Breast Cancer Diagnosis Workup
If a woman has an abnormal mammography or breast exam,
it is appropriate to do a workup to determine whether
cancer cells are present. If cancer cells are already
present, it must also be determined how much cancer is
present and how far the cancerous cells have spread.
The size and
spread of the cancer is classified as the stage
of the cancer. Knowing the stage of the cancer
is important because it is the primary factor in
the selection of treatment and in the prognosis
for the woman.
Thus, after an abnormal mammography or breast exam, the
woman will typically be referred for additional breast
imaging with diagnostic mammography, ultrasound, or other
imaging tests. Depending on the results of these imaging
tests, it may also be appropriate for the physician to
order a breast biopsy. The biopsy is the only definitive
way to determine whether cancer is present.
Staging the Breast Cancer
The cancer's stage is documented by using a standard
system which assigns letters and numbers to indicate
the size and spread of the cancer:
The T,N,M Staging System
The TNM staging system is based on a classification
of the size and spread of the Tumor, the involvement
of lymph nodes, and metastasis to other organs or
to the skeletal system.
stands for tumor (its size and how far it has spread
within the breast and to nearby organs).
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor (this sometimes happens)
Tis: Carcinoma in situ; intraductal carcinoma, lobular
carcinoma in situ, or Paget's disease of the nipple
with no associated tumor mass
T1: Tumor 2 cm (4/5 of an inch) or less in greatest
T2: Tumor more than 2 cm but not more than 5 cm (2 inches)
in greatest dimension
T3: Tumor more than 5 cm in greatest dimension
T4: Tumor of any size growing into the chest wall or skin
stands for spread to the regional (nearby)
NX: Regional lymph nodes cannot be assessed
(for example, removed previously)
N0: Cancer has not spread to regional lymph nodes.
N1: Cancer has spread to 1-3 axillary lymph node(s)
on the same side as the breast cancer and/or in
internal mammary nodes with microscopic disease
found by sentinel node biopsy but not
found on imaging studies or by clinical exam.
This category includes the situation where only a
small cluster of cancer cells is detected.
N2: Cancer has spread to 4-9 lymph nodes on the same
side as the breast cancer or in internal mammary
nodes found by imaging studies or clinical exam
in the absence of axillary lymph node metastasis
N3: Cancer has spread to 10 or more axillary lymph
nodes, or in infraclavicular (below the collar
bone) lymph nodes, or in supraclavicular nodes
(above the collar bone) or in internal mammary
lymph nodes(located beneath the breast and
inside the chest) found by imaging tests or
clinical exam in the presence of one or more
positive axillary lymph nodes, or in more than
3 axillary lymph nodes and in internal mammary
nodes found by sentinel node biopsy but not
found by imaging tests or clinical exam - all
on the same side as the breast
stands for whether there is metastasis
(spread to distant organs).
MX: Presence of distant spread (metastasis) cannot
M0: No distant spread
M1: Distant spread is present
The stages are commonly expressed numerically:
Stage 0 or carcinoma in situ (TISN0M0)
Ductal carcinoma in situ (DCIS) is the earliest
form of breast cancer. In DCIS, cancer cells are
located within a duct and have not invaded the
surrounding fatty breast tissue.
Lobular carcinoma in situ (LCIS), also called
lobular neoplasia, is sometimes classified as
stage 0 breast cancer, although many oncologists
believe it is not a true form of 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.
Stage I (T1N0M0)
The tumor is 2 cm (about 4/5 of an inch) or less
in diameter and has not spread to lymph nodes or
Stage II (T0N1M0 T1N1M0, T2N0,N1M0, T3N0M0)
The tumor is larger than 2 cm in diameter but
not larger than 5 cm (2 inches), or it has
spread to 1-3 axillary (underarm) lymph nodes
on the same side as the breast cancer. Both of
these can be present also. The tumor may also
be larger than 5 cm but has not spread to lymph
Stage III (T0N2M0, T1N2M0, T2N2M0, T3,N2M0, T4AnyN,M0, AnyT,N3,M0)
The tumor is smaller than 5 cm in diameter
and has spread to 4-9 axillary lymph nodes,
or the tumor is larger than 5 cm and has
spread to 1-9 axillary nodes or the tumor
grown into the chest wall or skin and 0-9
nodes are involved, or the tumor is any size
has spread to 10 or more nodes in the axilla
or to lymph nodes under the clavicle
(infraclavicular) or above the clavicle
(supraclavicular) or to lymph nodes in the
chest near the breast bone (internal mammary).
Patients with stage III cancer show no signs
that the cancer has spread to distant organs
Inflammatory breast cancer is classified as
stage III, unless it has spread to distant
organs or lymph nodes that are not near the
breast, in which case it would be stage IV.
Stage IV (AnyTAnyNM1)
The cancer, regardless of its size, has
metastasized to distant organs such as bones
or lungs or to lymph nodes not near the breast.
Once the diagnostic workup is completed, a proper
plan can be developed.
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