Transcript Staging Moments Head and Neck Case 3

AJCC Staging Moments
AJCC TNM Staging 7th Edition
Thyroid Case #3
Contributors:
Jatin P. Shah, MD Memorial Sloan-Kettering Cancer Center, New York, New York
Carol R. Bradford, MD University of Michigan Medical Center, Ann Arbor, Michigan
James Brierley, MB Princess Margaret Hospital/University Health Network, Toronto, Ontario
Thyroid Case # 3
Presentation of New Case
• Newly diagnosed thyroid cancer patient
• Presentation at Cancer Conference for treatment
recommendations and clinical staging
Thyroid Case # 3
History & Physical
• 56 yr old female who presented with a left sided
thyroid mass
• No smoking hx
• No family history of ca
Thyroid Case # 3
Imaging Results
• US thyroid
– 16x18mm left sided
thyroid mass
– No lymphadenopathy
• Chest x-ray
– Negative
Used with permission. Gharib H. Atlas pf Clinical
Endocrinology: Thyroid Diseases. Edited by
Stanley Korenman (series editor), Martin I. Surks.
©1999 Current Medicine, Inc.
Thyroid Case # 3
Diagnostic Procedure
• Procedure
– Fine needle aspiration (FNA) lt lobe thyroid
• Pathology Report
– Papillary carcinoma
Thyroid Case # 3
Clinical Staging
• Clinical staging
– Uses information from the physical exam, imaging,
and diagnostic biopsy
• Purpose
– Select appropriate treatment
– Estimate prognosis
Thyroid Case # 3
Clinical Staging
• Synopsis- older patient with palpable 1.8cm
mass left lobe thyroid, nodes negative on
imaging
• What is the clinical stage?
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T____
N____
M____
Stage Group______
Thyroid Case # 3
Clinical Staging
• Clinical Stage correct answer
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T1b s
N0
M0
Stage Group I
• Based on stage, treatment is selected
• Review NCCN treatment guidelines for this stage
• Review American Thyroid Association guidelines
http://www.thyroidguidelines.org/revised/differentiated
Thyroid Case # 3
Clinical Staging
• Rationale for staging choices
– T1b s for solitary tumor >1 <2cm limited to thyroid
– N0 because nodes were clinically negative on
physical exam and imaging
– 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
– Extrathyroid extension: none
– Histology: papillary
• There are no prognostic factors required for
staging
Thyroid Case # 3
Presentation after Surgery
• The procedure chosen based on the small
solitary lesion and clinically negative nodes in a
patient >45 yrs old, Stage 1, is total
thyroidectomy
• Presentation at Cancer Conference for adjuvant
treatment recommendations and pathologic
staging
Thyroid Case # 3
Surgery & Findings
• Procedure
– Total thyroidectomy
• Operative findings
– Invasion into adjacent strap muscle
– Enlarged regional nodes
Thyroid Case # 3
Pathology Results
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Papillary carcinoma, left lobe thyroid
Tumor size - 2.5cm
Extends to margin
Invades adjacent strap muscle
Multifocal papillary ca, right lobe thyroid
Mets 2/6 pretracheal nodes
Mets 1/2 left paratracheal nodes
Thyroid Case # 3
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
– For selection of adjuvant treatment
– Calculating end results (survival data)
Thyroid Case # 3
Pathologic Staging
• Synopsis- patient with 2.5cm tumor invading into
strap muscle, and involvement of Level VI nodes
• What is the pathologic stage?
(remember, clinical M may be used in pathologic staging)
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–
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T____
N____
M____
Stage Group______
Thyroid Case # 3
Pathologic Staging
• Pathologic Stage correct answer
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pT3 m
pN1a
cM0
Stage Group III
• Based on pathologic stage, there is more
information to estimate prognosis and adjuvant
treatment is selected
Thyroid Case # 3
Pathologic Staging
• Rationale for staging choices
– pT3 m is tumor with minimal extrathyroid extension
and multifocal
– pN1a because Level VI pretracheal and paratracheal
nodes were involved
– cM0 - use clinical M with pathologic staging unless
there is pathologic confirmation of distant metastases
Prognostic Factors
Clinically Significant
• Applicable to this case
– Extrathyroid extension: Minor, to strap muscles,
therefore the primary tumor is upstaged to T3
– Histology: papillary
• There are no prognostic factors required for
staging
AJCC Cancer Staging Atlas
T3 tumor with minimal
extrathyroid extension
>4cm limited to thyroid
extension to either sternothyroid
muscle or perithyroid soft tissues
Thyroid Case # 3
Recap of Staging
• Summary of correct answers
– Clinical stage T1b s N0 M0 Stage Group I
– Pathologic stage T3 m N1a cM0 Stage Group III
• 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 for selection of adjuvant treatment and prognosis
– Used to evaluate end-results (survival)