1. AJCC Staging Moments AJCC TNM Staging 7th Edition Rectal Case #3 Contributors: J. Milburn Jessup, MD Cancer Diagnosis Program, DCTD, NCI, Rockville, Maryland Mary Kay Washington, MD Vanderbilt University Medical Center, Nashville, Tennessee Jose Guillem, MD Memorial Sloan-Kettering Cancer Center, New York, New York Frederick L. Greene, MD Carolinas Medical Center, Charlotte, North Carolina

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

3. Rectal Case # 3 History & Physical 51 yr old male who presented with diarrhea and abdominal pain No family history of colon or rectal cancer

4. Rectal Case # 3 Imaging & Endoscopy Results Colonoscopy-single large circumferential fungating mass in rectum 2 to 5cm from anus Retroflexed endoscope with rectal tumor used with permission Julio Murra-Saca, MD El Savador Atlas of Gastrointestinal Video Endoscopy

5. Rectal Case # 3 Diagnostic Procedure Procedure –Biopsy rectal mass Pathology Report –Adenocarcinoma, invasive –Grade 2 CEA: 4.3

6. Rectal Case # 3 Imaging Results Endorectal ultrasound –Invasion into peri-rectal fat CT chest/abd/pelvis –Thickening in rectal and perirectal soft tissue –1.2cm peri-iliac node mesenteric node –1.7cm perirectal lymphadenopathy –No liver metastases used with permission Julio Murra-Saca, MD El Savador Atlas of Gastrointestinal Video Endoscopy

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

8. Rectal Case # 3 Clinical Staging Synopsis- patient with rectal mass and perirectal tissue involvement, and clinically involved nodes What is the clinical stage? –T____ –N____ –M____ –Stage Group______

9. Rectal Case # 3 Clinical Staging Clinical Stage correct answer –T3 –N1 –M0 –Stage Group IIIB Based on stage, treatment is selected Review NCCN treatment guidelines for this stage

10. Rectal Case # 3 Clinical Staging Rationale for staging choices –T3 for into non-peritonealized pericolic or perirectal tissues –N1 because nodes were clinically positive on imaging –M0 because there was nothing to suggest distant metastases; if there was, appropriate tests would be performed before developing a treatment plan

11. Prognostic Factors Clinically Significant Applicable to this case –CEA: 4.3 There are no prognostic factors required for staging

13. Rectal Case # 3 Surgery & Findings Patient received neoadjuvant Rx with chemotherapy and radiation therapy Procedure –Transabdominal resection Operative findings –Colo-anal anastomosis performed with 2 cm margin

14. Rectal Case # 3 Pathology Results Residual adenocarcinoma, rectum Tumor size - 3cm Grade 3, poorly differentiated Through muscle wall into pericolonic soft tissue Margins negative Circumferential resection margin clear by 8mm Mets 3/12 regional nodes No perineural or lymph-vascular invasion Tumor deposits were not identified

15. Rectal Case # 3 Pathologic Staging Pathologic staging –Uses information from the clinical staging supplemented or modified by information from surgery and the pathology report –yp is assessment at conclusion of therapy Purpose –Additional precise data for estimating prognosis –Calculating end results (survival data) –yp – extent of response to therapy

16. Rectal Case # 3 Pathologic Staging Synopsis- patient with rectal ca into pericolonic soft tissue, and positive nodes after neoadjuvant chemo and RT What is the pathologic stage? (remember, clinical M may be used in pathologic staging) –T____ –N____ –M____ –Stage Group______

17. Rectal Case # 3 Pathologic Staging Pathologic Stage correct answer –ypT3 –ypN1 –cM0 –ypStage Group IIIB Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected

18. Rectal Case # 3 Pathologic Staging Rationale for staging choices –ypT3 for into non-peritonealized pericolic or perirectal tissues after neoadjuvant chemo/RT –ypN1 because nodes were positive on exam after neoadjuvant chemo/RT –cM0 - classified by M status prior to therapy –y prefix used to show stage during or following neoadjuvant therapy

19. Prognostic Factors Clinically Significant Applicable to this case –CEA: 4.3 –Circumferential resection margin: 8mm –Tumor deposits: no –Perineural invasion: no There are no prognostic factors required for staging

20. AJCC Cancer Staging Atlas T3 into non-peritonealized pericolic or perirectal tissues (adventitia)

21. Rectal Case # 3 Recap of Staging Summary of correct answers –Clinical stage T3 N1 M0 Stage Group IIIB –Pathologic stage ypT3 ypN1 cM0 ypStage 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 y Pathologic Staging –Based on clinical data PLUS surgery and pathology report information after neoadjuvant therapy –Assesses response to treatment –Used to evaluate end-results (survival)