the breast is the primary site but you don t know exactly which quadrant is involved. Also, if you have more than one tumor (considered a single primary), and each tumor is in a different quadrant (IE: one in the LIQ and one in the LOQ), then the appropriate code is C50.9. The larger tumor is not always where the tumor started. Picking one quadrant over another does not accurately describe the presentation of this cancer. Therefore, the best choice is to assign C50.9. If there are multiple tumors and all tumors are in the SAME quadrant, then it is appropriate to assign that quadrant as the primary site.

5 Slide 5 BREAST ANATOMY This picture shows the location of the ducts and lobules. There are about lobes in each breast arranged radially around the nipple. The lobes are further subdivided into lobules which are drained by a system of ducts. The ducts (or lactiferous ducts) is the main excretory duct that connects the glands to the nipple. The aerola is the pigmented skin around the nipple. The fatty connective tissue (or adipose tissue) is the filler tissue around and between the ducts and lobules and gives the breast its shape. The amount of tissue varies depending on the size of the breasts. Two common types of breast cancer are duct and lobular carcinoma. Infiltrating and in situ duct carcinomas arise in the ducts. Infiltrating and in situ lobular carcinoma arise in the lobules. Sarcomas of the breast would arise in the connective tissue. However, sarcomas of the breast are quite rare.

6 Slide 6 BREAST ANATOMY Here is another view of the breast and the relationship of the breast tissue to the chest wall, muscles and ribs. The pectoralis muscle lies between the chest wall and the breast tissue. The chest wall consists of the rib, intercostal muscles and the serratus anterior muscle (but not the pectoralis muscle). Usually if extension to the muscle, nos is mentioned (especially if a modified radical mastectomy was done and chest wall is not stated), this usually means the pectoralis muscle. There are also ligaments (Cooper s ligaments) that provide support for the breast.

7 Slide 7 Of particular interest on this slide are the location of the lymph nodes. The axillary nodes are shown here under the arm and above the breast (low, mid, high). For the purpose of staging, intramammary nodes are considered axillary nodes. 75% of lymph node mets are through the axillary LN route. The internal mammary (these are not the same as intramammary) lie along the sternum in the intercostal spaces. Supraclavicular nodes are found under AND above the clavicle. Common metastatic sites are through the distant lymph nodes near the breast (supraclavicular, cervical, contralateral axillary). Also, breast cancer cells commonly spread through the blood to the bone, liver and brain.

8 Slide 8 CLINICAL STAGING: BREAST CANCER For breast: microscopic examination to confirm a diagnosis is Physical examination of breast, skin, and lymph nodes Imaging findings For the breast, microscopic examination of the breast (or other tissues) is mandatory to establish a diagnosis of breast carcinoma for AJCC Staging. Clinical staging for breast cancer should include careful examination of the skin, mammary gland and lymph nodes. The next two slides list some specific details of what to look for to help determine the clinical stage. Once any treatment has began, you cannot use any information following initiation of that treatment for clinical stage.

9 Slide 9 WHAT TO LOOK FOR Clinical Examination Changes in skin texture and color Nipple retraction or discharge Description of inflammatory Palpable masses Fixation of tumor Palpable lymph nodes Symptoms of metastasis bone pain, CNS problems, etc. Work-up for breast cancer begins with the physical examination. The breast should be examined and palpated for a mass. Lymph nodes in the arm, neck and chest area should be evaluated for swelling or adenopathy. In addition, other changes to breast, such as those listed on this slide, may be described and should be documented in the text.

10 Slide 10 WHAT TO LOOK FOR Imaging Studies Mammography Unsuspected mass on screening mammogram Size and Location Suspicious is not the same as suspicious for carcinoma. Must include statement of malignancy to constitute as a diagnosis Breast Ultrasound Size and Location Bone Scan CT Chest/Abdomen Mammography is used to identify location and other characteristics of a palpable breast mass. It is also used as a screening tool to identify possible breast malignancies before a mass is palpable. It is possible that the mammogram will just state suspicious. This is not a diagnosis of cancer and is not used as the date of diagnosis. There must be a statement of malignancy in addition to the use of an ambiguous term. Breast ultrasound may also be used to identify characteristics of a breast mass including size and location. Imaging such as bone scans, chest x-rays and CTs help in the identification of metastasis. For all imaging studies, you are looking for the size of primary tumor, chest wall invasion, and the presence or absence of regional or distant metastases.

11 Slide 11 PATHOLOGICAL STAGING: BREAST CANCER All data from clinical classification PLUS Surgical resection of tumor with no tumor grossly in the margins (macroscopically positive) the margins can be microscopically positive Resection of at least the low axillary nodes (Level 1) Generally includes 6 or more nodes Generally for invasive tumors, but there are exceptions or 1 or more sentinel lymph nodes resected To assign the Pathologic T (pt), there must be a resection of the tumor. And, the margins on the FINAL surgical resection must be negative or only MICROscopically positive. If the margins are MACROscopically positive, the case does not qualify for pathologic staging. The pt will be a ptx. See the following slide for a discussion of excision versus incision. To assign the Pathologic N (pn), it is recommended that at least the low axillary nodes (level 1) be resected. Usually six or more nodes would ordinarily be included in such a resection. But, remember from the discussion of the general rules, if less than 6 are removed, the status of the nodes that are removed should be coded. Or, instead of an axillary lymph node dissection, one or more sentinel lymph nodes may be resected and examined for pathologic staging. The sentinel node is the first lymph node in the first draining lymph node basin. If it is negative, it is assumed that all the rest of the nodes are negative. See the next slide for a more detailed description of a sentinel lymph node biopsy.

12 Slide 12 SENTINEL LYMPH NODE (SLN) BIOPSY A SLN is the first lymph node(s) to which cancer cells are likely to spread from the primary tumor A radioactive dye is injected in the tumor. The dye follows the lymphatic path to the first node in the drainage area of the tumor A scanner is used to identify the radioactive node and remove it If the SLN does not contain cancer cells, the rest of the regional lymph nodes may not need to be removed. It can be presumed that the nodes located after the SLN are also negative. Because fewer lymph nodes are removed, the potential for side effects is lower The sentinel lymph node is the first lymph node to which cancer is likely to spread from the primary tumor. Cancer cells may appear in the sentinel node before spreading to other lymph nodes. In some cases, there can be more than one sentinel lymph node. A SLN biopsy is a procedure in which the sentinel node is removed and examined under a microscope to determine whether cancer cells are present. SLN biopsy is based on the idea that cancer cells spread in an orderly way from the primary tumor to the sentinel lymph node(s), then to other nearby lymph nodes. A negative SLN biopsy result suggests that cancer has not spread to the lymph nodes. A positive result indicates that cancer is present in the SLN and may be present in other lymph nodes in the same area. In SLN biopsy, one or a few lymph nodes (the sentinel node or nodes) are removed. To identify the sentinel lymph node(s), the surgeon or radiologist injects a radioactive substance, blue dye, or both near the tumor. The surgeon then uses a scanner to find the sentinel lymph nodes(s) containing the radioactive substance or looks for the lymph node(s) stained with dye. Once the SLN is located, the surgeon makes a small incision (about ½ inch) in the skin overlying the SLN and removes the node(s). The sentinel node(s) is/are checked for the presence of cancer cells. If cancer is found, the surgeon will usually remove more lymph nodes during the biopsy procedure or during a follow-up surgical procedure. SLN biopsy may be done on an outpatient basis or require a short stay in the hospital. To understand the possible benefits of SLN biopsy, it helps to know about standard node removal. Standard node removal involves surgery to remove most of the nodes in the area of the tumor (regional lymph nodes). For example, breast cancer surgery may include removing most of the axillary lymph nodes, the group of lymph nodes under the arm. This is called an axillary lymph node dissection (ALND). If a SLN biopsy is done and the sentinel node does not contain cancer cells, the rest of the regional lymph nodes may not need to be removed. It can be presumed that the nodes located after the sentinel node are also negative. Because fewer lymph nodes are removed, there may be fewer side effects. When multiple regional lymph nodes are removed, the patient may experience side effects such as lymphedema (swelling caused by excess fluid build-up), numbness, a persistent burning sensation, infection, and difficulty moving the affected body area. Lymphoscintigraphy: Mapping of sentinel lymph nodes using radioisotopes to identify nodes for removal by sentinel node biopsy.

13 Slide 13 WHAT TO LOOK FOR Pathology Fine Needle Aspiration (FNA) With cells or fluid only Incisional vs Excisional Biopsies Look at the resection margins Excisional biopsy is a biopsy with only microscopically positive margins or no residual tumor on further resection. Considered surgical resection, not a diagnostic biopsy. Tumor size, grade, margins Lab Values (ERA, PRA, HER2) In general, the findings from a biopsy are included in the clinical stage. It is possible that a biopsy of a small breast tumor will result in removal of the entire tumor. When further surgery is done (lumpectomy or mastectomy), there is no residual evidence of the carcinoma. These biopsies that result in removal of the entire tumor are called excisional biopsies. The excisional biopsy will be considered part of the surgical treatment of the cancer, not a diagnostic biopsy. The findings from the excisional biopsy can be used in assigning the pathologic stage. The margins are also used to define if the biopsy is an incisional biopsy or an excisional biopsy. If there are MACROscopically positive margins (tumor can be seen at the margin grossly, or with the naked eye), the biopsy is an incisional biopsy. If the margins are negative or are only MICROscopically positive (tumor can be seen at the margin only under a microscope), the biopsy is considered an excisional biopsy. When a biopsy is done, look at the resection margins and look to see what residual tumor was remaining after further surgical resection to determine if it applies to clinical or pathologic staging.

14 Slide 14 "T" CLASSIFICATION: BREAST CANCER Size of the primary tumor is the key factor Review the section on Pathologic T on page 10 Review the section on Primary Tumor (T) on page 358 Review the Summary of Changes for the Tumor (T) on pages Review the section on Primary Tumor (T) on pages There are many different factors that affect how the T category will be assigned. It is important that you are familiar with what these different scenarios are. If a case you are abstracting involves one these scenarios, it is important that you review this information carefully in the manual to determine how they should be handled.

15 Slide 15 TUMOR SIZE T categories are very specific Round to the nearest mm (1cm = 10mm) Rounding guidelines: Page mm tumor: Round up. 11mm = T1c 2.04cm tumor: Convert to mm. 2.04cm = 20.4mm. Round down. 20mm = T1c Code the size of the invasive tumor Example: Tumor with large in situ component (4 cm) and small invasive component (0.5cm) Assign the T based on the invasive component. 5mm = T1a Tumor submitted in one block: Use microscopic description Tumor submitted in more than one block: Use gross description Do not add pieces together but may be done by the pathologist Because tumor size determines the T category, it is important that the size be determined as exactly as possible. The cutoffs for each T category are very specific. The T is based on the tumor size measured in millimeters. If the tumor size is reported as centimeters, then convert the centimeters to millimeters and then round to the nearest millimeter. Page 10 of the manual provides guidelines on how to round (up or down). Examples: If a tumor is 10.7mm, round up to 11mm. An 11mm tumor is a T1c. If a tumor is reported as 2.04cm you must first convert to mm. 2.04cm = 20.4mm. Then round to nearest mm. 20.4mm = 20mm. A 20mm tumor is also a T1c. For the clinical T, when there are multiple reports that state a multiple of tumor sizes, the manual does not specify which one has the priority. Instead, it states that the size should be taken from the report that would be considered to have the most accurate size for the case. The physicians should be assigning the clinical stage and would be able to make this determination. For the pathologic T, if the tumor has both invasive and in situ components, the T should be based on the size of the INVASIVE component only. The slide provides an example. Assigning this tumor as a T2 based on the 4cm tumor puts this case into a group with much larger tumor sizes when the invasive component (the component with the greatest potential to spread) was only.5cm. If the tumor is removed in more than one piece, and more than one tumor size is reported, the registrar should not be adding the pieces together. For a 1x2mm piece and a 3x4mm piece, do you add the 1 and 3, or 2 and 3? The registrar does not know how these tumors were oriented and therefore cannot make a decision on the overall tumor size. The pathologist may reconstruct the tumor size and report it on the pathology report. If so, then the aggregate size may be used by the registrar to determine the T.

16 Slide 16 "T" CLASSIFICATION: SPECIAL CONSIDERATIONS Multiple lesions in one breast One primary Use largest tumor size to assign the T category If multiple foci of microinvasion, code only the size of the largest focus. (Do not add sizes together.) Use multiplicity designation if possible T1(m) Analyze separately Simultaneous bilateral Multiple primaries Stage each primary separately If there are multiple lesions in one breast (and the MPH rules state it is a single primary), use the largest tumor size to classify the T category. Remember not to add the sizes together. There are special data items to record multiplicity in the cancer registry abstract, but this should also be documented in the text section of the abstract. Also, the T should be followed by the number of tumors in parenthesis to signify multi-focal (page 12). Example, 2 tumors, the largest measuring 7mm would be T1b(2). Tumors in each breast are considered separate primaries according to the MPH rules. In a case of simultaneous bilateral primaries, prepare an abstract for each primary and stage each primary separately.

17 Slide 17 "T" CLASSIFICATION: TERMS FOR IN SITU Non-infiltrating No stromal involvement Non-invasive Intracystic Intraductal Lobular neoplasia DCIS Confined to epithelium LCIS Intraepithelial Stage 0 Intraepidermal Papillary intraductal Paget s disease of the nipple with no underlying invasive cancer Tis for the breast is divided into 3 categories: DCIS, LCIS and Paget s. This slide lists some common terms used to describe in-situ in breast cancer. The ones on the left are probably more common. The ones on the right may be some that you don t see as often are therefore a little harder to remember.

18 Slide 18 PAGET DISEASE (8540/_) Histology: Based on statement by pathologist Can be in situ or invasive Usually /3 Change to /2 if called in situ on pathology report T category: Based on presence of underlying tumor or not WITH palpable mass Invasive component on pathology Assign T based on size of the underlying invasive tumor WITH palpable mass No invasive component on pathology Assign Tis (DCIS) or Tis (LCIS) based on histology of underlying noninvasive tumor WITHOUT underlying mass These are the ONLY tumors assigned as Tis (Paget s) Regardless of behavior code Review the paragraph on Paget s disease on page 354. Paget disease is a crusty like tumor of the nipple and areola. Paget is the presence of glandular cells (ductal carcinoma) in the squamous epithelium of the skin of the nipple. The glandular cells had to get to the skin by invasion from a duct. Therefore, it is usually associated with an underlying tumor of the ducts, but not always. Note: Pagetoid spread is a description of the spread and is not the same as Paget's disease of the nipple. In the ICD-O-3 (page 81), Paget disease is listed as 8540 with a behavior code of 3 (invasive). There is no listing for in situ. A statement of just Paget disease, without any other description, is correctly coded as behavior code 3. However, Paget disease can be either in situ or invasive. You should code the behavior stated in the pathology report. If the pathology states specifically that it is in situ, then assign a behavior code of /2. The survival rates for these are nearly identical to in situ ductal carcinoma (which is why AJCC groups Paget Disease with Tis), even if the behavior is /3. Paget is grouped with Tis because of its prognosis, not its behavior. Summary Stage in this case would be localized according to SEER. The behavior code for Paget by itself should only be changed to /2 if the pathologist calls it Paget disease in situ. This is also addressed in the breast MPH histology rules. So, you will code the behavior code based on what the pathologist calls it on the pathology report. You will assign the T category based on whether or not there is an underlying tumor or not. Paget disease with a palpable mass (on clinical exam) and with an invasive component (on pathology) is classified according to the invasive mass component. If there was a palpable mass, but there was no invasive component on the pathology, then assign Tis (DCIS) if the non-invasive tumor was DCIS or Tis (LCIS) if the non-invasive tumor was LCIS. If there is no underlying mass, again, the behavior can be in situ or invasive depending on what they called the Paget disease on pathology, then these are the only tumors that will be assigned a Tis (Paget s).

19 Slide 19 <=1mm >10mm and <=20mm >5mm and <=10mm >1mm and <=5mm Source: TNM Atlas. Do not reproduce. This slide gives a graphic view of the different T categories or primary tumor classifications. The next few slides will demonstrate how the larger the tumor is the higher the T category. Primary tumor (T) definitions are the same for clinical and pathological staging for the basic categories of T. T1 is an NOS category and is only used when there is not enough detailed information to assign the specific T1mi T1c subcategories. T1mic (microscopic invasion) is a path only stage. It would be difficult to determine there was only microscopic invasion unless it were examined under a microscope.

20 Slide 20 >20mm and <=50mm 50mm Source: TNM Atlas. Do not reproduce. Here you can get an idea of the T2 and T3 tumors. Notice that as the size increases, so does the T value.

21 Slide 21 "T4" CLASSIFICATION: Tumors can be any size Use if there is DIRECT extension to the: Chest wall Ribs under the chest wall Muscle under the chest wall Skin Inflammatory carcinoma Not a factor in staging Dimpling Tethering Nipple retraction Lymphatic invasion, NOS LVSI, NOS The T4 categories describe tumors that extend beyond the breast parenchyma. This includes extension to the chest wall, the ribs and muscle under the chest wall, the skin and inflammatory carcinoma. Review the paragraph on Chest Wall on page 352. The chest wall does not include the pectoral muscle. There can be several terms used to describe involvement of the skin. The use of the words dimpling, tethering, and nipple retraction does not mean skin involvement and does not affect which T category to choose. Again, T4 is a NOS description and should only be used when there is not enough details to assign T4a T4d.

22 Slide 22 Chest wall includes Ribs Intercostal muscles Serratus anterior muscle Does NOT include Pectoral muscle Source: TNM Atlas. Do not reproduce. T4a includes direct extension to the chest wall. This can be the ribs, intercostal muscles and serratus anterior muscle, but not the pectoral muscle.

23 Slide 23 OR Skin involvement described as: Edema of skin En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin") Source: TNM Atlas. Do not reproduce. Ulceration of the skin or a satellite skin nodule confined to the same breast are T4b classifications. The involvement would be of less than 1/3 of the breast and would not meet the criteria for inflammatory carcinoma. The following terms used to describe the skin involvement are also assigned T4b: Edema of skin En cuirasse Erythema Inflammation of skin Peau d'orange ("pigskin") All of these skin conditions indicate that the skin of the breast is involved extensively by tumor. These skin conditions alone are not a diagnosis of inflammatory carcinoma. These are the patients that will probably have neo-adjuvant treatment followed by a mastectomy.

24 Slide 24 Source: TNM Atlas. Do not reproduce. The term Peau d orange means it looks like an orange peel.

25 Slide 25 Source: TNM Atlas. Do not reproduce. T4c is a combination of both T4a and T4b. There is extension to chest wall AND ulceration AND/OR satellite nodules or edema (or any of the terms on the previous slide).

26 Slide 26 INFLAMMATORY BREAST CARCINOMA T4D Usually observed on physical exam Is a clinical diagnosis Need statement of inflammatory carcinoma Involves 1/3 or more of the skin May not state inflammatory on path report Use specific ICD-O-3 code ONLY IF stated on pathology: 8530/3 NCI Visuals Online. Terese Winslow (artist) Review the paragraph on Inflammatory Carcinoma on pages T4d is inflammatory carcinoma. Again, these are the patients that will probably have neo-adjuvant treatment followed by a mastectomy. Even the smallest, localized cancer, if left untreated, can eventually grow to involve the skin. The term inflammatory carcinoma should not be applied to a patient, such as this, with a neglected cancer presenting late in the course of the disease. IBC usually involves the majority of the skin of the breast and changes arise very quickly in the affected breast. Often there is no underlying palpable mass. Inflammatory carcinoma is primarily a clinical diagnosis. So, a statement of inflammatory carcinoma will probably be made on reports and dictation other than the pathology report. IBC is believed to be due to lymphatic obstruction from an underlying invasive adenocarcinoma. The vast majority of cases have a prominent dermal lymphatic infiltration by tumor. Dermal lymphatic infiltration without the characteristic clinical picture of inflammation is insufficient to qualify as inflammatory carcinoma. There has to be a statement of inflammatory carcinoma in order to assign a T4d. As you learned in the MP/H rules, the inflammatory carcinoma is only coded in the histology if it is stated in the final diagnosis on the pathology report. IBC has a specific code (8530) and is never in situ or localized. If there is a clinical statement of IBC, but the path report only states invasive ductal carcinoma, then code the histology stated on the path report (8500/3). The IBC will be reflected in the stage.

27 Slide 27 N" CLASSIFICATION: BREAST CANCER Two separate lists of codes and definitions Clinical N based on: Location of involved nodes If nodes are moveable, fixed or matted If nodes are clinically detected or not cn0 no suspicious nodes on clinical workup Pathologic N based on: Location of involved nodes Number of involved nodes Size of metastasis in the involved nodes If nodes are clinically detected or not The N classification for the regional lymph nodes have different definitions according to time frame. There is one for the clinical stage and one for the pathologic stage. The clinical N looks more at if the involved nodes were moveable or fixed and if they were clinically apparent (detected) or not. The pathologic N looks more at the number of involved nodes and the size of the metastasis within the involved nodes. For the clinical N, cn0 should be assigned where there are no suspicious nodes noted on either clinical exam or imaging studies. The definitions for each N category contain a variety of combinations of involvement. Often, it just takes practice and application in order to gain a thorough understanding of what is included in each category. This is definitely not something that can be memorized. Once the facts about the case are known, the appropriate N category based on that facts should be investigated.

28 Slide 28 Axillary, NOS: REGIONAL LYMPH NODES Level I (low) (superficial), NOS [adjacent to tail of breast]: Anterior (pectoral) Lateral (brachial) Posterior (subscapular) Level II (mid-level) (central), NOS: Interpectoral (Rotter s) Level III (high) (deep), NOS: Apical (subclavian) Axillary vein Intramammary Infraclavicular (subclavicular) Internal mammary (parasternal) Regional lymph node(s), NOS Nodules in axillary fat The regional lymph nodes for the breast are listed on this slide. The breast lymphatics drain by way of three major routes: axillary, transpectoral, and internal mammary. Intramammary lymph nodes are considered with, and coded as, axillary lymph nodes for staging purposes. So, it is listed under the Axillary NOS heading. All of the regional lymph nodes are ipsilateral, meaning they are located on the same side as the primary site. There are several words used to describe the different levels of axillary lymph nodes. You can find all of these terms (and the regional nodes for all sites, for that matter) in the Summary Staging Manual for each primary site. The AJCC and summary staging manual are excellent resources for additional information such as this. Nodules in the axillary fat are coded as lymph nodes. These are considered axillary nodes that have lost their structure or are intransit mets in the lymphatics.

29 Slide 29 A B C A) Axillary lymph nodes, level I, II, III B)Supraclavicular lymph nodes C) Internal mammary lymph nodes This slide provides a graphic representation of the regional nodes for the breast.

30 Slide 30 CLINICALLY DETECTED Clinically Detected: Detected by imaging studies or by clinical examination Example: Enlarged internal mammary node consistent with metastasis. No palpable axillary nodes. Not Clinically Detected: Not detected by imaging studies or by clinical examination Example: No palpable or suspicious nodes on clinical workup Sentinel node bx of internal mammary node positive It is important that you understand Clinically Detected and Not Clinically Detected in order to assign the N category. The code that you choose may depend on whether or not the nodes were clinically detected. A definition of each of these terms is also provided in the manual on pages 359 and 360.

31 Slide 31 CLINICAL N (CN) N Axillary nodes Internal Mammary Infraclavicular Supraclavicular N1a N2a * (movable) * (fixed) N2b * N3a * N3b * * N3c * This table does try to provide a brief summary of the focus of each N category for the clinical N. As you can see, the farther away from the primary site, the higher the N category. To understand the table, compare the N category in the table with the N category listed in the manual. N2 and N3 are NOS categories and should only be assigned when the details do not allow for the assignment of the more specific subcategories. Note about cn3c: cn3c is assigned when the supraclavicular nodes are involved clinically, regardless of the status of the axillary or internal nodes (+/-). Also, all of the nodes listed for cn are ipsilateral meaning on the same side of the body as the primary site. If the contralateral nodes are involved, this would be considered distant disease and reflected in the M category.

32 Slide 32 ISOLATED TUMOR CELLS (ITC) Single Tumor Cells or small clusters Mets measure < 0.2mm Fewer than 200 cells Detected by IHC or molecular methods May be verified on routine H&E stains Usually does not show evidence of malignant activity FOR BREAST: Nodes with ITC only are NOT considered positive lymph nodes, pn0(i+) For melanoma and Merkel cell carcinoma, + ITCs are considered positive lymph nodes The pn also introduces another new term: Isolated tumor cells (ITC). Review the section on Isolated Tumor Cell Clusters and Micrometastases on pages Review the paragraph on ITC s on page 11. Evaluation for detecting isolated tumor cells (ITC) is performed when deemed necessary. ITCs are single tumor cells within a lymph node and by definition measure <= 0.2mm. For the breast, nodes with ITC are not considered positive lymph nodes. This rule is site-specific. Be sure to review and apply the site specific rules for each site.

33 Slide 33 PATHOLOGIC N (PN) Isolated tumor cells (ITC) vs Micrometastases ITCs: <= 0.2mm designated as pn0 (i+) Micromets: > 0.2mm and <= 2mm designated as pn1mi Metastasis: > 2mm designated as pn1a or higher Molecular techniques pn0 (mol-) or pn0 (mol+) Sentinel node dissection info only pn_ (sn) The size of the metastasis in the lymph node determines if the patient has micromets or ITCs in the lymph nodes. Isolated tumor cells (ITCs) are defined as single cells or small clusters of cells not greater than 0.2mm in largest dimension and usually have no histologic evidence of malignant activity. In a patient who has had a negative lymph node dissection and an additional immunohistochemical examination was made for ITCs, the case would be staged as pn0(i-) or pn0(i+) based on the findings of the ITCs. Micrometastasis is defined as tumor deposits greater than 0.2mm but not greater than 2.0mm and have evidence of malignant activity. These cases would be considered a pn1mi. If nodes are positive but size of the mets is not stated, assume the mets are > 2 mm. A patient who had a sentinel node examination without a subsequent axillary dissection would be classified as pn(sn). The sn after the pn designation means that this is based solely on the pathological examination of the sentinel node(s).

34 Slide 34 BREAST PN N (path) Axillary nodes Internal mammary (IM) nodes N1 N1a 1-3 nodes N1b sentinel nodes, not clinical N1c sentinel nodes and 1-3 axillary nodes N2 N2a 4-9 nodes N2b clinical, no axillary nodes N3 N3a 10+ nodes or infraclavicular nodes N3b clinical axillary N3b sentinel nodes + > 3 axillary nodes N3c supraclavicular nodes Again, this table provides a brief summary of the focus of each N category for the pathologic N. To understand the table, compare the N category in the table with the N category listed in the manual. For the most part, the a subcategory (N1a, N2a, N3a) include involvement of the axillary nodes only. The b and c subcategories usually mean involvement of the internal mammary nodes with or without axillary node involvement. It also includes supraclavicular node involvement. N1, N2 and N3 are NOS categories and should only be assigned when the details do not allow for the assignment of the more specific subcategories.

35 Slide 35 "M" CLASSIFICATION: BREAST CANCER Identifies distant site(s) of metastatic involvement at time of diagnosis Special code of cm0(i+) Distant Node Involvement Any contralateral or bilateral node involvement Cervical and any nodes not listed as regional Supraclavicular nodes are coded under the N category Further contiguous extension to the skin Other discontinuous metastases The M category identifies the distant site(s) of metastatic involvement at the time of diagnosis. M includes any contralateral or bilateral node involvement, including contralateral axillary nodal involvement. Also, any nodes that are not listed as regional are classified in the M category. Supraclavicular node involvement was included in the N category. Note: in Summary Stage, supraclavicular nodes are considered distant. Direct extension to certain areas of the skin are considered distant. These are areas other than the skin of the primary breast, including the axilla, contralateral breast, sternum and upper abdomen. And, of course all other sites with discontinuous metastases are included here. For the breast, there is an additional M code of cm0(i+). This code is used when special studies are done and it identifies microscopic tumor cells in a non-primary or nonregional site. There are no other clinical signs of metastasis. Any clinical evidence of metastasis or mets that are histologically larger than 0.2mm, will be coded as M1.

36 Slide 36 "M" CLASSIFICATION: BREAST CANCER There is no pathologic M0 (pm0) A biopsy or removal of a suspected distant site Pathology report is negative cm0 A biopsy or removal of a distant site Pathology report is positive pm1 Don t forget, there is no pathologic M0. AJCC does not recognize a pathologic M0 category since it is not possible to rule out all possible metastatic sites. Therefore, if the patient has a biopsy or even if they remove an entire distant site and the pathology report is negative, this does not meet the criteria of pathologic staging. This should be assigned a cm0. This only applies to M0, not to all M categories. You can have a pathologic M1. If they remove a distant site and it is positive, this would be a pm1.

37 Slide 37 STAGE GROUP Clinical: ct cn cm ct cn pm ptis cn cm Pathologic: pt pn pm pt pn cm ptis cn cm ct1b cn0 cm0 = Stage IA ct2 cn2a cm0 = Stage IIIA pt1c pn1mi cm0 = Stage IB pt2 pnx cm0 = Stage 99 Now that you have the T, N and M for both the clinical and pathologic classifications, you can assign the Stage Group. Remember the stage groups are purely clinical (ct cn cm) or purely pathologic (pt pn pm). You do not mix, for example, a pt with a cn, when the cn is unknown, to get a pathologic stage group. And, remember the exceptions. The M can be either pathologic or clinical and in situ tumors (Tis) are both clinical and pathologic. The boxes at the bottom provide a few examples. As you can see, unknowns in the T, N, or M will most likely prevent the case from being assigned a stage group and will be a stage group unknown (99). The * associated with T1 tells you that even though T1mic, T1a, T1b and T1c aren t shown, they fit in the T1 category in this table. And, the same with the N. N1, N2, and N3 include the subcategories (except for N1mi in a T0 or T1 tumor). T4 puts the case into at least a IIIB category and N3 automatically puts a case into at least IIIC category or stage. M1 disease is always a stage IV.

38 Slide 38 RESOURCES AJCC Cancer Staging Manual, Seventh Edition CDC NPCR Education and Training Series Collaborative Staging Manual and Coding Instructions ICD-O-3 SEER Training Website TNM Atlas, 3rd ed. 2nd rev., by B. Spiessl et al. Springer Verlag 1992 The graphics, coding instructions, and other supportive information were provided by the following resources. Slide 39 This Concludes This Presentation Please return to the course content to complete additional case scenarios to reinforce the coding instructions.