Edition Tumor-node-metastasis Research Articles

Caucasian validation of downstaging from IIB to IIA in T1N1M0 patients within the 9th edition of the non-small cell lung cancer tumor-node-metastasis staging.

The 9th edition of the lung cancer tumor-node-metastasis (TNM) staging introduced adjustments, including the reclassification of T1N1M0 patients from stage IIB to IIA. This update used data mostly from Asian populations. However, the applicability of these adjustments to Caucasian patients remains uncertain. Stage II non-small cell lung cancer (NSCLC) patients from the Surveillance, Epidemiology, and End Results (SEER) database were included. Kaplan-Meier analysis with log-rank testing compared overall survival (OS) and cancer-specific survival (CSS). Propensity score matching (PSM) balanced baseline characteristics. The least absolute shrinkage and selection operator (LASSO)-based Cox analyses identified prognostic factors. Among 10,470 eligible stage II NSCLC patients (median age: 69 years; male: 53.1%), there were 2736 in stage IIA, 2112 in IIA New, and 5622 in IIB groups. Before PSM, survival outcomes of stage IIA New patients were similar to those of stage IIA patients but better than those of stage IIB. After PSM, stage IIA New and IIB patients showed similar survival rates (OS, p = 0.276; CSS, p = 0.565). Conversely, stage IIA New patients had worse outcomes than stage IIA patients (OS, p < 0.001; CSS, p = 0.005). LASSO-based Cox analyses confirmed stage IIA New patients had inferior prognosis compared to stage IIA patients (OS HR: 1 vs. 1.325, p < 0.001; CSS HR: 1 vs. 1.327, p < 0.001). The downstaging of T1N1M0 patients from stage IIB to IIA in the 9th edition TNM staging remains unverified in Caucasians. Caution is warranted in assessing the staging and prognosis of these individuals. Further validation of our findings is necessary.

Prognostic Significance of the Maximum Standardized Uptake Value on the Prognosis of Clinical Stage IA Lung Adenocarcinoma Based on the 8th Edition TNM Classification.

There are few reports on the utility of the maximum standardized uptake value (SUVmax) for predicting the prognosis of early-stage lung adenocarcinoma based on the latest tumor-node-metastasis (TNM) classification. This study aimed to determine whether clinicopathologic factors, including the SUVmax, affect prognosis in these patients. We enrolled 527 patients with c-stage IA lung adenocarcinoma who underwent lobectomy or greater resection between 2011 and 2017. Recurrence-free survival (RFS) and overall survival (OS) were analyzed using Kaplan-Meier curves and compared using the log-rank test. Factors associated with RFS and OS were determined using the Cox proportional hazards model. RFS was significantly different based on tumor stage. In contrast, there was no significant difference in OS between patients with stage IA2 and IA3 disease (p = 0.794), although there were significant differences in OS between patients with stage IA1 and IA2 disease (p = 0.024) and between patients with stage IA1 and IA3 disease (p = 0.012). Multivariate analysis demonstrated that SUVmax was independently associated with both RFS and OS among patients with c-stage IA lung adenocarcinoma (RFS, p = 0.017; OS, p = 0.047). Further, even though there was no significant difference in OS between patients with stage IA2 and IA3 disease (n = 410), SUVmax was able to stratify patients with high and low RFS and OS among these patients (RFS, p < 0.001; OS, p < 0.001). SUVmax was an important preoperative factor to evaluate prognosis among patients with c-stage IA lung adenocarcinoma as well as the current TNM classification.

Assessment of age as different variable types for determining survival in differentiated thyroid cancer

The current tumor, node, metastasis (TNM) system uses an age of 55 years as a threshold for differentiated thyroid cancer (DTC). The aim of our study was to explore the concept of using age as a continuous variable. A total of 36,559 patients with DTC in the Surveillance, Epidemiology, and End Results (SEER) database and 7491 patients in our centers were enrolled. Overall survival (OS) and cancer-specific survival (CSS) were compared. Furthermore, the different statistical model performance of the 6th edition TNM system and age cutoffs for papillary (PTC) and follicular thyroid cancer (FTC) were assessed. Then, a nomogram was built and validated to evaluate the efficacy of age as a continuous variable for predicting survival. The OS and CSS of patients with DTC were significantly increased in patients <55 years compared with those aged ≥55 years. However, no significant differences in prognosis were observed in certain groups as patients between 50 and 60 years were stratified by 1-year increments. Furthermore, the highest concordance index (C-index) was observed in the TNM staging without an age cutoff in SEER database (0.895), our two centers (0.877) and receiver operating characteristic (ROC) curves showed different age cutoffs for PTC and FTC. More importantly, the nomogram incorporating age as a continuous variable showed a favorable area under the ROC curve and calibration for training and validation groups. The utilization of age as a continuous variable is a rational approach for predicting outcome in DTC patients.

Cell graph neural networks enable the precise prediction of patient survival in gastric cancer

Gastric cancer is one of the deadliest cancers worldwide. An accurate prognosis is essential for effective clinical assessment and treatment. Spatial patterns in the tumor microenvironment (TME) are conceptually indicative of the staging and progression of gastric cancer patients. Using spatial patterns of the TME by integrating and transforming the multiplexed immunohistochemistry (mIHC) images as Cell-Graphs, we propose a graph neural network-based approach, termed Cell−GraphSignatureorCGSignature, powered by artificial intelligence, for the digital staging of TME and precise prediction of patient survival in gastric cancer. In this study, patient survival prediction is formulated as either a binary (short-term and long-term) or ternary (short-term, medium-term, and long-term) classification task. Extensive benchmarking experiments demonstrate that the CGSignature achieves outstanding model performance, with Area Under the Receiver Operating Characteristic curve of 0.960 ± 0.01, and 0.771 ± 0.024 to 0.904 ± 0.012 for the binary- and ternary-classification, respectively. Moreover, Kaplan–Meier survival analysis indicates that the “digital grade” cancer staging produced by CGSignature provides a remarkable capability in discriminating both binary and ternary classes with statistical significance (P value < 0.0001), significantly outperforming the AJCC 8th edition Tumor Node Metastasis staging system. Using Cell-Graphs extracted from mIHC images, CGSignature improves the assessment of the link between the TME spatial patterns and patient prognosis. Our study suggests the feasibility and benefits of such an artificial intelligence-powered digital staging system in diagnostic pathology and precision oncology.

Survival Predictability Between the American Joint Committee on Cancer 8th Edition Staging System and the Barcelona Clinic Liver Cancer Classification in Patients with Hepatocellular Carcinoma

This study compared the prognostic significance of staging between the American Joint Committee on Cancer 8th edition Tumor, Node, Metastasis (TNM) staging system and the Barcelona Clinic Liver Cancer (BCLC) classification in patients with hepatocellular carcinoma (HCC). The study population comprised patients with liver cancer registered in the Taiwan Cancer Database from 2007 to 2013 and was followed up until December 31, 2016. The study included patients with HCC, with known staging in both TNM and BCLC systems, and with follow-up >1 month. Primary endpoint was overall survival. Univariate and multivariate Cox proportional hazards model were constructed to investigate the significance of staging by two systems. Goodness-of-fit of model was evaluated via Akaike's information criterion (AIC), the lower the better. Among 73,136 patients with newly diagnosed liver cancer, a total of 37,062 patients with HCC (25.6% underwent surgery) were eligible. The mean age and overall survival of this cohort were 63.9 years and 27.2%, respectively. Overall survivals for stages I, II, III, and IV (the TNM system) were 54.5%, 34.9%, 10.3%, and 6.4%, respectively. Overall survivals for stages A, B, C, and D (the BCLC classification) were 54.5%, 29.2%, 9.8%, and 4.0%, respectively. The median follow-up time was 59.4 months. Multivariate Cox proportional hazards model revealed that both systems predicted overall survival, cancer-specific survival, disease-free survival, and local recurrence-free rate well. Values of ΔAIC of the BCLC classification and the TNM system were lower for the surgery group and nonsurgery group, respectively. The TNM system (8th edition) predicted long-term outcome better than the BCLC classification in patients with HCC. But in patients treated initially with surgery, the BCLC classification outperformed the 8th edition of the TNM system. IMPLICATIONS FOR PRACTICE: This work demonstrates that the Tumor, Node, Metastasis (TNM) system (8th edition) and the Barcelona Clinic Liver Cancer (BCLC) classification both predict long-term outcome significantly in patients with hepatocellular carcinoma but that the TNM system (8th edition) predicts long-term outcome better than the BCLC classification. For patients treated initially with surgery, BCLC classification outperforms in 8th edition TNM system in predicting long-term outcome.

A single-institution retrospective analysis of the differences between 7th and 8th edition of the UICC TNM staging system in patients with advanced lung cancer.

The TNM (Tumor, Node, Metastasis) classification of Union for International Cancer Control is a system describing the anatomical extent of the solid tumors that leads to staging and decision on the type of treatment. The latter TNM system (2017) as compared to the previous version (2010) has brought numerous changes. Our aim was to examine whether significant changes in the new TNM edition have altered the components of the TNM classification in patients and the stage of the disease to which they are ascribed. The study is retrospective and is based on radiological examination reports and case reports of 100 patients of the Department of Pneumonology, Allergology and Oncology of the Medical University in Lublin, Poland. One hundred randomly selected patients, who were hospitalized at the Clinic between 2013 and 2018 with primary lung cancer were enrolled in the study. The chi-square test, Mann-Whitney U test, Kruskal-Wallis test and an appropriate post-hoc test were used in statistical analysis. It was calculated that the T descriptor evaluated as per TNM in revision 8th in comparison to revision 7th changed in 41% of patients, the M descriptor - in 29% of patients, which resulted in change in staging in 11 patients. In spite of this scale amendments, only three patients could be treated differently because of the change in the stage of the disease. Changing the treatment method, including withdrawal from surgery, can help avoid unnecessary treatment, but on the other hand, may potentially reduce the patient's chances of survival by depriving them of the possibility of radical treatment.

Prognostic impact of solid tumor component diameter in early-stage non-small cell lung carcinoma treated with intensity-modulated fractionated radiotherapy: a retrospective analysis impact of solid tumor component diameter in NSCLC treated with IMRT.

Objective:To investigate the suitability of the new diameter-based subgroupings of the eighth edition Tumor Node Metastasis (TNM) classification system regarding radiotherapy treatment for early-stage non-small-cell lung cancer (NSCLC), we retrospectively re-analyzed the clinical data of patients treated with intensity-modulated radiotherapy using non-coplanar beams (ncIMRT) for Stage I NSCLC.Methods:Between March 2011 and March 2018, 92 patients with 94 tumors who were diagnosed with Stage I NSCLC according to the seventh edition TNM classification system were enrolled and underwent ncIMRT of 75 Gy in 30 fractions. Local control (LC), progression-free survival (PFS), and overall survival (OS) were retrospectively investigated according to the T-classification subdivisions of the eighth edition and maximal solid tumor component diameter.Results:The median follow-up period was 32.5 months. The median maximum tumor and solid tumor component diameters were 22 mm and 18 mm, respectively. 3-year LC, PFS, and OS rates were 84.1%, 69.4%, and 85.3%, respectively. The 3-year LC rates were 91.0 and 76.8% in the groups with tumor diameter ≤2 cm and >2 cm, corresponding to the T1c and T1b subdivisions of the eighth edition, respectively (p = 0.24). In the ≤2 cm and >2 cm solid tumor component groups, the 3 year LC rates were 93.6 and 63.2%, respectively, which were significantly different (p = 0.007).Conclusion:LC rates after radiotherapy in patients with Stage I NSCLC were correlated with solid tumor component diameter. High LC rates in patients with solid tumor components <2 cm in diameter were associated with high PFS and OS rates.Advances in knowledge:This study suggests that the eighth edition TNM classification system, which focuses on solid tumor components rather than tumor diameter, can be applied to radiotherapy.

Evaluation of the 8th Edition TNM Classification for Anaplastic Thyroid Carcinoma.

Background: The tumor–node–metastasis (TNM) classification system to categorized anaplastic thyroid cancer (ATC) was revised. Methods: The revised system was evaluated using a large database of ATC patients. Results: A total of 757 patients were analyzed. The proportion and median overall survival values (OS: months) for each T category were T1 (n = 8, 1.1%, 12.5), T2 (n = 43, 5.7%, 10.9), T3a (n = 117, 15.5%, 5.7), T3b (n = 438, 57.9%, 3.9), and T4 (n = 151, 19.9%, 5.0). The OS of the N0 and N1 patients were 5.9 and 4.3, respectively (log-rank p < 0.01). Sixty-three (58.3%) patients migrated from stage IV A to IV B by revision based on the existence of nodal involvement and 422 patients (55.7%) were stratified into stage IV B, without a worsening of their OS (6.1), leaving 45 patients (5.9%) in stage IV A with fair OS (15.8). The hazard ratios for the survival of the patients of stage IV B compared to stage IV A increased from 1.1 to 2.1 by the revision. No change was made for stage IV C (n = 290, 38.8%, 2.8). Conclusion: The revised TNM system clearly indicated the prognoses of ATC patients by extracting rare patients with fair prognoses as having stage IV A disease and categorized many heterogeneous patients in stage IV B.

Development and validation of prognostic nomogram based on log odds of positive lymph nodes for patients with gastric signet ring cell carcinoma.

ObjectiveOur aims were to establish novel nomogram models, which directly targeted patients with signet ring cell carcinoma (SRC), for individualized prediction of overall survival (OS) rate and cancer-specific survival (CSS).MethodsWe selected 1,365 SRC patients diagnosed from 2010 to 2015 from Surveillance, Epidemiology and End Results (SEER) database, and then randomly partitioned them into a training cohort and a validation cohort. Independent predicted indicators, which were identified by using univariate testing and multivariate analyses, were used to construct our prognostic nomogram models. Three methods, Harrell concordance index (C-index), receiver operating characteristics (ROC) curve and calibration curve, were used to assess the ability of discrimination and predictive accuracy. Integrated discrimination improvement (IDI), net reclassification improvement (NRI) and decision curve analysis (DCA) were used to assess clinical utility of our nomogram models.ResultsSix independent predicted indicators, age, race, log odds of positive lymph nodes (LODDS), T stage, M stage and tumor size, were associated with OS rate. Nevertheless, only five independent predicted indicators were associated with CSS except race. The developed nomograms based on those independent predicted factors showed reliable discrimination. C-index of our nomogram for OS and CSS was 0.760 and 0.763, which were higher than American Joint Committee on Cancer (AJCC) 8th edition tumor-node-metastasis (TNM) staging system (0.734 and 0.741, respectively). C-index of validation cohort for OS was 0.757 and for CSS was 0.773. The calibration curves also performed good consistency. IDI, NRI and DCA showed the nomograms for both OS and CSS had a comparable clinical utility than the TNM staging system.ConclusionsThe novel nomogram models based on LODDS provided satisfying predictive ability of SRC both in OS and CSS than AJCC 8th edition TNM staging system alone.

Validation of stage groupings in the eighth edition of the tumor node metastasis classification for lung adenocarcinoma.

BackgroundThe purpose of this study was to validate stage groupings in the 8th edition of the tumor node metastasis (TNM) classification for lung adenocarcinoma and explore the non‐anatomic factors that influence the prognosis of lung adenocarcinoma patients in China.MethodsWe retrospectively analyzed the data of 291 lung adenocarcinoma patients at our department between 2008 and 2013. Logrank tests and Cox regression models were used to analyze survival among adjacent stage groupings. Kaplan–Meier curves were used to estimate overall survival (OS).ResultsThere were significant differences in OS in adjacent stage groupings in early stages in the 8th edition. There were also significant differences between patients treated with radical surgery and limited resection (P = 0.027). Lepidic predominant adenocarcinoma (LPA) had better survival rates than acinar predominant (APA), papillary predominant, and solid predominant with mucin production adenocarcinoma (SPA) (P = 0.008). Survival rates of micropapillary predominant adenocarcinoma were lower than the others (P = 0.003). EGFR mutations were closely associated with lepidic predominant (65%, P = 0.56) but less commonly associated with solid predominant with mucin production adenocarcinoma (24%, P = 0.02). There was no significant difference in survival between EGFR gene mutation‐positive and negative groups (P = 0.402).ConclusionThe 8th edition TNM may be more accurate and applicable than the 7th edition for Chinese lung adenocarcinoma patients who have undergone surgical treatment. Stage IV patients may gain survival improvement from radical surgery.

Nomogram to Predict Cancer-Specific Survival in Patients with Pancreatic Acinar Cell Carcinoma: A Competing Risk Analysis.

Background: The objective of this study was to evaluate the probability of cancer-specific death of patients with acinar cell carcinoma (ACC) and build nomograms to predict overall survival (OS) and cancer-specific survival (CSS) of these patients.Methods: Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Patients diagnosed with ACC between 2004 and 2014 were retrospectively collected. Cancer-specific mortality and competing risk mortality were evaluated. Nomograms for estimating 1-, 2- and 3-year OS and CSS were established based on Cox regression model and Fine and Grey's model. The precision of the 1-, 2- and 3-year survival of the nomograms was evaluated and compared using the area under receiver operating characteristic (ROC) curve (AUC).Results: The study cohort included 227 patients with ACC. The established nomograms were well calibrated, and had good discriminative ability, with a concordance index (C-index) of 0.742 for OS prediction and 0.766 for CSS prediction. The nomograms displayed better discrimination power than 7th or 8th edition Tumor-Node-Metastasis (TNM) stage systems in training set and validation set for predicting both OS and CSS. The AUC values of the nomogram predicting 1-, 2-, and 3-year OS rates were 0.784, 0.797 and 0.805, respectively, which were higher than those of 7th or 8th edition TNM stage systems. Regard to the prediction of CSS rates, the AUC values of the nomogram were also higher than those of 7th or 8th edition TNM stage systems.Conclusion: We evaluated the 1-, 2- and 3-year OS and CSS in patients with ACC for the first time. Our nomograms showed relatively good performance and could be considered as convenient individualized predictive tools for prognosis.

Should Multifocal Papillary Thyroid Carcinomas Classified As T1A With A Tumor Diameter Sum of 1 To 2 Centimeters Be Reclassified As T1B?

Considering the diameter of the largest tumor while determining T stage in multifocal papillary thyroid microcarcinomas (PTMCs) might cause underestimation of tumoral stage. We aimed to investigate the effect of total tumor diameter (TTD) on tumor node metastasis (TNM) classification in multifocal T1a PTMCs. T1 tumors were grouped as T1a or T1b according to 7th TNM edition. For patients with multifocal T1a, TTD (the sum of the maximal diameter of each focus) was calculated, and these patients were further subgrouped as TTD ≤1 cm or TTD 1 to 2 cm. There were 724 patients with T1 tumors. Multifocality was observed in 150 (28.5%) of 527 patients with T1a and 84 (42.6%) of 197 patients with T1b tumors (P<.001). Lymph node metastasis (LNM), thyroid capsule invasion, and lymphovascular invasion were significantly higher in T1b compared to T1a (P<.001, P<.001, and P = .015, respectively). There were 8 (1.5%) patients with persistence but not any with recurrence in the T1a group. Persistence and recurrence were observed in 3 (1.5%) and 5 (2.5%) patients in the T1b group, respectively. Among 150 T1a patients with multifocal tumors, TTD was ≤1 cm in 89 (59.3%) and 1 to 2 cm in 61 (40.7%) patients. Number of tumor foci, LNM, and thyroid capsule invasion were significantly higher in multifocal T1a patients with TTD 1 to 2 cm compared to with TTD ≤1 cm (P<.001, P = .032, P = .014, respectively). TTD might be used as a parameter to determine patients at higher risk for persistence, and T1a multifocal PTMCs with TTD 1 to 2 cm can be reclassified as T1b. ETE = extrathyroidal extension LNM = lymph node metastasis PTC = papillary thyroid carcinoma PTMC = papillary thyroid microcarcinoma RAI = radioactive iodine TNM = tumor, node, metastasis TTD = total tumor diameter.

P1.03-065 Comparison of the Proposed IASLC 8th TNM Lung Cancer Staging System to the 7th Edition

We performed a validation study of the proposed International Association for the Study of Lung Cancer (IASLC) 8th tumor, node, metastasis (TNM) and grouping revisions on the non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) in our Institution, where we are a regular contributor of a subset of cases for the IASLC TNM staging revision projects. Data was collected from the Queensland Cancer Control Analysis Team (QCCAT) Queensland Oncology Online (QOOL) registry of NSCLC or SCLC cases presented to The Prince Charles Hospital (TPCH) between 2000 and 2015. It was validated against Queensland Integrated Lung Cancer Outcomes Project (QILCOP) registry with case identification number, first name, last name, and date of birth. Cases were classified according to IASLC TNM revisions 7th edition and then according to the proposed TNM revisions and stage groupings where data available. Kaplan-Meier curves were plotted and survival differences tested with Log-Rank test using SPSS Statistics ver. 23. The entire study population consisted of three thousand six hundred and thirty-seven cases. One thousand three hundred and ninety-two non-surgical patients had complete clinical staging and one thousand and fifteen patients with pathological staging were identified. Median survival in clinical staging by the 7th edition showed progressive reduction in median survival with increasing Stage (IA:1480, IB:714, IIA:715, IIB:391, IIIA:399, IIIB285, IV:196; days) which was similar in the proposed 8th edition staging noting small numbers in IA1 (IA1:1385, IA2:2098, IA3:1004, IB:801, IIA:550, IIB:589, IIIA:448, IIIB285, IIIC:265, IVA:218, IVB:106; days). A similar pattern was reflected in pathological staging 7th edition TNM staging (IA:3725, IB:3486, IIA:1796, IIB:1209, IIIA:841, IIIB:587, IV:869; “days”) and in the proposed 8th edition staging (IA1:1929, IA2:3586, IA3:3804, IB:3640, IIA:2977, IIB:1796, IIIA:949, IIIB:723, IVA:869; “days”). Log-Rank test in all the survival curves were <0.001. The proposed 8th edition TNM classification appears to be a more refined predictor of prognosis. However, our cohort only had small sample sizes for Stage I cases, which need validation and further hazard ratio and multivariate analysis is recommended. Acknowledgements: patients and staff at TPCH and UQTRC

The presentation, natural history and outcome of T1 a/b thyroid cancer with regard to new grading systems

The seventh edition tumor, node metastasis (TNM) classifies tumors <10 mm as T1a and tumors between 10 mm and 20 mm as T1b. Previous editions of the TNM staging system did not differentiate these lesions. We compare new classification in terms of presentation and outcome. Early thyroid cancers that were previously staged under the TNM sixth edition were re-staged using the TNM seventh edition to identify whether the new staging system differentiated lesions in terms of presentation and outcome. Differences in presentation, rates of recurrent disease and surgical complications were recorded and compared. Of 1,415 thyroid operations, 369 were for malignant disease and there were 220 papillary carcinomas. There were 35 T1a/b lesions accounting for 11% of malignancies with no increasing incidence. Reclassification showed 64% T1a and 36% T1b lesions. There were no differences in presentation. Outcomes in terms of persistent or recurrent disease were the same after median follow up was 6.8 years. Isolated T1a/b thyroid cancer made up only a small proportion of malignancies, the majority of which were discovered incidentally. We have not seen the increase in early lesions reported elsewhere. In our series, the seventh TNM edition did not differentiate early lesions and we ultimately feel that parameters other than size of primary lesion are likely to be of greater importance in determining prognosis.

Validation of the 7th Edition TNM Staging System for Hepatocellular Carcinoma: An Analysis of 8,828 Patients in a Single Medical Center

Major modification of the 7th tumor-node-metastasis (TNM) staging system for hepatocellular carcinoma (HCC) was divided into 6th stage IIIA to 7th IIIA (multiple tumors, any>5 cm) and IIIB (tumors involving a major vessel). This study aimed to validate 6th and 7th TNM systems in prognostic prediction, then analyze the impact of time, Child-Pugh classification and treatment modalities in survival. A total of 5,611 and 3,217 HCC patients were enrolled between 1986-2002 (past period) and 2003-2010 (recent period), respectively. The Akaike information criteria (AIC) within a Cox proportional hazard regression model were used to demonstrate the discriminatory ability for staging systems. The 1-, 3-, and 5-year survival rates of past and recent periods were 44.8, 24.9, 17.1%, and 65.5, 44.5, 34.6%, respectively (p<0.001). Rates of smaller HCC detection and received curative treatment were significantly higher in the recent period than in the past period (p<0.001). Survival rates were different in each Child-Pugh class (all p<0.001). Patients receiving curative treatment had highest survival rates, followed by non-curative treatment, and untreated patients (p<0.05). In both periods, significant differences in survival curves existed between each of the stages in the 6th and 7th TNM staging (all p<0.05), and also between IIIA and IIIB in the 7th TNM (p<0.001). The AIC of two periods in the 6th and 7th TNM systems were decreased, with 77,895 and 77,630, and 19,162 and 19,135, respectively. The 7th TNM provided better prognostic prediction than the 6th TNM after dividing into IIIA and IIIB. Survival rates of HCC have been improving in recent decades.

Comparison of the Sixth and Seventh Editions of the AJCC TNM Classification for Gallbladder Cancer

BackgroundThis study aimed to compare the seventh edition of the tumor node metastasis (TNM) staging system to the sixth edition to validate its usefulness in predicting prognosis for gallbladder cancer. MethodsGallbladder cancer patients were staged according to both the sixth and seventh editions of the American Joint Committee on Cancer (AJCC) staging system. ResultsA total of 142 patients underwent cholecystectomy for gallbladder cancer. According to the seventh edition, the survival time of N1 and N2 was different (P = 0.006), and the survival difference between N0 and N1 became significant after excluding cases with no lymph node dissection (P = 0.035). The −2 log likelihoods of the sixth and seventh edition TNM stages were 216.282 and 217.460, respectively, suggesting non-superiority of the seventh edition. Excluding cases with no lymph node dissection resulted in a lower −2 log likelihood score for both editions (sixth, 157.002; seventh, 158.758). ConclusionsSufficient lymph node dissection allows better prognostic stratification by application of the AJCC staging system. Even though the new N stage of the seventh edition showed some improvement in predicting prognosis, the overall performance of the seventh edition was not much better than the sixth. Further improvement is needed in the gallbladder cancer staging system.

Sixth and seventh tumor-node-metastasis staging system compared in gastric cancer patients

To investigate the clinical relevance and prognosis regarding survival according to the changes of the tumor-node-metastasis (TNM) in gastric cancer patients. We retrospectively studied 347 consecutive subjects who underwent surgery for gastric adenocarcinoma at the Division of General Surgery, Hospital of Busto Arsizio, Busto Arsizio, Italy between June 1998 and December 2009. Patients who underwent surgery without curative intent, patients with tumors of the gastric stump and patients with tumors involving the esophagus were excluded for survival analysis. Patients were staged according to the 6(th) and 7(th) edition TNM criteria; 5-year overall survival rates were investigated, and the event was defined as death from any cause. After exclusion, our study population included 241 resected patients with curative intent for gastric adenocarcinoma. The 5-year overall survival (5-year OS) rate of all the patients was 52.8%. The diagnosed stage differed in 32% of 241 patients based on the TNM edition used for the diagnosis. The patients in stage II according to the 6(th) edition who were reclassified as stage III had significantly worse prognosis than patients classified as stage II (5-year OS, 39% vs 71%). According to the 6(th) edition, 135 patients were classifed as T2, and 75% of these patients migrated to T3 and exhibited a significantly worse prognosis than those who remained T2, regardless of lymph node involvement (37% vs 71%). The new N1 patients exhibited a better prognosis than the previous N1 patients (67% vs 43%). 7(th) TNM allows new T2 and N1 patients to be selected with better prognosis, which leads to different staging. New stratification is important in multimodal therapy.

Adenocarcinoma of the Esophagogastric Junction: Territory of the Esophagus or Stomach, or an Independent Region?

The most recent union for international cancer control (UICC) tumor-node-metastasis (TNM) classification (7th edition) definitively classified adenocarcinoma of the esophagogastric junction (AEG) for the first time. A tumor whose epicenter is within 5 cm of the esophagogastric junction (EGJ) and also extends into the esophagus is classified and staged according to the esophageal cancer scheme. All other gastric tumors with an epicenter greater than 5 cm from EGJ or within 5 cm of EGJ without extension into the esophagus are staged using the gastric cancer scheme. Therefore, most AEGs, including adenocarcinomas of the cardia and subcardia, are now to be staged as esophageal adenocarcinomas rather than gastric cancers by the current edition of TNM classification. AEG has been classified into three subtypes during the last decade, as advocated by Siewert and Stein AEG type I (distal esophageal adenocarcinoma) is a tumor with the epicenter located 1–5 cm above EGJ regardless of invasion to EGJ. AEG type II (true carcinoma of the cardia) is a tumor invading EGJ with the epicenter located between 1 cm above and 2 cm below EGJ. AEG type III (carcinoma of the subcardia) is a tumor invading EGJ with the epicenter located 2–5 cm below EGJ. It is likely that AEG type I tumors may be esophageal adenocarcinomas, which are mainly derived from the Barrett’s esophagus. However, whether AEG type II/III tumors should be also classified as esophageal adenocarcinomas still remains unknown. Recently, Gertler et al. attempted to evaluate whether AEG type II/III tumors are better staged as esophageal or gastric cancer by analysis of a single-center cohort of 1,141 patients who underwent surgery for AEG type II/III tumors in Germany. In their cohort, by esophageal cancer staging and gastric cancer staging as per the 7th edition UICC TNM classification, the authors emphasized that some stage groups were lacking homogeneity (absence of distinct subsets of patients within a stage), monotonicity (continuous decreasing survival with increasing stage group), and distinctiveness (difference in survival between monotonic stage groups). They concluded that neither the esophageal nor the gastric scheme was perfectly suitable for patients with AEG types II/III in terms of prognostic stratification. In contrast, Huang et al. analyzed 142 consecutive resection patients in a single Chinese center and suggested that it may be better to classify carcinomas of the cardia involving the esophagus using gastric cancer staging than esophageal cancer staging of the 7th edition TNM classification. Hasegawa et al. reported the postoperative survival of 163 patients with AEG types II/III when classified by either the esophageal cancer scheme or gastric cancer scheme of the 7th edition TNM classification. When the esophageal cancer scheme was used, patient distribution was substantially deviated to stage IIIC and the survival curves for each stage were not well separated. In contrast, when the gastric cancer schema was used, patient distribution was relatively even and the survival curves were monotonously and distinctively separated. They concluded that gastric cancer staging may be more suitable than esophageal cancer staging for patients with AEG types II/III. These results should be interpreted in context with caution because they represent a single-center retrospective cohort study with a small number of patients. Nevertheless, that study may provide a valuable signpost for the future direction of the AEG staging system. Hulscher et al. reported no significant difference in the postoperative survival between transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) in patients with distal esophageal adenocarcinoma (AEG type I) or gastric adenocarcinoma of the cardia involving the distal Society of Surgical Oncology 2012

Staging of uveal melanoma metastases

AbstractPurpose To summarize the need and methods available to stage metastatic uveal melanoma.Methods Literature review and personal experience.Results In the Tumor, Node, Metastasis (TNM) classification, metastatic disease is assigned to category N1 (regional lymph node metastasis) and M1 (systemic metastasis) and stage IV by definition. For practical purposes, uveal melanoma spawns only systemic metastases. The latest 7th TNM edition, effective from January 2010, introduced subcategories of M1 based on the largest diameter of the largest metastasis (LDLM) at diagnosis of disseminated disease: M1a corresponds to LDLM 3.0 cm or less, M1b to LDLM 3.1‐8.0 cm and M1c to LDLM 8.1 mm or above. In addition to the TNM system, a staging system based on three variables: performance index as a measure of the general health of the patient, serum or plasma alkaline phosphatase level as a measure of the hepatic function and non‐measurable metastases and to LDLM as a measure of measurable metastases is available. It was developed at the Helsinki University Central Hospital and has been validated by the European Ophthalmic Oncology Group. An underlying multivariate model assigns patients into stages IVa, IVb and IVc with predicted median survival of less than 6 months, 6 to 12 months and over 12 months. In the validation data set, the corresponding observed median survival times were 18.6 months for stage IVa, 10.7 months for stage IVb, and 4.6 months for stage IVc.Conclusion Staging of cancer at diagnosis is important because it enables the physician to assess the extent of disease in a standardized way. This will help in choosing appropriate treatment and in assessing treatment outcomes between studies in a more comparable way.

Staging Gastric Cancer Patients after Complete Surgical Resection: Which System Should We Use?

The most commonly used staging system for gastric adenocarcinoma is the American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging system. The 2010 7th edition of the AJCC system made several changes from the 6th edition, including redefining T and N categories and moving the staging of proximal gastric tumors within 5 cm of the gastroesophageal junction to the esophageal cancer staging system. TNM stage grouping were also redefined, with stage II further divided into IIA and IIB and stage IIIA and IIIB further divided into IIIA, IIIB, and IIIC. Since the publication of the 7th edition AJCC staging system in 2010, several single and multi-institution studies have compared the 6th and 7th editions. Some studies have found the 7th edition to be superior. Other studies have found the 7th edition to be either inferior to or no better than the 6th edition. Two studies from the same institution found opposing results. All these studies vary in the sort of patients examined, the extent of surgery and pathological analysis, and the methods of data analysis. In this issue of Annals of Surgical Oncology, Dikken et al. compare disease-specific survival predictions for patients with gastric adenocarcinoma using the 6th and 7th editions of the AJCC staging system. Patients underwent surgery either at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York or at one of several institutions in the Netherlands as part of the Dutch Gastric Cancer Trial (DGCT). In this group of 2,196 patients, the authors find that the predictive accuracy of the 7th edition N categories is improved based on concordance measurements, but the predictive accuracy of the 7th edition TNM stages is decreased. Survivals using the AJCC 6th edition did not significantly differ for two of the six stage groups, while survivals using the 7th edition did not significantly differ for three of the seven stage groups. Thus, the authors conclude the AJCC 7th edition staging system has increased complexity with no improvement in predictive accuracy. Dikken et al. put together a large cohort of Western patients treated with relatively extensive lymphadenectomies and perform a thorough comparison of the 6th and 7th AJCC staging systems. One primary advantage of this study is the use of data from several institutions in two different countries. Most previous studies on this topic are from Asian countries, so this multi-institution study of Western patients is important in determining whether we are making progress with the AJCC staging system revisions. However, as with most studies of this nature, there are several potential problems. First, the extent of lymphadenectomy for this cohort of patients varied, which causes problems with stage migration. At MSKCC, ‘‘most patients underwent a D2 lymph node dissection’’ and DGCT patients were randomized to D1 versus D2 node dissection. Furthermore, 22–28 % of patients in this study had \15 nodes examined, and the AJCC staging system suggests ‘‘that at least 16 regional nodes be assessed pathologically.’’ Second, the varying extent of lymphadenectomy and adjuvant therapies for patients in this study may have affected pathological staging and survival. Sixteen percent of MSKCC patients received neoadjuvant chemotherapy, which can result in downstaging the T and/or N stages. The 15-years follow-up from the Dutch trial now demonstrates a significant 12 % Society of Surgical Oncology 2012