American Joint Committee On Cancer TNM Staging System Research Articles

A nomogram and risk stratification system for predicting survival in T1-2N0-1 breast cancer patients with liver metastasis in females: a population-based study

PurposeLiver was one of the most common distant metastatic sites in breast cancer. Patients with distant metastasis were identified as American Joint Committee on Cancer (AJCC) stage IV indicating poor prognosis. However, few studies have predicted the survival in females with T1-2N0-1 breast cancer who developed liver metastasis. This study aimed to explore the clinical features of these patients and establish a nomogram to predict their overall survival.Results1923 patients were randomly divided into training (n = 1154) and validation (n = 769) cohorts. Univariate and multivariate analysis showed that age, marital status, race, estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor-2 (HER2), chemotherapy, surgery and bone metastasis, brain metastasis were considered the independent prognostic indicators. We developed a nomogram according to these ten parameters. The consistency index (c-index) was 0.72 (95% confidence interval CI 0.70–0.74) in the training cohort, 0.72 (95% CI 0.69–0.74) in the validation cohort. Calibration plots indicated that the nomogram-predicted survival was consistent with the recorded 1-, 3- and 5-year prognoses. Decision curve analysis curves in both the training and validation cohorts demonstrated that the nomogram showed better prediction than the AJCC TNM (8th) staging system. Kaplan Meier curve based on the risk stratification system showed that the low-risk group had a better prognosis than the high-risk group (P < 0.001).ConclusionsA predictive nomogram and risk stratification system were constructed to assess prognosis in T1-2N0-1 breast cancer patients with liver metastasis in females. The risk model established in this study had good predictive performance and could provide personalized clinical decision-making for future clinical work.

Evaluation of AJCC staging system and proposal of a novel stage grouping system in retroperitoneal liposarcoma: the Fudan Zhongshan experience.

Overall survival (OS) varies significantly among individuals with heterogeneous retroperitoneal liposarcoma (RPLS), even among those with the same clinical stage. Improved staging of RPLS is a critical unmet need, given the disappointing results of external validations of the 8th American Joint Committee on Cancer (AJCC) TNM staging system. The cohort study included 220 consecutive patients who underwent surgical resection for primary RPLS at the largest sarcoma centre of Fudan University in China from September 2009 to August 2021, combined with 277 adult patients with RPLS in the SEER database from 1975 to 2020. Data analysis was performed from December 2021 to December 2022. Patients were retrospectively restaged according to the 8th and 7th editions of the TNM staging system as well as the new TNM (nTNM) staging system. The primary endpoint was overall survival (OS). Comparative analysis of postoperative survival was performed using the Kaplan-Meier method, and differences between subgroups were tested using the log-rank test. The OS prediction nomogram was generated based on baseline variables and tumour characteristics. Harrell's consistency index (C-index), area under the curve (AUC) of receiver operating characteristic curves (ROC), and calibration curves were used to evaluate the performance of the nomogram. A total of 497 patients were enrolled in the study, including 282 (56.7%) male patients. The median follow-up was 51 months (interquartile range, IQR, 23-83), and the OS rates at 1, 3, and 5 years were 87.9%, 75.3%, and 64.9%, respectively. According to the staging distribution of the AJCC 7th edition, 6 patients were stage IA (1.2%), 189 patients were stage IB (38%), 12 patients were stage IIA (2.4%), 150 patients were stage IIB (30.1%), 131 patients were stage III (26.3%), and 9 patients were stage IV (1.8%). With the 8th edition staging, this distribution changed: 6 patients (1.2%) were stage IA, 189 patients (38%) were stage IB, 12 patients (2.4%) were stage II, 24 patients (4.8%) were stage IIIA, 257 patients (51.7%) were stage IIIB, and 9 patients (1.8%) were stage IV. 182 patients (36.6%) were reclassified according to the nTNM staging system with the new T stage classification. The C-index and log-rank score improved after implementation of nTNM implementation. The nTNM system was associated with improved identification of high-risk patients compared with the AJCC 7th and 8th TNM. The FNCLCC stage proved to be highly prognostic with significant intergroup differences in OS. The calibration curve shows a high degree of agreement between the actual OS rate and the nomogram estimated OS rate. Compared with 8th AJCC TNM, 7th AJCC TNM staging system showed a more homogeneous staging distribution and a slight improvement in the prognostic accuracy of RPLS. The revised T-stage and nTNM systems showed better risk stratification performance. The FNCLCC stage was found to have high prognostic value, further emphasising histological grade is the least negligible prognostic factor in predicting patient survival. The constructed nomogram model enables individualized prognostic analysis and helps to develop risk-adapted therapy for RPLS patients.

Abstract 5177: Lymph node ratio is superior to AJCC N stage for predicting recurrence in papillary thyroid carcinoma

Abstract Objective: Recently, lymph node ratio (LNR) has emerged as an alternative to American Joint Committee on Cancer (AJCC) N stage, with superior prognostic value. The utility of LNR in Middle Eastern Papillary thyroid carcinoma (PTC) remains unknown. Therefore, we retrospectively analyzed a large cohort of 1407 PTC patients for clinico-pathological associations of LNR. Methods: Receiver operating characteristics (ROC) curve was used to determine the cut-off for LNR. We also performed multivariate logistic regression analysis to determine whether LNR or AJCC N stage was superior in predicting recurrence in PTC. Results: Based on ROC curve analysis, a cut-off of 0.15 was chosen for LNR. High LNR was significantly associated with adverse clinico-pathological characteristics such as male sex, extrathyroidal extension, lymphovascular invasion, multifocality, bilateral tumors, T4 tumors, lateral lymph node (N1b) involvement, distant metastasis, advanced tumor stage, ATA high risk category and tumor recurrence. On multivariate analysis, we found that LNR was a better predictor of tumor recurrence than AJCC N stage (Odds ratio: 1.96 vs. 1.30; p value: 0.0184 vs. 0.3831). We also found that LNR combined with TNM stage and ATA risk category improved the prediction of recurrence-free survival, compared to TNM stage or ATA risk category alone. Conclusions: The present study suggests LNR is an independent predictor of recurrence in Middle Eastern PTC. Integration of LNR with 8th edition AJCC TNM staging system and ATA risk stratification will improve the accuracy to predict recurrence in Middle Eastern PTC and help in tailoring treatment and surveillance strategies in these patients. Citation Format: Sandeep K. Parvathareddy, Abdul K. Siraj, Zeeshan Qadri, Saeeda O. Ahmed, Nabil Siraj, Felisa DeVera, Padmanaban Annaiyappanaidu, Maria A. Sabido, Wael Haqawi, Hassan Aldossari, Khawla S. Al-Kuraya. Lymph node ratio is superior to AJCC N stage for predicting recurrence in papillary thyroid carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5177.

Lymph node ratio is superior to AJCC N stage for predicting recurrence in papillary thyroid carcinoma.

ObjectiveRecently, lymph node ratio (LNR) has emerged as an alternative to American Joint Committee on Cancer (AJCC) N stage, with superior prognostic value. The utility of LNR in Middle Eastern papillary thyroid carcinoma (PTC) remains unknown. Therefore, we retrospectively analyzed a large cohort of 1407 PTC patients for clinicopathological associations of LNR.MethodsReceiver operating characteristics (ROC) curve was used to determine the cut-off for LNR. We also performed multivariate logistic regression analysis to determine whether LNR or AJCC N stage was superior in predicting recurrence in PTC.ResultsBased on ROC curve analysis, a cut-off of 0.15 was chosen for LNR. High LNR was significantly associated with adverse clinicopathological characteristics such as male sex, extrathyroidal extension, lymphovascular invasion, multifocality, bilateral tumors, T4 tumors, lateral lymph node (N1b) involvement, distant metastasis, advanced tumor stage, American Thyroid Association (ATA) high-risk category and tumor recurrence. On multivariate analysis, we found that LNR was a better predictor of tumor recurrence than AJCC N stage (odds ratio: 1.96 vs 1.30; P value: 0.0184 vs 0.3831). We also found that LNR combined with TNM stage and ATA risk category improved the prediction of recurrence-free survival, compared to TNM stage or ATA risk category alone.ConclusionsThe present study suggests LNR is an independent predictor of recurrence in Middle Eastern PTC. Integration of LNR with 8th edition AJCC TNM staging system and ATA risk stratification will improve the accuracy to predict recurrence in Middle Eastern PTC and help in tailoring treatment and surveillance strategies in these patients.

Modified cancer TNM classification for localized renal cell carcinoma based on the prognostic analysis of 3748 cases from a single center.

The optimal cutoff point for evaluating the prognosis of localized renal cell carcinoma (LRCC) remains unclear. This study aimed to verify the efficacy of tumor diameter in the 2010 American Joint Committee on Cancer (AJCC) TNM staging system and contribute to the modification of TNM staging on the prognosis of this disease. A total of 3748 patients with LRCC were enrolled and grouped according to the 2010 AJCC TNM staging system. COX analysis was used to stratify the prognosis. The optimal cutoff point of the tumor diameter in the T1 and T2 prognosis was explored. There were 3330 (88.9%) patients in stage T1 and 418 (11.1%) in stage T2. The cancer-specific mortality rate was 2.7% (100/3748). The mean follow-up was 49.8 months. A tumor diameter of 7 cm can determine the prognosis of patients at stages T1 and T2; however, 4.5 cm and 11 cm as the cutoff points for T1 and T2 sub-classification of patients with LRCC might show better recognition ability than 4 cm and 10 cm, respectively. The 2010 AJCC TNM stage can predict the prognosis of LRCC in stages T1 and T2. In addition, a tumor diameter of 4.5 cm and 11 cm might be the optimal cutoff points for the sub-classification of stages T1 and T2.

Comparison of a Tumor-Ratio-Metastasis Staging System and the 8th AJCC TNM Staging System for Gastric Cancer.

BackgroundDespite the implementation of the 8th American Joint Committee on Cancer (AJCC) TNM staging system for gastric cancer (GC) in 2017, it still holds a significant level of stage migration which affects patients’ proper classification and accurate prognosis. Here, to reduce this effect, we evaluated the prognostic value of a lymph node ratio (LNR) and established a novel tumor–ratio–metastasis (TRM) staging system.MethodThe data of 15,206 GC patients from the Sun Yat-sen University Cancer Center (Training set; n=2,032) and the US Surveillance, Epidemiology, and End Results (SEER) database (Validation set; n=13,174) were analyzed. The training set was classified into 5 LNR categories, based on which the novel TRM staging system was constructed. The overall survival (OS) between the TRM and AJCC TNM systems was compared in the training set and validated in the validation set. The likelihood ratio x2, liner trend x2, C-index, and Akaike information criterion (AIC) values were used to measure the discriminatory ability between the two different staging systems. Decision curve analyses (DCAs) were conducted to test the clinical value of the two staging systems.ResultThe patients were classified into the following categories: LNR0: 0%, LNR1: 0%<LNR ≤ 10%, LNR2: 10%<LNR ≤ 25%, LNR 3a: 25%<LNR ≤ 60%, and LNR 3b: LNR>60%. Univariate analyses demonstrated that the log-rank x2 of the LNR stage (Training/Validation set: x2 = 463.1/2880.8) was larger than the AJCC pN stage (Training/Validation set: x2 = 281.5/2240.8). For both the training set and validation set, stratified analyses using the Kaplan-Meier method identified significantly heterogeneous OS in every pN category but only one using the LNR. The TRM staging system had higher likelihood ratio x2, liner trend x2, C-index and smaller AIC values than the TNM system.ConclusionThe TRM staging system demonstrated improved homogeneity and discriminatory ability in predicting the prognosis of GC patients compared with the AJCC TNM staging system.

The clinicopathological and survival analysis of urological mucosal melanoma: A single-center retrospective observational study.

e21588 Background: Primary mucosal melanoma arising in the urinary tract is rare and poorly characterized. Methods: The records of patients with urological mucosal melanoma who presented to the department of Renal Cancer and Melanoma of Peking University Cancer Hospital between September, 2004 and April, 2019 were reviewed. Available clinicopathological and molecular characteristics were summarized, including pathological parameters, gene mutation, primary surgical intervention, systemic treatment and clinical course. The rates of local recurrence rate, loco-regional lymph node metastasis and distant metastasis were assessed. American Joint Committee on Cancer (AJCC) TNM Staging System for bladder cancer/renal pelvis and ureter cancer/urethral carcinoma (8th ed., 2017) were adopted for staging. Results: Fifty-eight patients were involved in the study with a median age of 62.5 years (range: 32-82). The anatomic sites of the primary urological mucosal melanomas were from the urethra (89.7%), bladder (6.9%), ureter (0%) and kidney (0%), and the left (4.4%) were from multiple loci. At initial diagnosis, 75.9% (n=44) were stage I/II disease, 1.7% (n=1) stage III, and 22.4% (n=13) stage IV. There was 3.4% incidence of CKIT mutation and 1.7% of BRAF mutation. After median follow-up of 22.6 mo, 31.4% (16/51) relapsed locally after organ-preserved surgery. 21.6% (11/51) and 39.2% (20/51) developed metastases to reginal lymph nodes and distance, respectively. The median relapse free survival and median overall survival were 12.2 (95%CI: 7.9-16.4) mo and 33.9 (95%CI: 19.2-48.6) mo, respectively. Univariate Cox analysis showed that TNM stage and systemic adjuvant therapy were the prognostic factors of OS, while no association was found with Breslow thickness, miotic rate, ulceration and gender. Conclusions: Urological mucosal melanoma predominantly arises from lower urinary tract with rare BRAF and CKIT mutation. AJCC TNM Staging System for urothelial carcinoma is proved practical for urothelial melanoma, which should be validated in larger population. Future research is required to identify adjuvant treatment approaches to improve disease outcomes.

Proposed modification of the eighth edition of the AJCC staging system for intrahepatic cholangiocarcinoma

BackgroundTo improve the prognostic accuracy of the 8th edition of the American Joint Committee on Cancer (AJCC) staging system for intrahepatic cholangiocarcinoma (ICC) with establishment and validation of a modified TNM (mTNM) staging system. MethodsData on patients who underwent curative-intent resection for ICC was collected from 15 high-volume centers worldwide (n = 643). An external validation dataset was obtained from the SEER registry (n = 797). The mTNM staging system was proposed by redefining T categories, and incorporating the recently proposed N status as N0 (no lymph node metastasis [LNM]), N1 (1–2 LNM) and N2 (≥3 LNM). ResultsThe 8th AJCC TNM staging system failed to stratify overall survival (OS) of stage II versus IIIA, stage IIIB versus IV, as well as overall stage III versus IV among all patients from the two databases, as well as stage I versus II, and stage III versus III among patients who had ≥6 LNs examined. There was a monotonic decrement in survival based on the proposed mTNM staging classification among patients derived from both the multi-institutional (Median OS, stage I 69.8 vs. II 37.1 vs. III 18.9 vs. IV 16.4 months, all p < 0.05), and SEER (Median OS, stage I 87.0 vs. II 29.3 vs. III 17.7 vs. IV 14.2 months, all p < 0.05) datasets, which was also verified among patients who had ≥6 lymph node harvested from both databases. ConclusionThe modified TNM staging system for ICC using the new T and N definitions provided an improved means to stratify patients relative to long-term OS versus the 8th AJCC staging.

Validation and modification of the AJCC 8th TNM staging system for pancreatic ductal adenocarcinoma in a Chinese cohort: A nationwide pancreas data center analysis.

ObjectiveTo validate the 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic ductal adenocarcinoma (PDAC) in a Chinese cohort of radically resected patients and to develop a refined staging system for PDAC.MethodsData were collected from the China Pancreas Data Center (CPDC) for patients with resected PDAC in 2016 and 2017, and cancer-specific survival (CSS) was evaluated using the Kaplan-Meier method and log-rank test. Univariate and multivariate analyses based on Cox regression were performed to identify prognostic factors. The recursive partitioning analysis (RPA), Kaplan-Meier method, and log-rank test were performed on the training dataset to generate a proposed modification for the 8th TNM staging system utilizing the preoperative carbohydrate antigen (CA)19-9 level. Validation was performed for both staging systems in the validation cohort.ResultsA total of 1,676 PDAC patients were retrieved, and the median CSS was significantly different between the 8th TNM groupings, with no significant difference in survival between stage IB and IIA. The analysis of T and N stages demonstrated a better prognostic value in the N category. Multivariate analysis showed that the preoperative serum CA19-9 level was the strongest prognostic indicator among all the independent risk factors. All patients with CA19-9 >500 U/mL had similar survival, and we proposed a new staging system by combining IB and IIA and stratifying all patients with high CA19-9 into stage III. The modified staging system had a better performance for predicting CSS than the 8th AJCC staging scheme.ConclusionsThe 8th AJCC staging system for PDAC is suitable for a Chinese cohort of resected patients, and the N category has a better prognostic value than the T category. Our modified staging system has superior accuracy in predicting survival than the 8th AJCC TNM staging system.

Compartmental Surgery With Microvascular Free Flap Reconstruction in Patients With T1-T4 Squamous Cell Carcinoma of the Tongue: Analysis of Risk Factors, and Prognostic Value of the 8th Edition AJCC TNM Staging System.

Compartmental surgery and primary reconstruction with microvascular free flaps represent the gold-standard in the treatment of oral tongue squamous cell carcinoma (OTSCC). However, there are still unclear clinical features that negatively affect the outcomes. This retrospective study included 80 consecutive patients with OTSCC who underwent compartmental surgery and primary reconstruction by free flap. The oncologic outcomes, the reliability of the 8th edition American Joint Committee on Cancer (AJCC) staging system and the prognostic factors were evaluated. Fifty-nine males and 21 females (mean age 57.8 years, range 27–81 years) were treated between November 2010 and March 2018 (one patient had two metachronous primaries). Seventy-one patients (88.75%, 52 males, 19 females, mean age of 57.9 years, range of 27–81 years) had no clinical history of previous head and neck radiotherapy and were considered as naive. Histology showed radical surgery on 80/81 lesions (98.8%), with excision margins >0.5 cm, while in 1 case (1.2%), a close posterior margin was found. According to the 8th AJCC classification, 37 patients (45.7%) were upstaged shifting from the clinical to the pathological stage, and 39 (48.1%) showed an upstaging while shifting from the 7th to the 8th AJCC staging system (no tumors were downstaged). Nodal involvement was confirmed in 33 patients (40.7%). Perineural and lymphovascular invasion were present in 9 (11.1%) and 11 (13.6%) cases, respectively. Twenty-two patients (27.1%) underwent adjuvant therapy. The 5-years disease-specific, overall, overall relapse-free, locoregional relapse-free and distant metastasis-free survival rates were 73.2, 66.8, 62.6, 67.4, and 86%, respectively. Patients with a lymph node ratio >0.09 experienced significantly worse outcomes. Univariate analysis showed that patients with previous radiotherapy, stage IV disease, nodal involvement, and lymphovascular invasion had significantly worse outcomes. Multivariate analysis focused naive patients and showed that lymphovascular invasion, advanced stage of disease, and node involvement resulted reliable prognostic factors, and patients with the same tumor stage and histological risk factors who did not undergo adjuvant therapy experienced significantly worse outcomes. In our series, surgery played a major role in the treatment of local extension; adjuvant therapy resulted strictly indicated in patients with advanced-stage disease associated with risk factors.

Magnetic resonance imaging for preoperative staging of pancreatic cancer based on the 8th edition of AJCC guidelines.

Preoperative staging of pancreatic cancer determines the choice of treatment. Magnetic resonance imaging (MRI) plays an important role in preoperative staging of pancreatic cancer. The American Joint Committee on Cancer (AJCC) TNM staging system was revised to its 8th version in 2016, there has been no report correlating the 8th edition of the AJCC TNM staging with preoperative MRI examinations and pathological findings. The purpose of our study is to determine the staging accuracy and evaluate the resectability by using MRI about pancreatic cancer compared with intraoperative or pathological findings according to the 8th edition of the AJCC TNM staging system. One hundred thirty-two patients with a pathological diagnosis of pancreatic cancer who underwent preoperative MRI were identified. The clinical data, MRI findings and pathological findings were analyzed. Preoperative MRI staging and resectability evaluation were compared with pathological findings. The accuracy of MRI for preoperative T and N staging was evaluated, and the sensitivity, specificity and accuracy of MRI in evaluating the resectability were assessed. All the staging and resectability assessments were according to the 8th edition of the AJCC TNM staging system. Analysis showed that the accuracy of MRI for evaluation of the T and N stages was 82.6% (109/132) and 74.2% (98/132), respectively. The sensitivity and specificity of MRI in assessing the resectability were 94.2% and 71.4%, respectively. Integrating the 8th edition of the AJCC TNM stage, no significant differences were identified between the preoperative MRI and pathological results for the staging of pancreatic cancer (P=0.805). MRI is highly accurate for T staging and moderately accurate for N staging. MRI provides important preoperative evaluation of the stage and resectability of pancreatic cancer based on the 8th edition of the AJCC TNM staging system.

Optimized modification of the eighth edition of AJCC TNM staging system for resected pancreatic ductal adenocarcinoma.

Aim: To reassess the prognostic performance of the American Joint Committee on Cancer (AJCC) 8th edition for pancreatic ductal adenocarcinoma (PDAC) and optimize the categorization of PDAC staging. Patients & methods: A total of 11,858 patients with resected PDAC from the Surveillance, Epidemiology and End Results database were retrospectively enrolled by sequential analyses. Results: There was no statistical significance between stage IIA and IIB tumors with hazard ratios of 2.065 and 2.184 (p =0.620) for stages IIA and IIB, respectively. With the proposed modification, there was a significant difference between the hazard ratios of stages IIIA and IIIB which were 2.481 and 2.715, respectively (p =0.009). The C-index of modified system was 0.609, slightly higher than AJCC 8th staging system 0.604. Conclusion: We proposed a modified eighth edition of the AJCC staging system by combining stage IIA with IIB and further subclassifying stage III patients in order to lead to better discriminative power.

Evaluation of the Eighth Edition of the American Joint Committee on Cancer TNM Staging System for Gastric Cancer: An Analysis of 7371 Patients in the SEER Database.

Objective To investigate the validity of the 8th edition of the American Joint Committee on Cancer (AJCC) TNM staging system for gastric cancer. Methods The clinicopathologic data of 7371 patients who were diagnosed with gastric cancer and had 16 or more involved lymph nodes (LNs) were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database and retrospectively reviewed. Results Stage migration occurred primarily during stage III between the 7th and 8th edition TNM staging systems. Stages IIIB and IIIC in the 7th edition staging system were divided in the 8th edition and had obvious differences in survival rates (both P < 0.001). The 8th edition TNM stages IIIC and IV showed similar survival rates (P = 0.101). The prognosis of patients with T4aN3bM0 was not different from that of patients with TxNxM1 (P = 0.433), while the prognosis of patients with T4bN3bM0 was significantly poorer than that of patients with TxNxM1 (P = 0.008). A revised TNM system with both T4aN3bM0 and T4bN3bM0 incorporated into stage IV was proposed. Multivariable regression analysis showed that the revised TNM system, but not the 7th and 8th editions, was an independent factor for disease-specific survival (DSS) in the third step of the analysis. Further analyses revealed that the revised TNM system had superior discriminatory ability to the 8th edition staging system, which was also an improvement over the 7th edition staging system. Conclusion The 8th edition of the AJCC TNM staging system is superior to the 7th edition for predicting the DSS rates of gastric cancer patients. However, for better prognostic stratification, it might be more suitable for T4aN3bM0/T4bN3bM0 to be incorporated into stage IV in the 8th edition TNM staging system.

Incorporating non-biological factors into the TNM staging system for better prognostication and decision-making in testicular cancer.

We combined county-level socioeconomic status (SES), marital status and insurance status to introduce NBF-stage, which were further incorporated into the American Joint Committee on Cancer (AJCC) TNM staging system to generate an integrated staging system for better prognostication and decision-making for testicular cancer patients. 15,324 eligible patients diagnosed with primary testicular cancer between January 1, 2007 and December 31, 2015 were strictly selected from the Surveillance, Epidemiology, and End Results (SEER) database. Independent survival predictors were determined based on Cox proportional hazards model. The Kaplan-Meier survival curves were conducted to describe the difference in predicting survival probability and the Multivariate Cox proportion hazard regression analyses were established to compare the cancer-specific survival (CSS) and overall survival (OS) difference among NBF stages or NBF-TNM subgroups. County-level SES, marital status and insurance status were independent prognostic non-biological factors (NBFs) in our study (P < 0.05). NBF-stage (combination of SES, marital status, and insurance status) was also an independent survival predictor in TC (P < 0.05). NBF1 patients had 167% increased risk of cancer-specific mortality (CSM) as compared to NBF0 patients in testicular cancer (P < 0.01). And NBF0 patients all had a better CSS as compared to NBF1 patients of the same TNM stage both in seminoma and non-seminomatous germ cell tumor (P < 0.05). Incorporation of NBFs into AJCC TNM staging system in testicular cancer would potentially impact treatment decisions where treatments would not be rendered for a typically curable cancer with multi-modal therapy.

Replication of newly proposed TNM staging system for medullary thyroid carcinoma: a nationwide study.

A recent study proposed new TNM groupings for better survival discrimination among stage groups for medullary thyroid carcinoma (MTC) and validated these groupings in a population-based cohort in the United States. However, it is unknown how well the groupings perform in populations outside the United States. Consequently, we conducted the first population-based study aiming to evaluate if the recently proposed TNM groupings provide better survival discrimination than the current American Joint Committee on Cancer (AJCC) TNM staging system (seventh and eighth edition) in a nationwide MTC cohort outside the United States. This retrospective cohort study included 191 patients identified from the nationwide Danish MTC cohort between 1997 and 2014. In multivariate analysis, hazard ratios for overall survival under the current AJCC TNM staging system vs the proposed TNM groupings with stage I as reference were 1.32 (95% CI: 0.38–4.57) vs 3.04 (95% CI: 1.38–6.67) for stage II, 2.06 (95% CI: 0.45–9.39) vs 3.59 (95% CI: 1.61–8.03) for stage III and 5.87 (95% CI: 2.02–17.01) vs 59.26 (20.53–171.02) for stage IV. The newly proposed TNM groupings appear to provide better survival discrimination in the nationwide Danish MTC cohort than the current AJCC TNM staging. Adaption of the proposed TNM groupings by the current AJCC TNM staging system may potentially improve accurateness in survival discrimination. However, before such an adaption further population-based studies securing external validity are needed.

Should patients with stage IB non-small cell lung cancer receive adjuvant chemotherapy? A comparison of survival between the 8th and 7th editions of the AJCC TNM staging system for stage IB patients.

The aims of this study were to compare the efficacy of platinum-based adjuvant chemotherapy in resected patients with stage IB NSCLC according to the 7th and 8th editions of the American Joint Committee on Cancer (AJCC) staging manuals on tumor, node, and metastasis (TNM) staging systems, respectively. This retrospective analysis included 569 patients who underwent pulmonary resection for primary non-small cell lung cancer. 5-year overall survival (OS) was compared in stage IB disease using the 8th and 7th editions of the TNM classification, respectively. Survival curves were plotted using the Kaplan-Meier method, and log-rank test was used to evaluate differences between subgroups. The 5-year overall survival was 76.9% and 83.5% (p = 0.044) for patients in the observation and adjuvant groups, respectively. The presence of adjuvant chemotherapy, lymphovascular invasion, TNM stage, and performance status (PS) were risk factors for OS in univariate analysis. In multivariate analysis, TNM stage [hazard ratio (HR) 5.403, 95% confidence interval (CI) 3.743-7.801, p < 0.001], PS (HR 4.375, 95% CI 2.856-6.703, p < 0.001) and adjuvant chemotherapy (HR 1.476, 95% CI 1.028-2.119, p = 0.035) were risk factors for OS. Subgroup analysis showed that for patients with 8th edition stage IB NSCLC, 5-year OS was 87.6% in the observation group (n = 265) and 82.4% in the adjuvant group (p = 0.021). For patients with 8th edition stage IIA NSCLC, 5-year OS was 48.1% and 87.7% in the observation group and the adjuvant group (p < 0.001), respectively. For patients with an Eastern Cooperative Oncology Group (ECOG) performance status (PS) score of 0, a better 5-year OS was seen in the adjuvant group (79.3% vs 91.6%, p = 0.001) By contrast, for patients with a PS score of ECOG 1, the 5-year OS was significantly improved in the observation group (58.6% vs 17.2%, p = 0.021). The 8th edition of the AJCC staging identified the beneficiary population of platinum-based adjuvant chemotherapy in early-stage NSCLC. Moreover, patients with good PS (ECOG 0) benefited from adjuvant chemotherapy. A large prospective randomized clinical trial is needed to determine the real role of adjuvant chemotherapy in this setting.

Combination of carcinoembryonic antigen with the American Joint Committee on Cancer TNM staging system in rectal cancer: a real-world and large population-based study.

AimThis study assessed the combination of carcinoembryonic antigen (CEA) with the American Joint Committee on Cancer (AJCC) TNM staging system, aiming to improve the AJCC TNM staging system, in terms of prognostic accuracy and clinical management of rectal cancer.MethodsEligible patients (N=22,132) were selected from the Surveillance, Epidemiology, and End Results database between January 1, 2004, and December 31, 2010. Patients with elevated CEA levels were designated as “C1 stage” and those with normal CEA amounts as “C0 stage”. The outcome of interest was cancer-specific survival (CSS). Cox proportional hazards regression analyses and Kaplan–Meier curves were used to identify independent prognostic factors and analyze the odds of CSS in patients with rectal cancer in different C and TNM stages, respectively.ResultsC1 stage was associated with a 61.0% risk increase in cancer-specific mortality (HR=1.610, 95% CI=1.219–1.705, P<0.001). In addition, C0-stage patients showed improved CSS compared with C1-stage counterparts. In addition, CSS was improved in stage IIB–C0 patients (HR=2.478, 95% CI=1.660–3.699) compared with stage IIIB–C1 patients (HR=2.431, 95% CI=2.021–2.924) or IIIA–C1 patients (HR=1.060, 95% CI=0.823–1.366, P=0.650) and stage IIC–C0 patients (HR=4.263, 95% CI=3.308–5.493) compared with stage IIIB–C1 or IIIA–C1 counterparts.ConclusionC stage is an independent prognostic factor of rectal cancer. The improved prognostic precision of the C–TNM staging system and, thus, more individualized risk-adaptive treatments support the incorporation of C stage into the AJCC TNM staging system in rectal cancer.

Clinical Validation of the Prognostic Stage Groups of the Eighth-Edition TNM Staging for Medullary Thyroid Carcinoma.

Despite advances in thyroid cancer staging systems, considerable controversy about the current staging system for medullary thyroid carcinoma (MTC) continues. We aimed to evaluate the prognostic performance of the current eighth edition of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control TNM staging system (TNM-8) and the alternative proposed prognostic stage groups based on recursive partitioning analysis (TNM-RPA). We retrospectively analyzed 182 patients with MTC treated at a single tertiary Korean hospital between 1995 and 2015. Survival analysis was conducted according to TNM-8 and TNM-RPA. The area under the receiver-operating characteristic curve (AUC), the proportion of variation explained (PVE), and the Harrell concordance index (C-index) were used to evaluate predictive performance. Under TNM-8, only two (1.1%) patients were downstaged compared with the seventh edition of the AJCC TNM staging system (TNM-7). The AUC at 10 years, PVE, and C-index were 0.679, 8.7%, and 0.744 for TNM-7 and 0.681, 8.9%, and 0.747 for TNM-8, respectively. Under TNM-RPA, 104 (57.14%) patients were downstaged compared with TNM-8. TNM-RPA had better prognostic performance with respect to cancer-specific survival (AUC at 10 years, 0.750; PVE, 20.9%; C-index, 0.881). The predictive performance of the revised TNM-8 in patients with MTC has not changed despite its modification from TNM-7. The proposed changes in TNM-RPA were statistically valid and may present a more reproducible system that better estimates cancer-specific survival of individual patients.

Differences and comparison of prognostic evaluation between AJCC staging system 7th edition and 8th edition for gastric cancer(A report of 1 383 cases)

Objective To compare the differences and clinical value of prognostic evaluation between American Joint Committee on Cancer (AJCC) TNM staging system 7th edition and 8th edition for gastric cancer (GC). Methods The retrospective case-control study was conducted. The clinicopathological data of 1 383 GC patients who were admitted to the First People′s Hospital of Changzhou between January 2008 and August 2012 were collected. Distal gastrectomy, proximal gastrectomy + pyloroplasty or total gastrectomy were performed according to preoperative evaluation and intraoperative exploration. Observation indicators: (1) surgical and postoperative situations; (2) follow-up and survival situations; (3) T staging comparison between AJCC TNM staging system 7th edition and 8th edition; (4) N staging comparison of AJCC TNM staging system 8th edition; (5) prognostic analysis in N staging of AJCC TNM staging system 8th edition; (6) TNM staging comparison between AJCC TNM staging system 7th edition and 8th edition; (7) prognostic analysis in different TNM staging between AJCC TNM staging system 7th edition and 8th edition. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to October 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). The survival curve and survival rate were respectively drawn and calculated by the Kaplan-Meier method, and the Log-rank test was used for survival analysis. Results (1) Surgical and postoperative situations: 1 383 GC patients underwent successful radical gastrectomy, including 923 with distal gastrectomy, 165 with proximal gastrectomy and 295 with total gastrectomy. Of 1 383 patients, 115 with postoperative complications were improved by symptomatic treatment, including 87 with surgical complications and 28 with non-surgical complications. Postoperative pathological examinations: total number of intraoperative lymph node dissection and number of lymph node metastasis were 25±12 and 7±4; 577 didn′t have lymph node metastasis and 806 had regional lymph node metastasis; 308 were in early GC and 1 075 in advanced GC. (2) Follow-up and survival situations: 1 383 patients were followed up for 1-117 months, with a median time of 34 months. The 1-, 3- and 5-year survival rates of 1 383 patients were respectively 90.5%, 71.9% and 61.1%. (3) T staging comparison between AJCC TNM staging system 7th edition and 8th edition: T staging definition between AJCC TNM staging system 7th edition and 8th edition was identical. T staging of 1 383 patients: 308, 192, 65, 628 and 190 were respectively detected in T1, T2, T3, T4a and T4b stagings. (4) N staging comparison between AJCC TNM staging system 7th edition and 8th edition: N staging definition between AJCC TNM staging system 7th edition and 8th edition was identical. N staging of 1 383 patients: 577, 255, 207, 230 and 114 were respectively detected in N0, N1, N2, N3a and N3b stagings. N3a and N3b were classified as N3 staging of AJCC TNM staging system 7th edition, but they were classified as independent staging of AJCC TNM staging system 8th edition. (5) Prognostic analysis in N staging of AJCC TNM staging system 8th edition: 5-year survival rate of patients in N0, N1, N2, N3a and N3b stagings was respectively 85.6%, 76.5%, 59.4%, 45.2% and 32.5% based on AJCC TNM staging system 8th edition, with a statistically significant difference in survival (χ2=394.400, P 0.05), betweenⅡA andⅡB stagings (χ2=0.265, P>0.05), and between ⅢB and ⅢC stagings (χ2=1.550, P>0.05). According to 8th edition, cases and 5-year survival rate were respectively 247, 89.5% in ⅠA staging and 147, 83.7% inⅠB staging and 77, 75.9% in ⅡA staging and 205, 70.7% in ⅡB staging and 288, 53.8% in ⅢA staging and 258, 37.3% in ⅢB staging and 161, 28.5% in ⅢC staging, with a statistically significant difference in survival among sub-stagings (χ2=234.900, P 0.05) and betweenⅡA andⅡB stagings (χ2=0.564, P>0.05). There was statistically significant differences in survival between ⅢA and ⅢB or ⅢC stagings (χ2=29.790, 43.060, P 0.05) and between T4aN3a and T4bN2 stagings (χ2=0.029, P>0.05). Conclusions Compared with AJCC TNM staging system 7th edition, N3a and N3b stagings are classified as independent staging in AJCC TNM staging system 8th edition, and 8th edition is more accurate in prognostic evaluation of GC patients in stage Ⅲ. Key words: Gastric neoplasms; American Joint Committee on Cancer; TNM staging; Survival; Prognosis

New and Important Changes in the TNM Staging System for Breast Cancer.

Expanded understanding of biologic factors that modulate the clinical course of malignant disease have led to the gradual integration of biomarkers into staging classifications. The American Joint Committee on Cancer (AJCC) TNM staging system is universally used and has largely displaced other staging classifications for most, although not all, cancers. Many of the chapters of the eighth edition of the AJCC TNM staging system integrated biomarkers with anatomic definitions. The Breast Chapter added estrogen receptor (ER) and progesterone receptor (PR) expression, HER2 expression, and/or amplification and histologic grade to the anatomic assessment of tumor size, regional lymph node involvement, and distant metastases (known as TNM). While preserving an anatomic staging system for continuity and for regions where modern biomarkers are not always available, the eighth edition emphasizes the increased prognostic precision of the clinical prognostic stage groups and the pathologic prognostic stage groups. The clinical prognostic stage groups are applicable to all patients with primary breast cancer before any treatment has been implemented, but require a clinical and imaging evaluation as well as a biopsy with grade and available ER, PR, and HER2 results; the pathologic prognostic stage groups are applicable to all patients treated with complete surgical excision as first treatment and also require a complete pathology report, grade, and ER, PR, and HER2. Applying the pathologic prognostic stage groups to a large database of patients staged by basic TNM groupings changed the stage grouping of almost 40% of patients. Grouping by pathologic prognostic stage groups led to a better prognostic distribution of the group and more precise individual prognostication.