Staging of Breast Cancer in the Neoadjuvant Setting

Abstract

The use of neoadjuvant chemotherapy has become more prevalent in the treatment of breast cancer patients. The finding of a pathologic complete response to neoadjuvant chemotherapy (no evidence of residual invasive cancer in the breast and lymph nodes at the time of surgical resection) has been shown to correlate with improved survival. The current version of the American Joint Committee on Cancer (AJCC) staging for breast cancer has a pretreatment clinical stage designation that is determined by clinical and radiographic examination of the patient and a postoperative pathologic stage classification based on the findings in the breast and regional lymph nodes removed at surgery. Pathologic staging has not been validated for patients receiving neoadjuvant chemotherapy; thus, prognosis is determined for these patients based on the pretreatment clinical stage. We hypothesized that clinical and pathologic staging variables could be combined with biological tumor markers to provide a novel means of determining prognosis for patients treated with neoadjuvant chemotherapy. Two scoring systems, based on summing binary indicators for clinical and pathologic substages, negative estrogen receptor status, and grade 3 tumor pathology, were devised to predict 5-year patient outcomes. These scoring systems facilitated separation of the study population into more refined subgroups by outcome than the current AJCC staging system for breast cancer, and provide a novel means for evaluating prognosis after neo-adjuvant therapy.

The effects of adding zoledronic acid to neoadjuvant chemotherapy on tumour response: exploratory evidence for direct anti-tumour activity in breast cancer

“…Carey et al (2005) reported that higher pathological stage in the surgical resection specimen using this revised classification system was significantly associated with lower rates of distant disease-free survival and overall survival in stage II/III breast cancer patients treated with neoadjuvant CT (n ¼ 132, median follow-up 5 years). In addition, the ClinicalPathologic Scoring (CPS) system has very recently been described to predict 5-year outcomes of breast cancer patients treated with neoadjuvant CT (Jeruss et al, 2008). This model incorporates clinical TNM stage at presentation and post-neoadjuvant CT pathological TNM stage, assigning points to each presenting clinical substage and post-treatment pathological substage, with a 5-year distant metastasis-free survival of 97% for a CPS score of 0 and 46% for a CPS score of 4.…”

Validation of a Novel Staging System for Disease-Specific Survival in Patients With Breast Cancer Treated With Neoadjuvant Chemotherapy

“…ER-negative disease and nuclear grade 3 tumor pathology were found to be independent risk factors for poor prognosis, and these variables were added to the CPS system to create a second staging system, the CPS ϩ EG system. 5,6 Application of the CPS ϩ EG staging system allowed for stratification of patients into seven groups with significantly different 5-year distant metastasis-free and disease-specific survival (DSS).…”

“…On the basis of these data, we concluded that the CPS ϩ EG staging system could provide more precise information regarding prognosis and facilitate decision making regarding adjuvant treatment strategies. 5,6 The current study was undertaken to validate the CPS ϩ EG staging system using a more contemporary cohort of patients from our institution as well as an external cohort of patients treated at The University of Michigan (Ann Arbor, MI).…”

Basal-like molecular subtype and HER4 up-regulation and response to neoadjuvant chemotherapy in breast cancer

“…Patients without any residual invasive cancer in the breast and axillary lymph nodes were considered to have pCR. Patients with residual in situ cancer only were also considered to have pCR (15). Gene expression patterns were correlated to the response to NAC.…”