Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

The new TNM-based staging of breast cancer


This review describes the changes that have been implemented in the Tumor–Node–Metastasis (TNM)-based staging of breast cancers by the new, 8th editions of the relevant Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC) publications. After giving a background for TNM being the common language of cancer staging and related activities like cancer treatment and registration, it summarizes not only the changes but reviews some highlights important for pathologists, and lists and comments on the differences between the publications and diagnostic practices based on them. A section is dedicated to the prognostic stages of breast carcinomas introduced in the AJCC Cancer Staging Manual, but not mentioned in the UICC TNM classification of malignant tumors. A few issues that are not appropriately covered by TNM according to the authors’ view (e.g., multifocal tumors, larger lymph node metastases identified by molecular methods, the heterogeneous prognosis of M1-defined stage IV disease) close the review with the final thoughts raising the vision of a potential loss of the common staging language.

This is a preview of subscription content, log in to check access.


  1. 1.

    Brierley JD, Gospodarowicz MK, Wittekind C (eds) (2017) TNM classification of malignant tumours, 8th edn. Chichester, John Wiley and Sons

  2. 2.

    Hortobagyi G, Connolly JL, D’Orsi CJ, Edge SB, Mittendorf EA, Rugo HS, Solin LJ, Weaver DL, Winchester DJ, Giuliano A (2017) Breast. In: Amin MB, Edge SB, Greene FL et al (eds) AJCC cancer staging manual, 8th edn. Springer, New York, pp 587–628. https://doi.org/10.1007/978-3-319-40618-3_48

  3. 3.

    http://www.uicc.org/resources/tnm Accessed 1 November 2017

  4. 4.

    Amin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK, Meyer L, Gress DM, Byrd DR, Winchester DP (2017) The eighth edition AJCC cancer staging manual: continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin 67(2):93–99. https://doi.org/10.3322/caac.21388

  5. 5.

    De Mascarel I, MacGrogan G, Debled M, Brouste V, Mauriac L (2008) Distinction between isolated tumor cells and micrometastases in breast cancer: is it reliable and useful? Cancer 112:1672–1678

  6. 6.

    Cserni G, Bianchi S, Vezzosi V, van Diest P, van Deurzen C, Sejben I, Regitnig P, Asslaber M, Foschini MP, Sapino A, Castellano I, Callagy G, Arkoumani E, Kulka J, Wells CA (2008) Variations in sentinel node isolated tumour cells/micrometastasis and non-sentinel node involvement rates according to different interpretations of the TNM definitions. Eur J Cancer 44:2185–2191

  7. 7.

    Cserni G, Amendoeira I, Bianchi S, Chmielik E, Degaetano J, Faverly D, Figueiredo P, Foschini MP, Grabau D, Jacquemier J, Kaya H, Kulka J, Lacerda M, Liepniece-Karele I, Penuela JM, Quinn C, Regitnig P, Reiner-Concin A, Sapino A, van Diest PJ, Varga Z, Vezzosi V, Wesseling J, Zolota V, Zozaya E, Wells CA (2011) Distinction of isolated tumour cells and micrometastasis in lymph nodes of breast cancer patients according to the new tumour node metastasis (TNM) definitions. Eur J Cancer 47(6):887–894. https://doi.org/10.1016/j.ejca.2010.11.011

  8. 8.

    TNM frequently asked questions http:// www.uicc.org/sites/main/files/atoms/files/E_TNM_FAQs_12_16.pdf Accessed 08 October 2017

  9. 9.

    https:// cancerstaging.org/About/news/Pages/Implementation-of-AJCC-8th-Edition-Cancer-Staging-System.aspx Accessed 08 October 2017

  10. 10.

    http://www.wileyanduicc.com/pdf/Corrected_pages.pdf Accessed 16 October 2017

  11. 11.

    Sobin LH, Gospodarowicz MK, Wittekind C (eds) (2009) TNM classification of malignant tumours, 7th edn. Chichester, John Wiley and Sons

  12. 12.

    Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A III (eds) (2010) AJCC cancer staging manual, 7th edn. New York, Springer

  13. 13.

    Caliskan M, Gatti G, Sosnovskikh I, Rotmensz N, Botteri E, Musmeci S, Rosali dos Santos G, Viale G, Luini A (2008) Paget’s disease of the breast: the experience of the European Institute of Oncology and review of the literature. Breast Cancer Res Treat 112(3):513–521. https://doi.org/10.1007/s10549-007-9880-5

  14. 14.

    Amendoeira I, Apostolikas N, Bellocq JP et al (2006) Quality assurance guidelines for pathology. In: Perry N, Broeders M, de wolf C, Törnberg S, Holland R, von Karsa L (eds) European guidelines for quality assurance in breast cancer screening and diagnosis, 4th edn. European Commission, Luxemburg, pp 219–311

  15. 15.

    Wazir U, Wazir A, Wells C, Mokbel K (2016) Pleomorphic lobular carcinoma in situ: current evidence and a systemic review. Oncol Lett 12(6):4863–4868. https://doi.org/10.3892/ol.2016.5331

  16. 16.

    Senkus E, Kyriakides S, Ohno S, Penault-Llorca F, Poortmans P, Rutgers E, Zackrisson S, Cardoso F, Guidelines Committee ESMO (2015) Primary breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 26(Suppl 5):v8–30. https://doi.org/10.1093/annonc/mdv298

  17. 17.

    National Comprehensive Cancer Network: Clinical practice guidelines in oncology, Breast cancer, Version 2.2017—April 6, 2017 https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf Accessed 23 October 2017

  18. 18.

    Cotton DW, Kirkham N (1991) The use of Vernier scales. Histopathology 19(6):579. https://doi.org/10.1111/j.1365-2559.1991.tb01517.x

  19. 19.

    Symmans WF, Peintinger F, Hatzis C, Rajan R, Kuerer H, Valero V, Assad L, Poniecka A, Hennessy B, Green M, Buzdar AU, Singletary SE, Hortobagyi GN, Pusztai L (2007) Measurement of residual breast cancer burden to predict survival after neoadjuvant chemotherapy. J Clin Oncol 25(28):4414–4422. https://doi.org/10.1200/JCO.2007.10.6823

  20. 20.

    Sparano JA, Gray RJ, Makower DF, Pritchard KI, Albain KS, Hayes DF, Geyer Jr CE, Dees EC, Perez EA, Olson Jr JA, Zujewski JA, Lively T, Badve SS, Saphner TJ, Wagner LI, Whelan TJ, Ellis MJ, Paik S, Wood WC, Ravdin P, Keane MM, Gomez Moreno HL, Reddy PS, Goggins TF, Mayer IA, Brufsky AM, Toppmeyer DL, Kaklamani VG, Atkins JN, Berenberg JL, Sledge GW (2015) Prospective validation of a 21-gene expression assay in breast cancer. N Engl J Med 373:2005–2014, 21, DOI: https://doi.org/10.1056/NEJMoa1510764

  21. 21.

    Giuliano AE, Connolly JL, Edge SB, Mittendorf EA, Rugo HS, Solin LJ, Weaver DL, Winchester DJ, Hortobagyi GN (2017) Breast cancer—major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 67(4):290–303. https://doi.org/10.3322/caac.21393

  22. 22.

    Obralić N, Beslija S (2006) How to make the best use of limited resources in breast cancer treatment—experiences in Bosnia & Herzegovina. J BUON 11(1):21–29

  23. 23.

    Tabár L, Duffy SW, Vitak B, Chen HH, Prevost TC (1999) The natural history of breast carcinoma: what have we learned from screening? Cancer 86(3):449–462. https://doi.org/10.1002/(SICI)1097-0142(19990801)86:3<449::AID-CNCR13>3.0.CO;2-Q

  24. 24.

    Tot T, Gere M, Pekár G, Tarján M, Hofmeyer S, Hellberg D, Lindquist D, Chen TH, Yen AM, Chiu SY, Tabár L (2011) Breast cancer multifocality, disease extent, and survival. Hum Pathol 42(11):1761–1969. https://doi.org/10.1016/j.humpath.2011.02.002

  25. 25.

    Tot T (2012) The role of large-format histopathology in assessing subgross morphological prognostic parameters: a single institution report of 1000 consecutive breast cancer cases. Int J Breast Cancer 2012:395415

  26. 26.

    Vera-Badillo FE, Napoleone M, Ocana A, Templeton AJ, Seruga B, Al-Mubarak M, AlHashem H, Tannock IF, Amir E (2014) Effect of multifocality and multicentricity on outcome in early stage breast cancer: a systematic review and meta-analysis. Breast Cancer Res Treat 146(2):235–244. https://doi.org/10.1007/s10549-014-3018-3

  27. 27.

    Tot T, Tabár L (2011) The role of radiological–pathological correlation in diagnosing early breast cancer: the pathologist’s perspective. Virchows Arch 458(2):125–131. https://doi.org/10.1007/s00428-010-1005-6

  28. 28.

    Tot T (2016) Diffuse invasive breast carcinoma of no special type. Virchows Arch 468(2):199–206. https://doi.org/10.1007/s00428-015-1873-x

  29. 29.

    Duffy MJ, Harbeck N, Nap M, Molina R, Nicolini A, Senkus E, Cardoso F (2017) Clinical use of biomarkers in breast cancer: updated guidelines from the European group on tumor markers (EGTM). Eur J Cancer 75:284–298

  30. 30.

    Hendry S, Salgado R, Gevaert T et al (2017) Assessing tumor-infiltrating lymphocytes in solid tumors: a practical review for pathologists and proposal for a standardized method from the International Immunooncology Biomarkers Working Group: part 1: assessing the host immune response, TILs in invasive breast carcinoma and ductal carcinoma in situ, metastatic tumor deposits and areas for further research. Adv Anat Pathol 24:235–251

  31. 31.

    Look MP, van Putten WL, Duffy MJ et al (2002) Pooled analysis of prognostic impact of urokinase-type plasminogen activator and its inhibitor PAI-1 in 8377 breast cancer patients. J Natl Cancer Inst 94(2):116–128. https://doi.org/10.1093/jnci/94.2.116

  32. 32.

    Kattan MW, Hess KR, Amin MB, Lu Y, Moons KG, Gershenwald JE, Gimotty PA, Guinney JH, Halabi S, Lazar AJ, Mahar AL, Patel T, Sargent DJ, Weiser MR, Compton C, members of the AJCC Precision Medicine Core (2016) American Joint Committee on Cancer acceptance criteria for inclusion of risk models for individualized prognosis in the practice of precision medicine. CA Cancer J Clin 66:370–374

  33. 33.

    Cserni G (2012) Intraoperative analysis of sentinel lymph nodes in breast cancer by one-step nucleic acid amplification (OSNA). J Clin Pathol 65(3):193–199. https://doi.org/10.1136/jclinpath-2011-200301

  34. 34.

    Shi F, Zhang Q, Liang Z, Zhang M, Liu X (2017) One-step nucleic acid amplification assay is an accurate technique for sentinel lymph node biopsy of breast cancer patients: a meta-analysis. Br J Cancer 117:1185–1191

  35. 35.

    Wells CA, Amendoeira I, Bellocq JP et al (2012) S2: pathology update. Quality assurance guidelines for pathology. In: Perry N, Broeders M, de wolf C, Törnberg S, Holland R, von Karsa L (eds) European guidelines for quality assurance in breast cancer screening and diagnosis, 4th edn, supplements. European Commission, Office for Official Publications of the European Union, Luxembourg, pp 73–120

  36. 36.

    Tai P, Yu E, Vinh-Hung CG, Vlastos G (2004) Survival of patients with metastatic breast cancer: twenty-year data from two SEER registries. BMC Cancer 4(1):60. https://doi.org/10.1186/1471-2407-4-60

  37. 37.

    Zombori T, Lehóczky L, Cserni B, Nyári T, Cserni G (2017) Evaluation of anatomic and prognostic stages of breast cancer according to the 8th edition of the TNM staging system—retrospective analysis based on data from deceased patients once diagnosed with breast cancer. Orv Hetil 158:1373–1381

  38. 38.

    https://adjuvantonline.com/ Accessed 17 October 2017

  39. 39.

    http://www.predict.nhs.uk/predict_v2.0.html Accessed 17 October 2017

Download references


This study was partially funded by the National Research, Development and Innovation Office grant GINOP-2.3.2-15-2016-00020.

Author’s contribution.

All authors of the manuscript made substantial contributions to.

– the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work (if applicable);


– drafting the work and/or revising it critically for important intellectual content;


– final approval of the version submitted for publication;


– agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Other contribution is acknowledged in the Acknowledgements section of the manuscript.


This work was partially funded by the National Research, Development and Innovation Office grant GINOP-2.3.2-15-2016-00020.

Author information

Correspondence to Gábor Cserni.

Ethics declarations

The authors have consulted the journal policy regarding compliance with ethical standards and state that accepted principles of ethical and professional conduct have been followed. The authors include information regarding sources of funding (previous section) and potential conflicts of interest (financial or non-financial) (next section). As no patients or patients’ data are involved, ethical approval and informed consent are not applicable, similarly to animal welfare-related issues.

Conflict of interest

The authors declare that they have no conflict of interest.

Electronic supplementary material


(XLSX 60 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Cserni, G., Chmielik, E., Cserni, B. et al. The new TNM-based staging of breast cancer. Virchows Arch 472, 697–703 (2018). https://doi.org/10.1007/s00428-018-2301-9

Download citation


  • Breast cancer
  • TNM staging