Evaluation of TNM Classification of Carcinoma of the Breast

Br. J. Cancer (1973) 28, 580 EVALUATION OF TNM CLASSIFICATION OF CARCINOMA OF THE BREAST K. SICHER esi J. A. H. WATERHOUSE From the Corenfry and Warwickshire Hospital anid Birmingham Regional Caneer Registry Received 10 Julv 1973. Accepted 6 September 1973 Summary.-A survey of the records of almost 2000 cases of carcinoma of the breast in the years 1960-67, since acceptance of the principles of the TNM system of classification, found only 9.20o lacking description. Although the TNM staging was not always allocated by the surgeon making the initial examination, the survey demonstrated that acceptance of the system has resulted in the inclusion of a much more detailed clinical description by the surgeon in the patient's record, from which it was generally possible to assess the TNM staging in the Radiotherapy Department. The more detailed survival rates available in the case of the TNM system, in comparison with the Manchester staging system, is cited as a further recommendation for its wider use. Although detailed localization of the tumour to subsites within the breast appears to have little influence on prognosis, the addi tion of a supplementary histological classification of node involvement is a valuable adjunct to the assessment of likely survival. THE DIPORTANCE of clinical classification of malignant tumours is implicit in anv worthwhile assessment of the relative efficacy of treatment regimens. In the field of mammary cancer in part,icular, much of the management of which is still a subject of controversy, evaluation of the relative merits of different methods of treatment depends essentiallv upon an accurate description of the initial findings in conveniently concise and readily accepted terms. Clinical trials are current in this and in other countries to test and compare alternative treatments, but the validity of their results and the relevance of comparisons between them hinge on the successful application of methods of description of the growth based on the same, generally accepted, principles for all centres. The TNMf system as recommended by the International Union against Cancer (U3ICC) in 1959 sets out to fulfil this function and experience of its use in breast cancer is now becoming more extensive. It was recommended at the IXth International Cancer Congress in 1966 that the system should be accepted internationally, for an initial period of at least 5 years. The principles of TNM staging of breast tumours, as described in the British Journal of Surgery (1960) or in the UICC's booklet (1968)* were formallv accepted for implementation by both surgeons and radiotherapists in the Birmingham Region soon afterwards. This paper sets out to make a preliminary assessment of the extent to which the recommendations have been followed in two of the Hospital Groups of the region (Groups 14 and 20), and to compare it with the 'Manchester system of staging which had been in general use for many years. At the same time comparisons are also made of the TIYM classification with histological evidence of axillarv node involvement, as well as with the situation of the tumour within the breast. * A new edition of this Booklet was produced in 1972, proposing some modifications for use in the period 19J73-77. 581 EVALUATION OF TNM CLASSIFICATION OF CARCLNOMA OF THE BREAST TABLE I.-Number of Cases Staged by Year of Registration Staging TN-\M and 'Manchester 1960 1961 1962 1963 1964 1965 1966 1967 190 173 187 210 176 179 206 200 T\-NM onlv 3 Neither Total 10 14 217 Manchester only 14 10 31 228 5 13 34 239 The period of time covered is 1960-67. Table I shows that the proportion of cases staged has not altered much in this time. A specially devised form giving full details of the TNM criteria is included in the records of each case. It is made clear that the TN.M staging should be made at the first examination but unhappily this condition was not invariably observed. The description of the growth, primary and secondaries, given by the surgeons was, however, sufficiently detailed in most cases for TNM assessment in the radiotherapy department. While on occasions the TNM staging is omitted, the information now given by the surgeons is much more detailed than it was before the scheme began. The simple direction " carcinoma breast-for mastectomy " has fortunately disappeared, and contrasts sharply with the present full and adequate description of the growth now given by the surgeonsan example which is followed also by their junior staff from registrars down. In nearly 2000 cases, for instance, only 6 3 25 244 25 30 15 246 17 38 21 255 _vv 21 33 17 9 34 24 277 267 _ . . Total 1521 100 171 181 1973 _v .L 9.20/0 were not staged at all and both TN1M and Manchester systems were recorded for 77-1%. Table II and Fig. 1 show the overall distribution by Manchester staging. Stage TABLE II.-Manchester Staging I I] I II1I IX Total staged Nc t staged Total DNumber 740 491 1 252 0 43-7 29-0 14 9 209 12-4 1692 281 1973 100-0 85- 9 14-2 100 C0 I at 43-7% is the largest group, while 14-2% had inadequate information for assessment of stage. The distribution by TNM system is shown in Table III, and in Fig. 2. As can be seen, only 2.4% had distant metastases (M1). A more detailed breakdown of the TNKM cases is made in Table IV, which shows the largest single group of cases to have been classified as T2No. A comparison of the TNM and Manchester 3U 40 30 20 10 0 - FIG. 1.-Distribution bv Manchester staging. K. S{ICHER AND J. A. H. WATERHUI-Ws'E T 75 (TUMOUR) 52.9 Z 50 0 25 in I S-7' n u h T2 T, 29- 7 8 7 U. r3 T4 N 75 (NODES) 24% 50 25 nvJ IV0 mN#2 Fi,.. 2. TABLE III. T 'Numbh:-r Nurmbor ', -*7 _- 4-2 52 9 2 -7 141 I ti 21 11:t'Vt h % IM i it-ta N 1I n 140" - TNMI ('la.-4icatio,' t um ,ur \Nunmbr T. T. T, T5 T, tal N3 Di-trihuti, n b- T-NM categ-co mi--. N, N1l -NI -N ~ . S- 2 -N 114 72 T. T 1 99 T4 21 T, ,tal -)s: 12 -6t 1 -3 .52' 69 4 -3 1621:3 1':t't hg 1'"' 1 -in17 '-, fth,- t, taml 197:3 (a "'ithoiit IDis&t, t JII(ta4. ox (i.e. Mo OI ) T,,tal ,, ~~~ ~~N.' N. ''-31 1- 2'1 42 2-3I: 1 3 2 ):3 NCI 14", 1%51 4 65 126 76 4- 6#4 4 15.2 2 'i .. . ) 21 -3 29 2'1 ., 21, "I, ,- - I 621 1-, T. 4 4 9.t 162120-' 62"- 'N 1 N,-, r 521 I 3-)% .1 2 t-,tal -f 352 ca-- x-re I1it -tra-t Itfr T-NM. ri, r,- TXBLE IJ-. TNJI I)e.t,ib"tio,' ,f ( s-l 'N UI1 'j45 t- )- 4 ''15 I 1'"' l EVALUATION OF TNM CLASSIFICATION OF CARCINOMA OF THE BREAST TABLE V.-C'omparison of TNM Classification and Manchester Staging Manchester stage TNlm classification T1N 03 T25 XNoAO TX,NM* T 3- 031 T 4 MN83 T2NI1M T,N1lM0 T3N1m0 I 111 456 104 4 1 1 T4N1MO II Im 9 6 1 4 75 25 303 112 1 12 77 14 IV N.K. 9 32 6 4 8 6 Total 114 501 199 21 1 11 9 1 T2-N-MO T IN- 2231 T 3N 192 8 32 1 T1SN2M T4N2M0 5 5 29 42 8 20 36 1 6 28 T1N-3M* T2,N3M0 T4NX3mO 2 3 2 6 16 33 1 1 2 (...truncated)