乳癌分期英文病例幻燈

AJCCStagingMomentsAJCCTNMStaging7thEditionBreastCase#2Contributors:StephenB.Edge,MDRoswellParkCancerInstitute,Buffalo,NewYorkDavidR.Byrd,MDUniversityofWashingtonMedicalCenter,Seattle,WashingtonDavidJ.Winchester,MDNorthShoreUniversityEvanstonHospital,Evanston,IllinoisDavidP.Winchester,MDNorthShoreUniversityEvanstonHospital,Evanston,Illinois第1頁BreastCase#2

PresentationofNewCaseNewlydiagnosedbreastcancerpatientPresentationatCancerConferencefortreatmentrecommendationsandclinicalstaging第2頁BreastCase#2

History&Physical62yroldwomannoticedanon-tendermassintheupperouterquadrant(UOQ)oftheleftbreastFamilyhx-breastcainmaternalauntatage70Physicalexaminationrevealsafirm,mobile,4cmmassintheUOQwithnooverlyingskinchangesandnopalpableadenopathy第3頁BreastCase#2

ImagingResultsMammogram-3.9cmdensityUOQ

leftbreast,rightbreastnegativeUltrasoundbreast-3.8cm

hypoechoicareaUOQleft

breast,leftaxillarynodes

negative,rightbreast

negativeUsedwithpermission第4頁BreastCase#2

DiagnosticProcedureProcedureUltrasound-guidedcoreneedlebiopsyUOQleftbreastPathologyReportInfiltratingductcarcinomaBloom-Scarff-Richardson(BSR)Grade3EstrogenreceptorpositiveProgesteronereceptorpositiveHER2negativebyIHC第5頁BreastCase#2

ClinicalStagingClinicalstagingUsesinformationfromthephysicalexam,imaging,anddiagnosticbiopsyPurposeSelectappropriatetreatmentEstimateprognosis第6頁BreastCase#2

ClinicalStagingSynopsis-patientwith3.9cmmass,infiltratingductca,axillaisnegativeonexamandimagingWhatistheclinicalstage?T____N____M____StageGroup______第7頁BreastCase#2

ClinicalStagingClinicalStagecorrectanswerT2N0M0StageGroupIIABasedonstage,treatmentisselectedReviewNCCNtreatmentguidelinesforthisstage第8頁BreastCase#2

ClinicalStagingRationaleforstagingchoicesT2for3.9cmprimarytumorN0becausenodeswereclinicallynegativeonphysicalexamandimagingM0becausetherewasnothingtosuggestdistantmetastases;iftherewas,appropriatetestswouldbeperformedbeforedevelopingatreatmentplan第9頁PrognosticFactors

ClinicallySignificantApplicabletothiscasePaget’sdisease:noBSR:Grade3Estrogenreceptor:positiveProgesteronereceptor:positiveHER2status:negativeMethodofnodeassessment:radiographic,physicalexaminationTherearenoprognosticfactorsrequiredforstaging第10頁第11頁BreastCase#2

Surgery&FindingsPatientdeclinedoptionofneoadjuvantsystemictherapyProcedureLumpectomyUOQleftbreast,sentinellymphnode(SLN)biopsyOperativefindingsSentinelnodeswerereportedasnegativeonfrozensection,additionalstainswillbeperformed第12頁BreastCase#2

PathologyResultsInfiltratingductcarcinomaSizeofinvasivecancer:4.1cmwithdermalinvasionBSRGradeIIIMarginsofresectionnegative–closestmargininferiorat4mmSentinelnodesNegativebyH&ESentinelNode1–cytokeratinimmunohistochemistryshowsclusterofisolatedtumorcells(ITCs),<0.1mminsize第13頁BreastCase#2

PathologicStagingPathologicstagingUsesinformationfromtheclinicalstagingsupplementedormodifiedbyinformationfromsurgeryandthepathologyreportPurposeAdditionalprecisedataforestimatingprognosisCalculatingendresults(survivaldata)第14頁BreastCase#2

PathologicStagingSynopsis-patientwith4.1cminfiltratingductca,1sentinelnodewithITCsdetectedonlyonIHCWhatisthepathologicstage?

(remember,clinicalMmaybeusedinpathologicstaging)T____N____M____StageGroup______第15頁BreastCase#2

PathologicStagingPathologicStagecorrectanswerpT2pN0(i+)cM0StageGroupIIABasedonpathologicstage,thereismoreinformationtoestimateprognosisandadjuvanttreatmentisselected

第16頁BreastCase#2

PathologicStagingRationaleforstagingchoicespT2Skininvasionisdefinedasfullthicknessinvolvementincludingepidermis.FocaldermalinvolvementisnotconsideredT4.pN0(i+)sentinelnodeshadITCsfoundonIHConly,H&Estainsnegative.ITCsusuallyhavenohistologicevidenceofmalignantactivity.cM0-useclinicalMwithpathologicstagingunlessthereispathologicconfirmationofdistantmetastases第17頁PrognosticFactors

ClinicallySignificantApplicabletothiscasePaget’sdisease:noBSR:Grade3Estrogenreceptor:positiveProgesteronereceptor:positiveHER2status:negativebyIHCMethodofnodeassessment:sentinelnodebiopsyIHCofnodes:positiveTherearenoprognosticfactorsrequiredforstaging第18頁AJCCCancerStagingAtlas

pN0(i+)isdefinedasPositiveITCsfoundon

H&EorIHC,noITCs>0.2mmNonconfluent,ornearlyconfluentclustersofcellsnotexceeding200cellsinasinglehistologiclymphnodecrosssection第19頁BreastCase#2

RecapofStagingSummaryofcorrectanswersClinicalstageT2N0M0StageGroupIIAPathologicstageT2N0(i+)cM0StageGroupIIAThestagingclassificationshaveadifferentpurposeandthereforecanbedifferent.Donotgobackandchangetheclinicalstagingbasedonpathologicstaginginformation.第20頁StagingM