Haagensen's Grave signs

Haagensen's Grave signs are a group of signs that when present in patients of carcinoma breast indicate inoperability.
These signs were identified by Haagensen and Stout in a review of the clinical features of patients of breast cancer treated at their hospital in the 1940s. Presence of these signs were associated with a 0% probablity of 5 year cure and 50% risk of local recurrence.
The grave signs as given by the duo include:

1. Skin ulceration
2. Fixation of tumor to the chest wall
3. Axillary nodes > 2.5 cm in diameter
4. Edema of < 1/3rd of the skin of breast
5. Presence of fixed axillary nodes

They felt that presence of only one of these criterias didnot indicate inoperability per se but the probablity of cure with surgery was minimal if two signs were present.
In addition the authors also identified a subset of patient with extremely poor outcome. These patients included:

1. Extensive skin edema ( >50% skin involved)
   
2. Satellite skin nodules
3. Inflammatory type of cancer
4. Clinically involved SCF and Internal Mammary nodes
5. Edema of arms
6. Presence of any TWO grave signs given above.
   

The importance of this study of 1139 patients was that id defined the criteria of operability of patients. Patients with one grave sign were considered operable - but those with two grave signs or those with features of extremely poor outcome were not.
This system was used by the Columbia Clinical Classification System which was the standard of staging in carcinoma breast.
The system is as follows:

Stage A	No skin edema, ulceration, or solid fixation of the tumor to the chest wall. Axillary nodes are not involved clinically
Stage B	No skin edema, ulceration, or solid fixation of the tumor to the chest wall. Clinically involved nodes, but less than 2.5 cm in transverse diameter and not fixed to overlying skin or deeper structures of the axilla
Stage C	Any one of the five grave signs of advanced breast carcinoma:
	(1) Edema of the skin of limited extent (involving less than one-third of the skin over the breast)
	(2) Skin ulceration
	(3) Solid fixation of the tumor to the chest wall
	(4) Massive involvement of axillary lymph nodes (measuring 2.5 cm or more in transverse diameter)
	(5) Fixation of the axillary nodes to overlying skin or deeper structures of the axilla
Stage D	All other patients with more advanced breast carcinoma, including:
	(1) A combination of any two or more of the five grave signs listed under stage C
	(2) Extensive edema of the skin (involving more than one-third of the skin over the breast)
	(3) Satellite skin nodules
	(4) The inflammatory type of carcinoma
	(5) Clinically involved supraclavicular lymph nodes
	(6) Internal mammary metastases as evidenced by a parasternal tumor
	(7) Edema of the arm
	(8) Distant metastases

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