AJCC TNM Staging 7th Edition Thyroid 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 Fine needle aspiration (FNA) lt lobe thyroid Pathology Report Papillary carcinoma

Thyroid Case # 3 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? T____ N____ M____ Stage Group______

Thyroid Case # 3 Clinical Staging Clinical Stage correct answer 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 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 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) T____ N____ M____ Stage Group______

Thyroid Case # 3 Pathologic Staging Pathologic Stage correct answer 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 extension to either sternothyroid muscle or perithyroid soft tissues >4cm limited to thyroid

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)