Staging Moments Melanoma Case 2

Report
AJCC Staging Moments
AJCC TNM Staging 7th Edition
Melanoma Case #2
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 # 2
Presentation of New Case
• Newly diagnosed melanoma patient
• Presentation at Cancer Conference for treatment
recommendations and clinical staging
Melanoma Case # 2
History & Physical
• 60 yr old female who presented with a 1x0.5cm
skin lesion left calf of leg, no palpable inguinal or
popliteal adenopathy
• 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 # 2
Imaging Results
• No imaging
Melanoma Case # 2
Diagnostic Procedure
• Procedure
– Excision skin lesion left leg
• Pathology Report
–
–
–
–
–
–
Superficial spreading melanoma
Clark’s Level III
Breslow 0.65mm tumor thickness
No ulceration
Mitosis <1/mm2
Extends to margin
Melanoma Case # 2
Clinical Staging
• Clinical staging
– Uses information from the physical exam, imaging,
and diagnostic biopsy
• Purpose
– Select appropriate treatment
– Estimate prognosis
Melanoma Case # 2
Clinical Staging
• Synopsis- patient with 1cm melanoma skin left
leg, Breslow tumor thickness 0.65mm, Clark’s
level III, no ulceration, mitosis <1/mm2, nodes
clinically negative
• What is the clinical stage?
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–
–
–
T____
N____
M____
Stage Group______
Melanoma Case # 2
Clinical Staging
• Clinical Stage correct answer
–
–
–
–
T1a
N0
M0
Stage Group IA
• Based on stage, treatment is selected
• Review NCCN treatment guidelines for this
stage
Melanoma Case # 2
Clinical Staging
• Rationale for staging choices
– T1a for <1.0mm in thickness, no ulceration, mitosis
<1/mm2
– 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
– Measured tumor thickness: 0.65mm
– Ulceration: no
– Mitotic Rate: <1/mm2
Melanoma Case # 2
Surgery & Findings
• Procedure
– Wide re-excision skin leg
– 1cm margin
• Operative findings
– No additional information
Melanoma Case # 2
Pathology Results
• Residual melanoma in situ
• Margin negative
Melanoma Case # 2
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 # 2
Pathologic Staging
• Synopsis- patient with original 0.65mm in tumor
thickness lesion and residual melanoma in situ
• What is the pathologic stage?
(remember, clinical M may be used in pathologic staging)
–
–
–
–
T____
N____
M____
Stage Group______
Melanoma Case # 2
Pathologic Staging
• Pathologic Stage correct answer
–
–
–
–
pT1a
cN0
cM0
Stage Group IA
• Based on pathologic stage, there is more
information to estimate prognosis and adjuvant
treatment is selected
Melanoma Case # 2
Pathologic Staging
• Rationale for staging choices
– pT1a for <1.0mm in thickness, no ulceration, mitosis
<1/mm2
– cN0 because nodes were clinically negative and
Stage IA patients do not require pathologic evaluation
of their lymph nodes
– cM0 – use clinical M with pathologic staging unless
there is pathologic confirmation of distant metastases
Prognostic Factors
Clinically Significant
• Applicable to this case
– Measured tumor thickness: 0.65mm
– Ulceration: no
– Mitotic Rate: <1/mm2
AJCC Cancer Staging Atlas
T1a is <1.0mm in thickness,
with ulceration or mitosis >1/mm2
Melanoma Case # 2
Recap of Staging
• Summary of correct answers
– Clinical stage T1a N0 M0 Stage Group IA
– Pathologic stage T1a cN0 cM0 Stage Group IA
• 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)

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