Lesson 2: Diagnosis, Tests & Staging

Staging

This section is really long - don't let it get you confused. Skip over the parts that don't interest you and just know that all the terminology is there for you if and when you need it. No one expects any of us to remember all the combinations.

Staging is the term used to decide how big your tumor is, IF it has spread and WHERE it has spread. This whole process is based on a lot of statistics and formulas and lots of scientific background. Please remember: Statistics are just numbers. Yes, if there is a 75% cure rate, 25% still have to not be cured. If 99% is the death rate, still 1% will survive. Statistics help you and your medical team to weigh the odds and decide what treatment options you want to pursue, but they are STILL JUST NUMBERS.

At this point in your diagnosis/treatment process, you need to arm yourself with terminology, background information. Whatever knowledge you can gain will be helpful when it comes time for you to make your decision(s). http://www.cancerlinksusa.com/breast/sta...

A pathologist is a physician who examines tissues and fluids from the body and renders a diagnosis based on his/her findings. Pathologists participate in a 5 year residency program and then are eligible to sit for the examination given by the American Board of Pathology for certification.

First, the pathologist processes the specimen in either or both of the following ways: a permanent section and/or a smear. A permanent section places the fresh specimen in a fixative (fluid) for several hours, depending on the size of the specimen. Formalin is the general fixative of choice - a combination of formaldehyde gas and buffered water. This process makes the cells harden and become "fixed". This fixed specimen is then placed in a machine which removes all the water from the specimen and replaces it with paraffin wax. This occurs overnight. The next day the histologic technician embeds the specimen in a large bloc of molten paraffin. It is solidified by chilling and then is cut into thin slices by a microtome. These sections then float out of a water bath and are placed onto glass slides.

The paraffin is dissolved and with the help of solvents, water is added back in. The slides are then stained. The dyes used commonly include hematoxylin (H) and eosin (E). These yield colors of pink, orange and blue and make it easier to identify different cells. The nucleus of a cell is usually stained blue, with the cytoplasm is pink or orange.

Another type of specimen is the frozen section. This section can be looked at within a few minutes of removal. These sections are not as good as permanent sections and are not as durable. Their immediate assessment though can be of great importance to the patient and surgeon in certain circumstances.

The other type of specimen is the smear. This is a liquid or small particles in liquid. The sample is "smeared" on a slide and air-dried or set with a fixative spray. The smears are then stained, covered and examined under a microscope. Smears can be examined almost immediately.

The pathologist does two types of examinations: the gross description and the microscopic examination. "Gross" really means how it appears to the naked eye. This dictated description usually includes the exact way it was labeled, a description of what it looks like and includes measurements. The slide or cassette is identified (Cassette A) and how it was cut, if at all, is noted. Sometimes, the gross description includes weight, a description of the texture of the surface and the coloration. Certain diagnoses can be ruled out at this point. All slides are identified as to which section of the specimen is included.

The microscopic examination describes what is found under the microscope. This is generally self-explanatory to the pathologist.

Finally, the pathologist renders a diagnosis, based on his/her findings. Usually a diagnosis is stated succinctly as follows: Order involved, site of the specimen removal, type of surgical procedure to obtain the sample and finally the diagnosis. http://oncli.com/pathology/

Pathology Terminology which might be helpful in your future:

For greater detail on the pathologist's report, check out: http://www.cancerguide.org/pathology.html

Now, I'd like to try to give you a layperson's insight into the pathology report.

First, your cancer might be called ductal carcinoma (cancer of the milk ducts) or lobular carcinoma (cancer of the lobules). It might be called invasive (means it has spread outside the location it began in). The report may add "adeno" to the front of the word carcinoma - adenocarcinoma (means cancer relating to a gland, since the milk ducts and lobules are sort of glands). If the cancer has not spread beyond where it started it is called intraductal (within the duct) carcinoma (cancer) in situ (literally staying in place) or lobular carcinoma in situ. These two types are known as non-invasive cancer (they haven't spread outside the area they started in)

Some other terms that might be in the report describe the surrounding tissue: fibrosis (scar tissue), papules (fingery projections, desmoplasia (scar reaction). There are a couple of other types of breast cancer, that are only a very small percentage of all breast cancers: tubular (cells look like little tubes), medullary (color of brain matter), mucinous (makes mucus) and papillary (makes those fingery projections).

Next they look at how agressive your tumor is and then to see how weird looking it is (poorly differentiated) - they don't look like normal cells are supposed to look (well differentiated). Next is how aggressive the tumor is - are the cells diving and how quickly. Then there is nuclear grade - the center of the cell is the nucleus - the odder that looks the higher the nuclear grade, with 4 being the worst.

Then the pathologist looks for spread to the blood vessels or lymphatic system. Spread is not good, because it means it is moving out of the area. They look at how many blood vessels are growing with the tumor. Lots of blood vessels can mean that the tumor is doing well and growing. Another sign to look for is necrosis (dead cancer cells). You would think dead cancer is good, but no, it means that the tumor has grown bigger than its blood supply.

The Bloom Richardson Score is a combination of all of the above, based on tube formation (tubes are good), regular/irregular shape, size and stain of the nucleus and mitotic activity (cell division). Each gets a score of 1 through 3. Total up to 5 is Grade 1, 6-7 is Grade 2 and 8+ Grade 3. Higher the total score, the more aggressive the tumor. Please note that all the statistics about breast cancer, staging, etc are numerical equations. If 90% are going to be really sick according to the stats, there are still 10% who will be fine. I had a friend who was diagnosed as Stage I breast cancer (more about staging soon) and she died within one year. I have another pal who has been Stage IV for over 10 years and she is doing fine. Remember that someone always has to react outside the numbers stated.

Remember those slices of tissue that the pathologist cuts up and preserves? Now they stain them and see if the edges are clean. This means that the cancer hasn't gone all the way to the ends of the tissue. If the stained slides are inky all the way to the edges, it means you have "dirty margins" and the cancer MAY not all have been surgically removed. This is not real precise, but is a good estimate. "Uninvolved" margins are good; "indeterminate" means they really don't know and "unclean" or "dirty" margins usually mean more work to destroy your cancer.

For the past decade or so, they also run some biological tests on the tumors. Is it Estrogen (E+) or Progesterone (P+) positive? (Means that E or P help the tumor to grow). The test to see how fast the cells divide by measuring the amount and type of DNA. Normal amounts are called diploid; abnormal is called aneuploid. Another "biomarker" is an overexpression of Her-2 neu (This is an oncogene receptor). There are several tests for this such as IHC (immunohistochemistry, which check the overexpression) and FISH (fluorescence in situ hydbridization which looks at the actual gene amplification.) Lots of new biomarkers are being considered now and we will look at them in another article.

Hopefully, this will give you a basis to at least attempting to delve into your own pathology report.

The next important step is to see if your cancer has spread and how significant that spread is. This is known as "staging" and is based on the TNM system (tumor, node, metastases - which means distant cancers). There are 4 Stages, with 4 being the most serious.

We've already looked at how the pathologist goes over the tumor. Now it will get classified, based on its size or if there are more than one tumors.

The nodes or lymph nodes are the first place the cancer can spread to. These will be tested by either Sentinel Node Biopsy (SNB) or Axillary Node Dissection (AND) - these are included in another lesson.

To see if the disease has spread to a far away sight in your body, such as the bones, lungs, liver, brain, several tests may be order. A bone scan, which is non-invasive can look for cancer in the bones, MRIs and CAT scans and X-rays can search out cancer cells in the other locations. It is important to know as much about your cancer as possible, so the doctor and you, as part of your health care team, can make informed decisions about the treatments available to you, including radiation, chemotherapy, hormonal therapy. There are also blood tests, known as "tumor markers", usually CA 15-3 and CA 27, 29 which monitor the tumor growth through blood samples.

Pathologists have their own type shorthand, so you might see any of the terms below in your path report -

Primary Tumor (T) - this is THE tumor or the main tumor in case you have more than one (example: I found my "lump", that was the primary tumor. When they did an ultrasound, they found a second, smaller tumor. My pathology report was based on the primary tumor.

TX - Primary tumor can't be assessed

T0 - No evidence of primary tumor

Tis - Carcinoma in situ

T1 - Tumor is 2 cm or less Subcategories: T1mic - 0.1 cm or less T1a - Greater than 0.1 cm but less than .5 cm T1b - Greater than .5 cm but less than 1 cm T1c - Greater than 1, but not more than 2 cm

T2 - Greater than 2 cm but less than 5 cm

T3 - Greater than 5 cm

T4 - Any size tumor that extends directly into chest wall, skin, ulceratings (oozing), edema (swelling) Subcategories: T4a - Extension to chest wall T4b - Edema or ulceration or skin nodules T4c - includes T4a and T4b T4d - Inflammatory carcinoma

The lower the T status, the better.

Next are the lymph nodes (N)

NX - Lymph nodes cannot be assessed

N0 - No spread to the lymph nodes

N1 - Spread to the lymph nodes

N2 - Spread to the lymph nodes and fixed to each other

N3 - Spread to the internal mammary lymph nodes (The first lymph nodes start from the breast through the axilla (armpit) and are known as ipsilateral. The mammary lymph nodes are further in the chest cavity and considered more serious) Again, the lower the number, the better.

Last staging category, Metastasis (M) - distant spread

MX - Metastasis can't be assessed

M0 - No metastasis

M1 - Spread through lymph nodes and/or other body sites

Finally, the three "scores" above are combined to decide what stage your cancer is at.

Stage 0 - Tis/NO/MO

Stage 1 - T1, NO/MO

Stage 11A - TO/N1/MO or T1/N1/MO or T2/NO/MO

Stage IIB - T2/N1/MO or T3/NO/MO

Stage IIIA - T0/N2/MO or T1/N2/MO or T3/N1/MO or T3/N2/MO

Stage IIIb - T4/Any N/MO or Any T/N3/MO

Stage IV - Any T/Any N, MI

So, hopefully you are not totally confused, but what it boils down to is (my own rough shorthand of this): Stage 1 - small tumor, nothing else Stage 2 - small tumor and a few nodes, or larger tumor and no nodes Stage 3 - Larger tumor and any or no nodes OR any size tumor and a bunch of positive nodes Stage 4 - Any spread outside the lymph nodes qualifies for stage 4.

Please, if you read a path report and it says Stage IV, do not immediately assume the worst. There are, and this will sound weird, stages of bad. Kind of like one of those old, bad jokes. Doctor to Patient: I have good news and bad news. Patient: Yes, doc? Doctor: Good news is they have baseball in Heaven. Patient: Sounds great to me. Doctor: Bad news is you're pitching tomorrow.

So I hope you understand there are degrees of everything - Stage 4 in black and white is always stage 4, but a small "met" to a leg bone surely can't be valued the same as "mets" to the spine, liver and lungs. See what I mean?

Finally, the pathology report and the staging process are merely tools to help the physicians decide what course of action is best offered to you, the patient. Someone always has to beat the odds and someone will always refuse treatment or decide to take their chances. For many, quality of life is a huge overriding concern in all medical decisions.

Please remember, doctors can suggest all they want. Final decision should be yours, based on informed consent, realistic expectations, family/friends input, solid knowledge base and your personal gut reaction. It's your body, your cancer, your life - do what's best for you.

  1  2  3  4  5 

Print this page