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)