Current AJCC Staging Research Articles

Discovery and validation of AMBLor as a prognostic biomarker for non-ulcerated cutaneous AJCC stage I/II melanoma.

9573 Background: Cutaneous melanoma incidence continue to increase, with a particular increase in the number of patients diagnosed with thin, < 1mm tumours with reduced probability of recurrence-free survival. The inability of current AJCC staging criteria to identify genuinely low risk subsets of patients with AJCC stage I/II tumours thus emphasises the acute need for credible prognostic biomarkers to stratify patient follow-up based on personalised risk. The combined immunohistochemical (IHC) expression of AMBRA1 and Loricrin (AMBLor) in the epidermis overlying non-ulcerated AJCC stage I melanomas has recently been identified as a prognostic biomarker and valuable pre SLNB test. The aim of the present study was to evaluate the potential for AMBLor as a prognostic biomarker for both AJCC stage I and II non-ulcerated melanoma. Methods: Prospective analysis of AMBLor was performed in two independent retrospective cohorts of non-ulcerated AJCC (8th edition) stage I and II cutaneous melanomas derived from the USA and Australia (discovery cohort) and Spain and the UK (Validation cohort) following validated automated immune-histological staining and binary scoring analysis to define at risk vs low risk subgroups. Each cohort was powered to represent rates of 10% or up to 20% metastasis for stage I or stage II disease respectively. Results: Data revealed retention of AMBLor in the discovery cohort of 541 melanomas correlated with significantly increased recurrence-free survival (RFS) of 96% compared to 87% for patients with stage I/II melanomas in which AMBLor was lost (P = 0.06; HR 3.6, 95% CI 1.99-6.84, NPV 96%). Subsequent AMBLor analysis in the validation cohort of 303 tumours, further confirmed retention of AMBLor was associated with increased RFS of 98% compared to 81% for patients with stage I/II tumours in which AMBLor was lost (P = 0.01; HR 8.16, 95% CI 3.68-18.07). Conclusions: Collectively data from this multi-international study confirm AMBLor as a prognostic biomarker marker able to identify genuinely low risk subsets of AJCC stage I/II melanomas. Inclusion of AMBLor into clinical melanoma management may therefore aid stratification of patient follow up, enable significant savings on healthcare resources and improve patient anxiety.

Prognostic significance of acellular mucin in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for appendiceal neoplasms

Appendiceal neoplasms have a propensity for peritoneal dissemination. The standard of care for select individuals is CRS/HIPEC. In the current 8th AJCC Staging system, a finding of only intraperitoneal acellular mucin (M1a) is classified as Stage IVa. There is concern that the current AJCC system may over-stage patients. This was a single-institution retrospective review of 164 cases of mucinous appendiceal neoplasm. Patients undergoing CRS/HIPEC with M1a disease were compared to patients with peritoneal deposits containing tumor cells (well-differentiated adenocarcinoma; low-grade mucinous carcinoma peritonei-M1b,G1). Overall and recurrence-free survival were assessed. Median age was 51years, 70% were female, and 75% White. Sixty-four patients had M1a disease and 100 M1b,G1 disease. M1a disease had a lower median PCI score (11 vs. 20, p = .0001) and a higher rate of complete CRS (62% vs. 50%, p = .021). Median follow-up was 7.6years (IQR 5.6-10.5years). For M1a disease, there were no recurrences and only one patient died during the study interval. In comparison, for M1b disease, 66/100 (66%) recurred with a 5-year RFS of 40.5% (HR 8.0, 95% CI 4.9-15.1, p < .0001), and 31/100 (31%) died with a 5-year OS of 84.8% (HR 4.5, 95% CI 2.2-9.2, p < .0001). Acellular mucin (M1a disease) after CRS/HIPEC for appendiceal neoplasm is associated with longer OS and RFS compared to M1b, G1 disease. Current AJCC staging does not accurately reflect the differing outcomes of these two patient populations. The presence of acellular mucin in the peritoneal cavity should not be perceived as a metastatic equivalent.

Prognostic value of tumor-to-parenchymal contrast enhancement ratio on portal venous-phase CT in pancreatic neuroendocrine neoplasms.

We aimed to evaluate the prognostic value of tumor-to-parenchymal contrast enhancement ratio on portal venous-phase CT (CER on PVP) and compare its prognostic performance to prevailing grading and staging systems in pancreatic neuroendocrine neoplasms (PanNENs). In this retrospective study, data on 465 patients (development cohort) who underwent upfront curative-intent resection for PanNEN were used to assess the performance of CER on PVP and tumor size measured by CT (CT-Size) in predicting recurrence-free survival (RFS) using Harrell's C-index and to determine their optimal cutoffs to stratify RFS using a multi-way partitioning algorithm. External data on 184 patients (test cohort) were used to validate the performance of CER on PVP in predicting RFS and overall survival (OS) and compare its predictive performance with those of CT-Size, 2019 World Health Organization classification system (WHO), and the 8th American Joint Committee on Cancer staging system (AJCC). In the test cohort, CER on PVP showed C-indexes of 0.83 (95% confidence interval [CI], 0.74-0.91) and 0.84 (95% CI, 0.73-0.95) for predicting RFS and OS, respectively, which were higher than those for the WHO (C-index: 0.73 for RFS [p = .002] and 0.72 for OS [p = .004]) and AJCC (C-index, 0.67 for RFS [p = .002] and 0.58 for OS [p = .002]). CT-Size obtained C-indexes of 0.71 for RFS and 0.61 for OS. CER on PVP showed superior predictive performance on postoperative survival in PanNEN than current grading and staging systems, indicating its potential as a noninvasive preoperative prognostic tool. • In pancreatic neuroendocrine neoplasms, the tumor-to-parenchymal enhancement ratio on portal venous-phase CT (CER on PVP) showed acceptable predictive performance of postoperative outcomes. • CER on PVP showed superior predictive performance of postoperative survival over the current WHO classification and AJCC staging system.

Real-life analysis of pathologic complete response with neoadjuvant trastuzumab plus taxane with or without pertuzumab therapy in HER2 positive locally-advanced breast cancer (HER2PATH Study).

e12610 Background: Studies in HER2+ locally-advanced breast cancer (LABC) patients with neoadjuvant dual HER2 blockage therapy demonstrated high rates of pathologic complete response (pCR). This study evaluates neoadjuvant chemotherapy (NCT) plus trastuzumab (H) with or without pertuzumab (P) therapy with a nation-wide real world setting. Methods: In this study, 1528 female HER2+ LABC patients’ data received NCT plus H with or without P were collected retrospectively from 21 centers. Ethics committee approved the study (NCT04765124). Primary end point was pCR rate (ypT0/Tis ypN0 in the current AJCC staging system). Results: Of the 1528, 951 (62.2%) were received NCT-H, 577 (37.8%) were received NCT-HP, follow-up durations were 30 months and 15 months, median ages were similar between 2 groups (47 years, range: 20-81 and 47 years, range 22-88, respectively). According to the menopausal and hormone receptor status 60% and 53.7% of patients were classified as premenopausal, 56% and 57.8% as estrogen receptor positive and 46.2% and 47.2% as progesterone receptor positive respectively at NCT-HP and NCT-H groups. Despite the patients at NCT-HP group mostly received docetaxel (75%), NCT-H group received weekly paclitaxel (59.4%) as taxane (p&lt;0.001). pCR rate for patients treated with NCT-HP was significantly better than that for patients received NCT-H (66.4% vs. 56.8%, respectively, p&lt;0.001) and there were not any statistical difference according to hormone receptor status. Two-years event-free survival (EFS) rates were 93.5% and 93.2% for NCT-HP and NCT-H groups, respectively (p=0.655), however, two years EFS rate was statistically significant in patients who achieved pCR compared to those who did not achieve pCR (95.1% vs. %90.6, p&lt;0.001). There was not any toxicity leading to death. Conclusions: Our analysis of this real world data shows higher rates of pCR than in clinical trials, also adding pertuzumab to NCT-H demonstrates higher pCR rates and EFS rates compared with NCT-H in patients with HER2+ LABC.

Classification and Staging of Melanoma in the Head and Neck.

The rates of melanoma continue to rise, with recent estimates have shown that 18% to 22% of new melanoma cases occur within the head and neck in the United States each year. The mainstay of treatment of nonmetastatic primary melanomas of the head and neck includes the surgical resection and management of regional disease as indicated. Thorough knowledge of the classification and staging of melanoma is paramount to evaluate prognosis, determine the appropriate surgical intervention, and assess eligibility for adjuvant therapy and clinic trials. The traditional clinicopathologic classification of melanoma is based on morphologic aspects of the growth phase and distinguishes 4 of the most common subtypes as defined by the World Health Organization: superficial spreading, nodular, acral lentiginous, and lentigo maligna melanoma. The data used to derive the AJCC TNM Categories are based on superficial spreading melanoma and nodular subtypes. Melanoma is diagnosed histopathologically following initial biopsy that will assist with classifying the tumor to guide treatment. Classification is based on tumor thickness and ulceration (T stage, Breslow Staging), Regional Lymph Node Involvement (N Stage), and presence of metastasis (M Stage). Tumor thickness (Breslow thickness) and ulceration are 2 independent prognostic factors that have been shown to be the strongest predictors of survival and outcome. Clark level of invasion and mitotic rate are no longer incorporated into the current AJCC staging system, but still have shown to be important prognostic factors for cutaneous melanoma. For patients with metastatic (Stage IV) disease Lactate Dehydrogenase remains an independent predictor of survival. The Maxillofacial surgeon must remain up to date on the most current management strategies in this patient population. Classification systems and staging provide the foundation for clinical decision making and prognostication for the Maxillofacial surgeon when caring for these patients.

Prognostic value of quantitative cervical nodal necrosis burden on MRI in nasopharyngeal carcinoma and its role as a stratification marker for induction chemotherapy.

This study aimed to assess the prognostic value of quantitative cervical nodal necrosis (CNN) burden in N staging risk stratification in patients with nasopharyngeal carcinoma. Univariate and multivariate Cox regression models evaluated the association between lymph node variables based on MRI images and survival. Revisions for the N classification system were proposed and compared to the 8th edition AJCC staging system using Harrell's concordance index (C-index). The survival outcomes of induction chemotherapy plus concurrent chemoradiotherapy (CCRT) and CCRT alone in patients with multiple CNNs were compared. In 1319 patients enrolled, CNN was not an independent prognostic factor for the main survival outcomes, but multiple CNNs (three or more necrotic nodes) were independent prognostic factors for distant metastasis-free survival (DMFS) (adjusted hazard ratio [HR], 2.05; p = 0.020) and progression-free survival (PFS) (HR, 1.78; p = 0.004), surpassing other nodal variables. On upgrading patients with multiple CNNs to revised N3 disease, the proposed N staging widened the differences in DMFS and PFS between N2 and N3 disease. The overall survival of patients with multiple CNNs who received CCRT plus induction chemotherapy was improved compared to that of those who received CCRT alone (76.1% vs. 55.7%; adjusted p = 0.030). Upgrading patients with multiple CNNs to stage N3 may improve prognostication of the current AJCC staging system. Multiple CNNs might be a potential marker for stratifying patients who would benefit from induction chemotherapy. • Quantitatively assessed the prognostic value of CNN burden in patients with NPC. • Upgrading patients with multiple CNNs to stage N3 may improve prognostication. • Multiple CNNs may be used as a stratification marker for induction chemotherapy.

Abstract PD9-01: Expanding downstaging criteria in AJCC pathologic prognostic staging using OncotypeDx Recurrence Score® assay in T1-2N0 hormone-receptor positive patients enrolled in the TAILORx trial

Abstract Background: The AJCC 8th edition pathologic prognostic staging (PPS) system, which incorporates both anatomic and biologic factors, was developed using data from patients captured in the National Cancer Database diagnosed 2010-2012 in whom complete anatomic (T, N and M category) as well as biologic data (grade, ER, PR, HER2) were available. The clinical endpoint was 3-year overall survival. In addition, the use of genomic assays was incorporated based on the initial report from the TAILORx trial, with patients with T1-2N0 hormone-receptor positive, HER2 negative (HR+,HER2-) breast cancer and an Oncotype DX Recurrence Score® (RS) result &amp;lt;11 being staged as PPS IA. Given availability of long-term prospective followup data from TAILORx, we undertook this study to examine if the RS criteria for downstaging to PPS IA can be expanded using the patients enrolled on this trial. Methods: TAILORx assigned T1-2N0 HR+HER2- breast cancer patients with RS &amp;lt;11 to endocrine therapy (ET) alone and RS &amp;gt;25 to chemotherapy followed by ET (CET). Those with RS 11-25 were randomized to ET or CET. 10,273 patients were enrolled. Patients with incomplete HR status or grade and those with T3 disease were excluded for this analysis. Recurrence-free survival (RFS) in patients with RS &amp;lt;11 were compared between patients that did and did not fall into current AJCC PPS IA category using the Kaplan-Meier method. Results: 9,535 patients were included for analysis. The majority were &amp;gt; 50 years old (n=6893, 72.3%), had T1 tumors (n=6561, 68.8%), grade 2 disease (n=5291, 55.5%), and underwent lumpectomy (n=6855, 71.9%). RS breakdown was &amp;lt;11 in 1539 (16.1%), 11-17 in 3423 (35.9%), 18-25 in 3088 (32.4%) and &amp;gt;25 in 1485 (15.6%). 8,698 (91.2%) patients were AJCC PPS IA (including all T1N0 patients regardless of RS), and 837 (8.8%) were not PPS IA. Median follow-up time was 95 months. PPS IA patients had 8-yr RFS of 94.2% which was statistically similar to patients with RS 11-17 that were not PPS IA (91.7%, p=0.07) and better than patients with RS &amp;gt;18 that were not PPS IA (85.4% for RS 18-25, 76.0% for RS &amp;gt;25, p&amp;lt;0.01). For patients with a RS 11-17 that were not PPS IA receiving ET alone, 8-yr RFS was 93.3% which was statistically similar to PPS IA patients receiving ET alone (94.9%, p=0.24). There was no RFS benefit with CET for patients with RS 11-17 not PPS IA (Table). Conclusions: Patients with T1-2N0 HR+HER2- breast cancer and RS&amp;lt;18 have similar RFS to patients staged as PPS IA by the current AJCC staging system, regardless of treatment, suggesting that consideration could be given to expanding the criteria for pathologic prognostic stage IA to include RS&amp;lt;18. Comparison of RFS in patients with Stage IA and not Stage IA by AJCC PPS, n=9535Stage IANot stage IA, RS 11-17Not stage IA, RS 18-25Not stage IA, RS &amp;gt;25All Patients, n=9535n=8698n=169n=269n=3998yr RFS % (95% CI)94.2 (93.6-94.8)91.7 (87.0-96.4)85.4 (80.3-90.5)76.0 (69.1-82.9)P-value*Ref0.07&amp;lt;0.01&amp;lt;0.01ET, n=5370n=5123n=88n=135n=248yr RFS % (95% CI)94.9 (94.1-95.7)93.3 (87.6-99.9)85.1 (77.8-92.4)58.3 (77.8-92.4)P-value*Ref0.24&amp;lt;0.01&amp;lt;0.01CET, n=4165n=3575n=81n=134n=3758yr RFS % (95% CI)93.2 (92.2-94.2)90.0 (82.4-97.6)85.8 (78.7-92.9)76.9 (69.8-84.0)P-value*Ref0.019&amp;lt;0.01&amp;lt;0.01ET endocrine therapy; CET chemoendocrine therapy*compared to T1-2N0 patients with PPS IA Citation Format: Olga Kantor, Harold J Burstein, Tari King, Steven Shak, Christy Russell, Armando E Giuliano, Gabriel N Hortobagyi, Eric P Winer, Larissa A Korde, Joseph A Sparano, Elizabeth A Mittendorf. Expanding downstaging criteria in AJCC pathologic prognostic staging using OncotypeDx Recurrence Score® assay in T1-2N0 hormone-receptor positive patients enrolled in the TAILORx trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD9-01.

Nomogram Based on Lactate Dehydrogenase-to-Albumin Ratio (LAR) and Platelet-to-Lymphocyte Ratio (PLR) for Predicting Survival in Nasopharyngeal Carcinoma.

PurposeThe prognosis of inflammation-related indicators like lactate dehydrogenase/albumin ratio (LAR) and the platelet/lymphocyte ratio (PLR) in nasopharyngeal carcinoma (NPC) is not yet clear. Our objective is to establish and verify the nomogram using LAR and PLR ratio for the first time to explore the prognostic value in NPC.Patients and MethodsThis was a retrospective collection of 1661 patients with non-metastatic NPC admitted to our hospital from 2010 to 2017. The final variables of overall survival (OS) and progression-free survival (PFS) were selected by Cox regression analysis to establish nomograms, and the methods to verify the prediction precision and discriminative ability of the nomograms were concordance index (C index), the receiver operating characteristic (ROC) curve and calibration curve. The risk stratification was carried out through the nomograms and compared with the current staging system by the Kaplan–Meier methods.ResultsMultivariate Cox analysis resulted that age, plasma Epstein–Barr Virus (EBV) DNA, T stage, N stage, white blood cells (WBC), PLR and LAR were independent prognostic risk factors for OS and PFS, and sex is an independent prognostic risk factor for OS. The C-indexes of OS nomogram were 0.722 (95% CI: 0.706–0.738) and 0.747 (95% CI: 0.717–0.777) in the training cohort and validation cohort, which were statistically higher than the current 8th AJCC staging system (0.646 and 0.688). The C-indexes of PFS nomogram were 0.696 (95% CI: 0.680–0.713) and 0.690 (95% CI: 0.660–0.720), which were also statistically higher than the current 8th AJCC staging system (0.632 and 0.666). Otherwise, ROC curves and the calibration curve for probability also confirmed satisfied consistency with actual observations.ConclusionLAR is a novel useful independent factor in NPC. The proposed nomogram LAR and PLR resulted in more accurate prognostic prediction than current staging system for NPC patients.

Extent of paranasal sinus involvement and its prognostic value in nasopharyngeal carcinoma: Proposed modification in the current UICC/AJCC staging system

PurposeThis study aimed to evaluate the prognostic value of paranasal sinus involvement (PSI) in NPC and to explore its appropriate position in the current AJCC staging system. Materials and methodsPretreatment MRI of 1317 patients with NPC treated with intensity-modulated radiotherapy (IMRT) between January 2010, and January 2013, were reviewed retrospectively. Survival was compared between patients with PSI-slight (sinus bone wall erosion only) and PSI-severe (tumor penetrated into sinus cavity). Multivariable analysis was performed to identify the independent predictors of survival. ResultsThe study included 1317 patients (median age 46 years; range, 11–78 years). PSI-slight was present in 15.2% (200/1317) patients and PSI-severe in 20.0% (263/1317) patients. Overall survival (OS), distant metastasis–free survival (DMFS), loco-regional recurrence–free survival (LRFS), and progression-free survival (PFS) were significantly lower in patients with PSI-severe (all P < .05). In multivariable analysis, PSI-severe was an independent prognostic factor for OS, DMFS, LRFS, and PFS (all P < .05). 96 AJCC T3 category patients with PSI-severe were reclassified as T4 category. The revised T category had significantly better predictive value (higher C-index) than that the AJCC system for survival (OS, .661 vs. .652; DMFS, .655 vs. .650; P < .05 for all). ConclusionPSI-severe is an independent negative prognostic factor in nasopharyngeal carcinoma, which is recommended to be classified as T4 category in the 8th AJCC staging system for NPC.

Clinicopathological correlation of radiologic measurement of post-therapy tumor size and tumor volume for pancreatic ductal adenocarcinoma

ObjectivesTumor size measurement is critical for accurate tumor staging in patients with pancreatic ductal adenocarcinoma (PDAC). However, accurate tumor size measurement is challenging in patients who received neoadjuvant therapy before resection, due to treatment-induced fibrosis and tumor invasion beyond the grossly identified tumor area. In this study, we evaluated the correlation between the tumor size and tumor volume measured on post-therapy computed tomography (CT) scans and the pathological measurement. Also, we investigated the correlation between these measurements and clinicopathological parameters and survival. Materials and methodsRetrospectively, we evaluated 343 patients with PDAC who received neoadjuvant therapy, followed by pancreaticoduodenectomy and had pre-operative pancreatic protocol CT imaging. We measured the longest tumor diameter (RadL) and the radiological tumor volume (RadV) on the post-therapy CT scan, then we categorized RadL into four radiologic tumor stages (RTS) based on the current AJCC staging (8th edition) protocol and RadV based on the median. Pearson correlation or Spearman’s coefficient (δ), T-test and ANOVA was used to test the correlation between the radiological and pathological measurement. Chi-square analysis was used to test the correlation with the tumor pathological response, lymph-node metastasis and margin status and Kaplan-Meier and Cox-proportional hazard for survival analysis. P-value < 0.05 was considered significant. ResultsAs a continuous variable, RadL showed a positive linear correlation with the post-therapy pathologic tumor size in the overall patient population (Pearson correlation coefficient: 0.72, P < 0.001) and RadV (δ: 0.63, p < 0.0001). However, there was no correlation between RadL and pathologic tumor size in patients with ypT0 and those with pathologic tumor size of ≤1.0 cm. Post-therapy RTS and RadV group correlated with ypT stage, tumor response grades using either CAP or MDA grading system, distance of superior mesenteric artery margin and tumor recurrence/metastasis. ConclusionAlthough RadL tends to understage ypT in PDAC patients who had no radiologically detectable tumor or small tumors (RTS0 or RTS1), radiologic measurement of post-therapy tumor size may be used as a marker for the pathologic tumor staging and tumor response to neoadjuvant therapy.

Grading Solid Pseudopapillary Tumors of the Pancreas: the Fudan Prognostic Index.

Ki-67 has been shown to predict outcome of patients with solid pseudopapillary tumor of the pancreas (SPTP) but has not been incorporated into a formal classification system to predict recurrence-free survival (RFS). This is a retrospective cohort study of patients with histologically confirmed diagnosis of SPTP who had at least 1year of follow-up at two tertiary academic centers. Survival data were assessed by Kaplan-Meier method and multivariable Cox regression model. Prognostic performance was compared among various systems. A total of 193 consecutive patients were included, ranging in age from 12 to 70years (median 33years). Seven patients (3.6%) developed tumor recurrence. The 3-, 5-, and 10-year RFS rates were estimated at 96.9%, 96.1%, and 94.8%, respectively. For the AJCC staging system, patients with stage I had similar prognosis to those with stage II. For the ENETS staging system, patients with stage I to III had similar prognosis. Grade based on Ki-67 was superior to both the AJCC and ENETS systems for predicting survival. Multivariate analysis revealed that large tumor size [> 10cm; hazard ratio (HR), 6.177 95% confidence interval (CI), 1.289-29.603; P = 0.023] and Ki-67 (HR, 17.199 95% CI, 4.001-73.930; P < 0.001) were independent predictors for RFS. The Fudan Prognostic Index based on the combination of Ki-67 and tumor size showed excellent discrimination for RFS and was more accurate and informative than other grading/staging systems. The Fudan Prognostic Index better predicts RFS compared with either Ki-67 alone or the current AJCC and ENETS TNM-based staging systems.

Variations in surgical treatment of stage I gallbladder carcinoma impacts survival.

495 Background: Variations in surgical care for stage I gallbladder carcinoma (GBC) may be associated with inferior outcomes. The aim of this study was to identify the variations in surgical treatment of GBC. Methods: All patients diagnosed with stage I GBC by AJCC 8 criteria from 2004-2013 were identified in the NCDB. Surgical treatment was categorized as cholecystectomy (C), cholecystectomy with lymph node dissection (C+LND), or radical cholecystectomy (RC). Independent predictors of improved overall survival (OS) and extent of surgery were identified by multinomial regression analyses. Results: Of 1756 patients with stage I GBC, 26% were T1a, 56% T1b, and 18.5% T1NOS. The majority were White non-Hispanic (61.8%) and female (68.5%), with 55.1% &gt; 70 years of age. Two-thirds of T1a tumors were treated with more aggressive surgery (28% C+LND, 4.2% RC), which did not differ by age. However, only 44.4% of patients with T1b tumors had more aggressive surgery, which was significantly less likely in patients &gt; 70 years, even after controlling for other factors (C+LND (OR:0.60; CI:0.44-0.81), RC (OR:0.52; CI:0.29-0.91)). Five-year OS was 54.34% for T1a and 43.05% for T1b (p = 0.02). After controlling for other factors, both C+LND (HR:0.46, CI:0.26-0.81) and RC (HR:0.31, CI:0.16-0.62) significantly improved 5-year OS for T1b tumors, whereas RC also improved 5-year OS for all patients &gt; 70 years old (p = 0.04). Conclusions: A majority of patients with T1b GBC had less than adequate surgery by the current AJCC staging, which significantly decreased survival in all patients. This was especially evident in older patients who were also the least likely to receive more aggressive surgery.

Low-Grade Appendiceal Mucinous Neoplasms: A Single Institution Experience of 64 Cases With Clinical Follow-up and Correlation With the Current (Eighth Edition) AJCC Staging.

Background. In this single-institution study, we applied the current (eighth edition) American Joint Committee on Cancer pathologic staging criteria to 64 low-grade mucinous neoplasms of the appendix (LAMNs), examined their histopathologic features, and studied the patients' clinical outcomes. Design. Sixty-four LAMNs, with a median follow-up of 52 months, were reviewed. Results. The distribution of pathologic stages was pTis (n = 39), pT3 (n = 1), pT4a (n = 5), pT4aM1a (n = 8), and pT4aM1b (n = 11). Recurrence was observed in only 2 patients (both with pT4aM1b disease), one of whom died of disease. All remaining patients were disease-free after a median clinical follow-up of 60 months. Conclusions. Our study confirms that pTis LAMNs have an excellent prognosis and suggests that pT4a and pT4aM1a LAMNs may also have a low risk of developing progressive disease.

Lymph node staging systems in oral squamous cell carcinoma: A comparative analysis

ObjectivesThe 8th edition of the AJCC has introduced a new nodal staging system for head and neck cancers. Alternate nodal staging systems exist, however they have not been compared to the current AJCC staging system. Materials and methodsA retrospective analysis of 643 patients with oral squamous cell carcinoma (OSCC) treated with surgery ± adjuvant therapy in a single institution between 2004 and 2014 was undertaken. Nodal staging was performed using AJCC 8th edition (AJCC8), number of positive lymph nodes (PN), log odds of positive lymph nodes (LODDS) and lymph node ratio (LNR). Survival analyses for disease free survival (DFS) and overall survival (OS) were performed with the different staging systems and they were compared on the basis of hazard consistency, hazard discrimination, explained variation and likelihood difference. ResultsOverall, PN and LNR best predicted OS and DFS in our cohort of patients. AJCC8 had poor discrimination between sub-stages of pN2. ConclusionPN and LNR provided the most accurate prediction of OS and DFS for patients with OSCC.

Pancreatic neuroendocrine tumours: Grade is superior to T, N, or M status in predicting outcome and selecting patients for chemotherapy:A retrospective cohort study in the SEER database

BackgroundPancreatic neuroendocrine tumours (pNETs) are a rare and heterogeneous group of tumours with an increasing incidence. Current staging criteria for pNETs remain limited and controversial. Meanwhile, the impact of chemotherapy on overall survival has not been fully defined. ObjectivesThe current study aimed to explore epidemiologic trends of pancreatic neuroendocrine tumours (pNETs). To determine feasible improvements to staging criteria and investigate the relationship between chemotherapy and survival. MethodsA retrospective cohort study design was used to analyse annual cancer incidence rates, patient demographics, tumour site and stage, and treatment of pNETs. Data were obtained from the National Cancer Institute's SEER registry for all patients diagnosed with pNETs between January 1973 and December 2015. ResultsPatients diagnosed after 2010 were more likely to present with age greater than 45 years, T0, T1 status, N0 status, M0 status, and well differentiation. Current AJCC staging criteria was applicable to patients with well differentiation, but not other differentiation. The revised system, defined by Grade, T, N, and M status, could robustly discriminate between survival curves. Chemotherapy was associated with significantly improved survival for patients with poorly differentiated and undifferentiated tumour grading. ConclusionsGrade is superior to ‘T’, ‘N’, or ‘M’ status in predicting outcomes and selecting patients for chemotherapy. It is necessary and feasible to combine grade into current staging criteria.

Number of positive nodes – Current relevance in determining prognosis of oral cavity cancer after the recent AJCC staging update

IntroductionLymph node involvement and the number of positive nodes is a significant prognosticator in oral cavity cancers and current staging system does not incorporate it as an integral part. Material and methodsThis was a retrospective study of oral cavity cancer patients who were operated during the time period of 2009–2017. The data was collected and analysed to assess the impact of increase in the number of positive nodes on survival and its comparison of survival statistics to current AJCC staging. ResultsA total of 1431 patients were included in this study and 32.5% of these patients had a node positive disease. Nodal positivity was a significant prognosticator on multivariate analysis. Number of positive nodes was modelled with restricted cubic spline function and it showed progressive worsening of survival functions with increase in number. On Kaplan Meier analysis there was a better separation of curves when number of positive nodes was used and Akaike information criterion (AIC) showed that it was a better prognosticator than existing AJCC staging. ConclusionNumber of positive nodes is a significant prognosticator of prognosis and hence should be considered in the AJCC staging system.

Impact of HPV-Status on Prognostic Potential of the AJCC Staging System for Larynx Cancer

We evaluated the ability of the American Joint Committee on Cancer 7th edition (AJCC) staging system to prognosticate the overall survival of patients with human papillomavirus (HPV)–positive laryngeal squamous cell carcinoma. Patients diagnosed with laryngeal squamous cell carcinoma treated with curative intent were identified in the National Cancer Database (NCDB) for this retrospective analysis. Multivariate analysis was utilized to determine factors correlated with overall survival in the HPV-negative and HPV-positive cohorts. Unadjusted and propensity-score weighted Kaplan-Meier estimation was used to determine overall survival of HPV-negative and HPV-positive patients across AJCC stage groupings. We identified 3,238 patients with laryngeal squamous cell carcinoma of which 2,812 were HPV-negative and 426 were HPV-positive. Overall survival adjusted for age, sex, and co-morbidity status confirmed significant differences between all consecutive stage groupings in the HPV-negative cohort (I vs. II, P<.001; II vs. III, P<.05; III vs. IVA, P<.001; IVA vs. IVB, P<.05) whereas only stage IVA and IVB (P <.01) exhibited a significant difference in overall survival for HPV-positive patients. The current AJCC staging system does not accurately distinguish risk of mortality for patients with HPV-positive disease. These data support the consideration of HPV status in estimating prognosis as well as clinical trial design and clinical decision making for patients with laryngeal squamous cell carcinoma.

Development of a New Clinical Severity Staging System for Patients With Nonmetastatic Papillary Thyroid Carcinoma

Importance The inclusion of patient features in addition to tumor morphology provides a more holistic staging system. Objective To identify prognostically important variables in papillary thyroid carcinoma (PTC) to incorporate into a comprehensive functional severity staging system (FSSS) and clinical severity staging system (CSSS) and to validate the model using a multi-institutional database. Design, Setting, and Participants Retrospective cohort study of adults 18 years or older newly diagnosed or treated for nonmetastatic PTC at the Siteman Cancer Center from 1995 through 2012. Binary logistic regression was used to explore the association between 5-year survival and age, comorbidities, and tumor morphologic features. Conjunctive consolidation was used to create staging systems that incorporated important patient and tumor information. The created FSSS and CSSS were compared with the current AJCC staging system and externally validated using the National Cancer Database (NCDB). Main Outcomes and Measures Five-year survival. Results The cohort consisted of 774 eligible patients with PTC. There were 119 (15%) deaths in the cohort and a 90% 5-year survival rate. The median age of the patients was 51 years (range, 18-91); 562 (73%) were women. Conjunctive consolidation combined age, comorbidity, and T stage to create a new CSSS with 3 categories where 5-year survival rates (95% CI) were as follows: stage A (n = 612), 95% (94%-97%); stage B (n = 131), 74% (67%-82%); and stage C (n = 31), 58% (41%-75%). The performance of the FSSS and CSSS was validated using the NCDB data. The new staging system indicates that patients with nonmetastatic disease, patients younger than 40 years, or patients without comorbidity regardless of age have a very high 5-year survival rate. Conclusions and Relevance The FSSS and CSSS had better predictive results than the current AJCC staging system. The addition of patient features to tumor morphology provides a more comprehensive staging system that improves prognostic accuracy. These comprehensive staging systems can improve scientific reporting of disease outcomes, support comparative effectiveness studies, and guide clinical care by defining prognosis for newly diagnosed patients.

Increasing Epic staging module adherence in an academic cancer center.

64 Background: Documenting tumor staging (TS) is an important quality measure from ASCO’s QOPI program as a useful Core component of care. Real-time, actionable TS documentation in structured fields is important to identify patient cohorts for value-based measurement and to trigger patient care interventions. TS at our institution was usually documented in plain text progress notes in our electronic health record (Epic, Verona WI), making it difficult to use for automating support services, clinical trial evaluation, pre-authorization, business operations, value-based initiatives, and clinical research. Methods: Entry of TS into structured fields in the Epic Staging Module was agreed upon as an internal cancer quality measure in Fiscal Year (FY) 16 (9/15 – 8/16). Patients with &gt; 2 visits to an oncology outpatient department and who began surgical, radiation or chemotherapy treatment in the reporting month were included. The physician providing the first treatment was accountable. Monthly physician and patient-level reports were provided to physician leaders, in a phased roll-out. Targets were based off FY15 performance, which were doubled for a minimum of 40% and maximum of 70% adherence. Results: Nine cancer care programs (CCPs) participated. Average compliance increased from 24% in 9/15 to 79% in 8/16. 2089 of 2894 (72%) charts had clinical and/or pathologic TS entered in the Module. Adherence was driven by CCP leaders sharing data and allowing advanced practice providers staging privileges. We uncovered discordance among providers on what clinical information to input into the Module: original diagnosis or presenting diagnosis on which to base treatment. Conclusions: Our multidisciplinary care teams improved our ability to capture TS at first treatment. A rolled-out, rather than big-bang “hard stop,” approach was successful, as we uncovered unexpected flaws in the system including aligning clinical and staging privileges with Epic access privileges, inaccuracies in Module implementation, and unclear definition between stage and disease state. There are deficiencies in the current AJCC staging system, particularly in its use for relapsed or recurrent cancer, which make defining real-time actionable processes difficult.

Liver resection for intrahepatic cholangiocarcinoma in AJCC‑stage Ⅳ: Anevaluation of the survival benefit and prognostic accuracy of current AJCC staging system on N and M classification.

Intrahepatic cholangiocarcinoma(ICC) is usually confirmed in advanced stage at the time of diagnosis or after surgical exploration, however, indication of surgical treatment is usually controversial for ICC in advanced stages. This retrospective study aims to evaluate clinical value of surgery for such tumors, in order to identify the appropriate patients who will benefit from surgery, and to evaluate the prognostic accuracy of the current staging system for advanced ICC. From January 2007 to December 2011, 387 consecutive surgically treated patients with ICC in AJCC‑stageⅣ were evaluated. Survival was compared among different patients grouped by different elements of AJCC staging system. The prognostic importance of extent of lymph node(LN) metastasis relative to the AJCC N and M classification system was assessed. Our data showed that survival was much better for patients in AJCC‑stageⅣA group (median survival time, MST, 9.0months) than in AJCC‑stageⅣB group (MST, 5.0months) (P<0.001). While in AJCC‑stageⅣB group, survival for patients in AnyTN2‑3M0 subgroup (MST, 9.0months) was much better than in AnyTN0M1 subgroup (MST, 3.0months); and better than in AnyTN2‑3M1 subgroup (MST, 4.0months) (P<0.001). Overall, R0 and R1 liver resection should be indicated for patients in AJCC‑stageⅣA group and AnyTN2‑3M0 subgroup in AJCC‑stageⅣB group, as patients in these groups will benefit from surgery with relatively better survival. Staging of advanced ICC by N2‑3 instead of M1 for extended LN metastasis classification is superior in comparison with the AJCC staging system.