1. AJCC Staging Moments AJCC TNM Staging 7th Edition Melanoma Case #3 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 # 3 Presentation of New Case Newly diagnosed melanoma patient Presentation at Cancer Conference for treatment recommendations and clinical staging

3. Melanoma Case # 3 History & Physical 79 yr old male who presented with a pigmented skin lesion left mid back, lesion enlarging and changing color, no lymphadenopathy No family hx Used with permission. Halpern A, Charles C, Marghoob A. Atlas of Cancer. Edited by Maurie Markman, Ashfaq A. Marghoob. ©2002 Current Medicine Inc.

4. Melanoma Case # 3 Imaging Results No imaging

5. Melanoma Case # 3 Diagnostic Procedure Procedure –Incisional skin bx left mid thoracic back Pathology Report –Melanoma –Breslow tumor thickness 0.8mm –Ulceration present –Mitoses 1/mm 2 –Clark’s level II –Margins involved

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

7. Melanoma Case # 3 Clinical Staging Synopsis- elderly patient with 0.8mm in tumor thickness melanoma skin left mid back with ulceration present, mitosis 1/mm 2, clinically negative nodes What is the clinical stage? –T____ –N____ –M____ –Stage Group______

8. Melanoma Case # 3 Clinical Staging Clinical Stage correct answer –T1b –N0 –M0 –Stage Group IB Based on stage, treatment is selected Review NCCN treatment guidelines for this stage

9. Melanoma Case # 3 Clinical Staging Rationale for staging choices –T1b for <1.0mm in thickness, mitosis 1/mm 2, and ulceration present –N0 because nodes were clinically negative on 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 –Measured tumor thickness: 0.8mm –Ulceration: present –Mitotic Rate: 1/mm 2

12. Melanoma Case # 3 Surgery & Findings Procedure –Wide excision –2 cm margin –Sentinel node procedure Operative findings –Sentinel nodes identified by dye and radioactive tracer

13. Melanoma Case # 3 Pathology Results Melanoma Superficial spreading and desmoplastic type Breslow tumor thickness 6.0mm Ulceration present Mitosis 1/mm 2 Margins negative 1/4 left axillary nodes positive for melanoma

14. Melanoma Case # 3 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)

15. Melanoma Case # 3 Pathologic Staging Synopsis- patient with 6mm in thickness melanoma, ulceration present, mitoses 1/mm 2, mets in 1 clinically negative regional node What is the pathologic stage? (remember, clinical M may be used in pathologic staging) –T____ –N____ –M____ –Stage Group______

16. Melanoma Case # 3 Pathologic Staging Pathologic Stage correct answer –pT4b –pN1a –cM0 –Stage Group IIIB Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected

17. Melanoma Case # 3 Pathologic Staging Rationale for staging choices –pT4b is >4mm in thickness, with ulceration present –pN1a because one clinically negative axillary node was positive –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 thickness: 6.0mm –Ulceration: present –Mitotic Rate: 1/mm 2

20. AJCC Cancer Staging Atlas T4b is >4.0mm in thickness, with ulceration N1a is clinically occult (microscopic) mets

21. Melanoma Case # 3 Recap of Staging Summary of correct answers –Clinical stage T1b N0 M0 Stage Group IB –Pathologic stage T4b N1a cM0 Stage Group IIIB 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 to evaluate end-results (survival)