Breast cancer grading

Breast cancer grading is useful prognosticator. It is done routinely on all invasive breast cancers.

The most common is the Nottingham system, also known as Scarff-Bloom-Richardson.

Nottingham system

Nottingham is based on:

1. Nuclear grade.
   • Small, regular (1.5-2x RBC dia.) = 1.
   • Moderated variability = 2.
   • Marked variation (>2.5x RBC dia.) = 3.
2. Tubule formation.
   • Majority of tumour - tubules >75% = 1.
   • Moderate - 10% to 75% = 2.
   • Minimal <10% = 3.
3. Mitotic rate.
   • 0-5 mitosis/10 HPF (1.52 mm^2 --or-- 0.0152 mm^2 * 10) = 1.
   • 6-10 mitosis/10 HPF (1.52 mm^2) = 2.
   • >11 mitosis/10 HPF (1.52 mm^2) = 3.

Mnemonic: TMN = tubule formation, mitotic rate, nuclear grade.

Notes:

• Elston & Ellis devised the system that is used. They also wrote a follow-up article in 2002.

Note about mitosis counting

• One MUST adjust for the size of the field of view.

• Most of the Resident scopes have an eye piece diameter of 22 mm. Therefore, the field diameter at 40 X is approximately 22 mm / 40 X ~= 0.55 mm and the field of view is pi/4*(0.55 mm)^2 = 0.2376 mm^2.
  • Thus, on a resident scope (with a FOV of 0.2376 mm^2) one should sample 6 or 7 fields of view (FsOV).
    • Calculation: 1.52 mm^2 (sampling area) / 0.2376 mm^2 (area / FOV ) = 6.40 FsOV.

• RANT: Sampling 10 fields, where the field of view (FOV) is 0.152 mm^2, is not the same as sampling ten fields, where the FOV is 0.312 mm^2. It surprises me that Elston & Ellis ignore the fact that "10 HPFs" on different microscopes represent different sample areas and that they do not standardize the sampling area.

Calculating Nottingham score

• Grade I = 3-5 points.
• Grade II = 6-7 points.
• Grade III = 8-9 points.

Notes:

• I've found most tumours are grade II.
• The mitotic score is usually 1/3.
• The nuclear score is rarely 1/3 -- even in the tubular subtype.

See also

• Invasive breast cancer.
• Breast cancer staging.