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 # 3
Presentation of New Case
• Newly diagnosed melanoma patient
• Presentation at Cancer Conference for treatment
recommendations and clinical staging
Melanoma Case # 3
History & 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 # 3
Imaging Results
• No imaging
Melanoma Case # 3
Diagnostic 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 # 3
Clinical Staging
• Clinical staging
– Uses information from the physical exam, imaging,
and diagnostic biopsy
• Purpose
– Select appropriate treatment
– Estimate prognosis
Melanoma Case # 3
Clinical 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 # 3
Clinical 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 # 3
Clinical 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 Factors
Clinically Significant
• Applicable to this case
– Measured tumor thickness: 0.8mm
– Ulceration: present
– Mitotic Rate: 1/mm2
Melanoma Case # 3
Surgery & Findings
• Procedure
– Wide excision
– 2 cm margin
– Sentinel node procedure
• Operative findings
– Sentinel nodes identified by dye and radioactive
tracer
Melanoma Case # 3
Pathology 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 # 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
– Calculating end results (survival data)
Melanoma Case # 3
Pathologic 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 # 3
Pathologic 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 # 3
Pathologic 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 Factors
Clinically Significant
• Applicable to this case
– Measured thickness: 6.0mm
– Ulceration: present
– Mitotic Rate: 1/mm2
AJCC Cancer Staging Atlas
T4b is >4.0mm in thickness, with
ulceration
N1a is clinically occult
(microscopic) mets
Melanoma Case # 3
Recap 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)