Breast cancer stages

Synonyms in a broader sense

TNM classification, carcinoma in situ, breast cancer, bone metastases, lung metastases, lymph node metastases, liver metastases

introduction

Breast cancer can have progressed to different degrees at the time of diagnosis, which is why the findings are divided into different tumor stages. This staging has been standardized for most cancers; one speaks of the TNM classification. The same factors are always taken into account:

• T stands for the tumor size

• N stands for Nodi (Latin = node) and indicates whether there are already daughter tumors in the lymph nodes,

• M stands for metastasis - i.e. daughter tumor - and indicates whether the cancer has already spread to other organs, e.g. the liver has invaded.

Numbers are assigned to each letter e.g. for T the numbers 0-4 etc. For different tumor types, however, the criteria for when a finding is e.g. T1 or T2 is different.

In addition, each of the capital letters can be preceded by a lowercase p. The p stands for a histopathologically assessed tumor, which means that the pathologist assesses the entire finding (after surgical removal) or a biopsy and classifies it on the basis of this. There are also other additional letters. The table below makes the classification even easier to understand:

TNM classification

TX or pTX: The finding cannot be assessed, e.g. because of a bad x-ray

T0 or pT0: There is no evidence of a tumor

Tis or PTis: It is a carcinoma in situ or a Paget's disease

T1 or pT1: The tumor is smaller than 2 cm
a: Less than 0.5 cm
b: Between 0.5 cm - 1 cm tall
c: Between 1 cm - 2 cm

T2 or pT2: The tumor is larger than 2 cm but not larger than 5 cm

T3 or pT3: The tumor is larger than 5 cm

T4 or pT4: The tumor is of any size and has spread into the surrounding tissue (not breast tissue) e.g. Sternum, pectoral muscles, ribs, etc.
a: Grown into the chest wall
b: Grown into the skin
c: Grown into skin and chest wall
d: Of the Breast cancer is accompanied by inflammation (exception M. Paget)

To get a better idea, you can use the following size comparisons:

T1 = roughly the size of a coffee bean

T2 = between the size of a grape and a peach stone

T3 = between the size of a fig and an apricot

Lymph nodes

The subsequent assessment of the lymph nodes is based on imaging tests and clinical examinations.

NX: Lymph nodes cannot be assessed

N0: No evidence of lymph node metastases

N1: metastases in axillary lymph nodes, which are displaceable against the surrounding tissue

N2: Metastases in axillary lymph nodes that have grown together or with other structures

N3: metastases in lymph nodes located along the internal mammary artery, which supplies blood to the breast

If a finding is surgically removed, the lymph nodes are often removed in the same procedure, e.g. from the armpit. (See breast cancer surgery) It is generally required that at least 10 lymph nodes are removed and examined by the pathologist during an axillary dissection (technical term for the removal of lymph node tissue from the armpit). The classification differs from that mentioned above for pN1, here the pathologist can specify further gradations.

pN1: metastases in mobile lymph nodes from the armpit

a: Only micrometastases that are smaller than 0.2 cm

b: metastases in lymph nodes, at least one of which is larger than 0.2 mm

You will find more information on this topic here: Lymph node involvement in breast cancer

Classification of breast cancer stages

Based on the TNM classification, a division into different stages is made, here according to the specifications of the UICC (union international contre le cancer). The individual stages summarize TNM combinations that have a similar prognosis:

Staging

Stage T-Class N-Class M-Class

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage IIA T1 or T2 N1 or N2 M0

Stage IIB T2 or T3 N1 or N0 M0

Stage IIIA T0 or T1 / T2 / T3 N2 or N1 and N2 M0

Stage IIIB T4 or any T N1 and N2 or N3 M0

Stage IV every T every N M1

Based on the classification, it is easier to make a statement about the chances of recovery and the prognosis.

Read more about the prognosis for breast cancer and the chances of a cure for breast cancer here.

Stage 1

Stage 1 is the stage associated with the best prognosis and healing expectation. Stage 1 is divided into stage 1A and 1B. Stage 1A describes breast cancer which, according to all of the so-called “staging” examinations, shows no spread, neither to regional and distant lymph nodes, nor to surrounding tissue or distant organs. According to the TNM classification, N0 is used, which means that nothing was found in lymph nodes ("Nodus"). M0 describes that there are no settlements in other organs either (“metastases”). Stage 1A also describes that the main tumor in the breast is less than 2 cm in extent. Stage 1B, on the other hand, includes smaller micrometastases in local lymph nodes located on the breast.

Find out more about: Tissue samples in breast cancer

Stage 1: life expectancy and chances of recovery

The life expectancy and the chance of recovery from stage 1 breast cancer are highest. This tumor stage indicates that although a tumor is present, it has not yet formed any colonization. In consultation with the patient, it must be decided whether the breast should be removed together with the tumor in one operation or whether a breast-conserving operation should take place. The latter option does involve a certain residual risk, but this disappears with standard subsequent irradiation. Subsequently, drug therapy with chemotherapeutic agents, antibodies and antihormones can be carried out, which reduce the risk of relapse. This therapy is recommended primarily for women under 35, but can sometimes cause severe side effects. The survival rate continues to increase with the newly developed therapy methods and is very good in stage 1. The survival rate is often given in 5 years or 10 years and in both cases in stage 1 it is well above 90%.

You can find out more about the topic here: Chances of recovery in breast cancer

Stage 2

Stage 2 describes breast cancer that has grown larger, especially in the breast itself, and has already minimally spread to nearby lymph nodes. It can again be divided into 2 sub-stages, 2A and 2B. 2A comprises a tumor that has either first colonized lymph nodes in the armpits or a tumor that is already 2-5 cm in size in the breast. 2B describes tumors that combine both properties or a tumor that has not spread but is already over 5 cm in size within the breast.

Stage 2: life expectancy and chances of recovery

The life expectancy of the tumor in stage 2 is still quite good, as is the chance of recovery. Stage 2 expresses in particular that there has not yet been any spread to distant body regions, but that the tumor is still locally limited in the breast in the immediately adjacent lymph nodes. With the therapy, which also consists of the surgical removal and subsequent irradiation, a cure can often be achieved. In addition to the tumor stage, further treatment depends on many other factors, from which certain chemotherapy and hormone therapies are derived. Different types of tumors respond differently to the therapies. Overall, life expectancy in stage 2 is still good.

Find out more about the topic here: Chemotherapy for breast cancer

Stage 3

Stage 3 can be divided into 3A, 3B and 3C. The entire stage 3 has in common that there is still no metastasis to distant tissues and organs. However, the tumor may have grown so large in the breast that it grows into the chest wall or grows out to the surface of the skin. All sizes of the tumors are included. The lymph nodes are also more affected at this stage. After the first lymph node station for breast cancer in the armpit, the tumor cells increasingly spread below and above the collarbone, then also to the lymph nodes along the breast arteries.

Stage 3: life expectancy and chances of recovery

Life expectancy and the chance of recovery decrease compared to stage 2. However, it is important that no distant settlements occur in stage 3 either. Only the lymph nodes can be severely affected. These are also surgically removed along with the removal of the tumor in the breast. Chemotherapy and hormone therapy is essential in stage 3, as it can significantly increase life expectancy in percentage terms. The local spread into the chest wall is particularly decisive for the prognosis. If too much surrounding essential tissue has already been infiltrated, surgical removal is difficult.

Learn more about: Irradiation for blood cancer or life expectancy for breast cancer

Stage 4

Stage 4 represents the last of the breast cancer stages. All tumors associated with diagnosed metastases in other organs are summarized under this stage. The amount of colonization in lymph nodes and the size of the original tumor can vary. In breast cancer, distant metastases primarily affect the lungs, bones, liver and brain.

You can find more information here: End-stage breast cancer

Stage 4: Life Expectancy and Chances of Recovery

Life expectancy and the chance of recovery drop drastically with the presence of metastases in distant organs. The primary reason for this is that the tumor has already reached many areas of the body via the bloodstream. For this reason, even if the tumor has apparently been removed successfully, the occurrence of recurrences is extremely likely. If multiple organs are affected by metastases, surgery is often difficult to perform. An exact life expectancy cannot be determined under any circumstances. With modern drug therapies, however, good results can be achieved and many years can be gained.

Read more here: Blood cancer prognoses or breast cancer life expectancy

Propagation studies

If the diagnosis of breast cancer has been made, a search is always made for possible daughter tumors (metastases). If daughter tumors are discovered, this has an impact on further therapy planning and the prognosis as a whole, so finding them is of great importance.

Metastases indicate advanced cancer. Therefore, general symptoms are often already present such as decreased performance, pain, loss of appetite, nausea, weakness, possibly fever and shortness of breath. The larger a tumor, the more likely it is that daughter tumors have already formed in other organs in the body.

However, breast cancer can also form metastases at a very early stage when the tumor is still small. This depends on the biological nature of the tumor cells and the type of tumor (see under breast cancers).

Find out more about the topic here: Metastasis in breast cancer

Info: metastasis

A 5 mm lump indicates the formation of daughter tumors in 10% of cases and a 20 mm lump in 50% of the cases.

Compared to other types of cancer, metastasis in breast cancer occurs relatively early. In breast cancer, daughter tumors can spread lymphogenically as well as hematogenously.

Lymphogen means that the tumor cells reach lymph nodes via the lymphatic system and form new nodes there.
Hematogenous means that the tumor cells reach various organs via the bloodstream and form nodes there.
Breast cancer first metastasizes to the lymph nodes of the armpit and / or des Sternum.

Not all organs in the body are equally likely to be attacked by daughter tumors. This is different for each type of cancer Colon cancer can be found e.g. most often daughter tumors in the liver. Breast cancer cells are most commonly found in:

• Lymph nodes
• Bone (Spine, Ribs, pelvis, skull),
• in the lung, on the pleura (Pleura) and
• in the liver.

Also the skin and the brain can be infested.

Lymph node metastases

Lymph node metastases play a special role. They are the most important factor in a prognosis for breast cancer and actually always occur before hematogenous metastases.
Lymph node metastases can show up as swelling or lumps in the armpit or breastbone.
In order to determine whether the tumor has already metastasized into the lymph nodes, the sentinel lymph node technique, which is described in detail under the topic of breast cancer surgery, is now used in addition to other methods.

Read more about the general topic here Metastases in breast cancer.

Bone metastases

In a quarter of all cases in which daughter tumors have formed, the first metastases are discovered in the bone, where they become noticeable as pain.
In order to detect metastases in the bone, the so-called Bone scintigraphy. With a bone scintigraphy, the patient is injected with a radioactive liquid before the examination. The substances that are contained in the liquid have the property of being deposited in those places in the bone where remodeling processes take place and from there they emit a weak radioactive signal. Normally, remodeling processes to a certain extent take place all over the bone. With a bone metastasis, but also with inflammatory diseases such as rheumatism However, these processes are increased at specific points: At these points, a particularly large amount of the radioactively marked liquid can collect and thus be made visible with a special X-ray device.
An X-ray image is then made of the areas suspected in the bone scintigraphy, which provides more precise information about whether a metastasis is present or, for B. "only" an inflammatory process. Bone metastases can also be used with Computed Tomography (CT) or Magnetic resonance imaging

Lung metastases

Metastases also occur relatively frequently in the lungs. Symptoms that may indicate the presence of metastases in the lungs are e.g. Shortness of breath, chronic cough, and easy fatigue.
Most of the time, these symptoms are rather weak than the tumor must have attacked a great deal of lung tissue before it made itself felt in this way.
Whether lung metastases are present is mostly determined by X-rays detected. In order to find out the exact location of metastases, a certain form of computed tomography (thin-slice spiral CT) or a reflection of the airways (bronchoscopy) can also be useful.

Liver metastases

The third most common location for metastasis is the liver. They often only become noticeable there late and creeping.
The symptoms arise because the tumor is increasingly taking up space and destroying healthy, functional liver tissue. The liver can compensate for this until a later point in time. Loss of appetite, weight loss, gastrointestinal disorders or fever can be possible symptoms, but they are also common in breast cancer if there are no liver metastases.
The liver is surrounded by a solid capsule, which is why an expanding tumor can tension this capsule, which in turn causes pain in the right upper abdomen. If the biliary tract is narrowed or blocked by daughter tumors, a Jaundice (Jaundice), which, as the name suggests, is first noticeable by a slight yellowing of the eyeballs. Liver dysfunction (see also Function of the liver) can often be detected by a blood test. Whether metastases are responsible for such a functional disorder can be determined by an ultrasound examination, computed tomography or magnetic resonance tomography.