胃癌AJCC分期第6版与第7版的差异及其对预后评估的分析与比较

目的 比较胃癌美国癌症联合会（AJCC）分期第6版与第7版的差异,分析、评价新的胃癌TNM分期方法的临床应用价值。方法 回顾性分析1995年9月至2007年12月在北京大学临床肿瘤学院接受治疗并具有完整临床病理资料的922例胃癌病人,比较其根据AJCC新旧两版标准分期后的预后情况。结果 胃癌第7版AJCC分期在T、N分期方面均进行了比较明显的调整,与第6版相比分期标准更为精细化,第7版分期标准对N分期进行的调整可以更好地对不同预后的病人进行区分,COX模型分析表明M分期、新版N分期、旧版TNM分期以及淋巴结清扫是否充分是反映胃癌预后最主要的独立因素。结论 与第6版分期相比,第7版的T分期、N分期标准更为合理,但新版的TNM综合分期标准对于预后评估却并未体现出优势,其具体临床价值仍有待探索。     

75例胃癌病理分型对其预后的影响评价

目的 探讨不同病理分型胃癌的病理特征对临床预后的影响,为临床的治疗及预后判断提供指导.方法 采用美国癌症联合委员会（AJCC） 2009年底发布的第7版胃癌分期法,对卫生部中日友好医院2003年1月至2005年12月收治的75例胃癌术后病例重新进行分型.分别以分化程度和肿痛大小进行分组,比较各组间的浆膜浸润率、淋巴结转移率;并比较新旧两版分期对随访患者5年生存率的影响.结果 不同分化程度的胃癌淋巴结转移率及浆膜浸润率比较,差异有统计学意义;高分化腺癌与中、低分化腺癌及印戒细胞癌的淋巴结转移率及浆膜浸润率比较,差异有统计学意义.将各分化组叠加,以肿瘤最大径≤4 cm和＞4 cm重新分组,见肿瘤最大径≤4 cm组与最大径＞4 cm组淋巴结转移率、浆膜浸润率的差异有统计学意义.75例可随访病历以新旧两版分别分期,新旧两版分期均可见分期越差,5年生存率越低.结论 第7版AJCC胃癌分期法较旧版Ⅱ、Ⅲ期患者明显增多,而Ⅰ、Ⅳ期患者相应减少,为临床对更多的胃癌患者术后施行放化疗提供了支持,从而使更多胃癌患者受益.     

日本《胃癌治疗指南》（第3版）解读

日本胃癌学会的第3版《胃癌治疗指南》将于2010?01?01起发行使用。第3版的主要内容是废止了以往在日本长期使用的解剖学N分期（淋巴结站的分类）方法,改为根据淋巴结转移个数确定的N分期方法;制定了新的以术式确定淋巴结清扫部位及简明的D1/D2淋巴结清扫手术。第3版在前两版的基础上,网络新的文献,评价最新的科学成果,将循证医学证据高级别的、行之有效的研究成果纳入《胃癌治疗指南》。第3版《胃癌治疗指南》依据JCOG9501试验结果,取消腹主动脉周围淋巴结清扫的D3手术;依据JCOG9912和SPIRITS试验,将无法手术切除和复发癌采取CDDP+TS?1的化学疗法作为标准化学疗法。因此,第3版《胃癌治疗指南》更具有时代特色和先进性,为临床医疗提供了更为先进的、科学的指导性意见和治疗方略。     

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胃癌分期经过半个世纪不断地改进、充实,使其为更精确的判定预后和选择治疗方案提供了科学依据。胃癌分期是胃癌外科进步和国际标准化、规范化治疗的极为重要的平台和基础。胃癌分期的产生、演变是在长期的临床实践、科学研究的基础上形成,特别是转化医学性质的基础和临床研究贯穿于其形成和发展的每个重要时期,尤其是胃癌预后因子T、N的确立,淋巴结转移程度分类基准评价体系的确立,以转移淋巴结个数评价系统为基础的第5版TNM分期的确立,以及2010年日本胃癌规约分期系统与UICC/AJCCTNM分期系统的统一产生的第7版TNM分期体系,无不显示出转化医学理念和转化研究成果的价值与作用。胃癌分期的演变过程是将最新研究成果快速转化为临床医学技术,解决临床问题的转化医学理念的具体体现和实践。     

清扫淋巴结数目对淋巴结阴性胃癌患者生存期的影响

对于淋巴结阴性的胃癌患者,UICC第7版TNM分期并没有规定最少应清扫多少枚淋巴结。本研究旨在探讨淋巴结阴性胃癌患者的淋巴结检出数目与预后的关系。将1992年12月至2006年12月间收治的435例经病理证实淋巴结阴性的胃癌患者纳入本研究,全部患者都施行D：胃癌根治术。     

第8版国际抗癌联盟和美国癌症联合委员会胃癌TNM分期系统简介及解读

目前胃癌的TNM分期已经成为临床胃癌诊疗的首选参考依据。在国际抗癌联盟(UICC)、国际胃癌协会(IGCA)和美国癌症联合委员会(AJCC)的共同协作推动下,通过对全世界范围内胃癌大数据的收集与分析,于2016年10月颁布了第8版胃癌TNM分期系统。第8版TNM分期系统对食管-胃结合部及贲门癌分期标准的选择做出了明确的定义;同时还在单一分期系统的基础上新增了临床TNM分期(cTNM)和新辅助治疗后分期(ypTNM)。此外,新版的分期系统将N3的两个亚组N3a和N3b作为独立组别纳入到分期系统,还对组织学分级进行了一些调整。总的来说,相比第7版胃癌TNM分期系统,新版的分期系统可以指导临床医生更加合理地制定治疗方案,更加科学地评价治疗效果,更加准确地评估预后。然而,随着临床广泛应用和进一步验证,以及新的预测因子的发现,必将会有新的分期系统替代和完善旧的分期系统。     

进展期胃癌临床治疗的现状

目的 探讨提高进展期胃癌临床治疗水平的策略。方法 在Medline上检索有关文献并综述。结果 第5版UICC／AJCC胃癌TNM分期对评估胃癌扩大淋巴结切除术的预后作用有意义。胃癌的分期、淋巴结切除的范围、程度及辅助性治疗方案等都是影响胃癌预后的因素。结论 对胃癌根治术的病例应实施个体化扩大淋巴结切除术和坚持综合性治疗原则。     

胃癌的淋巴结清扫及意义

胃癌是目前我国死亡率较高的恶性肿瘤之一。胃癌的浸润深度（T）和淋巴结转移程度（N）是评价肿瘤分期的重要依据,UICC及日本胃癌规约均认为淋巴结转移情况是评价胃癌预后的独立且重要的因素,因此,胃癌的淋巴结清扫程度与胃癌预后关系密切。东西方学者对胃癌淋巴结清扫范围的争论已持续多年,但越来越多的学者趋向于把D2清扫术作为胃癌治疗的标准术式。     

胃癌的临床分期及其重要意义

胃癌处理规约（日本）与UICC/TNM分类是国际上胃癌的两大重要临床分期系统。两大系统对胃癌的治疗具有重大作用,其演变过程反映了胃癌治疗过程的进步。两大系统在淋巴结转移分类法具有很大分歧,是两大分期系统的差异所在。2010年日本第14版《胃癌处理规约》与第7版UICC/TNM分类整合形成国际上统一的临床分期。新的分期的特征是以T（5段）、N（4段）、以淋巴结转移个数判定的N因子进行TNM分期,使不同分期的生存曲线能更精确的分层化。另外,临床分期是胃癌治疗方针确定的基础和依据,2010年第3版日本《胃癌治疗指南》即是以新版的胃癌TNM分期为依据确定的胃癌分期治疗的标准文本。     

从日本《胃癌治疗指南》（第5版）修订谈日本胃癌外科发展趋势

日本《胃癌治疗指南》自2001年3月制定以来进行了5次修订,其建立在日本大量经验性数据基础上,采用教科书形式介绍,但第5版《胃癌治疗指南》体现出从经验外科向循证医学外科的转变,包括非治愈性胃癌的减瘤手术、网膜囊外切除、近端和胃体部癌合并脾切除、胃癌侵犯食管的手术入路问题等,采纳了国际多中心临床试验（MRCT）研究结果。推荐cStageⅠ胃癌为腹腔镜手术适应证,而对于进展期胃癌正在进行MRCT（JLSSG0901）研究,有待结果发表。改变单一手术模式,注重术前新辅助化疗,对于临界可切除的高度淋巴结转移病例,进行新辅助化疗（SP方案）2~3疗程后,再行D2+No.16淋巴结清扫。对于胃癌腹膜转移的腹腔镜诊断标准以及食管胃结合部癌和残胃癌区域淋巴结定义和清扫范围,指南提出了日本标准,有待循证医学检验。     

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??The Union for International Cancer Control (UICC) and the American Joint Committee on Cancer (AJCC) gastric cancer TNM staging system (8th edition) explanation and elaboration SHAN Fei , LI Zi-yu, ZHANG Lian-hai, et al. Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Gastrointestinal Cancer Center, Peking University Cancer Hospital & Institute, Beijing 100142, China
Corresponding author: JI Jia-fu, E-mail: jijiafu@hsc.pku.edu.cn
Abstract The Union for International Cancer Control (UICC) and the American Joint Committee on Cancer (AJCC) have issued the Eighth Edition of TNM staging system manual in October 2016. The updated version made evidence-based, prominent revisions in cancer stage classification system. Specifically, the old TNM staging system based on post-operative pathological examination was replaced by a more sophisticated staging system including clinical staging (cTNM), pathological staging (pTNM), and neo-adjuvant post-treatment staging (ypTNM). These revisions help oncologists and other clinicians better determine the stage of gastric cancer patients according to their conditions and treatments. Consequentially, appropriate individualized anti-cancer treatment could be made possible for each patient. Also, the Eighth Edition revised the guidance in staging gastroesophageal junction cancer and cardia cancer. Another update is N3a and N3b, separated from N3, work as two independent groups in staging system. Comparing to the Seventh Edition, some adjustment was made in sub-classifying patients of stage III. The usefulness and appropriateness of the new updates need clinical validation around the world. Although a risk prediction model incorporating the recent advancement of molecular biology has not been developed as expected, the Eighth Edition provides a useful tool for clinicians in the transition to precision treatment for gastric cancer.     

Updates in the Eighth Edition of the Tumor-Node-Metastasis Staging Classification for Urologic Cancers

The Tumor-Node-Metastasis (TNM) classification on cancer staging, jointly developed by the American Joint Commission on Cancer (AJCC) and the Union for International Cancer Control (UICC), has been updated to its 8th edition with two contemporaneous versions published by the AJCC and UICC. While the goal of the AJCC and UICC is to have identical TNM staging systems, differences exist between these two publications including in the staging of urologic cancers. Among several new facets in the AJCC staging manual, a select few of greater import include an expanded section on imaging, presentation of levels of evidence for significant changes, and endorsement of risk assessment models that pass the AJCC quality criteria such as in prostate cancer. The updates for urologic cancers in the AJCC stage categories can be grouped into: (1) newly defined TNM categories and prognostic stage groupings, (2) clarifications and refinements of previously defined categories, and (3) more systematic and expanded presentation of prognostic factors. Changes are harmonized with the current reporting and treatment guidelines. Contributions from genitourinary pathology are evident in the AJCC classification from many of the International Society of Urological Pathology (ISUP) consensus conferences on prostate, kidney, testicular, and penile neoplasms that addressed staging issues and the timely publication of the 4th edition of the World Health Organization (WHO) classification of urinary and male genital organ tumors. New grading approaches for penile (WHO/ISUP grade), prostate (Grade group), and kidney (WHO/ISUP nucleolar grade) cancers were adopted in the AJCC system. Many of these updates in the AJCC staging manual are also included in the 8th UICC TNM edition. In an effort to achieve the optimal staging recommendations for urologic cancers, updates in the 8th TNM edition were generated through the acquisition of best evidences, tapping interdisciplinary resources including consensus recommendations, and enhanced data analysis.

Seventh Edition (2010) of the AJCC/UICC Staging System for Gastric Adenocarcinoma: Is there Room for Improvement?

Background

The gastric cancer AJCC/UICC staging system recently underwent significant revisions, but studies on Asian patients have reported a lack of adequate discrimination between various consecutive stages. We sought to validate the new system on a U.S. population database.

Methods

California Cancer Registry data linked to the Office of Statewide Health Planning and Development discharge abstracts were used to identify patients with gastric adenocarcinoma (esophagogastric junction and gastric cardia tumors excluded) who underwent curative-intent surgical resection in California from 2002 to 2006. AJCC/UICC stage was recalculated based on the latest seventh edition. Overall survival probabilities were calculated using the Kaplan–Meier method.

Results

Of 1905 patients analyzed, 54 % were males with a median age of 70 years. Median number of pathologically examined lymph nodes was 12 (range, 1–90); 40 % of patients received adjuvant chemotherapy, and 31 % received adjuvant radiotherapy. The seventh edition AJCC/UICC system did not distinguish outcome adequately between stages IB and IIA (P = 0.40), or IIB and IIIA (P = 0.34). By merging stage II into 1 category and moving T2N1 to stage IB and T2N2, T1N3 to stage IIIA, we propose a new grouping system with improved discriminatory ability

Conclusions

In this first study validating the new seventh edition AJCC/UICC staging system for gastric cancer on a U.S. population with a relatively limited number of lymph nodes examined, we found stages IB and IIA, as well as IIB and IIIA to perform similarly. We propose a revised stage grouping for the AJCC/UICC staging system that better discriminates between outcomes.     

A Comparison of Five Competing Lymph Node Staging Schemes in a Cohort of Resectable Gastric Cancer Patients

Background

New classifications for lymph node (LN) staging have recently been proposed to improve upon the UICC/AJCC N category staging convention. Ratio-based systems and logarithmic odds (LODDS) scores are two families of novel competing staging systems. We compared UICC/AJCC staging with 5 ratio and LODDS systems in predicting overall survival (OS) in patients with resected gastric cancer.

Methods

Using a large population-based dataset, we identified 12,184 nonmetastatic resectable gastric cancer patients between 1988 and 2004. We compared each subject’s UICC/AJCC N stage with five novel staging schemes. We analyzed the OS for each method. Our comparison metric was the log-rank Chi squared statistic; larger Chi squared statistics indicate improvements in N stage discrimination.

Results

Median OS was 2.1 years (95 % CI 2.0–2.2 years), while median patient follow-up for surviving patients was 8.3 years (range, 1 month–22 years). Although all 5 staging systems were either comparable or superior to the UICC/AJCC convention, a LN ratio method outperformed others in N stage discrimination based on log-rank tests for OS. This trend was independent of the number of LNs examined.

Conclusions

Novel LN staging methods have a higher degree of discrimination utility than the UICC/AJCC N convention. These methods may have a role in reducing the prognostic impact of LN count variability. Of the systems assessed, the LN ratio system that assigns greater risk attribution to cases with <16 LNs was the best classification method to predict OS in patients with resectable gastric cancer.     

Staging of hepatocellular carcinoma: assessment of the Japanese TNM and AJCC/UICC TNM systems in a cohort of 13,772 patients in Japan

OBJECTIVE: The aims of this study were to present evidence to develop and validate the Japanese Tumor-Node-Metastasis (TNM) staging system for primary liver cancer and to compare its discriminatory ability and predictive power with those of Vauthey's simplified staging, which was adopted as the TNM staging system of the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC). SUMMARY BACKGROUND DATA: Among many staging systems for hepatocellular carcinoma, the Japanese TNM staging system and the AJCC/UICC staging system were developed based on a survival analysis of surgical patients. These 2 staging systems have not been compared in large series. METHODS: The Liver Cancer Study Group of Japan (LCSGJ) prospectively collected clinicopathologic data of 63,736 patients with primary liver cancer from 1995 to 2001. Among them, 13,772 patients received curative hepatic resection. Based on univariate and multivariate survival analyses, the Japanese TNM staging system was developed. The accuracy of the Japanese TNM staging system for predicting patient survival was compared with that of the AJCC/UICC staging system using the cross-validation method. RESULTS: The independent prognostic factors (relative risk; 95% confidence interval) were vascular or bile duct invasion (1.36;1.29-1.43), liver cirrhosis (1.26;1.20-1.32), diameter (< or =2 cm or >2 cm) (1.21;1.14-1.28), alpha-fetoprotein (1.20;1.15-1.25), single/multiple (1.18;1.12-1.23), liver damage (1.15;1.10-1.20), hepatic involvement (1.14;1.09-1.19), histologic differentiation (1.14;1.08-1.20), gross classification (1.13;1.08-1.18), and esophageal varices (1.07;1.02-1.13). Based on these results, 3 criteria (vascular or bile duct invasion, diameter, and single/multiple) were selected. Patients with none of these 3 factors were considered T1, and those with 1, 2, and 3 factors were T2, T3, and T4, respectively. The number of patients and 5-year survival rates for T1, T2, T3, and T4 were 2078, 70%; 6853, 58%; 3021, 41%; and 582, 24% (P < 0.0001), respectively, while those for the AJCC-T were 8457, 61% in T1, 2888, 46% in T2, and 1189, 30% in T3 (P < 0.0001). While both the LCSGJ-T and the AJCC-T had good discriminating ability, the former was significantly superior (P = 0.0007). CONCLUSIONS: Our findings support the development of LCSG stage. While both staging systems allow for the clear stratification of patients into prognostic groups, the LCSGJ staging may be more appropriate for stratifying patients with early-stage HCC.     

Outcomes of liver transplantation in 490 patients with hepatocellular carcinoma: validation of a uniform staging after surgical treatment

BACKGROUND: The aim of this study was to compare the ability of staging systems (American Joint Committee on Cancer/Union Internationale contre le Cancer [AJCC/UICC], Japanese TNM, Pittsburgh, United Network for Organ Sharing [UNOS], Cancer of the Liver Italian Program [CLIP], Japan Integrated Staging [JIS], and Barcelona Clinic Liver Cancer [BCLC]) to predict survival after liver transplantation for hepatocellular carcinoma. STUDY DESIGN: Four hundred ninety consecutive patients who underwent liver transplantation for hepatocellular carcinoma at 4 centers (1985 to 2005) were identified using a registry (US, Belgium, Germany). End points were overall (OS) and recurrence-free survival (RFS). Survival by stage was compared with the log-rank test. Sequential stage-wise discrimination of each system was evaluated using Cox regression. RESULTS: Three- and 5-year overall survival rates were 71% and 64%, respectively; recurrence-free survival rates were 67% and 61%, respectively. Median followup among 327 living and 308 recurrence-free patients was 40 months. In only three systems--AJCC/UICC, Japanese TNM, and Pittsburgh--were overall and recurrence-free survivals longer for patients with low stage versus more advanced stage. For overall and recurrence-free survivals, sequential stages were different only for AJCC/UICC. In the Japanese TNM system, stages II and I were similar; for Pittsburgh, grades 3 and 2 were similar. For the United Network for Organ Sharing system, stages II and I and stages IVA1 and III were similar. All stages were similar for the Cancer of the Liver Italian Program. For the Japan Integrated Staging, scores 2 and 1 and scores 4 and 3 were similar. In the Barcelona Clinic Liver Cancer, stage D patients had significantly better survival than patients at stage C. CONCLUSIONS: The AJCC/UICC staging system provides the best stratification of prognosis for patients undergoing liver transplantation for hepatocellular carcinoma. This confirms previous analyses in patients treated with hepatic resection. The AJCC/UICC staging system should be considered for uniform prediction of outcomes after surgery for hepatocellular carcinoma.     

The ability of the American Joint Committee on Cancer Staging system to predict progression-free survival after radical prostatectomy

OBJECTIVE: To examine, in a retrospective analysis of outcome based on prostate-specific antigen (PSA) levels, whether the 1992 and revised 1997 staging criteria for prostate cancer can be used to predict progression-free survival for patients after radical prostatectomy for pT2 and pT3 prostate cancer. PATIENTS AND METHODS: In all, 291 patients with a PSA determination during a 6-month interval after radical prostatectomy were analysed (mean follow-up 5.2 years). In the absence of a uniform system of pathological staging, the histopathological stage was defined according to the 1992 and 1997 American Joint Cancer Committee/Union Internationale Contre le Cancer (AJCC/UICC) tumour-nodes-metastases (TNM) staging classification. Findings were correlated with the PSA value after surgery. The subgroups of pT2 and pT3 disease were compared for the time to PSA progression, using Kaplan-Meier data analysis and the log-rank test. RESULTS: The biochemical progression-free 5-year survival rates for stage pT2 were 83% (pT2a), 81% (pT2b) and 62% (pT2c); there were no significant differences in the pT2 subgroups. The recurrence-free rates for pT3 were 79% (pT3a), 65% (pT3b) and 50% (pT3c); the actuarial recurrence-free rate was significantly different for patients with 1997 AJCC pT3a vs pT3b disease (P=0.0132). There was no significant difference in the 1992 AJCC stages pT2a vs pT2b (P=0.1232) and the recurrence-free rate was not significantly different for patients with 1992 AJCC pT3a vs pT3b disease (P=0.9). There was a significant difference in the likelihood of a PSA relapse between patients with positive and negative surgical margins (P=0.131). CONCLUSION: These results support the current revised 1997 AJCC/UICC staging system for prostate cancer. There is an urgent need to develop a pathological equivalent to the AJCC/UIC TNM clinical staging system. Greater clinical input and evaluation from different institutions are essential to reach consensus on pathological staging categories that maximize the predictability of outcome after definitive therapy. Crucial issues are the definition and quantification of extraprostatic extension and definition of surgical margin categories.     

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。