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 YorkFrederick L. Greene, MD Carolinas Medical Center, Charlotte, North Carolina

Rectal Case # 3Presentation of New Case

• Newly diagnosed rectal cancer patient

• Presentation at Cancer Conference for treatment recommendations and clinical staging

Rectal Case # 3History & Physical

• 51 yr old male who presented with diarrhea and abdominal pain

• No family history of colon or rectal cancer

Rectal Case # 3Imaging & Endoscopy Results

• Colonoscopy-single large circumferential fungating mass in rectum 2 to 5cm from anus

Retroflexed endoscopewith rectal tumor

used with permissionJulio Murra-Saca, MDEl Savador Atlas of Gastrointestinal Video Endoscopy

Rectal Case # 3Diagnostic Procedure

• Procedure– Biopsy rectal mass

• Pathology Report– Adenocarcinoma, invasive– Grade 2

• CEA: 4.3

Rectal Case # 3Imaging 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 permissionJulio Murra-Saca, MDEl Savador Atlas of Gastrointestinal Video Endoscopy

Rectal Case # 3Clinical Staging

• Clinical staging – Uses information from the physical exam, imaging,

and diagnostic biopsy

• Purpose– Select appropriate treatment– Estimate prognosis

Rectal Case # 3Clinical Staging

• Synopsis- patient with rectal mass and perirectal tissue involvement, and clinically involved nodes

• What is the clinical stage?– T____– N____– M____– Stage Group______

Rectal Case # 3Clinical Staging

• Clinical Stage correct answer– T3– N1– M0– Stage Group IIIB

• Based on stage, treatment is selected

• Review NCCN treatment guidelines for this stage

Rectal Case # 3Clinical 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

Prognostic FactorsClinically Significant

• Applicable to this case

– CEA: 4.3

• There are no prognostic factors required for staging

Rectal Case # 3Surgery & Findings

• Patient received neoadjuvant Rx with chemotherapy and radiation therapy

• Procedure– Transabdominal resection

• Operative findings– Colo-anal anastomosis performed with 2 cm margin

Rectal Case # 3Pathology 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

Rectal Case # 3Pathologic 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

Rectal Case # 3Pathologic 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______

Rectal Case # 3Pathologic 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

Rectal Case # 3Pathologic 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

Prognostic FactorsClinically 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

AJCC Cancer Staging AtlasT3 into non-peritonealized pericolic or perirectal tissues (adventitia)

Rectal Case # 3Recap 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.

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)