AJCC Staging Moments

AJCC TNM Staging 7th Edition

Melanoma Case #2

Contributors: Jeffrey E. Gershenwald, MD University of Texas MD Anderson Cancer Center, Houston, Texas Daniel G. Coit, MD Memorial Sloan-Kettering Cancer Center, New York, New York Charles M. Balch, MD Johns Hopkins Medical Center, Baltimore, Maryland David R. Byrd, MD University of Washington Medical Center, Seattle, Washington

Melanoma Case # 2Presentation of New Case

• Newly diagnosed melanoma patient

• Presentation at Cancer Conference for treatment recommendations and clinical staging

Melanoma Case # 2History & Physical

• 60 yr old female who presented with a 1x0.5cm skin lesion left calf of leg, no palpable inguinal or popliteal adenopathy

• No family hx

Used with permission. Marghoob A, Halpern A. Atlas of Cancer. Edited by Maurie Markman, Ashfaq A. Marghoob. ©2002 Current Medicine, Inc.

Melanoma Case # 2Imaging Results

• No imaging

Melanoma Case # 2Diagnostic Procedure

• Procedure– Excision skin lesion left leg

• Pathology Report– Superficial spreading melanoma– Clark’s Level III– Breslow 0.65mm tumor thickness– No ulceration– Mitosis <1/mm2

– Extends to margin

Melanoma Case # 2Clinical Staging

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

and diagnostic biopsy

• Purpose– Select appropriate treatment– Estimate prognosis

Melanoma Case # 2Clinical Staging

• Synopsis- patient with 1cm melanoma skin left leg, Breslow tumor thickness 0.65mm, Clark’s level III, no ulceration, mitosis <1/mm2, nodes clinically negative

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

Melanoma Case # 2Clinical Staging

• Clinical Stage correct answer– T1a– N0– M0– Stage Group IA

• Based on stage, treatment is selected

• Review NCCN treatment guidelines for this stage

Melanoma Case # 2Clinical Staging

• Rationale for staging choices– T1a for <1.0mm in thickness, no ulceration, mitosis

<1/mm2

– N0 because nodes were clinically negative on physical exam *

– M0 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

– Measured tumor thickness: 0.65mm

– Ulceration: no

– Mitotic Rate: <1/mm2

Melanoma Case # 2Surgery & Findings

• Procedure– Wide re-excision skin leg– 1cm margin

• Operative findings– No additional information

Melanoma Case # 2Pathology Results

• Residual melanoma in situ

• Margin negative

Melanoma Case # 2Pathologic 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)

Melanoma Case # 2Pathologic Staging

• Synopsis- patient with original 0.65mm in tumor thickness lesion and residual melanoma in situ

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

– T____– N____– M____– Stage Group______

Melanoma Case # 2Pathologic Staging

• Pathologic Stage correct answer– pT1a– cN0– cM0– Stage Group IA

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

Melanoma Case # 2Pathologic Staging

• Rationale for staging choices– pT1a for <1.0mm in thickness, no ulceration, mitosis

<1/mm2

– cN0 because nodes were clinically negative and Stage IA patients do not require pathologic evaluation of their lymph nodes

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

Prognostic FactorsClinically Significant

• Applicable to this case

– Measured tumor thickness: 0.65mm

– Ulceration: no

– Mitotic Rate: <1/mm2

AJCC Cancer Staging AtlasT1a is <1.0mm in thickness, with ulceration or mitosis >1/mm2

Melanoma Case # 2Recap of Staging

• Summary of correct answers– Clinical stage T1a N0 M0 Stage Group IA– Pathologic stage T1a cN0 cM0 Stage Group IA

• 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)