乳癌分期英文病例幻灯

AJCCStagingMomentsAJCCTNMStaging7thEditionBreastCase#2Contributors:StephenB.Edge,MDRoswellParkCancerInstitute,Buffalo,NewYorkDavidR.Byrd,MDUniversityofWashingtonMedicalCenter,Seattle,WashingtonDavidJ.Winchester,MDNorthShoreUniversityEvanstonHospital,Evanston,IllinoisDavidP.Winchester,MDNorthShoreUniversityEvanstonHospital,Evanston,IllinoisBreastCase#2PresentationofNewCase•Newlydiagnosedbreastcancerpatient•PresentationatCancerConferencefortreatmentrecommendationsandclinicalstagingBreastCase#2History&Physical•62yroldwomannoticedanon-tendermassintheupperouterquadrant(UOQ)oftheleftbreast•Familyhx-breastcainmaternalauntatage70•Physicalexaminationrevealsafirm,mobile,4cmmassintheUOQwithnooverlyingskinchangesandnopalpableadenopathyBreastCase#2ImagingResults•Mammogram-3.9cmdensityUOQleftbreast,rightbreastnegative•Ultrasoundbreast-3.8cmhypoechoicareaUOQleftbreast,leftaxillarynodesnegative,rightbreastnegativeUsedwithpermissionBreastCase#2DiagnosticProcedure•Procedure–Ultrasound-guidedcoreneedlebiopsyUOQleftbreast•PathologyReport–Infiltratingductcarcinoma–Bloom-Scarff-Richardson(BSR)Grade3–Estrogenreceptorpositive–Progesteronereceptorpositive–HER2negativebyIHCBreastCase#2ClinicalStaging•Clinicalstaging–Usesinformationfromthephysicalexam,imaging,anddiagnosticbiopsy•Purpose–Selectappropriatetreatment–EstimateprognosisBreastCase#2ClinicalStaging•Synopsis-patientwith3.9cmmass,infiltratingductca,axillaisnegativeonexamandimaging•Whatistheclinicalstage?–T____–N____–M____–StageGroup______BreastCase#2ClinicalStaging•ClinicalStagecorrectanswer–T2–N0–M0–StageGroupIIA•Basedonstage,treatmentisselected•ReviewNCCNtreatmentguidelinesforthisstageBreastCase#2ClinicalStaging•Rationaleforstagingchoices–T2for3.9cmprimarytumor–N0becausenodeswereclinicallynegativeonphysicalexamandimaging–M0becausetherewasnothingtosuggestdistantmetastases;iftherewas,appropriatetestswouldbeperformedbeforedevelopingatreatmentplanPrognosticFactorsClinicallySignificant•Applicabletothiscase–Paget’sdisease:no–BSR:Grade3–Estrogenreceptor:positive–Progesteronereceptor:positive–HER2status:negative–Methodofnodeassessment:radiographic,physicalexamination•TherearenoprognosticfactorsrequiredforstagingBreastCase#2Surgery&Findings•Patientdeclinedoptionofneoadjuvantsystemictherapy•Procedure–LumpectomyUOQleftbreast,sentinellymphnode(SLN)biopsy•Operativefindings–Sentinelnodeswerereportedasnegativeonfrozensection,additionalstainswillbeperformedBreastCase#2PathologyResults•Infiltratingductcarcinoma•Sizeofinvasivecancer:4.1cmwithdermalinvasion•BSRGradeIII•Marginsofresectionnegative–closestmargininferiorat4mm•Sentinelnodes–NegativebyH&E–SentinelNode1–cytokeratinimmunohistochemistryshowsclusterofisolatedtumorcells(ITCs),0.1mminsizeBreastCase#2PathologicStaging•Pathologicstaging–Usesinformationfromtheclinicalstagingsupplementedormodifiedbyinformationfromsurgeryandthepathologyreport•Purpose–Additionalprecisedataforestimatingprognosis–Calculatingendresults(survivaldata)BreastCase#2PathologicStaging•Synopsis-patientwith4.1cminfiltratingductca,1sentinelnodewithITCsdetectedonlyonIHC•Whatisthepathologicstage?(remember,clinicalMmaybeusedinpathologicstaging)–T____–N____–M____–StageGroup______BreastCase#2PathologicStaging•PathologicStagecorrectanswer–pT2–pN0(i+)–cM0–StageGroupIIA•Basedonpathologicstage,thereismoreinformationtoestimateprognosisandadjuvanttreatmentisselectedBreastCase#2PathologicStaging•Rationaleforstagingchoices–pT2Skininvasionisdefinedasfullthicknessinvolvementincludingepidermis.FocaldermalinvolvementisnotconsideredT4.–pN0(i+)sentinelnodeshadITCsfoundonIHConly,H&Estainsnegative.ITCsusuallyhavenohistologicevidenceofmalignantactivity.–cM0-useclinicalMwithpathologicstagingunlessthereispathologicconfirmationofdistantmetastasesPrognosticFactorsClinicallySignificant•Applicabletothiscase–Paget’sdisease:no–BSR:Grade3–Estrogenreceptor:positive–Progesteronereceptor:positive–HER2status:negativebyIHC–Methodofnodeassessment:sentinelnodebiopsy–IHCofnodes:positive•TherearenoprognosticfactorsrequiredforstagingAJCCCancerStagingAtlaspN0(i+)isdefinedas1.PositiveITCsfoundonH&EorIHC,noITCs0.2mm2.Nonconfluent,ornearlyconfluentclustersofcellsnotexceeding200cellsinasinglehistologiclymphnodecrosssectionBreastCase#2RecapofStaging•Summaryofcorrectanswers–ClinicalstageT2N0M0StageGroupIIA–PathologicstageT2N0(i+)cM0StageGroupIIA•Thestagingclassificationshaveadifferentpurposeandthereforecanbedifferent.Donotgobackandchangetheclinicalstagingbasedonpathologicstaginginformation.StagingMomentsSummary•Reviewsite-specificinformation&rules•ClinicalStaging–Basedoninformationbeforetreatment–Usedtoselecttreatmentoptions•PathologicStaging–BasedonclinicaldataPLUSsurgeryandpathologyreportinformation–Usedtoevaluateend-results(survival)