AJCC Staging Moments

AJCC TNM Staging 7th Edition

Colon Case #1

Contributors: J. Milburn Jessup, MD Cancer Diagnosis Program, DCTD, NCI, Rockville, Maryland Mary Kay Washington, MD Vanderbilt University Medical Center, Nashville, Tennessee

Jose Guillem, MD Memorial Sloan-Kettering Cancer Center, New York, New YorkFrederick L. Greene, MD Carolinas Medical Center, Charlotte, North Carolina

Colon Case # 1Presentation of New Case

• Newly diagnosed colon cancer patient

• Presentation at Cancer Conference for treatment recommendations and clinical staging

Colon Case # 1History & Physical

• 51 yr old female who presented with an abnormal screening colonoscopy

• Family history of colon ca

Colon Case # 1Imaging & Endoscopy Results

• Colonoscopy-1.5cm pedunculated polyp at 60cm in transverse colon

• CT abd/pelvis-negative

used with permissionwww.gihealth.com

Colon Case # 1Diagnostic Procedure

• Procedure– Polypectomy, transverse colon at 60cm

• Pathology Report– Adenocarcinoma– Grade 2-3– Invasion into lamina propria– Stalk margins widely free, clear by 4mm

Colon Case # 1Clinical Staging

• Clinical staging – Uses information from the physical exam, imaging,

and diagnostic biopsy

• Purpose– Select appropriate treatment– Estimate prognosis

Colon Case # 1Clinical Staging

• Synopsis- patient with 1.5cm pedunculated polyp resected on screening colonoscopy, nodes negative on imaging

• What is the clinical stage?– T____– N____– M____– Stage Group______

Colon Case # 1Clinical Staging

• Clinical Stage correct answer– pTis– cN0– cM0– Stage Group 0

• Based on stage, treatment is selected• Review NCCN treatment guidelines for this

stage

Colon Case # 1Clinical Staging

• Rationale for staging choices

– pTis • Invasion of lamina propria• Pathologic since the stalk margin was clear

– cN0 because nodes were clinically negative on imaging

– cM0 because there was nothing to suggest distant metastases; if there was, appropriate tests would be performed before developing a treatment plan

Prognostic FactorsClinically Significant

• Applicable to this case

– Pre-op or Pre-Rx CEA: not done

• There are no prognostic factors required for staging

Colon Case # 1Presentation after Surgery

• Patient had polypectomy during their screening colonoscopy

• This patient was recommended for observation only, no further treatment

Colon Case # 1Pathologic Staging

• Pathologic staging – Uses information from the clinical staging

supplemented or modified by information from surgery and the pathology report

• Purpose– Additional precise data for estimating prognosis– Calculating end results (survival data)

Colon Case # 1Pathologic Staging

• Synopsis- patient with polyp resected on screening colonoscopy

• What is the pathologic stage?(remember, clinical M may be used in pathologic staging)

– T____– N____– M____– Stage Group______

Colon Case # 1Pathologic Staging

• Pathologic Stage correct answer– pTis– cN0– cM0– Stage Group 0

• Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected

Colon Case # 1Pathologic Staging

• Rationale for staging choices– pTis because

• Invasion of lamina propria• Pathologic since the stalk margin was clear

– cN0 – nodes were negative on imaging so this is clinical, but can be used in insitu cases only

– cM0 – use clinical M with pathologic staging unless there is pathologic confirmation of distant metastases

– AJCC 7th Edition Chapter 1, p12, allow pTis cN0 cM0 to be both a clinical Stage Group 0 and a pathologic Stage Group 0

Prognostic FactorsClinically Significant

• Applicable to this case

– Pre-op or Pre-Rx CEA: not done

• There are no prognostic factors required for staging

AJCC Cancer Staging AtlasTis Ca in situ or invasion of lamina propriaT1 invades submucosa

Colon Case # 1Recap of Staging

• Summary of correct answers– Clinical stage pTis cN0 cM0 Stage Group 0– Pathologic stage pTis cN0 cM0 Stage Group 0

• The staging classifications have a different purpose and therefore can be different. Do not go back and change the clinical staging based on pathologic staging information.

Staging Moments Summary

• Review site-specific information if needed

• Clinical Staging– Based on information before treatment– Used to select treatment options

• Pathologic Staging– Based on clinical data PLUS surgery and pathology

report information– Used to evaluate end-results (survival)