Comparison of the Survival Difference Between AJCC 6th and 7th Editions for Gastric Cancer Patients

Background  

The AJCC 7th edition changes the classification of T- and N-factors and the TNM stage of gastric cancer. We evaluated its prognostic impact.     

Comparison of the 6th and 7th Editions of the UICC-AJCC TNM Classification for Esophageal Cancer

Background

The new 7th edition of the Union for International Cancer Control?CAmerican Joint Committee on Cancer (UICC-AJCC) tumor, node, metastasis (TNM) staging system is the ratification of data-driven recommendations from the Worldwide Esophageal Cancer Collaboration database. Generalizability remains questionable for single institutions. The present study serves as a validation of the 7th edition of the TNM system in a prospective cohort of patients with predominantly adenocarcinomas from a single institution.

Methods

Included were patients who underwent transhiatal esophagectomy with curative intent between 1991 and 2008 for invasive carcinoma of the esophagus or gastroesophageal junction. Excluded were patients who had received neoadjuvant chemo(radio)therapy, patients after a noncurative resection and patients who died in the hospital. Tumors were staged according to both the 6th and the 7th editions of the UICC-AJCC staging systems. Survival was calculated by the Kaplan?CMeier method, and multivariate analysis was performed with a Cox regression model. The likelihood ratio chi-square test related to the Cox regression model and the Akaike information criterion were used for measuring goodness of fit.

Results

A study population of 358 patients was identified. All patients underwent transhiatal esophagectomy for adenocarcinoma. Overall 5-year survival rate was 38%. Univariate analysis revealed that pT stage, pN stage, and pM stage significantly predicted overall survival. Prediction was best for the 7th edition, stratifying for all substages.

Conclusions

The application of the 7th UICC-AJCC staging system results in a better prognostic stratification of overall survival compared to the 6th edition. The fact that the 7th edition performs better predominantly in patients with adenocarcinomas who underwent a transhiatal surgical approach, in addition to findings from earlier research in other cohorts, supports its generalizability for different esophageal cancer practices.     

胃癌第7版TNM分期的临床应用

目的:分析胃癌第7版与第6版TNM分期之间的差别.方法:回顾性分析316例胃癌患者的临床病理资料,按第6版及第7版TNM分期标准分别进行分期,并分析各期5年生存率.结果:两版TNM分期在同一期之间生存差异无统计学意义(P>0.05);第7版Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期5年生存率分别为64.2%、49.9%、17.8%、0.0%,4个分期5年生存率差异有统计学意义(P<0.05);ⅢA期、ⅢB期、ⅢC期5年生存率分别为32.2%、28.2%、5.0%,3个亚期5年生存率差异具有统计学意义(P ＜0.05).结论:第7版TNM分期更加细化,并对患者预后做出科学的评估.对不同分期的患者进行个体化综合治疗,具有临床应用价值.     

制订2009第7版食管癌TNM分期标准

目的报告参与制订2009第7版食管癌国际TNM分期的国际协作研究结果。方法收集全世界13个协作单位的4628例食管癌单纯切除病例的资料，采用全新的统计学模型，综合各预后影响因素反向归纳至最合理的TNM分期。结果全组总的1、5、10年死亡率分别为78％、42％、31％。远期生存的主要影响因素为肿瘤侵犯深度、淋巴结转移数目、有无远处转移、肿瘤的组织学类型和分化程度。将其优化组合后新的TNM分期中T1应细化为T1a和T1b，T4应细化为T4a和T4b，N应当根据淋巴结的转移数目分级，M1的亚分级应当取消，且应加入肿瘤组织学类型（H）和分化程度（G）因素。结论2009第7版食管癌分期标准重新定义了T、N、M，并分期为0、Ⅰa、Ⅰb、Ⅱ、Ⅲa、Ⅲb、Ⅳ期，可更好地预测食管癌患者手术切除治疗的预后。     

Evaluation of the Seventh Edition of American Joint Committee on Cancer TNM Staging System for Gastric Cancer: Results from a Chinese Monoinstitutional Study

Background

To investigate the validity of the 7th edition of American Joint Committee on Cancer (AJCC) TNM staging system for gastric cancer with special attention paid to pT2/pT3, pN1/pN2, and pN3a/pN3b category.

Materials and Methods

Clinicopathologic data of 1998 patients underwent R0 surgery for histologically proven gastric cancers with >15 lymph nodes retrieved were retrospectively reviewed.

Results

Prognoses were significantly different between pT2 and pT3 categories, between pN1 and pN2 categories, or between pN3a and pN3b categories. Each stage in the 6th edition was divided into the 7th edition stage with different survival rates. Moreover, stage IIIA, IIIB, and IIIC in the 7th edition system was divided into the 6th edition stage with different survival rates. Prognoses for patients in 7th edition T4aN1M0/T3N2M0/T2N3aM0, T4bN0-1M0/T4aN2M0/T3N3aM0, and T4aN3aM0/T4bN2M0 were similar to that of patients in T1N3bM0, T2N3bM0, and T3N3bM0, respectively, but significantly better than that of patients in T2N3bM0, T3N3bM0, and T4aN3bM0, respectively. However, no significant difference could be observed among patients in T4bN3aM0, T4aN3bM0, T4bN3bM0, and stage IV. A revised TNM system was proposed, in which T1N3bM0 was incorporated into stage IIIA, T2N3bM0 into stage IIIB, T3N3bM0 into stage IIIC, T4bN3aM0/T4aN3bM0/T4bN3bM0 into stage IV. Further analyses revealed the revised TNM system had better homogeneity, discriminatory ability, and monotonicity of gradients than the 6th and the 7th edition system.

Conclusions

It is reasonable to subclassify the 6th edition pT2 category and pN1 category into the 7th edition pT2/pT3 category and pN1/pN2 category, respectively. However, for better prognostic stratification, it might be more suitable for pN3a and pN3b categories to be considered individual determinants of the 7th edition TNM staging system.     

Staging of Adenocarcinoma of the Esophagogastric Junction: Comparison of AJCC 6th and 7th Gastric and 7th Esophageal Staging Systems

Background

Adenocarcinoma of esophagogastric junction (EGJ) is currently staged by the esophageal staging criteria according to the American Joint Committee on Cancer (AJCC) staging system, 7th edition. We compared the performance of 6th gastric (G6), 7th gastric (G7), and 7th esophageal (E7) staging systems.

Methods

A total of 202 curatively resected adenocarcinomas of EGJ were analyzed. Patient outcomes were assessed according to G6, G7, and E7 staging. Tumor invasion to the subserosal or serosa layer was regarded as invasion to the adventitia for E7 staging. Performance was measured based on monotonicity (decreasing survival with increasing stage), distinctiveness (survival difference between different stages), and homogeneity (homogenous survival in the same stage).

Results

Each staging system was monotonous except for T1-2N0 lesions of E7. This was related to the introduction of histologic grade in E7 staging. Distinctiveness in each staging system was variable. As for the homogeneity, patients whose disease was staged as Ib (E7) exhibited different survival when reassessed by G6 and G7; again, this was related to histologic grading. Patients with IIIb (G7) and IIIc (E7) disease had different survival when reassessed by G6 staging, reflecting the poorer survival of patients with more than 15 lymph node metastases.

Conclusions

Staging of EGJ cancer based on the current AJCC, 7th edition, criteria of esophageal cancer staging has several limitations. We recommend considering modifications of the following in future updates of the staging system: accurate anatomical definition of tumor depth, removal of histologic grade from staging parameters, and classification of more than 15 lymph node metastases as a highly advanced stage.     

Comparison of 6th and 7th AJCC TNM Staging Classification for Carcinoma of the Stomach in China

Background  

The 7th edition of American Joint Committee on Cancer tumor-node-metastasis (AJCC TNM) staging system was put into use recently. The study aimed to evaluate its predictive ability on survival and compare the difference between the 6th and 7th editions of AJCC TNM system in gastric carcinoma.     

Validation of the Updated 7th Edition AJCC TNM Staging Criteria for Gastric Adenocarcinoma

Introduction  

The recently published 7th edition of the American Joint Committee on Cancer (AJCC) TNM staging criteria for gastric adenocarcinoma contains important revisions to T and N classifications, as well as overall stage grouping. Our goal was to validate the new staging system using a cancer registry.     

Suitability of 7th UICC N Stage for Predicting the Overall Survival of Gastric Cancer Patients After Curative Resection in China

Background

Metastatic lymph node count (MLNC) is the most intensively prognostic indicator of gastric cancer. How to efficiently evaluate the best classification of MLNC is unclear. The purpose of this study was to evaluate the overall survival (OS) prediction of new UICC N stage in gastric cancer after curative surgery.

Materials and Methods

Data from 456 patients who underwent curative resection were used to choose the most efficient classification of MLNC for evaluation the OS of gastric cancer.

Results

Using univariate analysis, both the N stage of 7th edition UICC TNM classification (7th UICC N stage) and N stage of 5th/6th edition UICC TNM classification (5th/6th UICC N stage) were associated with the OS of gastric cancer after curative surgery. However, Cox regression multivariate analysis showed the 7th UICC N stage was an independent factor for predicting the OS of gastric cancer instead of the 5th/6th UICC N stage. Besides, we used the case-control matched fashion for further validation of the superiority of the 7th UICC N stage in prognostic prediction of gastric cancer. Last, we adopted the cut-point survival analysis to determine the most appropriate cutoffs for MLNC of all gastric cancer patients after curative surgery. We demonstrated the cutoff of 7th UICC N stage was similar to that produced from the cut-point survival analysis.

Conclusion

The 7th UICC N stage appears to provide a reliable prognostic category of MLNC of gastric cancer than the 5th/6th UICC N stage, and it is the efficiently prognostic indicator of gastric cancer after curative surgery.     

第7版与第6版胃癌TNM分期的比较

目的 比较第7版与第6版胃癌TNM分期方案.方法 对卫生部中日友好医院2003年1月至2005年12月收治并可随访的76例胃癌术后病例分别用第7版和第6版胃癌分期方法重新进行TNM分期,对两种分期结果分别进行成组卡方检验、配对卡方检验和Kappa检验,并比较二者对预后判断的效果.结果 第7版胃癌分期法与第6版比较,在T分期、N分期和TNM组合分期的结果一致性中等,Kappa值<0.75;其结果差异有统计学意义(P<0.05);第6版分期的生存曲线在Ⅲ、Ⅳ期生存曲线有多处交叉,而第7版各期生存曲线没有交叉.结论 第7版AJCC胃癌分期法优于第6版.     

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

Background

This 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.

Methods

Gallbladder cancer patients were staged according to both the sixth and seventh editions of the American Joint Committee on Cancer (AJCC) staging system.

Results

A 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).

Conclusions

Sufficient 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.     

TNM classification for perihilar cholangiocarcinoma: comparison between 5th and 6th editions of the AJCC/UICC staging system

Background A few investigators have evaluated the TNM classification for perihilar cholangiocarcinoma. The new sixth edition of the American Joint Committee on Cancer (AJCC)/Internal Union Against Cancer (UICC) staging system focuses on vascular invasion and regional lymph node metastasis.Methods For 166 patients with perihilar cholangiocarcinoma undergoing R0 resection, survival curves stratified according to TNM classifications were compared between fifth and sixth editions.Results The previous T3 now is divided into T3 and T4. Most new pT4 patients had invasion of the portal bifurcation; their survival was poorer than that for new pT3 patients. The 5-, 10-, and 15-year survival rates were worse in the previous stage III than in the previous stage IVA, although the difference fell short of significance. The previous stage IVA (T3AnyNM0) is divided into new stages: IIA (T3N0M0), IIB (T1-3N1M0), and III (T4AnyNM0). All patients in stage III had invasion of the portal bifurcation. Survival was similar between stages IA, IB, and IIA, while patients with T4N0M0 tumors survived longer than those with T4N1M0 tumors and similarly to those with stage IIB tumors.Conclusions The sixth edition provided improved prediction of survival in patients with perihilar cholangiocarcinoma; for still better prediction, cancer invasion of the portal bifurcation and regional lymph node metastasis should be weighted equally.     

Reframing Histological Risk Assessment of Oral Squamous Cell Carcinoma in the Era of UICC 8th Edition TNM Staging

ObjectivesTo assess whether application of the risk model originally proposed by Brandwein-Gensler, influences survival and disease progression in patients treated for oral squamous cell carcinoma (OSCCs)Materials and MethodsTumours from 134 T1 and T2 OSCC resections (7th edition) were scored independently by 3 histopathologists according to worst pattern of invasion (WPOI), lymphocytic host response (LHR) and perineural invasion (PNI) and categorised according to risk score. Local recurrence, locoregional recurrence, disease progression and overall survival were study endpoints. Interobserver variability of pathologist scoring was also assessed.ResultsSeventy-two patients (54%) were classified with low or intermediate risk and 62 (46%) patients were ‘high risk’. The inter-observer agreement was in moderate to strong agreement with the consensus scores (k range = 0.45–0.82). There was statistical significance between distant metastasis and ‘high risk’ tumours. Thirty tumours were upstaged to T3 in the 8th edition TNM staging, of which 83% had high risk scores. Overall risk score and TNM8 T stage has significant correlation with overall survival in comparison to the TNM 7 T stage.Conclusion‘High risk’ tumours were significantly associated with distant metastasis possibly due to the greater likelihood of aggressive features such as WPOI and PNI. Primary tumours are more likely to express high risk features with increasing T stage. None of the patients classified as ‘low risk’ died perhaps suggesting these tumours represent a rare variant of OSCC with excellent prognosis.     

Establishment of an Intraoperative Staging System (iStage) by Improving UICC TNM Classification System for Papillary Thyroid Carcinoma

Background

Papillary thyroid carcinoma generally has an indolent nature, but cases demonstrating certain features are progressive. UICC TNM classification is the most widely adopted system to evaluate the biological behavior of this carcinoma, but it is doubtful whether this system that evaluates only the preoperative findings can appropriately reflect patient prognosis. In this study, we established a new staging system (iStage) based on not only preoperative but also intraoperative findings.

Methods

We investigated the prognoses of 5,911 patients with papillary carcinoma without distant metastasis at diagnosis who underwent initial surgery between January 1987 and January 2005 and compared the utility of iStage with that of conventional classification systems, such as UICC Stage, MACIS score (>7 and ≤7), AMES, and CIH classification.

Results

Disease-free survival (DFS) and cause-specific survival (CSS) of patients with stage IVA were better than those of high-risk patients on other systems, and CSS of stage III patients did not differ from stage IVA patients. We established iStage by improving the original UICC stage. We set cutoff age to 55 years, instead of 45. Patients showing significant, not minimal, extrathyroid extension on intraoperative findings underwent T upgrading: tumor size 2 cm or smaller to T3 and larger than 2 cm to T4a. N classification was revised based on the size of node metastasis and extranodal tumor extension: N0, no preoperatively detected regional node metastasis; N1, preoperatively detected regional node metastasis measuring 3 cm or less and without extranodal tumor extension on intraoperative findings; N2, regional node metastasis >3 cm or having extranodal tumor extension on intraoperative examination. Five-year and 10-year DFS and CSS of iStage IVA patients were worse than high-risk patients on other classification systems, and iStage III patients showed a worse DFS, but not CSS, than iStage I or II patients.

Conclusions

We established a new classification system, iStage, based not only on preoperative but also on intraoperative findings, which has high utility. Appropriate intraoperative evaluation is mandatory to grade biological characteristics, including prognosis, of papillary carcinoma.     

Inadequacy of Lymph Node Staging in Gastric Cancer Patients: A Population-Based Study

Background In 1997, examination of at least 15 lymph nodes was recommended for adequate gastric cancer staging. However, the proportion of patients undergoing an adequate lymph node examination (LNE) has not been studied in a population-based manner. Methods We used Surveillance, Epidemiology, and End Results cancer registry data to assess LNE adequacy in adults with nonmetastatic gastric adenocarcinoma. We selected patients aged 18 through 80 years whose disease was diagnosed from 1998 through 2001 and who underwent at least partial gastrectomy. We evaluated the overall number of nodes, estimated the likelihood of adequate LNE (i.e., ≥15 nodes examined), and determined the influence of selected tumor and patient characteristics on LNE. Results In this 4-year period, 3593 patients met our study’s selection criteria. The median number of nodes examined was 10: 32% of patients underwent adequate LNE, and 9% of patients had no nodes examined. Node-positive patients were more likely to have undergone an adequate LNE than node-negative patients (42% vs. 23%; P < .0001). Younger age, female sex, and more radical surgery were associated with adequate LNE in both univariate and multivariate analysis (P < .0001). Geographical site was an important predictor; patients from one registry (Hawaii) were significantly more likely to have undergone adequate LNE than patients from all other registries (56% vs. 30%; P < .0001). Conclusions Our 4-year review of the Surveillance, Epidemiology, and End Results database revealed that only a third of patients with gastric cancer underwent adequate LNE, i.e., had the recommended minimum of 15 nodes examined for gastric cancer staging. Better results at one registry (Hawaii) indicate that substantial improvements could be made.     

Restaging of Differentiated Thyroid Carcinoma by the Sixth Edition AJCC/UICC TNM Staging System: Stage Migration and Predictability

BACKGROUND: The AJCC/UICC TNM staging system (TNM) is a widely accepted system for differentiated thyroid carcinoma (DTC). The objective of the present study was to evaluate the potential changes in cancer-specific survival (CSS) after reclassification from fifth to sixth edition TNM. METHODS: A total of 760 DTC patients managed at our institution from 1961 to 2001 were retrospectively restaged from the fifth to sixth edition TNM. CSS were calculated using Kaplan-Meier method and were compared by the log-rank test. The relative ability of each edition in predicting CSS was calculated by the proportion of variance explained (PVE). RESULTS: Upon reclassification, the proportion of T1 and T3 tumors increased from 14.2 to 33.4% and 10.0 to 33.7%; T2 and T4 decreased from 44.2 to 25.0% and 31.6 to 7.9%, respectively; N0 remained unchanged at 66.0%; N1a decreased from 25.7 to 4.7%; N1b increased from 8.4 to 29.3%; stages I and IV tumors increased from 55.7 to 60.3% and 3.4 to 17.6%, respectively; stages II and III tumors decreased from 20.5 to 13.9% and 20.4 to 8.2%, respectively. The sixth edition had a higher PVE value than the fifth edition. Significant differences in CSS were observed between stage III (fifth edition) and stage III (sixth edition) and between stage IV (fifth edition) and stage IVA (sixth edition). CONCLUSIONS: The sixth edition TNM caused marked changes in the pT, pN and allocation of patients into different tumor stages. It appeared to have superior predictability over the fifth edition.