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Skin Cancer Treatment (Professional) (cont.)

Stage Information for Skin Cancer

There are separate staging systems in the 7th edition of the American Joint Committee on Cancer's (AJCC) AJCC Cancer Staging Manual for carcinomas of the eyelid versus other skin surfaces.[1,2] The staging system for non-eyelid skin cancers is primarily designed for squamous cell carcinomas (SCCs). The staging system for carcinoma of the eyelid addresses carcinomas of all histologies.

Basal cell carcinoma (BCC) rarely metastasizes, thus, a metastatic work-up is usually not necessary. Regional lymph nodes should be routinely examined in all cases of SCC, especially for high-risk tumors appearing on the lips, ears, perianal and perigenital regions, or high-risk areas of the hand. In addition, regional lymph nodes should be examined with particular care in cases of SCCs arising in sites of chronic ulceration or inflammation, burn scars, or sites of previous radiation therapy treatment.

Table 2 has a separate list of risk features that should be evaluated for non-eyelid carcinomas; the relevant risk features should also be evaluated for SCCs of the eyelid. Even with relatively small tumor size, SCCs that occur in immunosuppressed patients tend to have more aggressive behavior than SCCs in nonimmunosuppressed patients. Although not a formal part of the AJCC staging system, it is recommended that centers prospectively studying SCC record the presence and type of immunosuppression in addition to the risk features listed in Table 2.

Staging for Cutaneous SCC and Other Cutaneous Carcinomas (Excluding Carcinoma of the Eyelid)

The American Joint Committee on Cancer has designated staging by TNM classification.[1] The TNM classification is used to stage both BCC and SCC.

Table 1. Primary Tumor (T) for Non-Eyelid Carcinomaa,b

a Reprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
b Excludes cutaneous squamous cell carcinoma of the eyelid.
c High-risk features for the primary tumor (T) staging.
TXPrimary tumor cannot be assessed.
T0No evidence of primary tumor.
TisCarcinoma in situ.
T1Tumor =2 cm in greatest dimension with <2 high-risk features.c
T2Tumor >2 cm in greatest dimension.
or
Tumor any size with =2 high-risk features.c
T3Tumor with invasion of maxilla, mandible, orbit, or temporal bone.
T4Tumor with invasion of skeleton (axial or appendicular) or perineural invasion of skull base.

Table 2. High-Risk Features for Primary Tumor (T) Staging for Non-Eyelid Carcinoma

a Reprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
Depth/invasion>2 mm thickness (Breslow thickness).
Clark level =IV.
Perineural invasion.
AnatomicPrimary site ear.
LocationPrimary site non-hair-bearing lip.
DifferentiationPoorly differentiated or undifferentiated.

Table 3. Regional Lymph Nodes (N) for Non-Eyelid Carcinomaa

a Reprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
NXRegional lymph nodes cannot be assessed.
N0No regional lymph node metastases.
N1Metastasis in a single ipsilateral lymph node, =3 cm in greatest dimension.
N2Metastasis in a single ipsilateral lymph node, >3 cm but =6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, =6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, =6 cm in greatest dimension.
N2aMetastasis in a single ipsilateral lymph node, >3 cm but =6 cm in greatest dimension.
N2bMetastases in multiple ipsilateral lymph nodes, =6 cm in greatest dimension.
N2cMetastases in bilateral or contralateral lymph nodes, =6 cm in greatest dimension.
N3Metastasis in a lymph node, >6 cm in greatest dimension.

Table 4. Distant Metastasis (M) for Non-Eyelid Carcinomaa

a Reprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
M0No distant metastases.
M1Distant metastases.

Patients with a primary cutaneous SCC or other cutaneous carcinoma with no evidence (i.e., clinical, radiologic, or pathologic) of regional or distant metastases are divided into the following two stages:

  • Stage I for tumors measuring 2 cm or less in size.
  • Stage II for tumors measuring more than 2 cm in size.

In instances where there is clinical concern about extension of the tumor into bone and radiologic evaluation has been performed (and is negative), these data may be included to support the stage I versus stage II designation. Tumors that are 2 cm or less in size can be upstaged to stage II if they contain two or more high-risk features.

Stage III patients are those with either of the following:

  • Clinical, histologic, or radiologic evidence of one involved lymph node measuring 3 cm or less in size.
  • Tumor extension into bone; namely, the maxilla, mandible, orbit, or temporal bone.

Stage IV patients are those with any of the following:

  • Tumor with direct or perineural invasion of skull base or axial skeleton.
  • Two or more involved lymph nodes.
  • Single or multiple involved lymph nodes measuring more than 3 cm in size.
  • Distant metastases.

Table 5. Anatomic Stage/Prognostic Groups for Non-Eyelid Carcinomaa

a Reprinted with permission from AJCC: Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301-14.
StageTNM
0TisN0M0
IT1N0M0
IIT2N0M0
IIIT3N0M0
T1N1M0
T2N1M0
T3N1M0
IVT1N2M0
T2N2M0
T3N2M0
Any TN3M0
T4Any NM0
Any TAny NM1

Staging for Carcinomas of the Eyelid

The AJCC has designated staging by TNM classification.[2] The TNM classification is used to stage all cell types of eyelid carcinomas.

Table 6. Primary Tumor (T) for Eyelid Carcinomaa

a Reprinted with permission from AJCC: Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
TXPrimary tumor cannot be assessed.
T0No evidence of primary tumor.
TisCarcinoma in situ.
T1Tumor =5 mm in greatest dimension.
Not invading the tarsal plate or eyelid margin.
T2aTumor >5 mm but not >10 mm in greatest dimension.
Or, any tumor that invades the tarsal plate or eyelid margin.
T2bTumor >10 mm but not >20 mm in greatest dimension.
Or, involves full thickness eyelid.
T3aTumor >20 mm in greatest dimension.
Or, any tumor that invades adjacent ocular or orbital structures.
Any T with perineural tumor invasion.
T3bComplete tumor resection requires enucleation, exenteration, or bone resection.
T4Tumor is not resectable because of extensive invasion of ocular, orbital, craniofacial structures, or brain.

Table 7. Regional Lymph Nodes (N) for Eyelid Carcinomaa

a Reprinted with permission from AJCC: Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
NXRegional lymph nodes cannot be assessed.
cN0No regional lymph node metastasis based upon clinical evaluation or imaging.
pN0No regional lymph node metastasis based upon lymph node biopsy.
N1Regional lymph node metastasis.

Table 8. Distant Metastasis (M) for Eyelid Carcinomaa

a Reprinted with permission from AJCC: Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
M0No distant metastasis.
M1Distant metastasis.

Table 9. Anatomic Stage/Prognostic Groups for Eyelid Carcinomaa

a Reprinted with permission from AJCC: Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
Stage 0TisN0M0
Stage IAT1N0M0
Stage IBT2aN0M0
Stage ICT2bN0M0
Stage IIT3aN0M0
Stage IIIAT3bN0M0
Stage IIIBAny TN1M0
Stage IIICT4Any NM0
Stage IVAny TAny NM1

References:

  1. Cutaneous squamous cell carcinoma and other cutaneous carcinomas. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 301–14.
  2. Carcinoma of the Eyelid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 523-6.
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