AJCC Staging Moments AJCC TNM Staging 7 th

AJCC Staging Moments AJCC TNM Staging 7 th 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 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 2 cm 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 2 cm 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 – – p. Tis c. N 0 c. M 0 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 – N 0 because nodes were clinically negative on physical exam * – M 0 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 5 mm 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 – – p. Tis c. N 0 c. M 0 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 – p. Tis for carcinoma in situ – c. N 0 because there is an exception for pathologic Stage 0 and Stage IA, they do not require pathologic evaluation of nodes – c. M 0 – 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 p. Tis c. N 0 c. M 0 Stage Group 0 – Pathologic stage p. Tis c. N 0 c. M 0 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)