Diagnosis and Staging

JoAnne Zujewski, MDHead, Breast Cancer Therapeutics

Clinical Investigations BranchCancer Therapy Evaluation ProgramDivision of Cancer Diagnostics and

TreatmentMay 2011

NEJM, November 23, 2000

Early Detections reduces the

risk of dying from breast

cancer.

Cancer Diagnosis: Defining the Cancer

• The first step in designing the treatment plan is carefully defining the cancer– Clinical examination– Radiology tests– Pathology tests– Blood tests

Breast Cancer Signs and Symptoms

• None• Lump or mass• Pain in breast• Tenderness• Thickening• Firmness• Nipple discharge

• Skin redness• Asymmetry• Enlargement• Nipple retraction• Dimpling• Mass in axilla

(armpit)• Warmth

BREAST CANCER

Defining the Cancer: Radiology

• Radiologic imaging can help determine the location and spread of the cancer– Local extent– Regional lymph nodes– Distant spread (metastases)

Mammography Technique

Mammography

Mammography Sensitivity in Younger Women

• Screening mammograms miss up to 25% of breast cancers in women in their 40s, compared to 10% of cancers for older women

Ultrasound

Breast MRIBreast MRI

• Important new tool for imaging the breast • High sensitivity• Detection and characterization of

otherwise-occult breast carcinoma

Breast Cancer Diagnosis

• Any breast change or lump needs to be evaluated

• Breast cancer needs to be diagnosed by biopsy– Fine needle aspiration– Core needle biopsy– Surgical biopsy

Mammotone & Minimally Invasive Breast Biopsy

(MIBB)The Mammotone and MIBB are different from the core needle biopsy in that a needle is inserted once and multiple specimens are removed through contiguous sampling. Core needle biopsies require the needle to be inserted multiple times.

Both the Mammotone and MIBB biopsy utilize a vacuum system. A probe is inserted and samples of tissue are collected in a chamber. Tissue samples are removed by action of a gentle vacuum.

Advantages of Needle Biopsies

• Simple procedure – does not require surgery• Accurate• Quick – only takes a few minutes• Not painful• Inexpensive• Quick results

Disadvantages of Needle Biopsies

• Entire lump is not removed• Open biopsy may be necessary

For Fine Needle Only:• Specialist needed to read results• In situ cancer not distinguishable from

invasive cancer

Image Guided Biopsy in Clinical Practice

• Allows treatment planning• Better cosmesis• Can mark site with clip• Less costly

• Needs specialized equipment• May still require confirmatory

pathology in minority of cases

Breast BiopsyA core needle biopsy of the area is recommendedA core needle biopsy of the area is recommended

Non-Surgical

Surgical

Ultrasound-Guided Breast Biopsy

Ultrasound

Image Guided Biopsy

Wire Localization: ExampleWire Localization: Example

Inking the Tumor Specimen in the O.RInking the Tumor Specimen in the O.R.

Needle Biopsies

• Fine Needle – A thin, hollow needle is used to remove a sample of tissue. The procedure is quick and can be done in a doctor’s office.

• Core Needle – A larger needle is inserted through a small incision in the skin, and a small core of tissue is removed. This type of needle biopsy is done with the assistance of mammography or ultrasound imaging using stereotactic techniques with the aid of the computer, which calculates the precise location of the lump.

Incisional Biopsy

• A surgical procedure where only a portion of a tumor is removed

• Generally reserved for lumps that are larger• Performed under local anesthesia in a

hospital or outpatient clinic

Excisional Biopsy

• A surgical procedure that removes the entire suspected area plus some surrounding normal tissue.

• Standard procedure for lumps that are smaller than an inch or so in diameter

• Similar to a lumpectomy• Performed under local anesthetic or general

anesthesia in a hospital or outpatient clinic

Advantages of Open Biopsies

• Quick – takes only one hour• More accurate than a needle biopsy• Larger samples provide information for

treatment plan

Excisional Only:• Removes entire lump• May be the only surgical treatment needed

Disadvantages of Open Biopsies

• Surgical procedure• Expensive• Side effects such as infection or blood

collection under the skin

Excisional Only:• Removing tissue can change the look and feel

of the breast

Cancer is diagnosed

in 1 of 5

breast biopsies

Staging

Breast cancerSpread to lymph nodes

Supraclavicular

Subclavicular

Distal (upper)

axillary

Central (middle)

axillary

Proximal (lower)

axillary

Mediastinal

Internal mammary

Interpectoral

(Rotter’s)

Breast Cancer: Stage I

T1a: T T1a: T 0.5 cm 0.5 cm

T1b: 0.5 cm < T T1b: 0.5 cm < T 1 cm 1 cm

T1c: 1 cm < T T1c: 1 cm < T 2 cm 2 cm

T1 N0 M0T1 N0 M0

T T 2 cm 2 cm

T1T1

N0 = no regional lymph node metastasisM0 = no distant metastasis

Breast Cancer: Stage IIA

T2 N0 M0T2 N0 M0

N1 = metastasis to movable ipsilateral axillary lymph node(s)M0 = no distant metastasis

2 cm < T 2 cm < T << 5 cm 5 cm

No evidenceNo evidenceof tumorof tumor

T0T0

T0 T0 T1T1

N1 M0N1 M0}

T2T2

Breast Cancer: Stage IIB

T3 N0 M0T3 N0 M0

N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1bM0 = no distant metastasis

T > 5 cmT > 5 cm

T2 N1 M0T2 N1 M0

T3T3

Breast Cancer: Stage IIIA

Metastasis to ipsilateral axillary lymph node(s) N1 = movableN2 = fixed to one another or to other structuresM0 = no distant metastasis

T3 N1 M0T3 N1 M0 T0T0T1T1T2T2T3T3

N2 M0N2 M0

Breast Cancer: Stage IIIB

Any T N3 M0Any T N3 M0

N3 = metastasis to ipsilateral internal mammary lymph node(s)M0 = no distant metastasis

Tumor of any sizewith direct extensionto chest wall or skin

T4d = inflammatorycarcinoma

T4 any N M0T4 any N M0

T4T4

Breast Cancer: Stage IV

M1 = distant metastasis (including metastases to cervical, or contralateral internal mammary lymph nodes)

Any T any N M1

FDG PET scanFDG PET scanBone Scan Bone Scan

Staging for Distant Disease: Staging for Distant Disease: Breast CancerBreast Cancer

Tumor in the breast, Tumor in the breast, but not elsewherebut not elsewhere

Multiple bone Multiple bone metastasesmetastases

Patient APatient A Patient BPatient B

The most common sites of distant disease in breast cancer are the The most common sites of distant disease in breast cancer are the bones, liver and lungsbones, liver and lungs

BREAST CANCER5-year survival: Number

of positive axillary lymph nodes

0%

20%

40%

60%

80%

5-Y

ear

Sur

viva

l5-

Yea

r S

urvi

val

0 1 2 3 4 5 6-10 11-15 16-20 >20

Number of Positive NodesNumber of Positive Nodes

Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.

How effective is therapy for breast cancer?

Site1974-1976

1983-1985

1992-1997

1996-2003

Breast 75 78 86 89.8

SEER, 1973-2003, DCP, NCI, 2009

Relative 5 Year Survival (%)

BHGI-DIAGNOSTICS