Invasive breast carcinoma - IARC

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TNM classification of carcinomas of the breast TNM Clinical Classification 1,2 T – Primary Tumour TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ Tis (DCIS) Ductal carcinoma in situ Tis (LCIS) Lobular carcinoma in situ Tis (Paget) Paget disease of the nipple with no tumour Note: Paget disease associated with a tumour is classified according to the size of the tumour. T 1 T 1 m i c T 1 a T 1 b T 1 c T 2 T 3 T4 Tumour 2 cm or less in greatest dimension Microinvasion 0.1 cm or less in greatest dimension a More than 0.1 cm but not more than 0.5 cm in greatest dimension More than 0.5 cm but not more than 1 cm in greatest dimension More than 1 cm but not more than 2 cm in greatest dimension Tumour more than 2 cm but not more than 5 cm in greatest dimension Tumour more than 5 cm in greatest dimension Tumour of any size with direct extension to chest wall or skin only as described in T4a to T4d Note:Chest wall includes ribs, intercostal muscles, and serratus anterior muscle but not pectoral muscle. T4a T4b T4c T4d Extension to chest wall Oedema (including peau d’orange), or ulceration of the skin of the breast, or satellite skin nodules confined to the same breast Both 4a and 4b, above Inflammatory carcinoma b Notes: a Microinvasion is the extension of cancer cells beyond the basement membrane into the adjacent tissues with no focus more than 0.1cm in greatest dimension. When there are multiple foci of microinvasion, the size of only the largest focus is used to classify the microinvasion (Do not use the sum of all individual foci). The presence of multiple foci of microinvasion should be noted, as it is with multiple larger invasive c a r c i n o m a s . b Inflammatory carcinoma of the breast is characterized by diffuse, brawny induration of the skin with an erysipeloid edge, usually with no underlying mass. If the skin biopsy is negative and there is no localized measurable primary cancer, the T category is pTX when pathologically staging a clinical inflammatory carcinoma (T4d). Dimpling of the skin, nipple retraction, or other skin changes, except those in T4b and T4d, may occur in T1, T2, or T3 without affecting the classification. N – Regional Lymph Nodes 3 N X Regional lymph nodes cannot be assessed (e.g. previously removed) N0 No regional lymph node metastasis N1 Metastasis in movable ipsilateral axillary lymph node(s) N 2 Metastasis in fixed ipsilateral axillary lymph node(s) or in clinically apparent* ipsilateral internal mammary lymph node(s) in the absence of clinically evident axillary lymph node metastasis N2a Metastasis in axillary lymph node(s) fixed to one another or to other structures N 2 b Metastasis only in clinically apparent* internal mammary lymph node(s) and in the absence of clinically evident axillary lymph node metastasis N3 Metastasis in ipsilateral infraclavicular lymph node(s) with or without axillary lymph node involvement; or in clinically apparent* ipsilateral internal mammary lymph node(s) in the presence of clinically evident axillary lymph node metastasis; or metastasis in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement N3a Metastasis in infraclavicular lymph node(s) N3b Metastasis in internal mammary and axillary lymph nodes N3c Metastasis in supraclavicular lymph node(s) Note: * clinically apparent = detected by clinical examination or by imaging studies (excluding lymphoscintigraphy) M – Distant Metastasis MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis pTNM Pathological Classification pT – Primary Tumour The pathological classification requires the examination of the primary carcinoma with no gross tumour at the margins of resection. A case can be classified pT if there is only microscopic tumour in a margin. The pT categories correspond to the T categories. Note: When classifying pT the tumour size is a measurement of the invasive component. If there is a large in situ component (e.g. 4 cm) and a small invasive component (e.g. 0.5 cm), the tumour is coded pT1a. pN – Regional Lymph Nodes 4 pNX Regional lymph nodes cannot be assessed (not removed for study or previously removed) pN0 No regional lymph node metastasis* pN1mi Micrometastasis (larger than 0.2 mm, but none larger than 2 mm in greatest dimension) pN1 Metastasis in 1 - 3 ipsilateral axillary lymph node(s), and/or in internal mammary nodes with microscopic metastasis detected by sentinel lymph node dissection but not clinically apparent** pN1a Metastasis in 1-3 axillary lymph node(s), including at least one larger than 2 mm in greatest dimension pN1b Internal mammary lymph nodes with microscopic metastasis detected by sentinel lymph node dissection but not clinically apparent pN1c Metastasis in 1 - 3 axillary lymph nodes and internal mammary lymph nodes with microscopic metastasis detected by sentinel lymph node dissection but not clinically apparent pN2 Metastasis in 4 - 9 ipsilateral axillary lymph nodes, or in clinically apparent*** ipsilateral internal mammary lymph node(s) in the absence of axillary lymph node metastasis pN2a Metastasis in 4-9 axillary lymph nodes, including at least one that is larger than 2 mm pN2b Metastasis in clinically apparent internal mammary lymph node(s), in the absence of axillary lymph node metastasis pN3 Metastasis in 10 or more ipsilateral 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 lymph nodes; or in more than 3 axillary lymph nodes with clinically negative, microscopic metastasis in internal mammary lymph nodes; or in ipsilateral supraclavicular lymph nodes pN3a Metastasis in 10 or more axillary lymph nodes (at least one larger than 2 mm) or metastasis in infraclavicular lymph nodes pN3b Metastasis in clinically apparent internal mammary lymph node(s) in the presence of one or more positive axillary lymph node(s); or metastasis in more than 3 axillary lymph nodes and in internal mammary lymph nodes with microscopic metastasis detected by sentinel lymph node dissection but not clinically apparent pN3c Metastasis in supraclavicular lymph node(s) Note: * Cases with only isolated tumour cells (ITC) in regional lymph nodes are classified as pN0. ITC are single tumour cells or small clusters of cells, not more than 0.2 mm in greatest dimension, that are usually detected by immunohistochemistry or molecular methods but which may be verified on H&E stains. ITCs do not typically show evidence of metastatic activity (e.g., proliferation or stromal reaction). ** not clinically apparent = not detected by clinical examination or by imaging studies (excluding lymphoscintigraphy). *** clinically apparent = detected by clinical examination or by imaging studies (excluding lymphoscintigraphy) or grossly visible pathologically. pM – Distant Metastasis The pM categories correspond to the M categories. 11
Stage Grouping Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage IIA T0 N1 M0 T1 N1 M0 T2 N0 M0 Stage IIB T2 N1 M0 T3 N0 M0 Stage IIIA T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1, N2 M0 Stage IIIB T4 N0,N1,N2 M0 Stage IIIC Any T N3 M0 Stage IV Any T Any N M1 _________ 1 {51,2976}. 2 A help desk for specific questions about the TNM classification is available at http://tnm.uicc.org. 3 The regional lymph nodes are: 1. Axillary (ipsilateral): interpectoral (Rotter) nodes and lymph nodes along the axillary vein and its tributaries, which may be divided into the following levels: (i) Level I (low-axilla): lymph nodes lateral to the lateral border of pectoralis minor muscle. (ii) Level II (mid-axilla): lymph nodes between the medial and lateral borders of the pectoralis minor muscle and the interpectoral (Rotter) lymph nodes. (iii) Level III (apical axilla): apical lymph nodes and those medial to the medial margin of the pectoralis minor muscle, excluding those designated as subclavicular or infraclavicular. Note: Intramammary lymph nodes are coded as axillary lymph nodes, level I. 2. Infraclavicular (subclavicular) (ipsilateral). 3. Internal mammary (ipsilateral): lymph nodes in the intercostal spaces along the edge of the sternum in the endothoracic fascia. 4. Supraclavicular (ipsilateral). 4 The pathological N classification requires the resection and examination of at least the low axillary lymph nodes (level I). Examination of one or more sentinel lymph nodes may be used for pathological classification. If classification is based solely on sentinel node biopsy without subsequent axillary lymph node dissection it should be designated (sn) for sentinel node, e.g. pN1(sn). 12 Tumours of the breast
Page 2: Previous volumes in this series Kle
Page 6 and 7: World Health Organization Classific
Page 8 and 9: Published by IARC Press, Internatio
Page 10 and 11: CHAPTER 1 Tumours of the Breast Can
Page 14 and 15: Invasive breast carcinoma I.O. Elli
Page 16 and 17: Rapid growth and greater adult heig
Page 18 and 19: tives, administrative and clerical
Page 20 and 21: Grade 1 - well differentiated: 3-5
Page 22 and 23: ent and this is occasionally extens
Page 24 and 25: Most melanotic tumours of the breas
Page 26 and 27: A Fig. 1.22 A Classic invasive lobu
Page 28 and 29: yet others at 90% {97,2147}. For pr
Page 30 and 31: Fig. 1.27 Medullary carcinoma. The
Page 32 and 33: myoepithelial cells in fibro a d e
Page 34 and 35: A Fig. 1.33 Neuroendocrine carcinom
Page 36 and 37: Macroscopy Fisher et al. reported t
Page 38 and 39: Fig. 1.39 Apocrine carcinoma. Note
Page 40 and 41: cells contain intracytoplasmic lume
Page 42 and 43: A Fig. 1.50 Carcinosarcoma. A Two a
Page 44 and 45: A B C Fig. 1.75 Lobular neoplasia.
Page 46 and 47: Intraductal proliferative lesions F
Page 48 and 49: A B absence of either microcalcific
Page 50 and 51: Fig. 1.83 Atypical ductal hyperplas
Page 52 and 53: A B Fig. 1.88 Large excision biopsy
Page 54 and 55: unusual variants as well. Using thi
Page 56 and 57: esemble those identified in invasiv
Page 58 and 59: A B Fig. 1.97 Microinvasive carcino
Page 60 and 61: A Papilloma may be subject to morph
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A B C Fig. 1.103 Papillary intraduc
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colour measuring from 0.5 to 12 cm.
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Immunoprofile The cases studied by
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Glycogen-rich, clear cell carcinoma
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Differential diagnosis There may be
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quality metaphase spreads from an i
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Fig. 1.67 Lobular carcinoma of brea
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detectable distant metastasis displ
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detected at a late stage as small t
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Extent of ductal carcinoma in situ
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Benign epithelial proliferations G.
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Fig. 1.112 Microglandular adenosis.
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A Apocrine adenoma ICD-O code 8401/
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A B Fig. 1.128 Adenomyoepithelioma,
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Mesenchymal tumours M. Drijkoningen
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1113,1275}. There is a complex patt
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A B Fig. 1.137 A Lipoma. Intraparen
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Fig. 1.141 Angiosarcoma after breas
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A Fig. 1.144 Mammary osteosarcoma.
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Fibroepithelial tumours J.P. Belloc
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aged women (average age of presenta
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lished data suggests a 21% rate of
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A Fig. 1.157 Syringomatous adenoma
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Malignant lymphoma and metastatic t
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used. Inflammatory conditions in th
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male population both in the USA and
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CHAPTER 2 Tumours of the Ovary and
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Polyembryoma 9072/3 Non-gestational
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Surface epithelial-stromal tumours
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A Fig. 2.04 A Serous borderline tum
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A Fig. 2.06 Serous borderline tumou
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A Fig. 2.10 Invasive peritoneal imp
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Fig. 2.15 Mucinous carcinoma with i
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Fig. 2.20 Mucinous endocervical-lik
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A Fig. 2.28 Mucinous cystic tumour
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early secretory endometrium {2605}.
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IV, 6% {2233}. Patients with grade
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A Fig. 2.37 A This polypoid intracy
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Fig. 2.40 Endometrioid cyst with at
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1 tumours are extremely rare. Almos
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Fig. 2.50 Borderline Brenner tumour
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express thrombomodulin and have bee
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serous and transitional cell carcin
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is yellow to tan with a variable ad
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Genetic susceptibility JGCTs may pr
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Clinical features F i b romas may b
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distinguishes this tumour from the
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A Fig. 2.77 A Retiform Sertoli-Leyd
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Mean ages of 21 and 38 years and me
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Tumours unassociated with PJS form
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mal origin without crystals of Rein
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Germ cell tumours F. Nogales A. Tal
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cases, anisokaryosis has no prognos
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ation may coexist in the same neopl
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Table 2.06 Grading of ovarian immat
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A B Fig. 2.102 A Mature cystic tera
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Diagnostic procedures Elevated urin
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associated with mature teratomas sh
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atives intimately admixed. The germ
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Fig. 2.113 Mixed germ cell-sex cord
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A Fig. 2.116 A Adenomatous hyperpla
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Fig. 2.117 Small cell carcinoma, hy
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Clinical features Adenoid cystic-li
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Histopathology This epithelial tumo
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sis. Corpus luteum of pregnancy has
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Lymphomas and leukaemias L.M. Roth
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Secondary tumours of the ovary J. P
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Occasionally, the colonic adenocarc
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Peritoneal tumours S.C. Mok J.O. Sc
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A B Fig. 2.140 Cystic adenomatoid m
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whelmingly poor {1038,1547,2310}. H
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CHAPTER 3 Tumours of the Fallopian
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TNM and FIGO classification of carc
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Endometrioid adenocarcinoma Endomet
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Two examples of adenofibroma of bor
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A Fig. 3.11 Adenomatoid tumour. A T
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Clinical features Patients range in
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Fig. 3.16 Uterus-like mass. The cys
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CHAPTER 4 Tumours of the Uterine Co
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TNM and FIGO classification of non-
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Epithelial tumours and related lesi
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endometrioid adenocarcinoma fro m a
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fers from the prototypical type I e
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the ovary and bladder. Unlike prima
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schema {1535,2602}. Although this c
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Table 4.03 Altered gene function in
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Mesenchymal tumours and related les
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areas are limited to less than 30%
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A B C Fig. 4.30 Leiomyosarcoma. A T
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e used sparingly and is reserved fo
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A B Fig. 4.38 Leiomyoma with perino
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cytological atypia, tumour cell nec
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Mixed epithelial and mesenchymal tu
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Prognosis and predictive factors Th
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tumours may superficially invade th
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A Fig. 4.46 A Gestational choriocar
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A Fig. 4.49 A Classic complete hyda
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Sex cord-like, neuroectodermal and
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Secondary tumours of the uterine co
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WHO histological classification of
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Epithelial tumours M. Wells J.M. Ne
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Fig. 5.04 Mechanisms of human papil
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Fig. 5.08 Keratinizing squamous cel
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in their Asian population {2957}. I
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have a strong association with high
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e red by squamous epithelium {380}.
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endometrioid adenocarcinoma of the
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metrial epithelium. In some cases t
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with distinct cell borders and a gr
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Mesenchymal tumours M.L. Carcangiu
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{781}, liposarcoma {2840,3016}, ost
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Mixed epithelial and mesenchymal tu
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Fig. 5.44 Wilms tumour. The tumour
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A Fig. 5.47 Implant of endometrial
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CHAPTER 6 Tumours of the Vagina Alt
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Epithelial tumours E.S. Andersen A.
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Aetiology The fact that both VAIN a
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Fig. 6.10 Fibroepithelial polyp.A m
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er of mitoses varies but is usually
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ICD-O codes Adenosquamous carcinoma
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A C Fig. 6.17 Sarcoma botryoides. A
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1-11 cm. They may arise anywhere in
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elsewhere in the female genital tra
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A Fig. 6.24 Yolk sac tumour. A The
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g rowing in sheets. Some may have s
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WHO histological classification of
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Epithelial tumours E.J. Wilkinson M
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even with additional sectioning, it
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type) is a highly diff e rentiated
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Clinical features Bartholin gland c
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glandular elements surrounded by fi
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Mesenchymal tumours R.L. Kempson M.
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Table 7.03 Differential diagnosis o
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Prognosis and predictive factors A
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Table 7.04 Clark levels of cutaneou
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A Fig. 7.23 Vulvar peripheral primi
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Familial aggregation of cancers of
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BRCA1 syndrome Definition Inherited
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dispose individuals to the developm
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Fig. 8.05 To assess whether wild-ty
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Fig. 8.07 Factors that modify risk
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BRCA2 syndrome R. Eeles S. Piver S.
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tubal or ovarian carcinomas. Howeve
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in typical nuclear foci that may re
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Breast tumours Frequency Breast can
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Fig. 8.14 Codon distribution of som
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Breast tumours Age distribution and
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Hereditary non-polyposis colon canc
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essary in the evaluation of the pat
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Age distribution and penetrance Mos
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Contributors Dr Vera M. ABELER** De
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Dr Carlo LA VECCHIA Laboratory of E
Page 366 and 367:
Dr Manuel TEIXEIRA Department of Ge
Page 368 and 369:
02.100 Dr. A. Ostor 02.101 Dr. F.A.
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52. Akhtar M, Robinson C, Ashraf Al
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180. Bapat K, Brustein S (1989). Ut
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307. Bolis GB, Maccio T (2000). Cle
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436. Chang J, Sharpe JC, A'Hern RP,
Page 378 and 379:
562. Costa MJ, Ames PF, Walls J, Ro
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689. Di Domenico A, Stangl F, Benni
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820. Falck J, Petrini JH, Williams
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943. Gad A, Azzopardi JG (1975). Lo
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1067. Grimes MM (1992). Cystosarcom
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1197. Herod JJ, Shafi MI, Rollason
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1323. Jacques SM, Qureshi F, Ramire
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1449. Khalifa MA, Mannel RS, Harawa
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1564. Lagios MD (1977). Multicentri
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1687. Loman N, Johannsson O, Kristo
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1807. McCluggage G, McBride H, Maxw
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1937. Mukai M, Torikata C, Iri H (1
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2056. Norris HJ, Taylor HB (1967).
Page 404 and 405:
2180. Park JS, Jones RW, McLean MR,
Page 406 and 407:
2304. Puls LE, Hamous J, Morrow MS,
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2 4 3 4 . Rosen PP, Groshen S, Saig
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2559. Schlesinger C, Silverberg SG
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2686. Silverberg SG (1999). Protoco
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2806. Stutz JA, Evans AJ, Pinder S,
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2942. Tornos C, Silva EG, Ordonez N
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3061. Wargotz ES, Norris HJ (1990).
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3189. Yoshioka T, Tanaka T (2000).
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References 425
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Biphasic teratomas, 168 BLM, 341, 3
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G GADD45, 343, 353 GCDFP-15, 25, 33
Page 428 and 429:
MPNST, see Malignant peripheral ner
Page 430:
Small cell / oat cell carcinoma, 32
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Invasive breast carcinoma - IARC

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