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

3. Colon Case # 1 History & Physical
51 yr old female who presented with an abnormal screening colonoscopy
Family history of colon ca

4. Colon Case # 1 Imaging & Endoscopy Results
Colonoscopy-1.5cm pedunculated polyp at 60cm in transverse colon
CT abd/pelvis-negative
used with permission

5. Colon Case # 1 Diagnostic Procedure
Polypectomy, transverse colon at 60cm
Pathology Report
Adenocarcinoma
Grade 2-3
Invasion into lamina propria
Stalk margins widely free, clear by 4mm

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

7. Colon Case # 1 Clinical Staging
Synopsis- patient with 1.5cm pedunculated polyp resected on screening colonoscopy, nodes negative on imaging
What is the clinical stage?
T____
N____
M____
Stage Group______

8. Colon 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. Colon Case # 1 Clinical Staging
Rationale for staging choices
pTis
Invasion of lamina propria
Pathologic since the stalk margin was clear
cN0 because nodes were clinically negative on imaging
cM0 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
Pre-op or Pre-Rx CEA: not done
There are no prognostic factors required for staging

12. Colon Case # 1 Presentation after Surgery
Patient had polypectomy during their screening colonoscopy
This patient was recommended for observation only, no further treatment

13. Colon Case # 1 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)

14. Colon Case # 1 Pathologic Staging
Synopsis- patient with polyp resected on screening colonoscopy
What is the pathologic stage? (remember, clinical M may be used in pathologic staging)
T____
N____
M____
Stage Group______

15. Colon 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

16. Colon Case # 1 Pathologic Staging
Rationale for staging choices
pTis because
Invasion of lamina propria
Pathologic since the stalk margin was clear
cN0 – nodes were negative on imaging so this is clinical, but can be used in insitu cases only
cM0 – use clinical M with pathologic staging unless there is pathologic confirmation of distant metastases
AJCC 7th Edition Chapter 1, p12, allow pTis cN0 cM0 to be both a clinical Stage Group 0 and a pathologic Stage Group 0

17. Prognostic Factors Clinically Significant
Applicable to this case
Pre-op or Pre-Rx CEA: not done
There are no prognostic factors required for staging

18. AJCC Cancer Staging Atlas Tis Ca in situ or invasion of lamina propria T1 invades submucosa

19. Colon 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.

20. 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)