AJCC Staging Moments

AJCC TNM Staging 7th Edition

Melanoma Case #3

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 # 3Presentation of New Case

• Newly diagnosed melanoma patient

• Presentation at Cancer Conference for treatment recommendations and clinical staging

Melanoma Case # 3History & Physical

• 79 yr old male who presented with a pigmented skin lesion left mid back, lesion enlarging and changing color, no lymphadenopathy

• No family hx

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

Melanoma Case # 3Imaging Results

• No imaging

Melanoma Case # 3Diagnostic Procedure

• Procedure– Incisional skin bx left mid thoracic back

• Pathology Report– Melanoma– Breslow tumor thickness 0.8mm– Ulceration present– Mitoses 1/mm2

– Clark’s level II– Margins involved

Melanoma Case # 3Clinical Staging

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

and diagnostic biopsy

• Purpose– Select appropriate treatment– Estimate prognosis

Melanoma Case # 3Clinical Staging

• Synopsis- elderly patient with 0.8mm in tumor thickness melanoma skin left mid back with ulceration present, mitosis 1/mm2, clinically negative nodes

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

Melanoma Case # 3Clinical Staging

• Clinical Stage correct answer– T1b– N0– M0– Stage Group IB

• Based on stage, treatment is selected

• Review NCCN treatment guidelines for this stage

Melanoma Case # 3Clinical Staging

• Rationale for staging choices– T1b for <1.0mm in thickness, mitosis 1/mm2, and

ulceration present

– N0 because nodes were clinically negative on imaging *

– 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: 0.8mm

– Ulceration: present

– Mitotic Rate: 1/mm2

Melanoma Case # 3Surgery & Findings

• Procedure– Wide excision– 2 cm margin– Sentinel node procedure

• Operative findings– Sentinel nodes identified by dye and radioactive

tracer

Melanoma Case # 3Pathology Results

• Melanoma• Superficial spreading and desmoplastic type• Breslow tumor thickness 6.0mm• Ulceration present• Mitosis 1/mm2

• Margins negative• 1/4 left axillary nodes positive for melanoma

Melanoma Case # 3Pathologic 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 # 3Pathologic Staging

• Synopsis- patient with 6mm in thickness melanoma, ulceration present, mitoses 1/mm2, mets in 1 clinically negative regional node

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

– T____– N____– M____– Stage Group______

Melanoma Case # 3Pathologic Staging

• Pathologic Stage correct answer– pT4b– pN1a– cM0– Stage Group IIIB

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

Melanoma Case # 3Pathologic Staging

• Rationale for staging choices– pT4b is >4mm in thickness, with ulceration present

– pN1a because one clinically negative axillary node was positive

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

Prognostic FactorsClinically Significant

• Applicable to this case

– Measured thickness: 6.0mm

– Ulceration: present

– Mitotic Rate: 1/mm2

AJCC Cancer Staging AtlasT4b is >4.0mm in thickness, with

ulceration

N1a is clinically occult(microscopic) mets

Melanoma Case # 3Recap of Staging

• Summary of correct answers– Clinical stage T1b N0 M0 Stage Group IB– Pathologic stage T4b N1a cM0 Stage Group IIIB

• 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)