1. 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

2. Thyroid Case # 3 Presentation of New Case
Newly diagnosed thyroid cancer patient
Presentation at Cancer Conference for treatment recommendations and clinical staging

3. 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

4. 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.

5. Thyroid Case # 3 Diagnostic Procedure
Fine needle aspiration (FNA) lt lobe thyroid
Pathology Report
Papillary carcinoma

6. Thyroid Case # 3 Clinical Staging
Uses information from the physical exam, imaging, and diagnostic biopsy
Purpose
Select appropriate treatment
Estimate prognosis

7. 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______

8. 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

9. 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

10. Prognostic Factors Clinically Significant
Applicable to this case
Extrathyroid extension: none
Histology: papillary
There are no prognostic factors required for staging

12. 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

13. Thyroid Case # 3 Surgery & Findings
Procedure
Total thyroidectomy
Operative findings
Invasion into adjacent strap muscle
Enlarged regional nodes

14. 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

15. 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)

16. 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______

17. 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

18. 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

19. 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

20. AJCC Cancer Staging Atlas T3 tumor with minimal extrathyroid extension
extension to either sternothyroid muscle or perithyroid soft tissues
>4cm limited to thyroid

21. 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.

22. 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)