Clinical implication of an insufficient number of examined lymph nodes after curative resection for gastric cancer

BACKGROUND:

The seventh edition of the tumor, lymph node (LN), metastasis (TNM) staging system increased the required number of examined LNs in gastric cancer from 15 to 16. However, the same staging system defines lymph node‐negative gastric cancer regardless of the number of examined LNs. In this study, the authors evaluated whether gastric cancer can be staged properly with fewer than 15 examined LNs.

METHODS:

The survival rates of 10,010 patients who underwent curative gastrectomy from 1987 to 2007 were analyzed. The patients were divided into 2 groups according to the number of examined LNs, termed the “insufficient” group (≤15 examined LNs) and the “sufficient” group (≥16 examined LNs). The survival curves of patients from both groups were compared according to the seventh edition of the TNM classification.

RESULTS:

Three hundred sixteen patients (3.2%) had ≤15 examined LNs for staging after they underwent standard, curative lymphadenectomy. Patients who had T1 tumor classification, N0 lymph node status, and stage I disease with an insufficient number of examined LNs after curative gastrectomy had a significantly worse prognosis than patients who had ≥16 examined LNs. Moreover, having an insufficient number of examined LNs was an independent prognostic factor for patients who had T1, N0, and stage I disease.

CONCLUSIONS:

Lymph node‐negative cancers in which ≤15 LNs were examined, classified as N0 in the new TNM staging system, could not adequately predict patient survival after curative gastrectomy, especially in patients with early stage gastric cancer. Cancer 2012. © 2012 American Cancer Society.     

The effectiveness of the new (7th) UICC N classification in the prognosis evaluation of gastric cancer patients: a comparative study between the 5th/6th and 7th UICC N classification

Background

The most important prognostic factor after curative surgery for gastric carcinoma is the presence of lymph node metastases. According to the 7th edition of the UICC TNM staging system for gastric cancer, N classification was categorized as N0 (no regional lymph node metastasis), N1 (1?C2 regional lymph node metastases), N2 (3?C6 regional lymph node metastases), and N3 (7 or more regional lymph node metastases). The purpose of this study was to evaluate the rationality of the new UICC/AJCC N classification in comparison with the 6th UICC classification.

Methods

From August 2002 to July 2006, 295 patients with gastric cancer underwent curative resection with D2 lymph node dissection by a single surgeon. We analyzed retrospectively the significant prognostic factors and identified the suitability of the 7th UICC N staging system.

Results

According to the 7th UICC N classification, the 5-year cumulative survival rates (5-YSR) of N0, N1, N2, N3a, and N3b were 89.7, 73.6, 54.9, 23.1, and 5.4%, respectively (P?<?0.0001). Using univariate analysis, the N classification of the 7th and 6th UICC/AJCC TNM staging system, T classification of the 7th UICC TNM staging system, size and location of tumor, and histology were associated with the overall survival of gastric cancer after curative surgery. However, Cox regression multivariate analysis showed the 7th UICC N classification was an independent prognostic factor instead of the 6th UICC N classification (P?<?0.0001).

Conclusion

The 7th UICC classification for lymph node metastasis is thought to be a more reliable prognostic factor for gastric cancer than the 6th classification.     

乳腺癌伴同侧锁骨上淋巴结转移的治疗

乳腺癌伴同侧锁骨上淋巴结转移(breast cancer with ipsilateral supraclavicular lymph node metastasis,ISLM)的分期曾一度改变.在1988年第5版的AJCC分期中,同侧锁骨上淋巴结的转移被定义为真正的远处转移,然而在2003年AJCC和UICC乳腺癌分期指南中规定,如果不伴有其他远处转移,同侧锁骨上淋巴结的转移划分为pN3c,被认为是局部晚期病变.虽然乳腺癌伴同侧锁骨上淋巴结转移患者预后明显好于真正M1患者,但其最佳治疗手段一直是探讨的热点,本文查阅相关文献,对乳腺癌伴同侧锁骨上淋巴结转移的治疗进展进行了简要综述.     

In-depth evaluation of the AJCC/UICC 1997 staging system of nasopharyngeal carcinoma: prognostic homogeneity and proposed refinements

PURPOSE: To critically evaluate the American Joint Commission on Cancer (AJCC)/International Union Against Cancer (UICC) 1997 staging system and look back on its achievements by comparing it with the AJCC/UICC 1992 and Ho 1978 staging systems. To identify areas for additional refinement, we analyzed the prognostic heterogeneity within each stage in depth, which provided important clues for the addition or better categorization of the different defining criteria. METHODS AND MATERIALS: We performed a retrospective review of the data from 1294 consecutive biopsy-proven nonmetastatic nasopharyngeal carcinoma patients and staged the extent of disease according to the defining criteria of the three staging systems. All patients had undergone detailed pretreatment assessment by fiberoptic endoscopy and CT. Radical-intent radiotherapy was given using the Ho technique according to our standard protocol. RESULTS: The AJCC/UICC 1997 staging system was superior to the other two staging systems, because it assigned patients to more uniform-size stage groupings and correlated better with prognosis. Parapharyngeal space involvement was not an independent predictor for survival, local control, or metastasis. On the other hand, carotid space involvement correlated with a greater likelihood of metastasis. Prognostic heterogeneity was found. Those with orbit, cranial nerve, or intracranial involvement fared worse within Stage T4; those with a maximal lymph node size >3 cm fared worse within Stage N2; and those with bilateral lymph node metastasis fared worse within Stage N3. CONCLUSION: The prognostic accuracy of the AJCC/UICC 1997 staging system can be improved further by recategorization of the T, N, and group stage criteria.     

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.     

Is the new UICC staging system of gastric cancer reasonable? (Comparison of 5-year survival rate of gastric cancer by old and new UICC stage classification).

In the new UICC TNM system for gastric cancer approved in 1985, a T1 lesion with lymph node (LN) metastasis is classified as stage, Ib; in the old TNM system this was classified as stage III. This is contradictory to a general rule of the UICC TNM system, whereby cancer with LN metastasis is classified as stage II or III. Two thousand and sixty-three patients with less than T4 gastric cancer who were treated at Seoul National University Hospital from 1970 to 1986 were analysed for significant prognostic factors. Survival curves were subsequently analysed according to the number of LN metastases and the depth of invasion. As a result of multivariate study for clinical and pathological features such as age, tumour location, gross appearance, histological type, depth of tumour invasion and regional lymph node metastasis, we confirmed that only two factors--regional lymph node metastasis and depth of gastric wall invasion--are significant. We showed that when the LN variable is classified according to the number of LN metastases (0 group, 1-3 group, > 3 group) like the UICC TNM classification of colorectal cancer, the survival curves are similar to those reported by the Japanese Research Society for Gastric Cancer. The authors propose the modification of the UICC TNM classification system according to depth of invasion and the number of LN metastases, whereby a T1 lesion with LN metastasis is classified as stage IIa instead of stage 1b.     

A novel lymph node staging system for gastric cancer including modified Union for cancer Control/American Joint Committee on cancer and Japanese Gastric Cancer Association criteria

BackgroundThe TNM system of the International Union for Cancer Control/American Joint Committee on Cancer (UICC/AJCC) and the Japanese Gastric Cancer Association (JGCA) systems are the most used lymph node (LN) staging systems in gastric cancer. This study estimated the influence of anatomic location-based node stations on survival and proposed a new staging method based on both the number and anatomical distribution of metastatic LNs (mLNs).MethodsStage I–III gastric cancer patients with radical gastrectomy were retrospectively evaluated. Overall survival (OS) was estimated in 1786 patients with UICC/AJCC stage N1–N3b disease and compared with estimates obtained using JGCA group 1–3 mLN staging.ResultsThe OS of UICC/AJCC stage N1–N3b patients with group 2 JGCA mLNs was significantly worse than that of patients with only group 1 mLNs. The OS of the patients with group 2 mLNs was similar to that of patients with group 1 mLNs but in the next more advanced UICC/AJCC-N stage. The OS of patients with group 3 mLNs was worse than that of patients with any UICC/AJCC-N stage and was similar to that of N3b patients with group 2 mLNs. A new pathological node (pN) staging classification was developed that advanced the N-staging of patients with group 2 mLNs. It was a better indicator of prognosis than the eighth UICC/AJCC-N and the thirteenth JGCA group staging systems.ConclusionsA simple, accurate pN staging system including both the number and location of mLNs had improved homogeneity, discriminatory ability, and gradient monotonicity.     

Evaluation of the New International Union Against Cancer TNM staging for gastric carcinoma

BACKGROUND: The lymph node (N) classification in the International Union Against Cancer (UICC) TNM staging system for gastric adenocarcinoma has been revised. The new classification is based on the number of positive regional lymph nodes instead of the anatomic location of the regional lymph node metastasis. Both classification systems were compared for prognostic significance. METHODS: A total of 4362 gastric carcinoma patients who underwent resection between 1969 and 1990 were analyzed. RESULTS: Thirteen percent of patients could not be staged according to the new system. Based on the previous classification, 647 patients were classified as pN1 and 711 patients as pN2. When reclassified, 587 patients remained pN1, 54 patients became pN2, and 6 patients became pN3. Of the 711 pN2 patients, 333 became pN1, 267 remained pN2, and 111 patients became pN3. Both lymph node classification methods defined groups with widely differing prognoses. The prognoses of patients classified as new pN2 were more homogeneous than those of the group classified as old pN2. Survival of new pT4/pN1 patients was significantly better than that of other subgroups in Stage IV. Nine potential prognostic factors, including lymph node metastasis, were studied in multivariate analysis. The hazard ratios were 1.38 (1.16-1.64) for pN1 and 2.55 (2.16-3.01) for pN2, based on the old classification. They were 1.51 (1.29-78) for pN1, 3.11 (2.56-3.78) for pN2, and 3.88 (2.98-5.05) for pN3, based on the new classification. CONCLUSIONS: The new N classification is superior as a prognostic factor to the old N classification, although there is inadequacy in stage grouping. [See editorial on pages 1763-5, this issue.] Copyright 2000 American Cancer Society.     

Perigastric lymph node metastases in gastric cancer: comparison of different staging systems

Background. Perigastric lymph node metastases in gastric cancer are classified differently by different staging systems: the distance of positive nodes from the primary tumor is considered by the 1987 International Union Against Cancer (UICC)-TNM system, but not by the Japanese staging system (of the Japanese Research Society for Gastric Cancer [JRSGC]); the new UICC-TNM system of 1997 is based on the number of involved nodes without differentiating perigastric from regional nodes. The aim of the present study was to assess which classification was more useful to predict prognosis in gastric cancer patients with metastases to the perigastric nodes. Methods. The results for 107 patients with lymph node metastases to the first and second tiers who underwent curative gastrectomy for gastric cancer from March 1988 to October 1997 were analyzed. In particular, we compared the clinical characteristics and the survival probabilities of: (1) patients with metastases to perigastric nodes located within 3 cm from the primary tumor, classified as N1; (2) patients with metastases to perigastric nodes located 3 cm beyond the primary tumor (N2 in the UICC-TNM and N1 in the Japanese classification), classified by us as N1–N2; and (3) patients with metastases to the second tier (classified by us as N2). We also assessed the number of positive nodes dividing the patients into groups according to the 1997 UICC TNM system. Results. On multivariate survival analysis, the mortality risks in the N1 and N1–N2 patients were comparable (relative risk [RR], N1–N2 versus N1, 1.32; 95% confidence interval [CI], 0.53–3.51) and were half the mortality risk in N2 patients (RR, N2 versus N1, 2.52; 95% CI, 1.33–4.79). The N1 and N1–N2 categories, while presenting markedly different distributions in the number of metastatic nodes (patients with more than seven metastatic nodes constituted less than 20% of the N1 group and more than 60% of the N1–N2 group), showed similar prognostic significance. Conclusion. In the present series, the distance of perigastric nodes from the primary tumor did not seem to exert a significant effect on prognosis, and the use of a combined classification based on anatomical location (JRSGC) and number of node metastases (UICC-TNM 1997) could be more useful than either system alone for prognostic purposes. Received on July 14, 1999; accepted on Nov. 18, 1999     

New aspects in the staging of lung cancer. Prospective validation of the International Union Against Cancer TNM classification.

BACKGROUND AND METHODS. To validate the new TNM definitions for lung cancer (International Union Against Cancer [UICC] TNM classification, 4th edition, 1987), the data of 3823 patients were analyzed prospectively in terms of concordance between clinical (TNM) and pathologically confirmed classification (pTNM), the value of the various diagnostic techniques in estimating the pathologically confirmed classification, and the prognostic relevance of the new TNM definitions. RESULTS. With regard to the primary tumor (T), clinical and pathologic classifications were identical in 63%; with regard to lymph node involvement (N), the agreement was 47%; for distant metastasis agreement occurred in 91% of cases and for the stages it occurred in 56%. As to the primary tumor (T), the accuracy of radiography (59%) was nearly identical to that of computed tomography (CT) (58%). Both techniques were less precise in determining the extent of lymph node involvement (CT, correct assessments in 50%; radiography, correct assessments in 43%). The statistically significant differences in the prognosis for the T, N, and M categories and for the stages and the categories of the new R classification could be confirmed. Allowance should be made for the different prognosis between T1N0M0 and T2N0M0 by the new Substages IA and Ib of Stage I. CONCLUSIONS. By the new TNM definitions for bronchus carcinoma, international conformity became feasible and practical, and the improvement of its prognostic relevance provided a more reliable basis for establishing guidelines for individual oncologic concepts.     

Cancer of the esophagus and esophagogastric junction

BACKGROUND:

Previous American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) stage groupings for esophageal cancer have not been data driven or harmonized with stomach cancer. At the request of the AJCC, worldwide data from 3 continents were assembled to develop data‐driven, harmonized esophageal staging for the seventh edition of the AJCC/UICC cancer staging manuals.

METHODS:

All‐cause mortality among 4627 patients with esophageal and esophagogastric junction cancer who underwent surgery alone (no preoperative or postoperative adjuvant therapy) was analyzed by using novel random forest methodology to produce stage groups for which survival was monotonically decreasing, distinctive, and homogeneous.

RESULTS:

For lymph node‐negative pN0M0 cancers, risk‐adjusted 5‐year survival was dominated by pathologic tumor classification (pT) but was modulated by histopathologic cell type, histologic grade, and location. For lymph node‐positive, pN+M0 cancers, the number of cancer‐positive lymph nodes (a new pN classification) dominated survival. Resulting stage groupings departed from a simple, logical arrangement of TNM. Stage groupings for stage I and II adenocarcinoma were based on pT, pN, and histologic grade; and groupings for squamous cell carcinoma were based on pT, pN, histologic grade, and location. Stage III was similar for histopathologic cell types and was based only on pT and pN. Stage 0 and stage IV, by definition, were categorized as tumor in situ (Tis) (high‐grade dysplasia) and pM1, respectively.

CONCLUSIONS:

The prognosis for patients with esophageal and esophagogastric junction cancer depends on the complex interplay of TNM classifications as well as nonanatomic factors, including histopathologic cell type, histologic grade, and cancer location. These features were incorporated into a data‐driven staging of these cancers for the seventh edition of the AJCC/UICC cancer staging manuals. Cancer 2010. © 2010 American Cancer Society.     

第7版UICC或AJCC鼻咽癌分期的IMRT验证研究

目的 验证第7版 UICC或AJCC 鼻咽癌分期系统在以MR为分期手段、IMRT为基础综合治疗策略下的合理性及适用性。方法 回顾分析2007—2011年间在本院经MRI分期和IMRT治疗的 720例初诊M₀期鼻咽癌患者的生存及失败情况,评价T、N分期对预测患者生存及失败的可靠性。Kaplan-Meier计算生存率,Logrank法检验差异,Cox模型多因素预后分析。结果 第7版 UICC或AJCC 鼻咽癌T分期是OS、CSS、DFS和DMFS的影响因素(P=0.013、0.025、0.001、0.002),但T₁、T₂、T₃期间相近(P=0.054~0.626)。从局部复发和远转风险来看,T₃与T₂期非常接近(P=0.796)。N分期是DFS、DMFS的影响因素(P=0.005,0.000)。但N₀和N₁期间相近(P=0.549、0.707)。在N₀—N₁期中也未发现单纯咽后淋巴结转移对OS、DFS和DMFS有影响(P=0.360、0.083、0.062)。结论 第7版UICC或AJCC鼻咽癌分期系统对经MRI分期和IMRT的鼻咽癌患者预后仍有较好预测价值,但有进一步优化的空间。     

胃癌根治术后淋巴结转移率与患者预后的关系

目的探讨淋巴结转移率对胃癌患者预后预测的意义。方法回顾性分析我院238例胃癌根治术患者的术后病理资料,分析胃癌患者预后和UICC/AJCC N分期及淋巴结转移率的关系。结果患者术后5年累计生存率为42.0%,UICC/AJCC N分期和淋巴结转移率均是胃癌患者的预后预测因素。根据UICC/AJCC N分期系统,获得淋巴结总数大于15枚和少于15枚的同一N分期患者术后5年生存率存在显著差异。但根据淋巴结转移率分期系统,淋巴结总数大于15枚和少于15枚的同一淋巴结转移率分期患者预后无显著差异。结论淋巴结转移率是胃癌患者的简单、可靠的预后预测因素,可以防止获得淋巴结总数不足导致的N分期降低。     

Topographic lymph node staging system shows prognostic superiority compared to the 8th edition of AJCC TNM in gastric cancer. A western monocentric experience

IntroductionThe current Tumor Node Metastasis staging system (TNM) for gastric cancer classifies the extent of lymph node metastasis based upon the number of lymph nodes involved. Choi et al. have recently proposed a new anatomical classification based upon the regionality of the involved nodes. This new classification seems to have a better predictive prognostic value than the traditional one. We investigated the prognostic role of the new anatomical based classification, reviewing our institutional gastric cancer database.MethodsWe performed a retrospective chart review of 329 patients who underwent gastrectomy at our Institution from 2003 to 2017. We excluded from data analysis any patient with distant metastases at the time of first diagnosis and or surgery, pathology other than adenocarcinoma, lymphadenectomy less than D2, impossibility to identify location of lymph nodes (LNs) on pathological report and neoadjuvant chemotherapy. The extent of D2 lymphadenectomy was defined according to Japanese Gastric Cancer Association criteria. LN metastasis were reclassified into three topographic groups (lesser, greater curvature, and extraperigastric nodes) and staged according to Choi. The new N stage was combined with the current pT according to the 8th edition of TNM and a new hybrid TNM stage was established. All patients were followed up until June 2019. The prognostic performance of the new stage and of the current anatomical numeric based system (TNM) was analyzed and assessed by the C-index, AIC and likelihood ratio χ² value.ResultsIn predicting both Overall Survival (OS) and Disease free Survival (DFS) the new N stage and the new TNM staging system had the highest C-index and likelihood ratio χ2 value and the lowest Akaike Information Criterion (AIC), showing a better accuracy and displaying a better prognostic performance.ConclusionsOur study is the first from the Western world to compare the new hybrid classification, based on the anatomical location of metastatic nodes, to the 8th of American Joint Committee on Cancer (AJCC) TNM staging system. Our findings on a small, monocentric sample suggest that hybrid topographic lymph node staging system is more accurate than TNM.     

Evaluation of the New American Joint Committee on Cancer/International Union against cancer classification of lymph node metastasis from gastric carcinoma in comparison with the Japanese classification.

BACKGROUND: A new system for the classification of gastric carcinoma, based on the number of metastatic lymph nodes, has been adopted by the current American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) TNM system (1997). The purpose of this study was to evaluate the rationality of this classification in comparison with the Japanese classification, which is based on the location of positive lymph nodes. METHODS: The authors analyzed 587 patients who underwent clinically curative gastrectomy with D2 lymphadenectomy for gastric carcinoma and each had 15 or more lymph nodes histologically examined from 1982 to 1992. Multivariate analysis with the Cox proportional hazards model was carried out to determine which classification was more effective. RESULTS: Within the pN1 or pN2 category of the new AJCC/UICC system, no significant difference in the survival rates existed between n1 patients and n2 patients of the Japanese classification. On the other hand, the survival rates significantly decreased, in the order of pN1, pN2, and pN3 (from greatest to smallest decrease), within the n1 and n2 categories. In multivariate analysis, lymph node involvement by the AJCC/UICC classification was selected as the most significant prognostic determinant, whereas the Japanese lymph node classification was not significantly prognostic. When survival rates were calculated within the pT1, pT2, and pT3-4 categories, no differences existed between pN0 and pN1. There was some discrepancy between the survival rate for each pT and pN category and the corresponding stage. CONCLUSIONS: The new AJCC/UICC classification for lymph node involvement of gastric carcinoma is basically acceptable and considered superior to the Japanese classification. Further analysis involving a greater number of cases may be necessary to confirm the applicability of this staging system.     

MRI在鼻咽癌分期中的作用

背景与目的:随着磁共振成像(magnetic resonance imaging,MRI)的广泛应用,MRI对于鼻咽癌的诊断价值已被证实明显优于CT.本研究旨在分析MRI与CT检查对鼻咽癌'92分期及6th UICC/AJCC分期的影响.方法:收集2003年1月至2004年6月收治的、经病理证实的初诊鼻咽癌250例,所有病例同时具有治疗前鼻咽和颈部的增强CT及MRI资料.结合临床资料如颅神经受损及颈淋巴结大小,分别采用CT和MRI检查进行'92分期及6th UICC/AJCC分期,评价两者之间的差异.结果:MRI在诊断鼻咽癌软组织超腔侵犯(口咽、鼻腔、咽旁间隙)、咽后淋巴结转移以及颅底骨质、副鼻窦、海绵窦/颅内、颞下窝及颈椎侵犯等方面均明显优于CT,而对于颈部巴结转移的检出两者无显著性差异.对于'92分期,MRI使32.0%的T分期发生改变(26.0%升级,6.0%降级);11.6%的N分期发生改变(6.4%升级,5.2%降级);30.4%的临床分期发生改变(24.0%升级,6.4%降级).对于6th UICC/AJCC分期,MRI使39.6%的T分期发生改变(36.0%升级,3.6%降级);9.2%的N分期发生改变(5.6%升级,3.6%降级);37.6%的临床分期发生改变(33.6%升级,4.0%降级).结论:MRI检测鼻咽癌局部病灶的侵犯范围要明显优于CT,而在颈部淋巴结转移的检出方面与CT结果相似.建立新的、以MRI为主要手段的鼻咽癌临床分期系统的研究具有临床必要性及可行性.     

Prognostic value of the 2002 TNM classification for breast carcinoma with regard to the number of metastatic axillary lymph nodes

BACKGROUND: The American Joint Committee on Cancer (AJCC) TNM classification for breast carcinoma had not been changed for 15 years, since the publication of the third edition in 1987. However, in the sixth edition, published in 2002, significant modifications were made with regard to the number of metastatic axillary lymph nodes. The authors investigated whether the sixth edition of the TNM classification provided more reliable prognostic information compared with the third edition. METHODS: The records of 1230 patients who underwent surgery for invasive breast carcinoma between 1993 and 1999 were reviewed. Each patient was assigned to axillary lymph node and disease stage groups according to the 1987 and 2002 AJCC TNM classifications. Disease-free survival (DFS) curves were calculated and plotted using the Kaplan-Meier method and the two-sided log-rank test was used to compare the survival curves of the patient groups. RESULTS: Of the 1067 patients who were classified as having Stages II and III disease according to the 1987 classification, 411 (38.5%) were shifted to higher disease stages using the 2002 classification. Among the 1987 Stage IIA, Stage IIB, and Stage IIIA patients, the DFS rates of the patients who were shifted to higher stages of disease were significantly worse than those of the patients for whom the stage of disease was not changed. Among those patients classified as having T4anyNM0 (Stage IIIB) disease according to the 1987 classification, there was no survival difference noted between those patients with T4N0,1,2M0 disease (who formed the Stage IIIB group) and those with T4N3M0 disease (who formed the Stage IIIC group) according to the new staging system. Of the 221 patients who formed the new Stage IIIC group, 12.2% were classified as having Stage IIA disease, 42.1% as having Stage IIB disease, 38.9% as having Stage IIIA disease, and 6.8% as having Stage IIIB disease according to the 1987 classification. The survival rates of these Stage IIA, Stage IIB, and Stage IIIA patients were not found to be significantly different; however, the survival of patients in the Stage IIIB group was found to be significantly worse than the survival of the patients in the other disease stage groupings, and the patients in the Stage IIIC group were not a prognostically homogeneous group. On the basis of these results, the authors placed patients with T4anyNM0 disease in the same group (Stage IIIB). When the 2002 classification was rearranged in this manner, patients with Stage IIIC disease formed a homogeneous group; the 5-year DFS rate of patients with Stage IIIB disease was found to be significantly worse than that for patients with Stage IIIC disease (P = 0.0011). CONCLUSIONS: In the 2002 TNM classification for breast carcinoma, patients with T4anyNM0 disease should form a distinct stage grouping and this stage grouping (Stage IIIC) should be placed before Stage IV, and Stage IIIB disease groupings should include patients with T1,2,3N3M0 disease. In this way, the authors hope that the 2002 AJCC TNM classification, which provides more reliable prognostic information than the 1987 classification, will become more refined.     

Staging of oropharyngeal squamous cell carcinoma of the head and neck: Prognostic features and power of the 8th edition of the UICC staging manual

IntroductionRecognizing the prognostic power differentiating HPV-associated oropharyngeal squamous cell cancer (OPSCC) from OPSCC with other causes, the UICC Cancer Staging Manual 8th edition realizes significant changes from the 7th edition. Purpose of this study was to evaluate the differences of prognostic impact between the 7th and the latest edition of TNM Classification as well as to examine risk factors like extranodal extension (ENE) and lymph node ratio (LNR) for HPV-mediated OPSCC.Material and methodsThe study includes 255 patients with OPSCC and initial diagnosis between 2008 and 2015. HPV status was determined according to p16 immunohistochemistry (IHC) and all patients were classified as defined by 7th and 8th edition of UICC. Prognostic influence of ENE and LNR was analyzed for patients with HPV-mediated OPSCC.Results41.2% of the OPSCC were p16-positive. Implementation of the 8th edition of the UICC lead to a better differentiation between the respective stages. Regarding HPV-positive OPSCC, Kaplan-Meier survival curves showed a significantly better overall survival (OS) for patients with a LNR ≤10% as well as for patients with negative ENE status (p = 0.004, p = 0.008).Conclusion8th edition of UICC achieves to differentiate properly between the UICC stages. However, the staging rule of ignoring ENE in HPV-mediated OPSCC should be further analyzed. Moreover LNR might be a possible additional prognostic factor – especially regarding HPV-positive tumors.     

国际抗癌联盟和日本胃癌协会胃癌淋巴结分期法与国人胃癌患者预后相关性的比较

目的 比较国际抗癌联盟(UICC)和日本胃癌协会(JGCA)两种胃癌淋巴结分期法与胃癌预后的相关性,评价其在胃癌预后评估中的指导意义和应用价值.方法 1996年1月至2005年12月间,经D2及以上胃癌根治手术,清扫淋巴结数目≥15枚,并有完整随访资料的395例胃癌患者为研究对象,分别以两种淋巴结分期法进行分期并绘制生存曲线.以Kaplan-Meier法进行生存率分析,Log rank检验评估组间的差异.结果 按UICC法分期后,各组间患者的生存率差异更明显.对T3期患者分别以两种方法分组并进行生存率比较显示,按照UICC法分期各组间的差异更明显.对两种分期后的N亚期以另一种标准相互再分期后,生存曲线显示,以UICC法对JGCA法分期后的各组再分期所产生的差异比以JGCA法对UICC法分期后的各组再分期后所产生的差异明显.在JGCA分期标准中,Ⅰa、Ⅰb、Ⅱ、Ⅲa、Ⅲb和Ⅳ期患者的5年生存率分别为100.0%、96.9%、79.3%、54.2%、16.8%和11.2%;在UICC TNM分期标准中,其5年生存率分别为100.0%、96.9%、75.4%、51.8%、18.4%和10.5%.各期患者的5年生存率差异均无统计学意义(P>0.05).结论 UICC TNM胃癌分期标准与预后的相关性更好,对胃癌患者的预后评估和治疗方案的制定有更为客观的指导意义;而施行标准的D2胃癌根治手术和清扫至少15枚淋巴结是实行UICC分期法所必需的.     

基于IMRT时代的第八版AJCC/UICC鼻咽癌临床分期建议

本文首次发表在Cancer,2016,122(4):546-558.

目的 准确的分期系统对癌症的治疗至关重要。随着癌症分期和治疗方法的演变,需要不断评价分期的适用性和改进性。方法 基于第7版AJCC/UICC分期回顾性分析香港和中国大陆2个肿瘤中心收治的 1609例接受调强放射治疗的首诊无转移鼻咽癌患者临床资料,所有患者治疗前均行核磁共振分期评估。结果 无其他T₃、T₄期解剖结构受侵患者中,伴有咀嚼肌间隙(翼内肌和/或翼外肌)侵犯、椎前肌侵犯及咽旁间隙侵犯的三组患者之间OS相近。伴广泛软组织(上述侵犯结构以外的软组织)受侵患者OS与伴有颅内侵犯或颅神经侵犯相似。仅2%患者锁骨上窝以上淋巴结转移者直径>6 cm,其OS率与下颈淋巴结转移者类似。用下颈(环状软骨尾侧缘水平以下)代替锁骨上窝并不影响N分期之间的风险差异性。采用推荐的T、N分期,T₄N_0-2、T_1-4N₃期OS相近。结论 经AJCC/UICC分期筹备委员会审阅后,建议第8版分期应将翼内肌/翼外肌从T₄降到T₂期,增加椎前肌为T₂期,用下颈取代锁骨上窝,将淋巴结最大直径>6 cm合并归为N₃期,将T₄、N₃期统一归为Ⅳ_A期。这些改变不仅使得相邻分期间风险差异性更好,而且使得临床实践性与全球适用性之间达到最佳平衡。