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Table 16 2 TNM staging for breast cancer (continued)
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pN2 Metastasis in four to nine axillary lymph nodes, or in clinically apparent1 internal mammary lymph nodes in the absence of axillary lymph node metastasis Metastasis in four to nine axillary lymph nodes (at least one tumor deposit greater than 20 mm) Metastasis in clinically apparent1 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 apparent1 ipsilateral internal mammary lymph nodes in the presence of one or more positive axillary lymph nodes; or in more than three axillary lymph nodes with clinically negative microscopic metastasis in internal mammary lymph nodes; or in ipsilateral supraclavicular lymph nodes Distant metastasis (M) Distant metastasis cannot be assessed No distant metastasis Distant metastasis
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Stage grouping Stage 0 Stage 1 Stage IIA Tis T1
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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
T0 T13 T2 T2 T3 T0 T13 T2 T3 T3 T4 T4 T4 Any T Any T
Stage IIB Stage IIIA
pN3a
Metastasis in 10 or more axillary lymph nodes (at least one tumor deposit greater than 20 mm), or metastasis to the infraclavicular lymph nodes Metastasis in clinically apparent 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 microscopic disease detected by sentinel lymph node dissection but not clinically apparent1 Metastasis in ipsilateral supraclavicular lymph nodes
Stage IIIB
Stage IIIC Stage IV
pN3b
Note: 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
pN3c
Clinically apparent is defined as detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination or grossly visible pathologically Not clinically apparent is defined as not detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination 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, eg, pN0(i+)(sn) 3 T1 includes T1mic RT-PCR, reverse transcriptase/polymerase chain reaction Reproduced, with permission, of the American Joint Committee on Cancer (AJCC), Chicago, Illinois AJCC Cancer Staging Manual, 6th edition, SpringerVerlag, 2002 wwwspringeronlinecom
Breast Cancer Occurring during Pregnancy or Lactation
Breast cancer complicates approximately one in 3000 pregnancies The diagnosis is frequently delayed, because physiologic changes in the breast may obscure the lesion When the cancer is confined to the breast, the 5-year survival rate is about 70% In 60 70% of patients, axillary metastases are already present, conferring a 5-year survival rate of 30 40% Pregnancy (or lactation) is not a contraindication to operation or treatment, and therapy should be based on the stage of the disease as in the nonpregnant (or nonlactating) woman Overall survival rates have improved, since
cancers are now diagnosed in pregnant women earlier than in the past and treatment has improved Breast-conserving surgery may be performed and radiation and chemotherapy given even during the pregnancy
Bilateral Breast Cancer
Bilateral breast cancer occurs in less than 5% of cases, but there is as high as a 20 25% incidence of later occurrence of cancer in the second breast Bilaterality occurs more often in familial breast cancer, in women under age 50 years, and when the tumor in the primary breast is lobular The incidence of second breast cancers increases directly
Breast
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Table 16 3 Histologic types of breast cancer
Type Infiltrating ductal (not otherwise specified) Medullary Colloid (mucinous) Tubular Papillary Invasive lobular Noninvasive Intraductal Lobular in situ Rare cancers Juvenile (secretory) Adenoid cystic Epidermoid Sudoriferous Frequency of Occurence 80 90% 5 8% 2 4% 1 2% 1 2% 6 8% 4 6% 2 3% 2 3% < 1%
should not occur unless there is an occult invasive cancer Sentinel node biopsy may be indicated in large DCIS treated with mastectomy
Barni S et al Locally advanced breast cancer Curr Opin Obstet Gynecol 2006 Feb;18(1):47 52 [PMID: 16493260] Fisher ER et al Pathologic findings from the National Surgical Adjuvant Breast and Bowel Project: twelve-year observations concerning lobular carcinoma in situ Cancer 2004 Jan 15;100 (2):238 44 [PMID: 14716756] Habel KL et al A population-based study of tumor gene expression and risk of breast cancer death among lymph nodenegative patients Breast Cancer Res 2006;8(3):R25 [PMID: 16737553] Irvine T et al Biology and treatment of ductal carcinoma in situ Expert Rev Anticancer Ther 2007 Feb;7(2):135 45 [PMID: 17288525] Kawase K et al Paget s disease of the breast: there is a role for breast-conserving therapy Ann Surg Oncol 2005 May;12(5): 391 7 [PMID: 15915373] Lerebours F et al Update on inflammatory breast cancer Breast Cancer Res 2005;7(2):52 8 [PMID: 15743511] Ring AE et al Breast cancer and pregnancy Ann Oncol 2005 Dec;16(12):1855 60 [PMID: 16030024] Tai P et al Short- and long-term cause-specific survival of patients with inflammatory breast cancer BMC Cancer 2005 Oct 22;5:137 [PMID: 16242046]
with the length of time the patient is alive after her first cancer about 1 2% per year In patients with breast cancer, mammography should be performed before primary treatment and at regular intervals thereafter, to search for occult cancer in the opposite breast or conserved ipsilateral breast
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