T4 breast cancer under closer inspection: A case for revision of the TNM classification

Breast cancer dermal lymphatic invasion recurrence and contralateral axillary lymph nodes metastasis after complete response to neoadjuvant therapy: A case report

INTRODUCTION AND IMPORTANCE

Non-luminal type breast cancer patients with pathological complete response (pCR) by neoadjuvant chemotherapy (NAC) usually have a good prognosis, but occasionally recurrence occurs.

CASE PRESENTATION

A 61-year-old woman was diagnosed with breast cancer T2N2aM0 stage IIIA and its intrinsic type was non-luminal type. After NAC, the patient achieved pCR and underwent breast-conserving surgery and axillary lymph node dissection (ALND). Radiotherapy and trastuzumab of one-year duration was added. However, six years and two months later, local recurrence and contralateral axillary lymph node (CLALN) metastasis were identified. After resection, anti-human epidermal growth factor receptor 2 (HER-2) therapy was done, however, six months after operation, purpura was observed on the right chest and tended to increase. One and a half years after re-operation, dermal lymphatic invasion (DLI) recurrence without clinical inflammatory signs was diagnosed. A skin resection was performed >1.5 cm away from the purpura, and the surgical margins were negative but four months later, a recurrence re-emerged.

CLINICAL DISCUSSION

CLALN metastasis is considered distant metastasis based on the current TNM classification. However, as previous ALND or radiotherapy can change lymphatic flow, the resulting CLALN may not be distant metastasis. DLI recurrence without clinical inflammatory signs is likely to be resistant to anti-HER2 even in non-luminal type, and even a 2-cm margin for skin surgical lines may result in positive margins.

CONCLUSION

There are cases where CLALN after ALND should also be considered possible metastasis. In DLI recurrence, the skin excision margin line should be set very generously.

Inflammatory breast cancer appearance at presentation is associated with overall survival

Background

Inflammatory breast cancer (IBC) is a clinical diagnosis. Here, we examined the association of a “classic” triad of clinical signs, swollen involved breast, nipple change, and diffuse skin change, with overall survival (OS).

Method

Breast medical photographs from patients enrolled on a prospective IBC registry were scored by two independent reviewers as classic (triad above), not classic, and difficult to assign. Chi‐squared test, Fisher's exact test, and Wilcoxon rank‐sum test were used to assess differences between patient groups. Kaplan–Meier estimates and the log‐rank test and Cox proportional hazard regression were used to assess the OS.

Results

We analyzed 245 IBC patients with median age 54 (range 26–81), M0 versus M1 status (157 and 88 patients, respectively). The classic triad was significantly associated with smoking, post‐menopausal status, and metastatic disease at presentation (p = 0.002, 0.013, and 0.035, respectively). Ten‐year actuarial OS for not classic and difficult to assign were not significantly different and were grouped for further analyses. Ten‐year OS was 29.7% among patients with the classic sign triad versus 57.2% for non‐classic (p < 0.0001). The multivariate Cox regression model adjusting for clinical staging (p < 0.0001) and TNBC status (<0.0001) demonstrated classic presentation score significantly associated with poorer OS time (HR 2.6, 95% CI 1.7–3.9, p < 0.0001).

Conclusions

A triad of classic IBC signs independently predicted OS in patients diagnosed with IBC. Further work is warranted to understand the biology related to clinical signs and further extend the understanding of physical examination findings in IBC.

The role of skin ulceration in breast carcinoma staging and outcome

Breast carcinoma with skin ulceration (SU) is considered a locally advanced disease. The purpose of the study is to investigate if SU is an independent adverse factor. Breast carcinoma patients with SU (n=111) were included in the study. A subset (n=38, study cohort) was matched with cases that had no SU (n=38, matched cohort); the survival analyses were compared between these groups. Then, cases (n=80) were staged independent from SU into stage I, II or III. Disease free survival (DFS) and overall survival (OS) were analyzed. Patients with larger tumors tended to present with distant metastases more often than patients with smaller tumors (P=.004). In the matched cases, the 5-year DFS probability was 53% for the study cohort and 58% for the matched cohort; and for OS 75% for the study cohort and 84% for the matched cohort with no statistical significant difference. However, there was a trend towards worse DFS for the patients whose tumors had SU. When the cases were staged based on tumor size and node status (I, II or III), the OS was statistically significant (P=.047) but not the DFS (P=.195). Relatively small tumors with SU had an extent of disease similar to that observed in patients with early stages disease. The survival analysis suggests that SU may not be an adverse factor. However, more cases are needed to further examine this finding.

TNM-O: ontology support for staging of malignant tumours

BACKGROUND

Objectives of this work are to (1) present an ontological framework for the TNM classification system, (2) exemplify this framework by an ontology for colon and rectum tumours, and (3) evaluate this ontology by assigning TNM classes to real world pathology data.

METHODS

The TNM ontology uses the Foundational Model of Anatomy for anatomical entities and BioTopLite 2 as a domain top-level ontology. General rules for the TNM classification system and the specific TNM classification for colorectal tumours were axiomatised in description logic. Case-based information was collected from tumour documentation practice in the Comprehensive Cancer Centre of a large university hospital. Based on the ontology, a module was developed that classifies pathology data.

RESULTS

TNM was represented as an information artefact, which consists of single representational units. Corresponding to every representational unit, tumours and tumour aggregates were defined. Tumour aggregates consist of the primary tumour and, if existing, of infiltrated regional lymph nodes and distant metastases. TNM codes depend on the location and certain qualities of the primary tumour (T), the infiltrated regional lymph nodes (N) and the existence of distant metastases (M). Tumour data from clinical and pathological documentation were successfully classified with the ontology.

CONCLUSION

A first version of the TNM Ontology represents the TNM system for the description of the anatomical extent of malignant tumours. The present work demonstrates its representational power and completeness as well as its applicability for classification of instance data.

Skin involvement and breast cancer: are T4b lesions of all sizes created equal?

BACKGROUND

Nonmetastatic, noninflammatory, invasive breast cancers with skin involvement (SI) are classified as T4b, regardless of size. This study evaluated disease-specific survival (DSS) to determine whether size should be considered for these lesions rather than grouping them all into stage III.

STUDY DESIGN

Surveillance, Epidemiology, and End Results data linked to Medicare claims were reviewed. Skin involved and non-SI tumors were reclassified using the American Joint Committee on Cancer, 7(th) edition groupings using tumor size and nodal involvement alone without considering SI (neostage). Disease-specific survival was adjusted for demographics, histology, and treatment using competing risk methods with propensity score-based weighting and bootstrap standard errors.

RESULTS

Among 924 SI patients diagnosed between 1992 and 2005, tumors were 0.1 to 2.0 cm, 2.1 to 5.0 cm, and >5.0 cm in 11.6%, 51.1%, and 37.3% of patients, respectively. There were no nodal metastases in 22.3%, 1 to 3 positive nodes in 31.7%, 4 to 9 positive in 28.6%, and ≥10 positive in 17.4% of patients. For SI patients, adjusted 5-year DSS was 95.8% (95% CI, 95.6-96.0) for neostage I, declining progressively to 36.4% (95% CI, 33.8-39.2) for neostage IIIC patients. Adjusted 5-year DSS for SI and non-SI tumors (n = 66,185) was similar for neostage I, IIA, and IIB, and markedly lower for IIIA and IIIC. Adjusted DSS for SI IIIA was similar to non-SI IIIC.

CONCLUSIONS

Noninflammatory SI breast cancers have widely varied DSS that differs by tumor size and nodal involvement and therefore should not all be stage III. Skin involvement should be subordinate to T and N groupings to classify SI with non-SI lesions having similar prognoses.

T4b breast masses: a retrospective review of 12 cases presenting to a metropolitan tertiary care center

INTRODUCTION

Due to increased awareness of breast cancer resulting in early detection, there is a decreased incidence nationwide of late-stage breast cancer, including that which presents with skin involvement (T4b).

METHODS

A retrospective analysis of a 10-month period from August 2007 to May 2008 at Howard University Hospital (HUH), Washington, DC, revealed 12 patients diagnosed with T4b breast cancer and compared to similarly staged patients in the Surveillance, Epidemiology, and End Results (SEER) database. Finally, a logistic regression for the likelihood of T4b diagnosis was performed patients in the SEER database.

RESULTS

HUH patients with T4b tumors were more likely than SEER patients to present with predictors of poor clinical outcome, including high-grade histology (100% vs 59.4%, p = .04) and estrogen receptor- (75% vs 30.3%, p = .001) and progesterone receptor- negative (91.7% vs 43.9%, p = .001) status. Conversely, HUH patients were younger (57.8 y vs 66.3 y, p = .03) and had smaller tumors (11.1 cm vs 28.2 cm, p = .02) than SEER patients with similarly staged tumors. Older patients (OR, 2.36; 95% CI, 1.50-2.00; p < .001; 60-80 y), African American patients (OR, 1.63; 95% CI, 1.26-2.11; p < .001), and patients with high-grade (OR, 5.51; 95% CI, 3.88-6.52; p < .001) tumors were more likely to be diagnosed with T4b tumors, whereas patients who lived in an area with increased median household income (OR, 0.99; 95% CI, 0.99-0.99; p = .001) were less likely to be diagnosed with a T4b lesion.

CONCLUSION

While much research has focused on the socioeconomic causes for the development of T4b tumors, both patient and tumor biologic conditions cannot be eliminated as causative agents.

Breast cancer with non-inflammatory skin involvement: current data on an underreported entity and its problematic classification

We evaluated 166 breast cancer cases with non-inflammatory skin involvement (NISI), which were classified in the TNM classification as T4b. The distribution of tumour sizes and stages was: < or =3 cm:24.1%, 3.1-5 cm:21.7%, 5.1-10 cm:33.1%, >10 cm:21.1%; stages:I/II:21.0%, III:43.4%, IV:35.6%. To assess the impact of NISI on axillary lymph node involvement (ALNI), we analyzed a sub-group of 50 patients with tumours < or =5 cm and compared them with a matched control group. NISI was found to be associated with increased ALNI (HR, 2.66; 95%CI, 1.59-4.63; p<0.0001). According to the inherent rules of tumour classification, only tumours with similar morphologic extent and prognostic significance should be combined. Since there is a high grade of heterogeneity, this basic tenet is clearly violated regarding breast cancer with NISI. Our proposal is to eliminate these tumours from the T4 category and to classify them simply by size (T1-3). Due to its prognostic significance, NISI should be indicated by an optional descriptor (e.g. S1).

TNM: therapeutically not mandatory

Cancer survival may be inversely related to the speed at which a primary tumour grows and disseminates. Assessment of prognosis using surgical and/or radiological definition of disease extent, i.e. staging, has thus become a standard intervention in newly diagnosed patients, with the most popular framework being the tumour-node-metastasis (TNM) system. However, increasing use of biomarkers--non-TNM factors that predict therapeutic benefit, rather than adverse disease outcome--has weakened the decision-making dominance of TNM. This shift from risk-led to benefit-led practice is now starting to blur the time-honoured qualitative distinction between curable (M(0), early stage, adjuvant) and incurable (M(1), early metastatic, palliative) disease treatment strategies; the same biologic drug strategy may improve average survival outcomes by similar increments for two patients, one of whom is 'adjuvant' and the other 'metastatic'. Plausibly, then, biomarker-positive patients presenting with high-TNM (M(1)) disease may enjoy the same, if not more, disease-free and/or overall survival benefit as conventional low-TNM (M(0)) patients when treated with standard adjuvant interventions. Conversely, M(0) patients concerned by quality-of-life issues such as alopecia may in future be able to choose better-tolerated personalized drug regimens similar to those now used with survival benefit in palliative settings, even if such adjuvant regimens have not yet been validated by level 1 data. To these ends, a modernised decision-oriented disease staging system called METS (molecular/extra-primary/tumour/symptoms) is presented here.