Staging Moments AJCC Cancer Staging Sixth Edition Lung Case #3 Lung Case #3 Presentation of New Case Newly diagnosed lung cancer patient Presentation at Cancer Conference for treatment recommendations and clinical staging Lung Case #3 History & Physical 65 yr-old female who presented with inappropriate behavior and thoughts Current smoker, using nicotine patch to quit No other medical problems Lung Case #3 Imaging Results Chest x-ray-infiltrate CT & MRI brain-2cm mets in each right frontal & right occipital lobes CT chest-2.4cm LUL lung mass, bilateral mediastinal nodes Used with permission. Schuchert M, Luketich J: Solitary Sites of Metastatic Disease in Non-Small Cell Lung Cancer. Current Treatment Options in Oncology. 4(1):65-79. Current Science, Inc. Lung Case #3 Diagnostic Procedure Procedure-CT guided biopsy LUL lung Pathology Report-Adenocarcinoma, bx LUL lung Lung Case #3 Clinical Staging Clinical staging Uses information from the physical exam, imaging, and diagnostic biopsy Purpose Select appropriate treatment Estimate prognosis Lung Case #3 Clinical Staging Synopsis-patient with 2.4cm LUL lung mass, bilat mediastinal nodes, and brain mets What is the clinical stage? T____ N____ M____ Stage______ Lung Case #3 Clinical Staging Clinical Stage correct answer T1 N3 M1 Stage IV Based on stage, treatment is selected Review NCCN treatment guidelines for this stage–resection of mets Lung Case #3 Clinical Staging Rationale for staging choices T1 for ca <3cm N3 because nodes were clinically positive on imaging M1 because distant metastases (brain) were found on imaging; if additional mets were suspected, appropriate tests would be performed before developing a treatment plan Reproduced with permission from The NCCN Lung Cancer Guidelines. © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These Guidelines and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the guideline, go online to www.nccn.org. Lung Case #3 Presentation after Surgery The procedure chosen based on the 2.4cm LUL lung mass, bilat mediastinal nodes, and brain mets, Stage IV, is resection of metastases Presentation at Cancer Conference for adjuvant treatment recommendations and pathologic staging Lung Case #3 Surgery & Findings Procedure-gross resection brain mets Operative findings-no additional info Lung Case #3 Pathology Results Pathology Report-Met adenocarcinoma, rt frontal and occipital lobe brain tumor Lung 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 Calculating end results (survival data) Lung Case #3 Pathologic Staging Synopsis-patient with 2.4cm LUL lung mass, bilat mediastinal nodes, brain mets What is the pathologic stage? (remember, clinical M may be used in pathologic staging) T____ N____ M____ Stage______ Lung Case #3 Pathologic Staging Pathologic Stage correct answer pTx pNx pM1 Stage IV Based on pathologic stage, there is more information to estimate prognosis and adjuvant treatment is selected Lung Case #2 Pathologic Staging Rationale for staging choices pTx because the primary tumor was not removed, pathologic staging cannot be completed pNx because regional nodes were not removed, pathologic staging cannot be completed pM1 because the brain mets were proven histologically AJCC Cancer Staging Atlas N3 Contralateral mediastinal or hilar; ipsilat/contralat scalene; supraclavicular LN Lung Case #3 Recap of Staging Summary of correct answers Clinical stage T1 N3 M1 Stage IV Pathologic stage Tx Nx M1 Stage IV 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 Based on clinical data PLUS surgery and pathology report information Used to evaluate end-results (survival) Pathologic Staging Acknowledgements Author Development & Review Donna M. Gress, RHIT, CTR AJCC Technical Specialist Reviewers Michael J. Liptay, MD Stephen B. Edge, MD David P. Winchester, MD Rush University Medical Center, Chicago, Illinois Roswell Park Cancer Institute, Buffalo, New York Northwestern University Evanston Hospital, Evanston, Illinois Acknowledgements AJCC Cancer Staging Manual Sixth Edition Lung and Esophagus Task Force Valerie W. Rusch, M.D., Chair Memorial Sloan-Kettering Cancer Center New York, New York Henry D. Appelman, M.D. University of Michigan Ann Arbor, Michigan Roger Byhardt, M.D. Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin Ellen Edry, C.T.R. Lowell General Hospital Lowell, Massachusetts Laurie Gaspar, M.D. University of Colorado Health Sciences Center Denver, Colorado Robert J. Ginsberg, M.D. Toronto General Hospital Toronto, Ontario, Canada James E. Herndon, II, Ph.D. Duke University Medical Center Durham, North Carolina David H. Johnson, M.D. Vanderbilt Ingram Cancer Center Nashville, Tennessee David P. Kelsen, M.D. Memorial Sloan-Kettering Cancer Center New York, New York William Mackillop, M.D. Kingston Regional Cancer Center Kingston, Ontario, Canada Steven J. Mentzer, M.D. Brigham and Women’s Hospital Boston, Massachusetts Mark B. Orringer, M.D. Taubman Health Care Center Ann Arbor, Michigan Edward Patz, M.D. Duke University Medical Center Durham, North Carolina William D. Travis, M.D. Armed Forces Institute of Pathology Washington, DC Andrew Turrisi, M.D. Medical University of South Carolina Charleston, South Carolina Acknowledgements Reproduced with permission from The NCCN Lung Cancer Guidelines. © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These Guidelines and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the guideline, go online to www.nccn.org.