求助:乳腺癌分期的问题 - 华夏病理网论坛

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楼主发表于 2009-07-07 18:38|举报|关注(0)
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一个5cm大小的乳腺导管癌,大量取材后,仅发现一个0.2cm的浸润灶,他的分期应该定在哪期?是T1a还是T2?,这两个分期术后治疗的方案实在是相差太大了

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本帖最后由于 2009-07-07 21:33:00 编辑

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1 楼发表于2009-07-11 23:21:00举报|引用
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Thanks very much, Dr. zhao

It's very useful.

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2 楼发表于2009-07-11 19:09:00举报|引用
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Primary tumor (T):

TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass)
T1: Tumor is 2 cm (3/4 of an inch) or less across.
T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across.
T3: Tumor is more than 5 cm across.
T4: Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.

Dr. logos,

You are a good pathologist. Seems it is not easy to convince you. Read sbove carefuly.

Tis:

Cancer is "in situ," or, has not spread

T1-T4:

Describe tumor size and status of spreading

From above every one knows that the tumor size indicates the size of invasion.

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3 楼发表于2009-07-11 19:00:00举报|引用
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The American Joint Committee on Cancer (AJCC) TNM System

A staging system is a standardized way for the cancer care team to summarize information about how far a cancer has spread. The most common system used to describe the stages of breast cancer is the American Joint Committee on Cancer (AJCC) TNM system.

The stage of a breast cancer can be based either on the results of physical exam, biopsy, and imaging tests (called the clinical stage), or on the results of these tests plus the results of surgery (called the pathologic stage). The staging described here is the pathologic stage, which includes the findings after surgery, when the pathologist has looked at the breast mass and nearby lymph nodes. Pathologic staging is likely to be more accurate than clinical staging, as it allows the doctor to get a firsthand impression of the extent of the cancer.

The TNM staging system classifies cancers based on their T, N, and M stages:

T stands for tumor (its size and how far it has spread within the breast and to nearby organs).
N stands for spread to lymph nodes (bean-shaped collections of immune system cells that help fight infections and cancers).
M is for metastasis (spread to distant organs).

Additional letters or numbers appear after T, N, and M to give more details about the tumor, lymph nodes, and metastasis:

The letter T followed by a number from 0 to 4 describes the tumor's size and spread to the skin or to the chest wall under the breast. Higher T numbers mean a larger tumor and/or wider spread to tissues near the breast.

The letter N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are affected.

The letter M followed by a 0 or 1 indicates whether the cancer has spread to distant organs -- for example, the lungs or bones.

Breast cancer T, N, and M categories

Primary tumor (T):

TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass)
T1: Tumor is 2 cm (3/4 of an inch) or less across.
T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across.
T3: Tumor is more than 5 cm across.
T4: Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.

Nearby lymph nodes (N) (based on looking at them under a microscope):

NX: Nearby lymph nodes cannot be assessed (for example, removed previously).
N0: Cancer has not spread to nearby lymph nodes.
N1: Cancer has spread to 1 to 3 axillary (underarm) lymph node(s), and/or tiny amounts of cancer are found in internal mammary lymph nodes (those near the breast bone) on sentinel lymph node biopsy.
N2: Cancer has spread to 4 to 9 axillary lymph nodes under the arm, or cancer has enlarged the internal mammary lymph nodes.
N3: One of the following applies:

- Cancer has spread to 10 or more axillary lymph nodes.
- Cancer has spread to the lymph nodes under the clavicle (collar bone).
- Cancer has spread to the lymph nodes above the clavicle.
- Cancer involves axillary lymph nodes and has enlarged the internal mammary lymph nodes.
- Cancer involves 4 or more axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.

Metastasis (M):

MX: Presence of distant spread (metastasis) cannot be assessed.
M0: No distant spread.
M1: Spread to distant organs is present. (The most common sites are bone, lung, brain, and liver.)

Breast cancer stage grouping

Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping. Cancers with similar stages tend to have a similar outlook and thus are often treated in a similar way. Stage is expressed in Roman numerals from stage I (the least advanced stage) to stage IV (the most advanced stage). Non-invasive cancer is listed as stage 0.

Stage 0: Tis, N0, M0: This is ductal carcinoma in situ (DCIS), the earliest form of breast cancer. In DCIS, cancer cells are still within a duct and have not invaded deeper into the surrounding fatty breast tissue. Lobular carcinoma in situ (LCIS) is sometimes classified as stage 0 breast cancer, but most oncologists believe it is not a true breast cancer. In LCIS, abnormal cells grow within the lobules or milk-producing glands, but they do not penetrate through the wall of these lobules. Paget disease of the nipple (without an underlying tumor mass) is also stage 0. In all cases the cancer has not spread to lymph nodes or distant sites.

Stage I: T1, N0, M0: The tumor is 2 cm (about 3/4 of an inch) or less across and has not spread to lymph nodes or distant sites.

Stage IIA: T0, N1, M0 / T1, N1, M0 / T2, N0, M0: One of the following applies:

The tumor is 2 cm or less across (or is not found) and has spread to 1 to 3 axillary lymph nodes.
The tumor is 2 cm or less across (or is not found) and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
The tumor is 2 cm or less across (or is not found), has spread to 1 to 3 axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
The tumor is larger than 2 cm across and less than 5 cm but hasn't spread to the lymph nodes.

The cancer hasn't spread to distant sites.

Stage IIB: T2, N1, M0 / T3, N0, M0: One of the following applies:

The tumor is larger than 2 cm and less than 5 cm across. It has spread to 1 to 3 axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
The tumor is larger than 5 cm across but does not grow into the chest wall or skin and has not spread to lymph nodes.

The cancer hasn't spread to distant sites.

Stage IIIA: T0-2, N2, M0 / T3, N1-2, M0: One of the following applies:

The tumor is not more than 5 cm across (or cannot be found). It has spread to 4 to 9 axillary lymph nodes, or it has enlarged the internal mammary lymph nodes.
The tumor is larger than 5 cm across but does not grow into the chest wall or skin. It has spread to 1 to 9 axillary nodes, or to internal mammary nodes.

The cancer hasn't spread to distant sites.

Stage IIIB: T4, N0-2, M0: The tumor has grown into the chest wall or skin, and one of the following applies:

It has not spread to the lymph nodes.
It has spread to 1 to 3 axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
It has spread to 4 to 9 axillary lymph nodes, or it has enlarged the internal mammary lymph nodes.

The cancer hasn't spread to distant sites.

Inflammatory breast cancer is classified as stage IIIB unless it has spread to distant lymph nodes or organs, in which case it would be stage IV.

Stage IIIC: T0-4, N3, M0: The tumor is any size (or can't be found), and one of the following applies:

Cancer has spread to 10 or more axillary lymph nodes.
Cancer has spread to the lymph nodes under the clavicle (collar bone).
Cancer has spread to the lymph nodes above the clavicle.
Cancer involves axillary lymph nodes and has enlarged the internal mammary lymph nodes.
Cancer has spread to 4 or more axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.

The cancer hasn't spread to distant sites.

Stage IV: T0-4, N0-3, M1: The cancer can be any size and may or may not have spread to nearby lymph nodes. It has spread to distant organs (the most common sites are the bone, liver, brain, or lung), or to lymph nodes far from the breast.

If you have any questions about the stage of your cancer and what it might mean in your case, be sure to ask your doctor.

Breast cancer survival rates by stage

The numbers below come from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, and are based on women who were diagnosed with breast cancer between 1988 and 2001. There are some important points to note about these numbers:

The 5-year survival rate refers to the percentage of patients who live at least 5 years after being diagnosed with cancer. Many of these patients live much longer than 5 years after diagnosis. Five-year relative survival rates (such as the numbers below) take into account the fact that some patients with cancer will die from other causes. They are considered to be a more accurate way to describe the outlook for patients with a particular type and stage of cancer.

The SEER database does not divide survival rates by substages, such as IIA and IIB. The rates for these substages are likely to be close to the rate for the overall stage. For example, the survival rate for stage IIA is likely to be slightly higher than that listed for stage II, while the survival rate for stage IIB would be expected to be slightly lower.

These numbers were taken from patients treated several years ago. Although they are among the most current numbers we have available, improvements in treatment since then mean that the survival rates for people now being diagnosed with these cancers may be higher.

While survival statistics can sometimes be useful as a general guide, they may not accurately represent any one person's prognosis. A number of other factors, including other tumor characteristics and a person's age and general health, can also affect outlook. Your doctor can tell you how these numbers may apply to you, as he or she is familiar with the aspects of your particular situation.

Stage	5-year Relative Survival Rate
0	100%
I	100%
II	86%
III	57%
IV	20%

The American Joint Committee on Cancer (AJCC) TNM System

A staging system is a standardized way for the cancer care team to summarize information about how far a cancer has spread. The most common system used to describe the stages of breast cancer is the American Joint Committee on Cancer (AJCC) TNM system.

The stage of a breast cancer can be based either on the results of physical exam, biopsy, and imaging tests (called the clinical stage), or on the results of these tests plus the results of surgery (called the pathologic stage). The staging described here is the pathologic stage, which includes the findings after surgery, when the pathologist has looked at the breast mass and nearby lymph nodes. Pathologic staging is likely to be more accurate than clinical staging, as it allows the doctor to get a firsthand impression of the extent of the cancer.

The TNM staging system classifies cancers based on their T, N, and M stages:

T stands for tumor (its size and how far it has spread within the breast and to nearby organs).
N stands for spread to lymph nodes (bean-shaped collections of immune system cells that help fight infections and cancers).
M is for metastasis (spread to distant organs).

Additional letters or numbers appear after T, N, and M to give more details about the tumor, lymph nodes, and metastasis:

The letter T followed by a number from 0 to 4 describes the tumor's size and spread to the skin or to the chest wall under the breast. Higher T numbers mean a larger tumor and/or wider spread to tissues near the breast.

The letter N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the breast and, if so, how many lymph nodes are affected.

The letter M followed by a 0 or 1 indicates whether the cancer has spread to distant organs -- for example, the lungs or bones.

Breast cancer T, N, and M categories

Primary tumor (T):

TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass)
T1: Tumor is 2 cm (3/4 of an inch) or less across.
T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across.
T3: Tumor is more than 5 cm across.
T4: Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer.

Nearby lymph nodes (N) (based on looking at them under a microscope):

NX: Nearby lymph nodes cannot be assessed (for example, removed previously).
N0: Cancer has not spread to nearby lymph nodes.
N1: Cancer has spread to 1 to 3 axillary (underarm) lymph node(s), and/or tiny amounts of cancer are found in internal mammary lymph nodes (those near the breast bone) on sentinel lymph node biopsy.
N2: Cancer has spread to 4 to 9 axillary lymph nodes under the arm, or cancer has enlarged the internal mammary lymph nodes.
N3: One of the following applies:

- Cancer has spread to 10 or more axillary lymph nodes.
- Cancer has spread to the lymph nodes under the clavicle (collar bone).
- Cancer has spread to the lymph nodes above the clavicle.
- Cancer involves axillary lymph nodes and has enlarged the internal mammary lymph nodes.
- Cancer involves 4 or more axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.

Metastasis (M):

MX: Presence of distant spread (metastasis) cannot be assessed.
M0: No distant spread.
M1: Spread to distant organs is present. (The most common sites are bone, lung, brain, and liver.)

Breast cancer stage grouping

Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping. Cancers with similar stages tend to have a similar outlook and thus are often treated in a similar way. Stage is expressed in Roman numerals from stage I (the least advanced stage) to stage IV (the most advanced stage). Non-invasive cancer is listed as stage 0.

Stage 0: Tis, N0, M0: This is ductal carcinoma in situ (DCIS), the earliest form of breast cancer. In DCIS, cancer cells are still within a duct and have not invaded deeper into the surrounding fatty breast tissue. Lobular carcinoma in situ (LCIS) is sometimes classified as stage 0 breast cancer, but most oncologists believe it is not a true breast cancer. In LCIS, abnormal cells grow within the lobules or milk-producing glands, but they do not penetrate through the wall of these lobules. Paget disease of the nipple (without an underlying tumor mass) is also stage 0. In all cases the cancer has not spread to lymph nodes or distant sites.

Stage I: T1, N0, M0: The tumor is 2 cm (about 3/4 of an inch) or less across and has not spread to lymph nodes or distant sites.

Stage IIA: T0, N1, M0 / T1, N1, M0 / T2, N0, M0: One of the following applies:

The tumor is 2 cm or less across (or is not found) and has spread to 1 to 3 axillary lymph nodes.
The tumor is 2 cm or less across (or is not found) and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
The tumor is 2 cm or less across (or is not found), has spread to 1 to 3 axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
The tumor is larger than 2 cm across and less than 5 cm but hasn't spread to the lymph nodes.

The cancer hasn't spread to distant sites.

Stage IIB: T2, N1, M0 / T3, N0, M0: One of the following applies:

The tumor is larger than 2 cm and less than 5 cm across. It has spread to 1 to 3 axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
The tumor is larger than 5 cm across but does not grow into the chest wall or skin and has not spread to lymph nodes.

The cancer hasn't spread to distant sites.

Stage IIIA: T0-2, N2, M0 / T3, N1-2, M0: One of the following applies:

The tumor is not more than 5 cm across (or cannot be found). It has spread to 4 to 9 axillary lymph nodes, or it has enlarged the internal mammary lymph nodes.
The tumor is larger than 5 cm across but does not grow into the chest wall or skin. It has spread to 1 to 9 axillary nodes, or to internal mammary nodes.

The cancer hasn't spread to distant sites.

Stage IIIB: T4, N0-2, M0: The tumor has grown into the chest wall or skin, and one of the following applies:

It has not spread to the lymph nodes.
It has spread to 1 to 3 axillary lymph nodes and/or tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.
It has spread to 4 to 9 axillary lymph nodes, or it has enlarged the internal mammary lymph nodes.

The cancer hasn't spread to distant sites.

Inflammatory breast cancer is classified as stage IIIB unless it has spread to distant lymph nodes or organs, in which case it would be stage IV.

Stage IIIC: T0-4, N3, M0: The tumor is any size (or can't be found), and one of the following applies:

Cancer has spread to 10 or more axillary lymph nodes.
Cancer has spread to the lymph nodes under the clavicle (collar bone).
Cancer has spread to the lymph nodes above the clavicle.
Cancer involves axillary lymph nodes and has enlarged the internal mammary lymph nodes.
Cancer has spread to 4 or more axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy.

The cancer hasn't spread to distant sites.

Stage IV: T0-4, N0-3, M1: The cancer can be any size and may or may not have spread to nearby lymph nodes. It has spread to distant organs (the most common sites are the bone, liver, brain, or lung), or to lymph nodes far from the breast.

If you have any questions about the stage of your cancer and what it might mean in your case, be sure to ask your doctor.

Breast cancer survival rates by stage

The numbers below come from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, and are based on women who were diagnosed with breast cancer between 1988 and 2001. There are some important points to note about these numbers:

The 5-year survival rate refers to the percentage of patients who live at least 5 years after being diagnosed with cancer. Many of these patients live much longer than 5 years after diagnosis. Five-year relative survival rates (such as the numbers below) take into account the fact that some patients with cancer will die from other causes. They are considered to be a more accurate way to describe the outlook for patients with a particular type and stage of cancer.

The SEER database does not divide survival rates by substages, such as IIA and IIB. The rates for these substages are likely to be close to the rate for the overall stage. For example, the survival rate for stage IIA is likely to be slightly higher than that listed for stage II, while the survival rate for stage IIB would be expected to be slightly lower.

These numbers were taken from patients treated several years ago. Although they are among the most current numbers we have available, improvements in treatment since then mean that the survival rates for people now being diagnosed with these cancers may be higher.

While survival statistics can sometimes be useful as a general guide, they may not accurately represent any one person's prognosis. A number of other factors, including other tumor characteristics and a person's age and general health, can also affect outlook. Your doctor can tell you how these numbers may apply to you, as he or she is familiar with the aspects of your particular situation.

Stage	5-year Relative Survival Rate
0	100%
I	100%
II	86%
III	57%
IV	20%

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4 楼发表于2009-07-11 18:18:00举报|引用
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这是我和肿瘤科医生一起讨论一个病人的TNM分期的时候产生的疑惑，虽然书上也的确提到临床预后明显决定于病人肿瘤浸润的大小而不是肿瘤的大小，我们也认为T分期里面应该是说肿瘤浸润灶的大小，但各类书上都用了肿瘤大小（或者tumor size），都没有明确解释这里的“肿瘤大小”是指肿瘤浸润灶的大小，显然有违医学的严谨性，很容易让其他人产生误解，导致TNM分期的严重分歧。

我希望能找到有“这里的肿瘤大小是指肿瘤的浸润灶大小”之类说明或解释的原始文献，以坚定自己这样理解的信心，并为自己理解提供依据，即便以后出现医疗纠纷，也可以直接拿出证据（毕竟国内医疗纠纷举证责任倒置）

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5 楼发表于2009-07-08 12:08:00举报|引用
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All sizes mentioned above are the size of invasive carcinoma.

我查阅了AJCC的一些有关乳腺癌分期的文件，找不到上述表述的直接证据，能给我具体链接吗？谢谢

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6 楼发表于2009-07-08 07:44:00举报|引用
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学习积累

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: 做点实事

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7 楼发表于2009-07-08 01:03:00举报|引用
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本帖最后由于 2009-07-08 01:04:00 编辑

以下是引用logos在2009-7-8 0:08:00的发言：

All sizes mentioned above are the size of invasive carcinoma.

我查阅了AJCC的一些有关乳腺癌分期的文件，找不到上述表述的直接证据，能给我具体链接吗？谢谢

All pathologists should know that the size of staging means the invasive component. I do not know what you mean direct evidence.You do not believe or the surgeons or oncologists do not believe it.

No matter what size of DCIS, the stage should be Tis if no invasion is present.