AJCC Staging Moments

AJCC TNM Staging 7th Edition

Melanoma Case #1

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 # 1Presentation of New Case

• Newly diagnosed melanoma patient

• Presentation at Cancer Conference for treatment recommendations and clinical staging

Melanoma Case # 1History & Physical

• 83 yr old female who presented with a 2cm maximal diameter brown lesion right cheek over the right malar eminence, no ulceration, no cervical lymphadenopathy

• 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 # 1Imaging Results

• No imaging

Melanoma Case # 1Diagnostic Procedure

• Procedure– Excision skin lesion rt cheek

• Pathology Report– Melanoma in situ– Lentigo maligna type– Radial margin involved

Melanoma Case # 1Clinical Staging

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

and diagnostic biopsy

• Purpose– Select appropriate treatment– Estimate prognosis

Melanoma Case # 1Clinical Staging

• Synopsis- elderly patient with 2cm maximal diameter melanoma in situ lesion with margins involved, no lymphadenopathy

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

Melanoma 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

Melanoma Case # 1Clinical Staging

• Rationale for staging choices– Tis for carcinoma in situ

– 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– Ulceration: no

Melanoma Case # 1Surgery & Findings

• Procedure– Re-excision skin lesion with 5mm margin

• Operative findings– No additional information

Melanoma Case # 1Pathology Results

• Residual melanoma in situ

• Lentigo maligna type

• Clark’s Level I

• Extends close to radial margins

Melanoma 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)

Melanoma Case # 1Pathologic Staging

• Synopsis- patient with melanoma in situ, Clark’s level I lesion, no nodes removed, clinically nodes negative

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

– T____– N____– M____– Stage Group______

Melanoma 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

Melanoma Case # 1Pathologic Staging

• Rationale for staging choices– pTis for carcinoma in situ

– cN0 because there is an exception for pathologic Stage 0 and Stage IA, they do not require pathologic evaluation of nodes

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

Prognostic FactorsClinically Significant

• Applicable to this case– Ulceration: no

• There are no prognostic factors required for staging

AJCC Cancer Staging AtlasTis is melanoma in situ

Melanoma 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)