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AJCC Staging Moments AJCC TNM Staging 7th Edition Thyroid Case #3 Contributors: Jatin P. Shah, MD Memorial Sloan-Kettering Cancer Center, New York, New York Carol R. Bradford, MD University of Michigan Medical Center, Ann Arbor, Michigan James Brierley, MB Princess Margaret Hospital/University Health Network, Toronto, Ontario Thyroid Case # 3 Presentation of New Case • Newly diagnosed thyroid cancer patient • Presentation at Cancer Conference for treatment recommendations and clinical staging Thyroid Case # 3 History & Physical • 56 yr old female who presented with a left sided thyroid mass • No smoking hx • No family history of ca Thyroid Case # 3 Imaging Results • US thyroid – 16x18mm left sided thyroid mass – No lymphadenopathy • Chest x-ray – Negative Used with permission. Gharib H. Atlas pf Clinical Endocrinology: Thyroid Diseases. Edited by Stanley Korenman (series editor), Martin I. Surks. ©1999 Current Medicine, Inc. Thyroid Case # 3 Diagnostic Procedure • Procedure – Fine needle aspiration (FNA) lt lobe thyroid • Pathology Report – Papillary carcinoma Thyroid Case # 3 Clinical Staging • Clinical staging – Uses information from the physical exam, imaging, and diagnostic biopsy • Purpose – Select appropriate treatment – Estimate prognosis Thyroid Case # 3 Clinical Staging • Synopsis- older patient with palpable 1.8cm mass left lobe thyroid, nodes negative on imaging • What is the clinical stage? – – – – T____ N____ M____ Stage Group______ Thyroid Case # 3 Clinical Staging • Clinical Stage correct answer – – – – T1b s N0 M0 Stage Group I • Based on stage, treatment is selected • Review NCCN treatment guidelines for this stage • Review American Thyroid Association guidelines http://www.thyroidguidelines.org/revised/differentiated Thyroid Case # 3 Clinical Staging • Rationale for staging choices – T1b s for solitary tumor >1 <2cm limited to thyroid – N0 because nodes were clinically negative on physical exam and imaging – M0 because there was nothing to suggest distant metastases; if there was, appropriate tests would be performed before developing a treatment plan Prognostic Factors Clinically Significant • Applicable to this case – Extrathyroid extension: none – Histology: papillary • There are no prognostic factors required for staging Thyroid Case # 3 Presentation after Surgery • The procedure chosen based on the small solitary lesion and clinically negative nodes in a patient >45 yrs old, Stage 1, is total thyroidectomy • Presentation at Cancer Conference for adjuvant treatment recommendations and pathologic staging Thyroid Case # 3 Surgery & Findings • Procedure – Total thyroidectomy • Operative findings – Invasion into adjacent strap muscle – Enlarged regional nodes Thyroid Case # 3 Pathology Results • • • • • • • Papillary carcinoma, left lobe thyroid Tumor size - 2.5cm Extends to margin Invades adjacent strap muscle Multifocal papillary ca, right lobe thyroid Mets 2/6 pretracheal nodes Mets 1/2 left paratracheal nodes Thyroid 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 – For selection of adjuvant treatment – Calculating end results (survival data) Thyroid Case # 3 Pathologic Staging • Synopsis- patient with 2.5cm tumor invading into strap muscle, and involvement of Level VI nodes • What is the pathologic stage? (remember, clinical M may be used in pathologic staging) – – – – T____ N____ M____ Stage Group______ Thyroid Case # 3 Pathologic Staging • Pathologic Stage correct answer – – – – pT3 m pN1a cM0 Stage Group III • Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected Thyroid Case # 3 Pathologic Staging • Rationale for staging choices – pT3 m is tumor with minimal extrathyroid extension and multifocal – pN1a because Level VI pretracheal and paratracheal nodes were involved – cM0 - use clinical M with pathologic staging unless there is pathologic confirmation of distant metastases Prognostic Factors Clinically Significant • Applicable to this case – Extrathyroid extension: Minor, to strap muscles, therefore the primary tumor is upstaged to T3 – Histology: papillary • There are no prognostic factors required for staging AJCC Cancer Staging Atlas T3 tumor with minimal extrathyroid extension >4cm limited to thyroid extension to either sternothyroid muscle or perithyroid soft tissues Thyroid Case # 3 Recap of Staging • Summary of correct answers – Clinical stage T1b s N0 M0 Stage Group I – Pathologic stage T3 m N1a cM0 Stage Group III • 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. 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 for selection of adjuvant treatment and prognosis – Used to evaluate end-results (survival)
