AJCC TNM STAGING, 6th Edition

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TUMOR SIZE [T] factor:

• TX: the primary breast cancer cannot be (or has not yet been) found or sized/measured 
• Tis: this indicates non-invasive breast cancer 
• Tis (DCIS): non-invasive cancer & variously also called ductal CIS & d-CIS 
• Tis (LCIS): non-invasive cancer & variously also called lobular CIS & l-CIS 
• Tis (Paget's): Paget's disease of the skin/nipple (breast cancer cells in the skin-surface epidermal membrane) when there is no associated invasive breast cancer within that breast. 
• T1: the tumor is 2 cm. (centimeters) or less in greatest dimension
  [determination of tumor size can be tricky: imaging studies can suggest that a tumor is only 1.9 cm., but really careful pathology studies may ultimately show that it is actually 4.0 cm.]
           
  >T1mic: microinvasive, 0.1 cm. or less in greatest dimension (1/32nd of an inch)
  >T1a: tumor greater than 0.1 cm., up to 0.5 cm. (up to almost 3/16ths of an inch)
  >T1b: tumor greater than 0.5 cm., up to 1.0 cm.
  >T1c: tumor greater than 1.0 cm., up to 2.0 cm. (a dime is 1.8 cm; a penny is 1.9 cm)
  
• T2: tumor greater than 2.0 cm. & up to 5 cm. (a USA quarter is barely less than 2.5 cm) 
• T3: tumor greater than 5.0 cm. in maximum size 
• T4: tumor of any size that ALSO "involves" skin and/or chest wall (there is continuing debate as to whether "clinical signs" below or "histological presence" constitutes "involves"4):
        
  >T4a: either directly extends into chest-wall tissue (not including pectoralis muscle [pectoralis invasion does not affect the T ]...chest wall tissue includes ribs & periostium & perchondrium, intercostal muscles & investing soft tissue, and serratus anterior muscle); or,
  
  >T4b: clinically obvious classical skin changes (ulceration, edema, peau d‘orange and satellite skin nodules...mere retraction or dimpling does not count4)& ca. directly extends into skin...that is, apparently, skin involvement without "inflammatory" clinical or histologic features is not consequential beyond size3 & the tumor size is the categorizer for T; or,
  
  >T4c: is combined T4a and T4b; or,
  
  >T4d: is "inflammatory carcinoma," defined as "diffuse brawny induration of the skin of the breast with an erysipeloid [red/dark & warm/inflamed] edge, usually without an underlying palpable mass."
  

REGIONAL LYMPH NODE STATUS [N] (on same side as the breast cancer) factor:

Note: for the past 60 years, pathology labs have studied surgically removed lymph nodes with varying degrees of completeness & intensity. A "positive" lymph node is one in which the pathology study determines the presence of cancer which has biologically traveled from the primary breast cancer into the lymph node. For the pN status to be "positive", an opinion of positivity must be rendered via the pathologist's powers of interpretation (does the small cluster look like cancer cells or benign rests or mechanically transported benign or malignant epithelium?). Awareness came to us in about 2001 of "look back" studies in the world's finest cancer centers have determined that 25% of cases originally called "node negative" years ago were actually "node positive"! So, especially since the advent of "sentinel node biopsy", some labs have tended to provide much greater thoroughness and intensity of service in the search to determine "node negative" vs. "node positive". Such may include total processing of all nodes (examining every bit of each node that was found), step-cutting of each node (making pathology slides...for exam under a microscope...at at least 3 different levels through the thickness [in each layer...as with a layer cake] of the lymph node pieces), and the use of both routine H&E staining for microscope slide making and IHC marker staining (or molecular testing: rt-PCR). Our lab intensely searches nodes for mets.

• NX: node status can not be (or has not been) assessed.
    
• N0: "negative" lymph nodes...
  
  >pN0: negative by H&E only
  >pN0(i-): H&E and IHC negative
  >pN0(i+): H&E neg and IHC pos; no ca. cell cluster bigger than 0.2 mm
  >pN0(mol-): H&E and molecular negative
  >pN0(mol+): H&E neg & molecular pos.
  has no category if H&E positive but less than 0.2 mm; so, pathologist needs to explain an opinion as to which (pN0...not a "true" met. vs. pN1mi, a very small but true met. [L08-13238]).
  
  
• N1: 1-3 separately positive, movable, clinically negative nodes...
  
   >pN1mi: micromet. >0.2, none >2 mm.
   >pN1a: mets 1-3 axillary nodes
   >pN1b: mets in int. mammary nodes
   >pNic: mets in ax. & int. mammary nodes
     
• N2: 4-9 positive axillary nodes; or, clinically pos. internal mammary node (s) with neg. axillary
  
   >pN2a: 4-9 axillary pos. nodes, at least one met being bigger than 2mm
   >pN2b: positive clinically pos. int. mammary node (s) with neg. axillary nodes
     
• N3: 10 or more pos. axillary nodes; or, pos. infra-clavicular node (s); or, positive clinically pos. internal mammary node (s) in presence of greater than 3 nodes pos. axillary; or, greater than 3 pos. axillary nodes with clinically neg. internal mammary nodes
   
  >pN3a: 10 or more pos. axillary nodes, with at least one deposit being larger than 2mm; or, pos. infra-clavicular node (s)
  
  >pN3b: clinically positive internal mammary nodes that are positive & in association with one or more positive axillary nodes; or, more than 3 positive axillary nodes plus clinically negative but microscopically positive internal mammary nodes.
  
  >pN3c: positive supra-clavicular node (s)
  
  

DISTANT METASTASIS [M] factor:

• MX: distant metastasis status can not be (or has not been) assessed
  
• M0: no positive evidence distant metastasis
    
• M1: definite positive evidence of distant metastasis
  
  

STAGE ASSIGNMENT

Reference:

• AJCC Cancer Staging Manual, 5th Edition, 1997, pages 172-177 
• AJCC Cancer Staging Manual, 6th Edition, 2002. 
• paper out of Switzerland, Cancer 104(9):1862 - 1870, published online 29 Aug 2005. 
• paper out of Switzerland & Germany on the imprecision as to "skin involvement: & proper T3 & T4 assignment, Annals of Oncology 16(10):1618-1623, published online on July 20, 2005. 

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(posted 10 January 2003; latest addition 27 December 2008)