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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
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.