AJCC Staging Moments
AJCC TNM Staging 7th Edition
Colon Case #1
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 York
Frederick L. Greene, MD Carolinas Medical Center, Charlotte, North Carolina
Colon Case # 1
Presentation of New Case
• Newly diagnosed colon cancer patient
• Presentation at Cancer Conference for treatment
recommendations and clinical staging
Colon Case # 1
History & Physical
• 51 yr old female who presented with an
abnormal screening colonoscopy
• Family history of colon ca
Colon Case # 1
Imaging & Endoscopy Results
• Colonoscopy-1.5cm pedunculated polyp at 60cm
in transverse colon
• CT abd/pelvis-negative
used with permission
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Colon Case # 1
Diagnostic Procedure
• Procedure
– Polypectomy, transverse colon at 60cm
• Pathology Report
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Adenocarcinoma
Grade 2-3
Invasion into lamina propria
Stalk margins widely free, clear by 4mm
Colon Case # 1
Clinical Staging
• Clinical staging
– Uses information from the physical exam, imaging,
and diagnostic biopsy
• Purpose
– Select appropriate treatment
– Estimate prognosis
Colon Case # 1
Clinical Staging
• Synopsis- patient with 1.5cm pedunculated
polyp resected on screening colonoscopy, nodes
negative on imaging
• What is the clinical stage?
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T____
N____
M____
Stage Group______
Colon Case # 1
Clinical Staging
• Clinical Stage correct answer
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pTis
cN0
cM0
Stage Group 0
• Based on stage, treatment is selected
• Review NCCN treatment guidelines for this
stage
Colon Case # 1
Clinical Staging
• Rationale for staging choices
– pTis
• Invasion of lamina propria
• Pathologic since the stalk margin was clear
– cN0 because nodes were clinically negative on
imaging
– cM0 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
– Pre-op or Pre-Rx CEA: not done
• There are no prognostic factors required for
staging
Colon Case # 1
Presentation after Surgery
• Patient had polypectomy during their screening
colonoscopy
• This patient was recommended for observation
only, no further treatment
Colon 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)
Colon Case # 1
Pathologic Staging
• Synopsis- patient with polyp resected on
screening colonoscopy
• What is the pathologic stage?
(remember, clinical M may be used in pathologic staging)
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–
–
–
T____
N____
M____
Stage Group______
Colon Case # 1
Pathologic Staging
• Pathologic Stage correct answer
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–
–
–
pTis
cN0
cM0
Stage Group 0
• Based on pathologic stage, there is more
information to estimate prognosis and adjuvant
treatment is selected
Colon Case # 1
Pathologic Staging
• Rationale for staging choices
– pTis because
• Invasion of lamina propria
• Pathologic since the stalk margin was clear
– cN0 – nodes were negative on imaging so this is
clinical, but can be used in insitu cases only
– cM0 – use clinical M with pathologic staging unless
there is pathologic confirmation of distant metastases
– AJCC 7th Edition Chapter 1, p12, allow pTis cN0 cM0
to be both a clinical Stage Group 0 and a pathologic
Stage Group 0
Prognostic Factors
Clinically Significant
• Applicable to this case
– Pre-op or Pre-Rx CEA: not done
• There are no prognostic factors required for
staging
AJCC Cancer Staging Atlas
Tis Ca in situ or invasion of lamina propria
T1 invades submucosa
Colon 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)