Differentiated and anaplastic thyroid carcinoma: Major changes in the American Joint Committee on Cancer eighth edition cancer staging manual

Answer questions and earn CME/CNE This is a review of the major changes in the American Joint Committee on Cancer staging manual, eighth edition, for differentiated and anaplastic thyroid carcinoma. All patients younger than 55 years have stage I disease unless they have distant metastases, in which case, their disease is stage II. In patients aged 55 years or older, the presence of distant metastases confers stage IVB, while cases without distant metastases are further categorized based on the presence/absence of gross extrathyroidal extension, tumor size, and lymph node status. Patients aged 55 years or older whose tumor measures 4 cm or smaller (T1‐T2) and is confined to the thyroid (N0, NX) have stage I disease, and those whose tumor measures greater than 4 cm and is confined to the thyroid (T3a) have stage II disease regardless of lymph node status. Patients aged 55 years or older whose tumor is confined to the thyroid and measures 4 cm or smaller (T1‐T2) with any lymph node metastases present (N1a or N1b) have stage II disease. In patients who demonstrate gross extrathyroidal extension, the disease is considered stage II if only the strap muscles are grossly invaded (T3b); stage III if there is gross invasion of the subcutaneous tissue, larynx, trachea, esophagus, or recurrent laryngeal nerve (T4a); or stage IVA if there is gross invasion of the prevertebral fascia or tumor encasing the carotid artery or internal jugular vein (T4b). The same T definitions will be used for both differentiated and anaplastic thyroid cancer, but the basic premise of the anatomic stage groups will remain the same. CA Cancer J Clin 2018;68:55‐63. © 2017 American Cancer Society.     

Prostate cancer – major changes in the American Joint Committee on Cancer eighth edition cancer staging manual

Answer questions and earn CME/CNE The eighth edition of the American Joint Committee on Cancer (AJCC) tumor‐node‐metastasis (TNM) Staging Manual has been updated and improved to ensure the highest degree of clinical relevance and to improve its utility for patient evaluation and clinical research. Major changes include: 1) pathologically organ‐confined disease is now considered pT2 and is no longer subclassified by extent of involvement or laterality, 2) tumor grading now includes both the Gleason score (as in the seventh edition criteria) and the grade group (introduced in the eighth edition criteria), 3) prognostic stage group III includes select, organ‐confined disease based on prostate‐specific antigen and Gleason/grade group status, and 4) 2 statistical prediction models are included in the staging manual. The AJCC will continue to critically analyze emerging prostate cancer biomarkers and tools for their ability to prognosticate and guide treatment decision making with the highest level of accuracy and confidence for patients and physicians. CA Cancer J Clin 2017;67:245–253 . © 2017 American Cancer Society .     

Cancer of the esophagus and esophagogastric junction—Major changes in the American Joint Committee on Cancer eighth edition cancer staging manual

Answer questions and earn CME/CNE New to the eighth edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual for epithelial cancers of the esophagus and esophagogastric junction are separate, temporally related cancer classifications: 1) before treatment decision (clinical); 2) after esophagectomy alone (pathologic); and 3) after preresection therapy followed by esophagectomy (postneoadjuvant pathologic). The addition of clinical and postneoadjuvant pathologic stage groupings was driven by a lack of correspondence of survival, and thus prognosis, between both clinical and postneoadjuvant pathologic cancer categories (facts about the cancer) and pathologic categories. This was revealed by a machine‐learning analysis of 6‐continent data from the Worldwide Esophageal Cancer Collaboration, with consensus of the AJCC Upper GI Expert Panel. Survival is markedly affected by histopathologic cell type (squamous cell carcinoma and adenocarcinoma) in clinically and pathologically staged patients, requiring separate stage grouping for each cell type. However, postneoadjuvant pathologic stage groups are identical. For the future, more refined and granular data are needed. This requires: 1) more accurate clinical staging; 2) innovative solutions to pathologic staging challenges in endoscopically resected cancers; 3) integration of genomics into staging; and 4) precision cancer care with targeted therapy. It is the responsibility of the oncology team to accurately determine and record registry data, which requires eliminating both common errors and those related to incompleteness and inconsistency. Despite the new complexity of eighth edition staging of cancers of the esophagus and esophagogastric junction, these key concepts and new directions will facilitate precision cancer care. CA Cancer J Clin 2017;67:304–317. © 2017 American Cancer Society.     

The eighth edition American Joint Committee on Cancer (AJCC) melanoma staging system: implications for melanoma treatment and care

Introduction: The eighth edition of the American Joint Committee on Cancer (AJCC) melanoma staging system was implemented in the United States on 1 January 2018.

Areas covered: This article provides an overview of important changes in the eighth edition AJCC staging system from the seventh edition based on analyses of a large international melanoma database. The clinical implications of these changes for melanoma treatment are also discussed.

Expert commentary: A standardized and contemporary cancer staging system that facilitates accurate risk stratification is essential to guide patient treatment. The eighth edition of the AJCC staging system is currently the most widely accepted approach to melanoma staging and classification at initial diagnosis.     

Head and Neck cancers—major changes in the American Joint Committee on cancer eighth edition cancer staging manual

Answer questions and earn CME/CNE The recently released eighth edition of the American Joint Committee on Cancer (AJCC) Staging Manual, Head and Neck Section, introduces significant modifications from the prior seventh edition. This article details several of the most significant modifications, and the rationale for the revisions, to alert the reader to evolution of the field. The most significant update creates a separate staging algorithm for high‐risk human papillomavirus‐associated cancer of the oropharynx, distinguishing it from oropharyngeal cancer with other causes. Other modifications include: the reorganizing of skin cancer (other than melanoma and Merkel cell carcinoma) from a general chapter for the entire body to a head and neck‐specific cutaneous malignancies chapter; division of cancer of the pharynx into 3 separate chapters; changes to the tumor (T) categories for oral cavity, skin, and nasopharynx; and the addition of extranodal cancer extension to lymph node category (N) in all but the viral‐related cancers and mucosal melanoma. The Head and Neck Task Force worked with colleagues around the world to derive a staging system that reflects ongoing changes in head and neck oncology; it remains user friendly and consistent with the traditional tumor, lymph node, metastasis (TNM) staging paradigm. CA Cancer J Clin 2017;67:122–137. © 2017 American Cancer Society.     

Validation of the seventh edition of the American Joint Committee on Cancer TNM staging system for gastric cancer

BACKGROUND:

The seventh edition of the American Joint Committee on Cancer (AJCC) TNM classification for gastric cancer was published in 2010 and included major revisions. The aim of the current study was to evaluate the validity of the seventh edition TNM classification for gastric cancer based on an Asian population.

METHODS:

A total of 2916 gastric cancer patients who underwent R0 surgical resection from 1989 through 2008 in a single institute were included, and were analyzed according to the seventh edition of the TNM classification for validation.

RESULTS:

When adjusted using the seventh edition of the TNM classification, upstaging was observed in 771 patients (26.4%) and downstaging was observed in 178 patients (6.1%) compared with the sixth edition of the TNM classification. The relative risk (RR) of seventh edition pT classification was found to be increased with regular intensity compared with the sixth edition pT classification. The RR of seventh edition pN classification was found to be increased with irregular intensity compared with the sixth edition pN classification. In survival analysis, there were significant differences noted for each stage of disease, but only a marginal difference was demonstrated between stage IA and stage IB (P = .049). In the hybrid TNM classification, which combines the seventh edition pT classification and the sixth edition pN classification, both pT and pN classifications demonstrated a more ideal distribution of the RR, and 5‐year survival rates also showed a significant difference for each stage (P <.01).

CONCLUSIONS:

The seventh edition of the TNM classification was considered valid based on the results of the current study. However, the hybrid TNM classification, comprised of a combination of the seventh edition pT classification and sixth edition pN classification, should be considered for the next edition. Cancer 2011. © 2011 American Cancer Society.     

The new (Version 9) American Joint Committee on Cancer tumor,node, metastasis staging for cervical cancer

The American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging for all cancer sites has been periodically updated as a published manual for many years. The last update, the eighth edition AJCC Cancer Staging Manual went into use on January 1, 2018. The AJCC has since restructured and updated its processes, and all AJCC staging-related data are now housed on its new application programming interface. Consequently, the next AJCC TNM staging update, AJCC version 9 TNM staging, will be published electronically and will be released chapter by chapter. The first chapter of version 9 AJCC TNM staging is the updated cervical cancer staging, which is now published. This article highlights the changes to the AJCC TNM cervical cancer staging; these changes align with the International Federation of Gynecology and Obstetrics staging. The most important of the changes are: 1) the incorporation of imaging and surgical findings, 2) the elimination of lateral spread from T1a, 3) the addition of a subcategory to T1b (T1b3), and 4) histopathology is updated to reflect human papillomavirus-associated and human papillomavirus-independent carcinomas.     

Survival outcomes used to generate version 9 American Joint Committee on Cancer staging system for anal cancer

The American Joint Committee on Cancer (AJCC) staging system for all cancer sites, including anal cancer, is the standard for cancer staging in the United States. The AJCC staging criteria are dynamic, and periodic updates are conducted to optimize AJCC staging definitions through a panel of experts charged with evaluating new evidence to implement changes. With greater availability of large data sets, the AJCC has since restructured and updated its processes, incorporating prospectively collected data to validate stage group revisions in the version 9 AJCC staging system, including anal cancer. Survival analysis using AJCC eighth edition staging guidelines revealed a lack of hierarchical order in which stage IIIA anal cancer was associated with a better prognosis than stage IIB disease, suggesting that, for anal cancer, tumor (T) category has a greater effect on survival than lymph node (N) category. Accordingly, version 9 stage groups have been appropriately adjusted to reflect contemporary long-term outcomes. This article highlights the changes to the now published AJCC staging system for anal cancer, which: (1) redefined stage IIB as T1–T2N1M0 disease, (2) redefined stage IIIA as T3N0–N1M0 disease, and (3) eliminated stage 0 disease from its guidelines altogether.     

External validation study of the 8th edition of the American Joint Committee on Cancer staging system for perihilar cholangiocarcinoma: a single-center experience in China and proposal for simplification

BackgroundSeveral changes have been made to the primary tumor (T) and lymph node (N) categories in the new 8^th edition of the American Joint Committee on Cancer (AJCC) staging system for perihilar cholangiocarcinoma (pCCA). This study was conducted to validate the 8^th edition of the AJCC staging system for pCCA in China.MethodsA total of 335 patients who underwent curative-intent resection for pCCA between January 2010 and December 2018 were retrospectively enrolled. The overall survival (OS) of groups of patients was calculated using the Kaplan-Meier method. The log-rank test was used to compare OS between groups. The concordance index (C-index), Akaike information criteria (AIC), and time-dependent area under receiver operating characteristic (ROC) curve (AUC) were computed to evaluate the discriminatory power of the 8^th and 7^th editions of the AJCC staging system.ResultsThe T category changed in 25 (7.5%) patients, the N category changed in 39 (11.6%) patients, and the tumor-node-metastasis (TNM) stage changed in 157 (46.9%) patients when the 8^th and 7^th editions were compared. No statistically significant difference in survival was observed between T2aN0M0 and T2bN0M0. The C-index of the 8^th edition was 0.609 [95% confidence interval (CI): 0.568–0.650], which was slightly higher than that of the 7^th edition (C-index, 0.599, 95% CI: 0.558–0.640). The time-dependent AUC value also corroborated that the 8^th edition had a better performance than the 7^th edition.ConclusionsThe 8^th edition of the AJCC staging system for pCCA showed a better ability than the 7^th edition to discriminate patient survival. However, further simplification of the 8^th edition is still needed.     

Comparison of the seventh and eighth editions American Joint Committee Cancer classification system in oral cavity squamous cell cancers

The aim of our study was to evaluate the predictive ability of the American Joint Committee Cancer (AJCC) eighth edition (AJCC8) staging system for oral cavity cancers and validate these changes rendering the hypothesis of improving prognostication. We conducted a retrospective study including all oral cavity squamous cell carcinoma patients visiting our tertiary center from 2012 to 2015, staged as per the AJCC seventh edition (AJCC7) and AJCC8 systems. Stage-specific disease-free survival (DFS) and overall survival (OS) were calculated using the Kaplan-Meier method. Concordance index (CI) and Akaike information criterion (AIC) were used to calculate the predictive accuracy of the both systems. The study sample consisted of 863 subjects followed up for a median of 24 months. Buccal mucosa complex (BMC) was the most common site (n = 496). We observed a 25.8% (n = 222) overall upstaging in the eighth edition, significantly seen in early tongue cancers (TCs) (Stage I) and advanced BMC cancers (Stage III). An increase in CI and reduction in AIC scores were indicative of a superior predictive accuracy for the eighth edition in assessing DFS (confidence interval [CI*] = 0.650–0.654; AIC = 3,022–3,014) and OS (CI* = 0.643–0.648; AIC = 2089–2086) across all stages. The accuracy was higher for TCs as compared to BMC. Although not statistically significant, we observed an increase in soft risk factors at higher stages in the eighth edition as compared to its predecessor. We concluded that the AJCC8 has a higher predictive accuracy than the AJCC7 edition, making it a reliable prognosticative tool.     

Survival outcomes used to validate version 9 of the American Joint Committee on Cancer staging system for appendiceal cancer

The standard for cancer staging in the United States for all cancer sites, including primary carcinomas of the appendix, is the American Joint Committee on Cancer (AJCC) staging system. AJCC staging criteria undergo periodic revisions, led by a panel of site-specific experts, to maintain contemporary staging definitions through the evaluation of new evidence. Since its last revision, the AJCC has restructured its processes to include prospectively collected data because large data sets have become increasingly robust and available over time. Thus survival analyses using AJCC eighth edition staging criteria were used to inform stage group revisions in the version 9 AJCC staging system, including appendiceal cancer. Although the current AJCC staging definitions were maintained for appendiceal cancer, incorporating survival analysis into the version 9 staging system provided unique insight into the clinical challenges in staging rare malignancies. This article highlights the critical clinical components of the now published version 9 AJCC staging system for appendix cancer, which (1) justified the separation of three different histologies (non-mucinous, mucinous, signet-ring cell) in terms of prognostic variance, (2) demonstrated the clinical implications and challenges in staging heterogeneous and rare tumors, and (3) emphasized the influence of data limitations on survival analysis for low-grade appendiceal mucinous neoplasms.     

Breast Cancer—Major changes in the American Joint Committee on Cancer eighth edition cancer staging manual

Answer questions and earn CME/CNE The revision of the eighth edition of the primary tumor, lymph node, and metastasis (TNM) classification of the American Joint Commission of Cancer (AJCC) for breast cancer was determined by a multidisciplinary team of breast cancer experts. The panel recognized the need to incorporate biologic factors, such as tumor grade, proliferation rate, estrogen and progesterone receptor expression, human epidermal growth factor 2 (HER2) expression, and gene expression prognostic panels into the staging system. AJCC levels of evidence and guidelines for all tumor types were followed as much as possible. The panel felt that, to maintain worldwide value, the tumor staging system should remain based on TNM anatomic factors. However, the recognition of the prognostic influence of grade, hormone receptor expression, and HER2 amplification mandated their inclusion into the staging system. The value of commercially available, gene‐based assays was acknowledged and prognostic input added. Tumor biomarkers and low Oncotype DX recurrence scores can alter prognosis and stage. These updates are expected to provide additional precision and flexibility to the staging system and were based on the extent of published information and analysis of large, as yet unpublished databases. The eighth edition of the AJCC TNM staging system, thus, provides a flexible platform for prognostic classification based on traditional anatomic factors, which can be modified and enhanced using patient biomarkers and multifactorial prognostic panel data. The eighth edition remains the worldwide basis for breast cancer staging and will incorporate future online updates to remain timely and relevant. CA Cancer J Clin 2017;67:290–303. © 2017 American Cancer Society.     

Proposed modification of the eighth edition of the AJCC-ypTNM staging system of esophageal squamous cell cancer treated with neoadjuvant chemotherapy: Unification of the AJCC staging system and the Japanese classification

BackgroundThe eighth edition of the American Joint Committee on Cancer (AJCC) tumor node metastasis (AJCC-TNM 8th) system adopted the newly separate post-neoadjuvant pathologic stage group (ypTNM). However, it is not compatible with the Japanese pathologic classification after neoadjuvant chemotherapy (JPN-CT-pTNM). The aim of this study is to clarify the subjects of the AJCC-ypTNM 8th and propose a unification of the AJCC and Japanese systems to create novel AJCC-CT-pTNM 8th.MethodsParticipants were 304 esophageal squamous cell carcinoma (ESCC) patients who underwent neoadjuvant chemotherapy followed by 3 stage esophagectomy between 2010 and 2019. Predictive probabilities of pN, pM in AJCC-ypTNM 8th and JPN-CT-pTNM 11th systems were evaluated to propose novel system.ResultsIn training data from 234 patients, the overall survival rate was statistically better for ypStage IIIA than ypStage II (P = 0.040) resulting in staging inversion in AJCC-ypTNM 8th. Predictive probability of pathological N status in AJCC-ypTNM 8th (Akaike Information Criterion: AIC = 979.53) was superior to that in JPN-CT-pTNM 11th (AIC = 999.07). In AJCC-ypTNM 8th, 71% (15/21) of ypM1 diseases were supraclavicular lymph nodes (No. 104 L/N as regional in JPN-CT-pTNM 11th) metastases with considerably good prognosis. The predictive probability of the novel AJCC-CT-pTNM 8th [unification of ypStage II and IIIA, conversion of supraclavicular L/Ns metastases from ypM to ypN] (AIC = 1054.24) was superior to that of the existing AJCC-ypTNM 8th (AIC = 1070.74). The feasibility of novel system was validated using test data from 70 patients.ConclusionsUnification of the AJCC and Japanese systems yields a simpler and more precise predictive system after neoadjuvant chemotherapy.     

Evaluation of the Seventh American Joint Committee on Cancer/International Union Against Cancer Classification of gastric adenocarcinoma in comparison with the sixth classification

BACKGROUND:

The seventh TNM staging system for gastric cancer of the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) had a more detailed classification than the sixth TNM staging system for both the tumor (T) and lymph nodes (N). The authors compared survival rates assessed by the seventh staging system with those by the sixth system.

METHODS:

The authors analyzed the prospectively collected database on patients with gastric cancer who underwent surgery at Seoul National University Hospital between 1986 and 2006, and calculated the survival rates of 9998 cases with primary cancer, R0 resection, and >14 retrieved lymph nodes.

RESULTS:

The 5‐year cumulative survival rates (5YSR) according to the seventh edition T or N classifications were significantly different. The 5YSR according to seventh edition of the TNM staging system were 95.1% (stage IA), 88.4% (stage IB), 84.0% (stage IIA), 71.7% (stage IIB), 58.4% (stage IIIA), 41.3% (stage IIIB), and 26.1% (stage IIIC), which were significantly different from each other. The 5YSR of the seventh edition T2 and T3 classifications had significant differences in patients with every N classification, and the 5YSR of seventh edition N1 and N2 classifications had significant differences in T2 patients, T3 patients, and T4 patients. Each stage in the sixth edition was divided into the seventh edition stage with different survival rates. In addition, the number of homogenous groupings in seventh edition TNM stages was increased from 1 to 2.

CONCLUSIONS:

The seventh system provided a more detailed classification of prognosis than the sixth system, especially between T2 and T3 tumors and N1 and N2 tumors, although further studies were found to be needed for the N3a and N3b classification. Cancer 2010. © 2010 American Cancer Society.