NAACCR WEBINAR 2016-2017 SERIES Collecting Cancer Data Melanoma Part 2 – Staging

Corry

Marketing Manager

FROM THE CANSWER FORUM:

NAACCR WEBINAR 2016-2017 SERIES: Collecting Cancer Data:  Melanoma Part 2 – Staging

TNM Staging, Rules for Classification

  • Clinical
    • Complete excision of the primary tumor
    • Clinical assessment (physical exam and imaging only) of the regional lymph nodes and intralymphatic metastasis.
  • Pathologic
    • Wide-excision/re-excision is considered definitive treatment
    • Pathologic assessment of regional nodes after sentinel lymph node biopsy and/or complete regional lymphadenopathy.
    • Pathologic confirmation of intralymphatic (satellite or in-transit metastasis).
      • Would be highly unusual to have pathologically confirmed intralymphatic metastasis and no lymph nodes removed.

Primary Tumor

  • “T” based on:
    • Breslow’s depth
    • Ulceration (cannot assume no ulceration if no mention of ulceration)
      • Note: for TNM: if no mention, do not code A or B
      • Note: for SSF2, if no mention, code 000
    • Webinar Q&A: Q: For T1 tumors: If we have information only for ulceration but no information about mitosis or info for mitosis but no info about ulceration, will we go with T1 and no subcategory?
    • A: For T1b the thickness is less than or equal to 1.0 mm with ulceration OR mitoses greater than or equal to 1 /mm2.  So if you have info on ulceration (i.e. ulceration present) and no info on mitotic rate you should be able to use T1b. To assign T1a you would need info on both ulceration AND mitotic rate.
    • Webinar Q&A: Q: How come you cannot assume no ulceration if no mention of ulceration?
    • A: The absence or presence of ulceration is an important prognostic factor.
    • Mitotic rate (sometimes)
    • Webinar Q&A: Q: Are you still able to have a Path Stage without Mitotic Activity stated?
    • A: It depends on the T value.  If it is T2 or higher, yes. If it is a T1 with ulceration, yes. If it is a T1 without ulceration, you would need the mitotic activity to end up with a stage (assuming no mets).
  • Excision of the primary tumor is part of the clinical evaluation.
  • Wide excision or re‐excision are a definitive surgeries that meet the criteria for pathologic stage

cN Regional Lymph Nodes

  • Based on imaging and physical done prior to definitive surgery (wide excision).
    • In‐transit or satellite metastasis (no positive lymph nodes)
      • Satellites (microsatellite): Nodules occurring in the lymphatic channels within 2cm of the primary lesion.
      • In‐transit metastasis: Metastasis in the lymph lymphatic channel occurring between the primary and the lymphatic basin
      • Satellite or In‐transit mets identified prior to definitive surgery.

pN Regional Lymph Nodes

  • Surgically removed regional lymph nodes
  • Micrometastasis vs Macrometastasis
  • A and B categories only for pN
  • Micrometastasis
    • cN0
      • Not enough tumor in a lymph node to be felt during physical exam or seen on imaging.
      • Lymph nodes positive for malignancy on surgical exam.
      • Clinically occult
  • Macrometastasis
    • Clinically apparent lymph node metastasis
      • Enough tumor is present in the lymph nodes to make them palpable or to appear malignant on imaging

Sentinel Node Biopsy

  • Usually done on cN0 patients with cT1b or higher.
  • Radioactive dye is injected around the site of the melanoma
  • Dye is traced to nodes that the tumor drains to.
  • May be multiple nodes in multiple basins

Metastasis from an Unknown Primary

  • If a patient presents with a positive lymph node and an adequate work‐up fails to reveal a primary tumor, code the lymph node as regional.

Distant Metastasis

  • M1a
    • Metastasis to the skin, subcutaneous tissue, or distant lymph nodes
  • M1b
    • Metastasis to the lung
  • M1c
    • Metastasis to any other “visceral” sites
    • Distant metastases to any site combined with an elevated LDH