AJCC Staging Moments
AJCC TNM Staging 7th Edition
Rectal Case #3
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
Rectal Case # 3Presentation of New Case
• Newly diagnosed rectal cancer patient
• Presentation at Cancer Conference for treatment recommendations and clinical staging
Rectal Case # 3History & Physical
• 51 yr old male who presented with diarrhea and abdominal pain
• No family history of colon or rectal cancer
Rectal Case # 3Imaging & Endoscopy Results
• Colonoscopy-single large circumferential fungating mass in rectum 2 to 5cm from anus
Retroflexed endoscopewith rectal tumor
used with permissionJulio Murra-Saca, MDEl Savador Atlas of Gastrointestinal Video Endoscopy
Rectal Case # 3Diagnostic Procedure
• Procedure– Biopsy rectal mass
• Pathology Report– Adenocarcinoma, invasive– Grade 2
• CEA: 4.3
Rectal Case # 3Imaging Results
• Endorectal ultrasound– Invasion into peri-rectal fat
• CT chest/abd/pelvis– Thickening in rectal and perirectal soft tissue– 1.2cm peri-iliac node mesenteric node– 1.7cm perirectal lymphadenopathy– No liver metastases
used with permissionJulio Murra-Saca, MDEl Savador Atlas of Gastrointestinal Video Endoscopy
Rectal Case # 3Clinical Staging
• Clinical staging – Uses information from the physical exam, imaging,
and diagnostic biopsy
• Purpose– Select appropriate treatment– Estimate prognosis
Rectal Case # 3Clinical Staging
• Synopsis- patient with rectal mass and perirectal tissue involvement, and clinically involved nodes
• What is the clinical stage?– T____– N____– M____– Stage Group______
Rectal Case # 3Clinical Staging
• Clinical Stage correct answer– T3– N1– M0– Stage Group IIIB
• Based on stage, treatment is selected
• Review NCCN treatment guidelines for this stage
Rectal Case # 3Clinical Staging
• Rationale for staging choices– T3 for into non-peritonealized pericolic or perirectal
tissues
– N1 because nodes were clinically positive 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
– CEA: 4.3
• There are no prognostic factors required for staging
Rectal Case # 3Surgery & Findings
• Patient received neoadjuvant Rx with chemotherapy and radiation therapy
• Procedure– Transabdominal resection
• Operative findings– Colo-anal anastomosis performed with 2 cm margin
Rectal Case # 3Pathology Results
• Residual adenocarcinoma, rectum• Tumor size - 3cm • Grade 3, poorly differentiated • Through muscle wall into pericolonic soft tissue• Margins negative• Circumferential resection margin clear by 8mm• Mets 3/12 regional nodes• No perineural or lymph-vascular invasion• Tumor deposits were not identified
Rectal Case # 3Pathologic Staging
• Pathologic staging – Uses information from the clinical staging
supplemented or modified by information from surgery and the pathology report
– yp is assessment at conclusion of therapy
• Purpose– Additional precise data for estimating prognosis– Calculating end results (survival data)– yp – extent of response to therapy
Rectal Case # 3Pathologic Staging
• Synopsis- patient with rectal ca into pericolonic soft tissue, and positive nodes after neoadjuvant chemo and RT
• What is the pathologic stage?(remember, clinical M may be used in pathologic staging)
– T____– N____– M____– Stage Group______
Rectal Case # 3Pathologic Staging
• Pathologic Stage correct answer– ypT3– ypN1– cM0– ypStage Group IIIB
• Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected
Rectal Case # 3Pathologic Staging
• Rationale for staging choices– ypT3 for into non-peritonealized pericolic or perirectal
tissues after neoadjuvant chemo/RT
– ypN1 because nodes were positive on exam after neoadjuvant chemo/RT
– cM0 - classified by M status prior to therapy
– y prefix used to show stage during or following neoadjuvant therapy
Prognostic FactorsClinically Significant
• Applicable to this case
– CEA: 4.3
– Circumferential resection margin: 8mm
– Tumor deposits: no
– Perineural invasion: no
• There are no prognostic factors required for staging
AJCC Cancer Staging AtlasT3 into non-peritonealized pericolic or perirectal tissues (adventitia)
Rectal Case # 3Recap of Staging
• Summary of correct answers– Clinical stage T3 N1 M0 Stage Group IIIB– Pathologic stage ypT3 ypN1 cM0 ypStage 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
• y Pathologic Staging– Based on clinical data PLUS surgery and pathology
report information after neoadjuvant therapy– Assesses response to treatment– Used to evaluate end-results (survival)