Lumping, Splitting, and Making Sense: Implications of Soft Tissue Sarcoma Staging for Prognosis, Therapy, and Research

Abstract

Alex B. Haynes, MD, MPH and Raphael E. Pollock, MD, PhDDepartment of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TXThe concept of staging cancer originated in the earlytwentieth century as a way of understanding the extent andseverity of disease and thereby estimating prognosis. Theseearly efforts at classifying cancer were anatomically basedand as such this has provided the foundation for modernstaging. The tumor, node, metastasis classification systemof staging was first introduced in the 1940s as a stan-dardized method of anatomic staging and used assessmentof primary tumor extent, lymph node involvement, anddistant disease. Through an objective assessment of thesethree parameters, patients were able to be grouped in arough estimation of the severity of the disease. Thisapproach was adopted by the American Joint Committeeon Cancer (AJCC) and provides the underpinning of themodern staging system for solid tumors. Refinements havebeen made for individual malignancies whereby otherpertinent factors such as serum markers and histologicgrade have been included in staging.As therapeutic strategies have improved and becomemore complex, stage has played an important role intreatment decisions, in comparisons of results acrossinstitutions and across time, and in assessment of progno-sis. The decision to include elements of multimodal care isoften based on stage, such as in adjuvant therapy formalignant melanoma or neoadjuvant approaches to rectalcancer. Additionally, standardized staging is important inclassifying patients for clinical research so that findingsabout treatment and outcome can be applied to theappropriate population of patients. Finally, staging plays animportant role in cancer epidemiology. Measuring anddefining the rate of early and late stage presentation canhelp to better direct prevention, screening, and diagnosis,as well as the application of the correct therapy at thecorrect point in time.Staging of soft tissue sarcoma presents some uniquedifficulties, which Maki et al. illustrate.