596
Fig. 48.2 Schematic diagram o f
the breast and regional lymph
nodes
RULES FOR CLA SSIFICATIO N
T h e an ato m ic T N M system is a m eth o d fo r co d in g ex ten t o f
d isease. T h is is do ne by a ssig n in g a categ o ry o f ex tent o f d is-
ease fo r the tu m o r (T ), re g io n a l lym p h n od es (N ), and d istant
m etastases (M ). T, N , and M are a ssig n e d by c lin ical m eans
and by ad d in g surg ical find ings an d p ath o lo g ical in fo rm ation
to the clin ical info rm atio n (see C h ap ter 1). T h e d o cu m en ted
pro g n o stic im p act o f p o stn eo a d ju v a n t ex te n t o f d isea se and
resp o n se to th erap y w a rra n t c le ar d e fin itio ns o f the use o f the
“y p " prefix and re sp o n se to therapy. T h e use o f n eoad ju v an t
therap y do es not c h an g e th e c lin ical (p retreatm en t) stage. A s
p e r T N M rules, th e c lin ical stage is identified w ith the prefix
“c” (e.g., cT ). In a d d ition, clin ic al stag in g can in clud e th e use
o f fine need le asp iratio n (F N A ) o r co re n eed le b io p sy and
sentin el lym ph nod e b io p sy b efo re n eo ad ju v an t therapy.
T h ese are den o ted w ith th e p o stscrip ts “f ’ an d “sn,” re sp ec -
tively. N o dal m etastases co n firm ed by F N A o r co re n eed le
b io p sy are c lassified as m a c ro m e tasta se s (cN 1), re g a rd le ss o f
the size o f the tu m o r focus in the final p ath o lo g ical sp ecim en .
A m erica n Jo in t C o m m itte e on C án ce r • 2017
F o r ex am p le, if, p rio r to n e o ad ju v an t sy stem ic therapy, a
p atien t w ith a 1 cm p rim ary h as no p alp ab le nodes but has an
u ltraso u n d -g u id e d F N A b iop sy o f an ax illary lym p h node that
is po sitiv e, the p a tie n t w ill be c ateg o rize d as c N 1 (f) fo r clini-
cal (p retrea tm e n t) stag in g and is assig n ed to Stage
IIA . L ikew ise, if the p atien t h as a p o sitiv e axillary sentinel
nod e id en tified p rio r to n eo ad ju v an t sy stem ic therapy, the
tu m o r is c ateg o rize d as c N l (sn) (S tag e IIA ). A s p er TNM
rules, in the a b se n c e o f path o lo g ical T e v alu ation (rem oval of
the p rim ary tu m o r), w h ich is id entified w ith prefix “p ” (e.g.,
pT ), m ic ro sc o p ic e v alu atio n o f n o d e s b efo re neoadjuvant
therapy, even by c o m p le te rem o v al such as sentinel node
biopsy, is still c lassified as c lin ic al (cN ).
Clinical Classification
C lin ic al c ateg o riza tio n o f a c á n c e r is b a se d on findings of
history, p h y sica l e x am in atio n , an d any im a g in g studies that
are d one. Im a g in g stu d ie s are no t re q u ire d to assig n clinical
48 Breast 597

c ateg o ries o r stage. C ase s w ith a b io p sy o f ly m p h n o d e s o r

m e ta sta tic sites m ay b e s tag e d c lin ic ally , in c lu d in g th e b io p sy T1
in fo rm a tio n .

Physical Examination
P hysical e x a m in a tio n in c lu d e s c a refu l in s p e c tio n and p a lp a -
tion o f the skin, m a m m a ry g la n d , an d ly m p h n o d e s (ax illary ,
>10-20 mm=T1c
su p ra cla v ic u la r, an d c erv ic a l), im a g in g , a n d p a th o lo g ic al > '
ex am in atio n o f th e b re a st o r o th e r tissu e s as a p p ro p ria te to
e sta b lish the d ia g n o sis o f b re a st c a rc in o m a . T h e e x te n t o f
tissu e e x am in ed p a th o lo g ic a lly fo r c lin ic al s tag in g is n o t as
g reat as that re q u ire d fo r p a th o lo g ic a l stag in g (see
“P a th o lo g ic a l C la ssific a tio n ” in th is ch ap ter).

Imaging
Im aging findings are co n sid ered ele m en ts o f stag in g if they
are c o llected w ithin 4 m o n th s o f diag n o sis o r th ro u g h c o m p le -
tion o f surgery, w h ich ev er is lo n g e r in th e ab se n c e o f disease
progression. R elevant im ag in g findings inclu de the size o f the
prim ary invasive c án c e r and o f ch est w all invasión an d the
presence o r ab sence o f region al o r d ista n t m etastases. Im aging Fig. 48.3 TI is defined as a tum or 20 mm or less in greatest dimensión.
and clinical findings ob tain ed a fte r a p atient has b een treated T lm i is a tumor 1 m m o rle s s in greatest diameter (not illustrated). T ía is
w ith neo ad ju v an t ch em o therap y, h o rm o n al therapy, im m u n o - defined as tumor more than I mm but not more than 5 mm in greatest
dimensión; T lb is defined as tum or more than 5 mm but not more than
therapy, o r rad iatio n therap y are n ot c o n sid e re d ele m en ts o f
10 mm in greatest dimensión; T ic is defined as tum or more than 10 mm
initial clinical staging. If reco rd ed in the m ed ical reco rd , these but not more than 20 mm in greatest dimensión
should be d enoted u sing the m od ifier prefix “ ye.”
B reast cán cer clinical T, N , and M c ateg orizatio ns are based
on a com b inatio n o f clinical ex am in atio n and im aging findings.
Clinical findings are usually integrated w ith im agin g to deter-
m ine the size o f prim ary tu m o r and the presen ce o r absence o f
m últiple synchrono us lesions involving the sam e b reast q u a d -
rant or different breast q uadrants (i.e., m u ltifo cal o r m ulticen-
tric disease, respectively). T h e im agin g m odalities m ost
com m only used to help determ ine T and N features are m am -
m ography and ultrasound. T h e routine use o f b reast m agnetic
resonance (M R ) im aging in new ly d ia gn osed c án c e r patients
has not been show n to have significant benefit in ob tain in g clear
surgical m argins23-26 and its effect on im p rov in g local recu r-
rence and survival is u n d er d eb ate.27'28 If M R im ag in g o f the
breast is perform ed, it should be d one in c o nsu ltation w ith the
m ultidisciplinary treatm ent team , using a d ed icated b reast coil,
and interpreted by a b reast im ag ing team cap ab le o f perfo rm in g
M R im aging-gu ided biopsy. M R im aging is ind icated in
patients presenting w ith axillary b reast cán cer m etástasis w ith
no evident breast tu m o r on clinical, m am m o g rap h ic, and sono-
graphic exam ination (occult b reast p rim ary) an d m ay help
facilítate b reast-con serving th erap y in this p atient subgroup.

Primary Tumor (T) - Clinical and Pathological

T3
The T c ateg o ry o f th e p rim ary tu m o r is d e fin e d b y th e sam e
criteria re g a rd le ss o f w h e th e r it is b a se d on c lin ic a l o r p a th o -
logical c rite ria , o r bo th . T h e T c ate g o ry is b a se d p rim arily on
Fig.48.4 T2 (above dotted line) is defined as tum or more than 20 mm but
the size o f the invasive c o m p o n e n t o f th e cán cer. See not more than 50 mm in greatest dimensión, and T3 (below dotted line) is
Figs. 4 8 .3 , 4 8 .4 a n d 4 8 .5 fo r illu stra tio n s o f th e T -ca te g o rie s. defined as tumor more than 50 mm in greatest dimensión
598
S a t e llit e
n o d u le
Fig. 48.5 T4 is defined as a tumor o f any size with direct extensión to
chest wall and/or to the skin (ulceration or skin nodules). (a) T4a ¡s exten-
sión to the chest wall. Adherence/invasion to the pectoralis muscle is NOT
extensión to the chest wall and is not categorized as T4. (b) T4b, illustrated
here as satellite skin nodules, is defined as edema (including peau
T h e m á x im u m size o f a tu m o r fo c u s is u sed as an e stím a te o f
d ise a se v o lu m e . T h e la rg e st c o n tig u o u s d im e n s ió n o f a tu m o r
fo c u s is u sed , a nd sm all s a te llite fo ci o f n o n c o n tig u o u s tu m o r
are n o t a d d e d to the size. T h e c e llu la r fibrous re a ctio n to
invasiv e tu m o r c ells is g e n e ra lly in c lu d e d in th e m e a su re -
m en t o f a tu m o r p rio r to tre a tm e n t; ho w ev er, th e d e n se fib ro -
sis o b s e rv e d fo llo w in g n e o a d ju v a n t tre a tm e n t is g e n e ra lly
not in c lu d e d in th e p a th o lo g ic al m e a su re m e n t b e c a u se its
e x te n t m ay o v e re stim a te th e re sid u a l tu m o r v o lu m e.
T u m o r S ize
T h e c lin ic a l size o f a p rim ary tu m o r (T ) c an be m e asu re d
b a se d o n c lin ic a l fin d in g s (p h y sic al e x a m in a tio n a n d im a g -
ing m o d a litie s, su ch as m a m m o g ra p h y , u ltra so u n d , and M R
im a g in g ) a n d p a th o lo g ic a l fin d in g s (g ro ss a n d m ic ro sc o p ic
m e a su re m e n ts). C lin ic a l tu m o r size (c T ) s h o u ld be b a se d on
th e c lin ic al fin d in g s th a t are ju d g e d to b e m o st a cc u ra te fo r a
p a rtic u la r c ase , a lth o u g h it m ay still be s o m ew h a t in a c cu rate
b e c a u s e the e x te n t o f so m e b re a st c a n c e rs is n o t a lw ay s
a p p a re n t w ith c u rre n t im a g in g te c h n iq u e s a n d b e c a u se
tu m o rs a re c o m p o se d o f v a ry in g p ro p o rtio n s o f n o n in v a siv e
an d invasive d ise a se , w h ic h th e se te c h n iq u e s are c u rre n tly
u n a b le to d istin g u ish .
Im a g in g C la s s ific a tio n o f T u m o r (T)
T h e A m e ric a n C o lle g e o f R ad io lo g y (A C R ) B I-R A D S lexi-
cón p ro v id e s g e n eral g u id e lin e s fo r th e re p o rtin g o f m a m -
m o grap hy, b re a st u ltraso u n d , an d b re a st MR im a g in g
stu d ie s.29 A ll b re a st im a g in g re p o rts sh o u ld fo llo w th ese
g u id e lin e s. In fo rm a tio n re levant to p rim ary tu m o r size sho u ld
b e a cc u ra te ly m e a su re d in at least th e lo n g est d ia m e te r in the
plañ e o f m e a su re m e n t an d sho u ld b e in c lu d e d in the re p o rt
b o d y a n d th e final im p ressio n sec tio n s. If the p rim ary tu m o r
A m e ric a n Jo in t C o m m itte e on C áncer • 2017
d'orange) o f the skin, or ulceration o f the skin o f the breast, or satellite
skin nodules confined to the same breast. These do not meet the criteria for
inflammatory carcinoma, (c) T4b illustrated here as edema (including
peau d ’orange) o f the skin. (d) T4c is defined as both T4a and T4b. T4d
(not illustrated) is inflammatory cáncer (see text for definition)
also is a sso c iated w ith su ch fe a tu re s as c alcifica tio n s o r archi-
te c tu ra l d isto rtio n , this c o m b in e d size sho u ld be provided in
th e rep ort. If p re sen t, e x te n sió n o f the p rim ary tu m o r to the
ip sila teral n ip p le , o v e rly in g skin, o r u n d e rly in g chest wall
sh o u ld be c le arly in d icated . M R im a g in g is m ore accurate
th an u ltraso u n d an d m am m o g ra p h y in co n firm in g chest wall
in v o lv em en t b y d e m o n stra tin g a b n o rm a l e n h an c e m e n t within
c h e s t w all stru c tu re s.311 W h en m o re th an o n e m alig n an t lesión
is id en tified o n im a g in g , th e size a n d d e sc rip tio n o f their loca-
tio n s (i.e., q u a d ra n t a n d /o r d ista n ce fro m the n ipple and/or
d ista n ce to th e ind ex tu m o r) sh o u ld be d efin ed in the imaging
rep o rt. T h e sam e tu m o r m ay have d ifferen t m easurem ents
usin g d iffe re n t m o d a litie s (e.g., m a m m o g ra p h y versus ultra-
so u n d v ersu s M R im a g in g ). I f availab le, M R im aging mea-
su re m en ts c o u ld be u sed b a se d on p rio r stu d ies dem onstrating
b e tte r c o rre la tio n w ith o v erall tu m o r size. H ow ever, if index
tu m o r size d ifferen c e b e tw ee n d ifferen t im a g in g modalities,
in c lu d in g th a t o f M R im a g in g , sig n ific a n tly affects T classifi-
c atio n o r o v erall c lin ic al stag e, im a g in g -g u id e d b iop sy could
be c o n sid e re d to co n firm d isea se ex ten t. Im ag in g -g u id ed tis-
su e b io p sy c an s im ila rly b e c o n sid e re d fo r any additional
le sio n s su sp ic io u s fo r m u ltifo ca l o r m u ltic e n tric secondary
lesio n s th at a ffe c t c lin ic al m a n a g em e n t.
Size sh o uld be m easured to the n earest m illim eter. If the
tu m o r size is slightly less than o r gre a te r than a cutoff for a
given T classificatio n, the size sh o u ld be ro un ded to the milli-
m e te r read in g th at is c lo se st to the cutoff. F o r exam ple, a
rep o rted size o f 4 .9 m m is rep o rted as 5 m m , o r a size of
2 .04 cm is rep o rted as 2.0 cm (2 0 m m ). T he excep tion to this
ro u n d in g ru le is fo r a breast tu m o r sized b etw een 1.0 and
1.4 m m . T h e se sizes are ro u nd ed up to 2 m m , b ecause rounding
dow n w o uld result in the c a n c e r's being catego rized as micro-
invasive carcin o m a (T I m i) defined as a size o f 1.0 m m or less.
600
N1 N 2a
Fig.48.6 Clinical Lymph Node Categories: cN 1 is defined as metástasis
in movable ipsilateral level I. II axillary lymph nodes. cN2a is defined as
metástasis in ipsilateral level I, II axillary lymph nodes fixed to one
another (matted). cN2b is defined as metástasis only in clinically detected
ipsilateral internal mammary nodes and in the absence of clinically evi-
dent level I, II axillary lymph node metástasis. cN3a is defined as metás-
Im a g in g C la ssific a tio n of R e g io n al Ly m p h N o d e s (N)
Im a g in g is not n e c e ssa ry to a ssig n th e c lin ic a l n o d e c a te -
gory. R o u tin e use o f a x illa ry u ltra so u n d in b re a st c á n c e r
p a tie n ts is c o n tro v e rsia l. M e ta -a n a ly s e s 32-33 su g g e st th at
a m o n g p a tie n ts w h o p ro v e to have p o sitiv e n o d e s, c lin i-
c a lly o c c u lt a x illa ry n o d al m e ta sta se s c an b e d e te c te d in
a b o u t h a lf on p re o p e ra tiv e u ltra s o u n d e v a lu a tio n . In c e n -
te rs th a t ro u tin e ly im p le m e n t re g io n a l n o d al u ltra so u n d ,
im a g in g s h o u ld in c lu d e at le a st ip s ila te ra l a x illa ry le v e ls I
and II. L y m p h n o d e m e a su re m e n ts are o b ta in e d b y b o th
lon g a n d sh o rt a x is le n g th s on u ltra so u n d . H o w ev er, u ltra -
so u n d m e a su re m e n ts are o p e ra to r- and te c h n iq u e -d e p e n -
d e n t. U ltra s o u n d -g u id e d n e ed le b io p sy of th e ind ex
Am erican Jo in t C o m m itte e on Cáncer • 2017
N 2b
tasis in ipsilateral infraclavicular (level III axillary) lymph node(s) with
or without level I, II axillary lymph node involvement. cN3b is defined as
metástasis in clinically detected ipsilateral internal mammary lymph
node(s) and clinically evident axillary lymph node(s). cN3c is defined as
metástasis in ipsilateral supraclavicular lymph node(s) with or without
axillary or internal mammary lymph node involvement
a x illa ry n o d e w ith c lip p la c e m e n t s h o u ld b e co n sid ered in
k e e p in g w ith p re v io u sly p u b lish e d g u id e lin e s .19 Imaging
o r h is to p a th o lo g ic a l e v id e n c e o f a x illa ry L ev el I or II
ly m p h a d e n o p a th y w a rra n ts an im a g in g in vestigation of
L evel III a x illa ry , in te rn a l m a m m a ry c h a in , a n d supracla-
v ic u la r ly m p h n o d e in v o lv e m e n t. In te rn a l m am m ary nodes
c an be im a g e d u sin g u ltra s o u n d .34 A lte rn a tiv e ly , they may
b e e v id e n t on b re a st M R im a g in g o r c h e s t C T if perform ed.
U ltra so u n d , C T, o r p o s itro n e m is sio n to m o g ra p h y (PET)-
C T m ay be' u sed to d e m ó n stra te any p o ssib le metastatic
s u p ra c la v ic u la r ly m p h n o d es. L y m p h n o d e m easurem ents
are o b ta in e d b y th e le n g th o f th e ir sh o rt a x is on cross-sec-
tio n a l im a g in g .