American Joint Committee On Cancer 8th Edition Research Articles

Does T Stage Affect Prognosis in Patients With Stage Iv B Differentiated Thyroid Cancer

Objective: Differentiated thyroid cancer (DTC), the most common subtype of thyroid cancer, has a relatively good prognosis. The 8th edition of the American Joint Committee on Cancer (AJCC) pathologic tumor-node-metastasis (T [primary tumor size], N [regional lymph nodes], M [distant metastasis]) staging system did not take the T stage into consideration in stage IV B DTC patients. We evaluated the prognostic value of the T stage for advanced DTC survival. Methods: DTC cases that were considered stage IV B in the AJCC 8th edition were extracted from the Surveillance, Epidemiology, and End Results database. T stage (AJCC 6th standard) was categorized into T0-2, T3 and T4. We analyzed overall survival (OS) and cancer specific survival (CSS) in the overall group as well as in pathologic subgroups. We used the Kaplan-Meier method and log-rank test for univariate analysis and the Cox regression model for multivariate analysis. Results: A total of 519 cases were extracted. Patients with earlier T stages showed significantly better OS and CSS in univariate analysis. T stage was an independent prognostic factor for both OS and CSS in multivariate analysis. Subgroup analysis in papillary and follicular thyroid cancer showed that T4 was an independent prognostic factor for both OS and CSS. Conclusion: AJCC 8 stage IV B DTC patients could be further stratified by T stage. Further studies with larger samples and AJCC 8 T stage information are necessary. Abbreviations: AJCC = American Joint Committee on Cancer; CI = confidence interval; CSS = cancer specific survival; DTC = differentiated thyroid cancer; FTC = follicular thyroid cancer; FVPTC = follicular variant of papillary thyroid carcinoma; HR = hazard ratio; OS = overall survival; PTC = papillary thyroid cancer; SEER = surveillance, epidemiology, and end results database.

Nodal Metastasis in Oral Squamous Cell Carcinoma: Predictive Impact of MRI-Derived Depth of Invasion According to the 8th Edition American Joint Committee on Cancer Staging System

To evaluate the relationship between the magnetic resonance imaging (MRI)-derived depth of invasion (DOI) and nodal recurrence in clinically node-negative patients with oral squamous cell carcinoma (SCC). The institutional review board approved this retrospective study. The study population consisted of 90 patients with clinical T1-2N0 oral SCC classified according to the 7th edition American Joint Committee on Cancer (AJCC) staging system; 41 were staged as T1N0 and 49 as T2N0. They (55 males and 35 females; median age, 70 years; age range, 29 - 92 years) had undergone routine pretreatment radiological examinations including MRI and 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) fused imaging. The clinical pretreatment stage had been identified at a routine preoperative conference; the radiological diagnosis of nodal involvement was based on accepted morphologic criteria and FDG uptake. The primary tumors were located in the buccal mucosa (n = 4), upper gingiva (n = 11), lower gingiva (n = 12), hard palate (n = 3), tongue (n = 52), and floor of the mouth (n = 8). All patients were treated with local resection alone as primary treatment and watchful waiting for neck management. We reviewed DOI on pretreatment MRI and reclassified T stage according to the 8th edition AJCC. During the median follow-up period of 36 months (range, 2 - 122 months), the initial sites of recurrence were classified as local, nodal, and distant. Using Student's t-test and Pearson's chi-squared test, the MRI-derived DOI and T stage according to the 7th and 8th editions were assessed as predictive factors for nodal recurrence. The MRI-derived DOI was recorded as ≤ 5 mm in 42-, 5-10 mm in 37-, and > 10 mm in 11 patients. According to the 8th edition, 22 tumors were T1, 61 were T2, and 7 were T3 stage. During the follow-up period, 11 and 16 patients, respectively, suffered local and nodal recurrence; there were no patients with distant recurrence. The mean (± standard deviation) value of the MRI-derived DOI was significantly higher in the patients with nodal recurrence (8.4 ± 2.4 mm) than the others (4.7 ± 3.4 mm) (p < 0.001). The MRI-derived DOI classified significantly different risk groups for nodal recurrence; the incidence was 2% for tumor ≤ 5mm, 27% for 5-10 mm, and 46% for > 10 mm (p = 0.001). T stage according to the 8th edition also predicted the nodal recurrence; the incidence was 0% for T1, 21% for T2, and 43% for T3 stage (p = 0.016). However, T stage according to the 7th edition was not a significant factor for the nodal recurrence; no factors predicted the local recurrence. The MRI-derived DOI can predict nodal metastasis and the information may assist in treatment planning for oral SCC.

The 8th edition of the American Joint Committee on Cancer staging system provide improved prognostic accuracy in T1-2N1M0 postmastectomy breast cancer patients

Objective: To validate whether the prognostic stage groups by the 8th edition of the American Joint Committee on Cancer (AJCC) staging system provides improved prognostic accuracy in T1-2N1M0 postmastectomy breast cancer patients compared to 7th edition. Methods: a total of 1 823 female patients with T1-2N1M0 breast cancer who underwent mastectomy and axillary lymph node dissection without neoadjuvant chemotherapy were analyzed and restaged according to 8th edition. Univariate analysis of prognostic factors was evaluated by using log-rank test. Multivariate analysis was estimated by using the Cox proportional hazards model. The prognostic accuracy of the two staging systems was compared using receiver operating characteristic (ROC) analyses and the concordance index (C-index). Results: 5-year locoregional recurrence rate (LRR) for the whole group was 6.0%, 5-year distant metastasis (DM) rate was 11.5%, 5-year disease-free survival (DFS) was 85.0%, and 5-year overall survival (OS) was 93.1%. Cox analysis showed that 7th edition of the AJCC staging system and progesterone receptor status were independent risk factors for LRR, DM, DFS and OS (P<0.05). Compared with stage by 7th edition, 1 278(70.1%) were assigned to a different prognostic stage group: 1 088 (85.1%) to a lower stage and 190 (14.9%) to a higher stage. LRR, DM, DFS and OS were significantly different between prognostic stage ⅠA, ⅠB, ⅡA, ⅡB and ⅢA according to 8th edition of the AJCC staging system(P<0.001). Prognostic stage had significantly higher C-indexes and provided better estimation of prognosis compared to stage by 7th edition of the AJCC staging system (P<0.001). Conclusion: The prognostic stage groups of 8th edition AJCC staging system has superior prognostic accuracy compared to 7th edition in T1-2N1M0 breast cancer, and has better clinical therapeutic guidance value.

Prognostic Factors and Treatment Strategies for Intrahepatic Cholangiocarcinoma from 2004 to 2013: Population-Based SEER Analysis

BACKGROUND: Seventy percent of intrahepatic cholangiocarcinoma (ICC) patients are inoperable. Treatment for unresectable patients is essential to improve poor survival. AIMS: We aimed to evaluate the prognostic factors for ICC patients, and investigate the potential treatment strategies for unresectable patients. METHODS: ICC patients were identified in SEER registry in 2004–2013. Univariate and multivariate Cox proportional hazard regression analysis were performed to evaluate the effect of treatment strategies. RESULTS: Of 2248 cases diagnosed in 2010–2013 and staged according to the American Joint Committee on Cancer (AJCC) 7th edition, 1706 (76.13%) did not receive cancer-directed surgery. This portion increased compared to those diagnosed between 2004 and 2009 and staged according to the AJCC 6th edition (72.87%). In addition, the percentage of stage 4 cases increased, while stage 3 cases decreased, because AJCC 7th staging system categorized both T4 and N1 patients into stage IV, which were previously categorized into stage III by AJCC 6th staging system. Patients with radiofrequency ablation (RFA) showed a poorer survival in 2004–2009 (P = .0213), but an almost the same survival as patients with tumor resection in 2010–2013 (P = .51), suggesting that RFA performed better in recent years. Lymphadenectomy showed protective effect for unresectable patients. Radiotherapy improved cancer-specific survival in non-surgery patients (P < .0001).The proportion of stage IV patients increased tremendously from 37.4% in 2004–2009 to 58.7% in 2010–2013. Among 1319 stage IV patients (2010–2013), surgery at distant metastatic sites improved cancer-specific survival. CONCLUSIONS: For unresectable tumors, RFA, radiotherapy, lymphadenectomy, and surgery of distant metastases showed significant benefits to improve cancer-specific survival.

AJCC 7th edition staging classification is more applicable than AJCC 8th edition staging classification for invasive IPMN

BackgroundBoth the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) staging systems have been introduced for pancreatic adenocarcinoma. However, the applicability of these classifications for invasive intraductal papillary mucinous neoplasms (IPMN) has not been systematically examined.MethodsPatients with invasive IPMN were retrieved from a cohort of 18 geographical sites (1973–2014 varying) in the Surveillance, Epidemiology, and End Results (SEER) cancer registry. The 7th and 8th editions of the AJCC staging were compared. Survival rates and multivariate analyses were computed.ResultsIn total, 1216 patients with resected invasive IPMN were included. A major difference between the 7th and 8th systems is the definition of stage IIA (7th, beyond the pancreas without involvement of major arteries; 8th, maximum tumor diameter > 4 cm). The hazard ratio (HR) of stage IIA disease (versus stage IA, HR = 2.33, P < 0.001) was higher than that of stage IB disease (HR = 1.48, P = 0.087) by the 7th edition classification, whereas the HR of stage IIA disease (HR = 1.26, P = 0.232) was even lower than that of stage IB disease (HR = 1.48, P = 0.040) by the 8th edition classification. In addition, for the 8th edition staging system, tumor size was not a predictor of survival in patients with resectable tumor > 2 cm (size > 4 cm versus > 2 ≤ 4 cm, HR = 0.91, P = 0.420).ConclusionsThe AJCC 7th edition staging classification is more applicable than the 8th edition classification for invasive IPMN.

The Prognostic Value of the AJCC 8th Edition Staging System for Patients Undergoing Neoadjuvant Chemotherapy for Breast Cancer.

The American Joint Committee on Cancer (AJCC) 8th edition staging system for breast cancer has been validated in the upfront surgery setting, but has not been examined for its prognostic impact on patients undergoing neoadjuvant chemotherapy. The National Cancer Data Base was used to identify patients with invasive unilateral breast cancer from 2010 to 2015 who underwent neoadjuvant chemotherapy. AJCC clinical stage classification was compared between the 7th and 8th editions. Receiver operating characteristic analysis of Kaplan-Meier overall survival (OS) was used to determine the predictive fit of the 7th and 8th edition staging in estimating OS. AJCC 7th and 8th clinical staging assignments were applied to 57,466 patients who underwent neoadjuvant chemotherapy for stage I-III breast cancer from 2010 to 2015. Overall, 37.5% of patients were downstaged and 27.8% were upstaged from the 7th to the 8th edition classification. Kaplan-Meier curves comparing 7th and 8th edition staging differed in OS rates, with a mean follow-up time of 41.5months. AJCC 8th edition prognostic staging was a better predictor of OS than 7th edition anatomic staging for both clinical stage [area under the curve (AUC) 0.67 vs. 0.62, p<0.01] and pathological stage (AUC 0.70 vs. 0.66, p<0.01). Sixty-five percent of patients have a shift in clinical stage in the AJCC 8th edition. AJCC 8th edition staging has better predictive value for OS than 7th edition staging. While validation of these findings with an independent dataset is needed, 8th edition staging will help improve prognostic modeling in patients undergoing neoadjuvant chemotherapy.

Modifications of the AJCC 8th edition staging system for intrahepatic cholangiocarcinoma and proposal for a new staging system by incorporating serum tumor markers

BackgroundSeveral studies have noted that the discriminatory ability and stratification performance of the AJCC 8th edition staging system is not entirely satisfactory. We aimed to improve the American Joint Committee on Cancer (AJCC) 8th edition staging system for intrahepatic cholangiocarcinoma (ICC). MethodsA multicentric database from three Chinese mainland centers (n = 1601 patients) was used to modify the 8th edition staging system. This modified TNM (mTNM) staging system was then validated using the SEER database (n = 761 patients). A new TNM staging system, by incorporating serum tumor markers (TNMIS) into the mTNM staging system was then proposed. ResultsThe 8th edition staging system did not provide an adequate stratification of prognosis in the Chinese multicentric cohort. The mTNM staging system offered a better discriminatory capacity in the multicentric cohort than the original 8th edition. External validation in the SEER cohort showed that the mTNM staging system also had a good stratification performance. After further incorporating a serum marker stage into the mTNM staging, the TNMIS staging system was able to stratify prognosis even better. ConclusionThe proposed mTNM staging system resulted in better stratification performance and the TNMIS staging system provided even more accurate prognostic classification than the conventional TNM system.

Practical Challenges in Measurement of Depth of Invasion in Oral Squamous Cell Carcinoma: Pictographical Documentation to Improve Consistency of Reporting per the AJCC 8th Edition Recommendations.

Depth of invasion (DOI) and tumour thickness (TT) are known prognostic indicators in oral squamous cell carcinoma (OSCC), but varying definitions have been used by pathologists for reporting. The American Joint Committee on Cancer (AJCC) has proposed adoption of a uniform definition of DOI and incorporated this measurement in the revised TNM staging (8th edition); however, unambiguous DOI determination can be a challenge in clinical practice. We reviewed archived slides of 95 cases of T1/T2N0 OSCC and listed the challenges in accurate DOI measurement with pictographical documentation. The impacts of DOI and TT on disease-free survival (DFS) were also assessed. The mean DOI and TT was 5.89mm and 7.32mm respectively. Challenge in horizon estimation for DOI measurement was experienced in 75/95 cases (78.9%). The most common challenges were lack of adjacent uninvolved mucosa in sections or presence only on one side, rounded/convoluted nature of the tumour surface for tongue and polypoidal tumours, and angulation of adjacent mucosa for alveolar or lip tumours. In cases with very thin epithelium, DOI was equal to TT. In spite of the challenges, Kaplan-Meier analysis showed DOI > 5mm significantly predicted poorer DFS while TT did not. We recommend various guidelines to help improve consistency in measuring DOI and recording of TT in ambiguous cases for accurate staging of OSCC.

Challenging AJCC 8 Staging for Soft Tissue Sarcoma Using the NCDB

To determine whether the new American Joint Committee on Cancer (AJCC) 8 grouping of soft tissue sarcoma (STS) with nodal disease (N1M0) and metastatic disease (M1) as stage IV correctly represents the prognosis of these previously separate patient groups, using the National Cancer Database. Adults with STS identified in the 2004 to 2014 National Cancer Database, classified by the World Health Organization 2013 system into 10 histologic subgroups, were grouped according to AJCC 8 staging and analyzed according to demographic characteristics, histology, primary site, disease extent, and adjuvant treatment. Primary retroperitoneal sites, "other/unusual" histologic subgroups, and those with delays in therapy (>180 days from diagnosis) were excluded. We used χ2 tests, Cox proportional hazard models, and propensity-score matched analyses. Of 82,987 patients identified, 55,417 met inclusion criteria; 29,855 (53.9%) were male, and 25,262 (46.1%) were female. Median age was 60 years (range, 18-90 years). Overall survival (OS) of STS of all sites was significantly different between N1M0 and N0-1M1 patients at 5 years (34.4%; [95% confidence interval {CI}, 30.1%-38.8%] vs 10.1% [95% CI, 9%-11%], respectively) and 10 years (27.3% [95% CI, 22.5%- 32.2%] vs 5.4% [95% CI, 4.5%-6.5%], respectively; log-rank test, P < .001). For STS of trunk and extremities in N1M0 and N0-1M1 patients, the N1M0 cohort was associated with significantly greater OS on multivariate Cox proportional hazards models (hazard ratio, 0.48; 95% CI, 0.41-0.58; P < .001), and this OS difference remained significant for propensity-matched cohorts of all primary sites (HR, 0.53; 95% CI, 0.44-0.64; P < .001). In adult STS, including those of the trunk and extremity, OS is superior with N1M0 compared with N0-1M1 disease. These results suggest that the AJCC 8th edition grouping of N1 and M1 patients into stage IV may obscure the more favorable prognosis of patients with N1M0 disease.

Survival outcomes of eye-sparing surgery for adenoid cystic carcinoma of lacrimal gland.

To survey adenoid cystic carcinoma of lacrimal glands in Asian population and investigate the predictability in prognosis following the 8th edition American Joint Committee on Cancer (AJCC) staging guideline. Retrospective study. The clinical entities and surgical outcomes of the patients who were histologically confirmed with a diagnosis of lacrimal adenoid cystic carcinoma in National Taiwan University Hospital between January 1995 and December 2015 were retrospectively reviewed. Enrolled were 11 patients. The median follow-up was 7.2 years. Eight patients (72.7%) were diagnosed as T1 or T2 disease, and three patients (27.3%) were diagnosed as T3 or T4 disease according to the AJCC 8th edition guideline. Eye-sparing surgery with radiotherapy was performed in nine patients. Local recurrence was noted in six patients (54.5%) with median disease-free interval of 23.5 months. Six patients (54.5%) developed distant metastases, including lung, bone, and cranial invasions. Overall survival rate during the study period was 54.6%. Five-year overall survival was 81.8% and ten-year overall survival was 68.2%. The Log-rank test for overall survival and disease-free survival between patients with less than T3 disease (p=0.001) and patients with T3 or T4 disease (p=0.006) revealed significant differences. This study highlighted the aggressive nature of adenoid cystic carcinoma of lacrimal glands. Eye-sparing surgery with adjunctive radiotherapy may achieve relatively optimal disease control in diseases staged T1 or T2, but in advanced disease metastasis and mortality are usually inevitable.

Comparison of the seventh and eighth editions of the American Joint Committee on Cancer (AJCC) staging for oropharyngeal squamous cell carcinomas (OPSCC): A Surveillance, Epidemiology and End Results Program (SEER) database analysis.

e17538 Background: The recently released eighth edition of the American Joint Committee on Cancer (AJCC) Staging Manual, Head and Neck Section, incorporates significant changes to the prior seventh edition. The changes reflect the improved understanding of tumor biology, prognostic factors and molecular markers that effect outcomes in Head and Neck cancers. A key update restages OPSCC by human papilloma virus (HPV) positive and negative cancers as data demonstrated that these tumors have significantly different biology and outcomes. Methods: Using SEER data from 2004 – 2014, we identified male patients with squamous cell carcinomas of the tonsil, base of tongue and soft palate aged between 21 and 64 years old (those clinical characterizes were considered as surrogate markers for HPV positive status). We classified them by the AJCC 8th edition staging for HPV positive OPSCC and by AJCC 7th edition staging. The prediction performance by two staging editions were compared regarding overall survival (OS) and Disease free survival (DFS). Kaplan-Meier method and Cox proportional hazard model were applied, and the discrimination performance was measured by the concordance statistics (C-statistics). Results: A total of 8202 eligible patients were included in the analysis with a median follow up period of 51 months. 7415 (90.4%) patients had previously received radiation and 7038 (85.8%) patients had previously received chemotherapy. The median age of patients was 56 years. Distribution of stage I disease increased from 2% to 19.6% in AJCC 8th edition. 10-year overall survival (OS) for AJCC 8th stages I (74%), II (78%), III (55%) and IV (32%). Using Stage I as reference, the hazard ratio for stage II, III, and IV is 0.98 (95%CI: 0.87-1.09), 2.29 (95%CI: 2.04-2.57), and 5.88 (95%CI: 4.96-6.98). Similar results were noted for ten year disease free survival. The C-statistics measured overall discrimination for 8th edition is 0.68 and 0.63 for the 7th edition (P &lt; 0.001). Conclusions: Based on this SEER analysis, the overall performance of discrimination improved from AJCC 7th to 8th edition; but in this study population, AJCC 8th edition does not distinguish stage I and II sufficiently as expected as it does for stages III and IV disease. Limitations of the SEER database include the surrogate for P16 status and under reported and incomplete data.

Comparing the American Joint Committee on Cancer (AJCC) breast cancer staging eighth versus seventh edition and breast cancer biology in large databases.

e12077 Background: The AJCC 8th edition Breast Cancer Staging system includes biomarkers (estrogen receptor, progesterone receptor, Her2), grade and a genomic assay, to better reflect outcomes, compared to the 7th edition. We used databases with anatomic, biomarker and genomic information to determine if the 8th edition reflects biology better than the 7th edition. Methods: 696 breast cancer patients in The Cancer Genome Atlas (TCGA) and Text Information Extraction System (TIES) were staged both with 7th and 8th edition. Results: From the 7th to 8th editions, 66% of stage 2 patients migrated (64% to stage 1, 1.5% to stage 3). 36% of stage 3 patients migrated (22% to stage 1, 13% to stage 2). We analyzed the differences between stage 1 and 2 in both editions, and the overall survival hazard ratio calculated using Cox regression was greater in the 8th edition than the 7th (HR=1.50, HR=1.22 respectively). We performed Gene Set Enrichment Analysis (GSEA) and found that gene sets related to cell cycle and cell proliferation (E2F targets, G2M checkpoint) were significantly enriched in higher stage in 8th edition but not 7th. Mutant Allele Tumor Heterogeneity (MATH) and Homologous Recombination Defects (HRD) were elevated in higher stages in the 8th edition (p=0.022, p&lt;0.001 respectively), but not the 7th. Immune cells (CD8 Tcell, NK cell) as well as CYT (Immune cytolytic activity score), and Tcell exhaustion markers (PD1, PDL1) were all found to be elevated in higher stage in 8th edition, but not 7th. Conclusions: The 8th edition AJCC Breast Cancer Staging system categorizes cancers by aggressive biology better than the 7th edition. We also found that higher stage tumors trigger an enhanced immune response, but are unable to overcome the aggressive cancer biology.

Validation of the 8th AJCC Cancer Staging System for Pancreas Neuroendocrine Tumors Using Korean Nationwide Surgery Database.

PurposeThe 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic neuroendocrine tumor (PNET) included several significant changes. We aim to evaluate this staging system compared to the 7th edition AJCC staging system and European Neuroendocrine Tumors Society (ENETS) system.Materials and MethodsWe used Korean nationwide surgery database (2000-2014). Of 972 patients who had undergone surgery for PNET, excluding patients diagnosed with ENETS/World Health Organization 2010 grade 3 (G3), only 472 patients with accurate stage were included.ResultsPoor discrimination in overall survival rate (OSR) was noted between AJCC 8th stage III and IV (p=0.180). The disease-free survival (DFS) curves of 8th AJCC classification were well separated between all stages. Compared with stage I, the hazard ratio of II, III, and IV was 3.808, 13.928, and 30.618, respectively (p=0.007, p < 0.001, and p < 0.001). The curves of OSR and DFS of certain prognostic group in AJCC 7th and ENETS overlapped. In ENETS staging system, no significant difference in DFS between stage IIB versus IIIA (p=0.909) and IIIA versus IIIB (p=0.291). In multivariable analysis, lymphovascular invasion (p=0.002), perineural invasion (p=0.003), and grade (p < 0.001) were identified as independent prognostic factors for DFS.ConclusionThis is the first large-scale validation of the AJCC 8th edition staging system for PNET. The revised 8th system provides better discrimination compared to that of the 7th edition and ENETS TNM system. This supports the clinical use of the system.

Cells to Surgery Quiz: May 2019

Cells to Surgery Quiz: May 2019

Number of nodal metastases and prognosis in metastatic cutaneous squamous cell carcinoma of the head and neck.

Existing prognostic systems for metastatic cutaneous squamous cell carcinoma of the head and neck (cSCCHN) do not discriminate between the number of involved nodes beyond single versus multiple. This study aimed to determine if the number of metastatic lymph nodes is an independent prognostic factor in metastatic cSCCHN and whether it provides additional prognostic information to the American Joint Committee on Cancer (AJCC) staging. We retrospectively analysed 101 patients undergoing curative intent treatment for metastatic cSCCHN to parotid and/or neck nodes by surgery +/- radiotherapy at Liverpool Hospital, Sydney, Australia. The impact of number of nodal metastases on disease-free survival (DFS) and risk of distant metastases was assessed using multivariate Cox regression. The mean number of nodal metastases was 2.5 (range 1-12). On multivariate analysis, increasing number of nodal metastases significantly predicted reduced DFS (hazard ratio 1.17; 95% confidence interval 1.05-1.30; P = 0.004), with a 17% increased risk of recurrence or death for each additional node. This remained significant in multivariate models adjusted for AJCC 8th edition nodal and TNM stages. Number of nodal metastases was also associated with risk of distant metastatic failure (hazard ratio 1.21; 95% confidence interval 1.05-1.39; P = 0.009). Increasing number of nodal metastases is associated with decreased DFS and increased risk of distant metastases in metastatic cSCCHN, with a cumulative risk increase with each additional node. It provides additional prognostic information to the AJCC staging, which may be improved by incorporating information on the number of nodal metastases beyond the current single versus multiple distinction.

Proposed revision of the 8th edition AJCC clinical staging system for esophageal squamous cell cancer treated with definitive chemo-IMRT based on CT imaging

PurposeTo validate and propose revision of the 8th edition American Joint Committee on Cancer (AJCC) clinical staging system for esophageal squamous cell cancer (ESCC) patients treated with definitive intensity-modulated radiation therapy combined with concurrent chemotherapy (Chemo-IMRT) based on computed tomography (CT) imaging.MethodsThe clinical data of patients with ESCC treated with Chemo-IMRT were collected and retrospectively reviewed. All CT images were independently reevaluated and restaged according to the 8th edition AJCC staging system. The overall survival (OS) rates were analyzed statistically. ROC curves of the various parameters of the primary tumor and metastatic lymph nodes were generated in order to identify the cutoff values correlated to patient survival using the area under curve.ResultsThe gross tumor volume of the primary tumor (GTV-prT) and the clinical N stage (cN) were independent factors that influenced OS. The 5-year OS rate of patients with GTV-prT ≤28 cm3, GTV-prT > 28 and ≤ 56 cm3, and GTV-prT > 56 cm3 were 54.6, 31.1 and 18.6%, respectively. The 5-year OS rate of patients with cN0, cN1 SLNM (−), cN2 SLNM (−), cN3 SLNM (−) and SLNM (+) were 62.8 (P < 0.001), 34.0 (P = 0.16), 20.0 (P = 0.785), 0 (P < 0.001) and 26.9%, respectively. After restaging the SLNM as regional MLNs, the 5-year OS rates of the patients with cN0, 1, 2 and 3 were 62.8, 36.3, 23.7 and 7.8%, respectively. Various GTV-prT were combined with the cN to establish a new clinical TNM staging system: I, GTV-prT1 and cN0; II, GTV-prT2 or 3 and cN0, GTV-prT1 and cN1; III, GTV-prT1 and cN2, GTV-prT2 and cN1,2; Iva, GTV-prT3 and cN1,2; IVb, GTV-prTany and cN3; IVc, TanyNanyM1. Subsequently, the OS differed significantly between the adjacent GTV-prT cN categories, except those of stage I vs. II.ConclusionThe SLNM should be dealt with as a regional rather than a distant disease in patients with ESCC when treated with CRT. The proposed nonsurgical staging system based on the GTV-prT and N appears to be a simple and accurate prognosis predictor for patients with ESCC who have undergone definitive Chemo-IMRT.

Prognostic factors for disease-free survival in patients with pancreatic ductal adenocarcinoma after surgery: a single center experience

Abstract Objective: To evaluate the risk factors for the disease-free survival (DFS) of pancreatic ductal adenocarcinoma (PDAC) patients after surgery, and to validate the clinical applicability and prognostic stratification of the 8th edition American Joint Committee on Cancer (AJCC) staging system. Methods: A cohort of 185 patients with PDAC who underwent surgical resection in the General Surgery Department of Peking University First Hospital from January 2010 to December 2017 was enrolled retrospectively. The clinicopathological characteristics and survival data were analyzed to find out risk factors correlated to DFS. The survival curves were calculated according to the 8th edition of AJCC staging system. Results: Among the 185 PDAC patients, 125 (67.6%) with pancreatic head carcinoma underwent pancreatoduodenectomy or total pancreatectomy, and 60 (32.4%) with tumors located in the pancreatic body and tail underwent distal pancreatectomy and splenectomy. R0 resection was achieved in 97 patients (52.4%), and the R1 and R2 resections rate was 44.9% and 2.7%, respectively. One hundred five patients (56.8%) received postoperative adjuvant chemotherapy. The median overall survival (OS) was 21 (95% confidence interval [CI] 17.7–24.3) months, and median DFS was 15 (95% CI 13.6–16.5) months. Univariate analysis showed that AJCC T and N staging, status of resection margin, grade of tumor differentiation, perineural invasion, intravascular cancer embolus, combined vascular resection, neutrophil-to-lymphocyte ratio (NLR) ≥ 2, carcinoembryonic antigen ≥5 ng/mL, carbohydrate antigen 19-9 (CA 19-9) ≥ 400 U/mL, and without postoperative adjuvant chemotherapy were correlated with shorter DFS. Furthermore, AJCC T3, N1 and N2 staging, R2 resection, low-grade or undifferentiated tumors, combined vascular resection, NLR ≥ 2, CA 19-9 ≥ 400 U/mL, and without postoperative adjuvant chemotherapy were independent risk factors for DFS. Both the DFS and OS curves were well separated by stage using the 8th staging classification. Conclusions: The 8th edition of AJCC T, primary tumor; N, regional lymph nodes; M, distant metastasis staging system could predict the prognosis of PDAC accurately. Patients with AJCC T3, N1 and N2 staging, R2 resection, low-grade or undifferentiated tumors, combined vascular resection, NLR ≥ 2, CA 19-9 ≥ 400 U/mL, and without postoperative adjuvant chemotherapy, have a significantly higher risk of tumor recurrence and shorter DFS after surgery. R0 resection and adjuvant chemotherapy could significantly prolong the DFS of PDAC patients.

A 10-year retrospective study of melanoma stage at diagnosis in the academic emergency hospital of Sibiu county.

Melanoma is considered to be the most aggressive skin cancer, with an increasing incidence worldwide. An accurate staging of melanoma is crucial in describing the cancer status, estimating prognosis and deciding the optimal treatment solution. In the present study, melanoma staging highlights the importance of early detection, most of the patients having been diagnosed with advanced stages of this skin cancer. A retrospective study was conducted among 117 patients of the Academic Emergency County Hospital of Sibiu, diagnosed with melanoma between 2007 and 2016. The staging of the patients with melanoma was made using the American Joint Committee on Cancer (AJCC) 7th edition, and reconsidered in the light of the AJCC 8th edition. The results showed that the majority of the cases had distant metastases, 40.17% were diagnosed with stage IV melanoma. 25.65% of the patients were diagnosed with stage III melanoma, having a regional disease. The rest of the cases had localized melanoma (stages I and II, 30.76%), while only 3.42% of them were diagnosed with melanoma in situ, the melanoma type with the greatest chances of survival. Analyzing the Breslow index, it was observed that the most common tumor thickness was 2.1 to 4 mm (34.19%). In conclusion, as the incidence of melanoma increases in Romania, further efforts are needed to improve the early detection of melanoma. There are hopes that with the correct and early diagnosis of melanoma, the mortality rate of this neoplasm will decrease in the future.

Staging soft tissue sarcoma of the head and neck: Evaluation of the AJCC 8th edition revised T classifications.

The American Joint Committee on Cancer (AJCC) has proposed new T classifications for head and neck sarcomas in the 8th edition of the AJCC Cancer Staging Manual, but these classifications have not been evaluated for prognostic utility in tumor staging. The predictive ability of revised AJCC T classifications was evaluated by nonlinear multivariable regression using records from the Surveillance, Epidemiology, and End Results database (N = 2756). A proposed staging algorithm was developed using a subset of records and compared to the AJCC 7th edition using a separate validation dataset. Categorization of tumor size using revised AJCC 8th edition T classifications accurately reflected the predictive information of this intrinsically continuous variable. A proposed staging system based on revised AJCC T classifications showed significant improvement in clinical performance compared to the previous AJCC 7th edition staging system. Stratifying risk of sarcoma-specific death by categorization of tumor size is informative for head and neck sarcoma. A staging algorithm based on revised AJCC 8th edition T classifications is validated and proposed for further evaluation in staging sarcomas of the head and neck.

Abstract P1-03-03: Comparing staging assignments based on the 7th and 8th editions of the American Joint Committee on Cancer staging system for breast cancer

Abstract Background: The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for breast cancer has redefined breast cancer staging to better represent the heterogeneity of the disease. The previously established TNM system reflected only tumor size (T), nodal status (N), and distant metastasis (M). The updated staging system introduces new clinical and pathological prognostic staging systems by incorporating tumor grade, tumor markers, and genomic assays. Prospective comparisons of staging assignment between AJCC 7th and 8th edition staging systems have not been performed in the United States. The objective of this study was to compare subjects' assigned stage between the AJCC 7th and 8th edition staging systems. Methods: Data were collected from patients with non-metastatic breast carcinoma who presented to the University of Chicago between January 1, 2018 and May 31, 2018. Upstaging or downstaging was defined as an increase or decrease by one or more letter or number stages (i.e. from IIA to IIB or IB). Descriptive data were generated for all collected data. Analysis was performed in Stata 14.0. Results: Clinical anatomic and prognostic stages were assigned to 246 patients while pathologic anatomic and prognostic stages were assigned to 142 patients. Forty-seven patients underwent neoadjuvant therapy and were not assigned a pathologic prognostic stage, while 57 patients had not undergone surgery at our institution by the end of the study period and were not assigned a pathologic stage. Two patients had lobular carcinomia in situ and were no longer considered to have a malignancy by the 8th edition staging system; anatomic staging was otherwise unchanged from 7th edition to 8th edition staging in this cohort. Of the 246 patients assigned clinical anatomic and prognostic stages, 48 patients were upstaged (19.5%), 37 were downstaged (15.0%), and 161 were not affected (65.5%) by prognostic staging. Of the 142 patients assigned pathologic anatomic and prognostic staging, nine patients were upstaged (6.3%), 32 were downstaged (22.5%), and 101 were not affected (71.1%) by prognostic staging. Four patients were eligible to be downstaged in pathologic prognostic staging by genomic assays such as Oncotype (consisting of Stage 1B or higher patients with T1N0M0 HER2 - ER + PR - Grade 3 disease or T2N0M0 HER2 - ER + disease). Of these patients, three had genomic assays performed by the end of the study period. Results from genomic assays did not affect the staging of these three patients. Stage Changes with the AJCC 8th Edition Upstaged % (n)Downstaged % (n)No Change in Stage % (n)Clinical Stage19.5 (48)15.0 (37)65.5 (161)Pathologic Stage6.3 (9)22.5 (32)71.1 (101) Conclusions: Approximately one third of breast cancer patients were assigned new clinical or pathologic stages with the AJCC 8th edition staging system. These findings confirm that implementation of the new criteria for staging will be important to many patients in discussions of treatment and prognosis. Citation Format: Brian R, Tseng J, Bao J, Jaskowiak N. Comparing staging assignments based on the 7th and 8th editions of the American Joint Committee on Cancer staging system for breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-03-03.