Transcript Staging Moments Melanoma Case 1

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 # 1
Presentation of New Case
• Newly diagnosed melanoma patient
• Presentation at Cancer Conference for treatment
recommendations and clinical staging
Melanoma Case # 1
History & 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 # 1
Imaging Results
• No imaging
Melanoma Case # 1
Diagnostic Procedure
• Procedure
– Excision skin lesion rt cheek
• Pathology Report
– Melanoma in situ
– Lentigo maligna type
– Radial margin involved
Melanoma Case # 1
Clinical Staging
• Clinical staging
– Uses information from the physical exam, imaging,
and diagnostic biopsy
• Purpose
– Select appropriate treatment
– Estimate prognosis
Melanoma Case # 1
Clinical 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 # 1
Clinical 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 # 1
Clinical 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 Factors
Clinically Significant
• Applicable to this case
– Ulceration: no
Melanoma Case # 1
Surgery & Findings
• Procedure
– Re-excision skin lesion with 5mm margin
• Operative findings
– No additional information
Melanoma Case # 1
Pathology Results
• Residual melanoma in situ
• Lentigo maligna type
• Clark’s Level I
• Extends close to radial margins
Melanoma Case # 1
Pathologic 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 # 1
Pathologic 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 # 1
Pathologic 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 # 1
Pathologic 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 Factors
Clinically Significant
• Applicable to this case
– Ulceration: no
• There are no prognostic factors required for
staging
AJCC Cancer Staging Atlas
Tis is melanoma in situ
Melanoma Case # 1
Recap 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)