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

3. Melanoma Case # 1 History & Physical 83 yr old female who presented with a 2cm maximal diameter brown lesion right cheek over the right malar eminence, no ulceration, no cervical lymphadenopathy 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 # 1 Imaging Results No imaging

5. Melanoma Case # 1 Diagnostic Procedure Procedure –Excision skin lesion rt cheek Pathology Report –Melanoma in situ –Lentigo maligna type –Radial margin involved

6. Melanoma Case # 1 Clinical Staging Clinical staging –Uses information from the physical exam, imaging, and diagnostic biopsy Purpose –Select appropriate treatment –Estimate prognosis

7. Melanoma Case # 1 Clinical Staging Synopsis- elderly patient with 2cm maximal diameter melanoma in situ lesion with margins involved, no lymphadenopathy What is the clinical stage? –T____ –N____ –M____ –Stage Group______

8. Melanoma Case # 1 Clinical Staging Clinical Stage correct answer –pTis –cN0 –cM0 –Stage Group 0 Based on stage, treatment is selected Review NCCN treatment guidelines for this stage

9. Melanoma Case # 1 Clinical Staging Rationale for staging choices –Tis for carcinoma in situ –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 –Ulceration: no

12. Melanoma Case # 1 Surgery & Findings Procedure –Re-excision skin lesion with 5mm margin Operative findings –No additional information

13. Melanoma Case # 1 Pathology Results Residual melanoma in situ Lentigo maligna type Clark’s Level I Extends close to radial margins

14. Melanoma Case # 1 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 # 1 Pathologic Staging Synopsis- patient with melanoma in situ, Clark’s level I lesion, no nodes removed, clinically nodes negative What is the pathologic stage? (remember, clinical M may be used in pathologic staging) –T____ –N____ –M____ –Stage Group______

16. Melanoma Case # 1 Pathologic Staging Pathologic Stage correct answer –pTis –cN0 –cM0 –Stage Group 0 Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected

17. Melanoma Case # 1 Pathologic Staging Rationale for staging choices –pTis for carcinoma in situ –cN0 because there is an exception for pathologic Stage 0 and Stage IA, they do not require pathologic evaluation of 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 –Ulceration: no There are no prognostic factors required for staging

19. AJCC Cancer Staging Atlas Tis is melanoma in situ

20. Melanoma Case # 1 Recap of Staging Summary of correct answers –Clinical stage pTis cN0 cM0 Stage Group 0 –Pathologic stage pTis cN0 cM0 Stage Group 0 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)