1. AJCC TNM Staging 7th Edition Melanoma Case #2
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

2. Melanoma Case # 2 Presentation of New Case
Newly diagnosed melanoma patient
Presentation at Cancer Conference for treatment recommendations and clinical staging

3. 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.

4. Melanoma Case # 2 Imaging Results
No imaging

5. Melanoma Case # 2 Diagnostic 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

6. Melanoma Case # 2 Clinical Staging
Uses information from the physical exam, imaging, and diagnostic biopsy
Purpose
Select appropriate treatment
Estimate prognosis

7. 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?
T____
N____
M____
Stage Group______

8. 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

9. 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

10. Prognostic Factors Clinically Significant
Applicable to this case
Measured tumor thickness: 0.65mm
Ulceration: no
Mitotic Rate: <1/mm2

12. Melanoma Case # 2 Surgery & Findings
Procedure
Wide re-excision skin leg
1cm margin
Operative findings
No additional information

13. Melanoma Case # 2 Pathology Results
Residual melanoma in situ
Margin negative

14. Melanoma Case # 2 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)

15. 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______

16. 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

17. 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

18. Prognostic Factors Clinically Significant
Applicable to this case
Measured tumor thickness: 0.65mm
Ulceration: no
Mitotic Rate: <1/mm2

19. AJCC Cancer Staging Atlas. T1a is <1. 0mm in thickness,
AJCC Cancer Staging Atlas T1a is <1.0mm in thickness, with ulceration or mitosis >1/mm2

20. 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.

21. 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)