Journal Thoracic Oncology

Abstracts Journal of Thoracic Oncology • Volume 12 Issue S1 January 2017
ED05: THE 8TH EDITION OF THE TNM STAGING SYSTEM
MONDAY, DECEMBER 5, 2016 - 16:00-17:30
ED05.04 WHAT’S NEW IN ESOPHAGEAL CANCER STAGING?
Thomas Rice
Thoracic and CV Surgery, Cleveland Clinic, Cleveland/OH/United States of America
References 1. Detterbeck FC, Nicholson AG, Kondo K, Van Schil P, Moran C.
The Masaoka-Koga Stage Classification for Thymic Malignancies Clarification
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Monden Y, Nakahara K, Tanioka T. Follow-up study of thymomas with special
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FC, Parsons AM. Thymic tumors. Ann Thorac Surg 2004;77:1860-9. 4. Kondo
K, Monden Y. Therapy for thymic epithelial tumors: a clinical study of 1,320
patients from Japan. Ann Thorac Surg 2003;76:878–84. 5. Koga K, Matsuno
Y, Noguchi M, et al. A review of 79 thymomas: modification of staging system
and rappraisal of conventional division into invasive and non-invasive
thymoma. Pathol Int 1994;44:359–67. 6. Detterbeck FC, Stratton K, Giroux
D, et al. The IASLC/ITMIG Thymic Epithelial Tumors Staging Project: Proposal
for an Evidence-Based Stage Classification System for the Forthcoming (8th)
Edition of the TNM Classification of Malignant Tumors. J Thorac Oncol. 2014;9:
S65–S72 7.Nicholson AG, Detterbeck FC, Marino M, et al.,The ITMIG/IASLC
Thymic Epithelial Tumors Staging Project: Proposals for the T component
for the Forthcoming (8th) Edition of the TNM Classification of Malignant
Tumors. J Thorac Oncol. 2014;9: S73–S80 8. Kondo K, Schil PV, Detterbeck FC,
et al. The IASLC/ITMIG Thymic Epithelial Tumors Staging Project: Proposals
for the N and M Components for the Forthcoming (8th) Edition of the TNM
Classification of Malignant Tumors. J Thorac Oncol. 2014;9: S81-S87 9. Bhora
FY, Chen DJ, Detterbeck FD,et al., The ITMIG/IASLC Thymic Epithelial Tumors
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Keywords: Thymoma, TNM Staging System, Thymic carcinoma
What’s New in Esophageal Cancer Staging? Thomas W. Rice, MD The 8th
edition cancer staging manuals will be published later this year, 1,2 and the
new staging recommendations will go into effect January 1, 2017. Staging
cancer of the esophagus and esophagogastric junction for the 8th edition of
the AJCC/UICC manuals was developed on a strong 7th edition foundation. 3,4
A greatly enhanced Worldwide Esophageal Cancer Collaboration (WECC)
database, with a substantial increase in both numbers of patients (22,654)
entered and variables (39) collected, 5-7 permitted a more dynamic and
dependable Random Forest–based machine learning analysis. Random
Forest analyses provided risk-adjusted survival estimates for all patients,
from which distinctive and homogeneous stage groups with monotonically
decreasing survival were identified. 8-10 Cancer Categories There were no
major changes in cancer categories; however, there were some important
refinements for T, N, grade, and location. Subcategorization of pT1 into pT1a
and pT1b enhanced and improved Stage I grouping. Regional lymph nodes
(N) were clarified in a new and simplified map. Undifferentiated cancers now
require additional analyses to expose histopathologic cell type. If glandular
origin can be determined, the cancer is staged as Grade 3 adenocarcinoma; if
squamous origin can be determined or if the cancer remains undifferentiated
after full analysis, it is staged as Grade 3 squamous cell carcinoma. Cancer
location, not important for adenocarcinoma stage grouping, in conjunction
with grade is necessary to subgroup only pT3N0M0 squamous cell carcinoma.
The definition of the esophagogastric junction was revised; cancers
involving the esophagogastric junction with epicenters 2 cm or less into
the gastric cardia are staged as adenocarcinomas of the esophagus, while
those with more than 2-cm involvement are staged as stomach cancers.
Stage Groupings Pathologic Stage Grouping (pTNM) Historically, pathologic
stage after esophagectomy alone has been the sole basis for all cancer
staging, regardless of classification (c, yc, yp, r, and a). Today, pathologic
stage has lost some of its clinical relevance for advanced-stage cancer as
neoadjuvant therapy replaces esophagectomy alone. However, it remains
important for early-stage cancers and as a key reference point. Dissimilar
stage group composition and survival profiles necessitated separate staging
groupings for adenocarcinoma and squamous cell carcinoma. Neoadjuvant
Pathologic Stage Grouping (ypTNM) New to the 8th edition is stage grouping
of patients with esophageal cancers who have had neoadjuvant therapy
and pathologic review of the resection specimen (ypTNM). Drivers of this
addition include absence of equivalent pathologic (pTNM) categories for the
peculiar neoadjuvant pathologic categories (ypT0N0-3M0 and ypTisN0-3M0),
dissimilar stage group compositions, and markedly different survival profiles.
Grade and location play no role in neoadjuvant pathologic stage grouping.
The groupings are identical for both histopathologic cell types. Clinical
Stage Grouping (cTNM) Also new to the 8th edition is clinical stage grouping
(cTNM) prior to treatment decision. Clinical staging is done typically in the
absence of complete histologic cancer data, because clinical TNM categories
are typically defined by imaging and examination of needle aspiration and
biopsy specimens. Dissimilar stage group composition and survival profiles
necessitated clinical stage grouping (cTNM) distinct from pathologic stage
grouping (pTNM). There is separate clinical staging for adenocarcinoma and
squamous cell carcinoma. How to proceed with TNM-8? 8th edition staging
for cancer of the esophagus and esophagogastric junction are data driven and
expanded from pathologic stage (pTNM) to include also pathologic stage after
neoadjuvant therapy (ypTNM) and clinical stage (cTNM) before treatment
decision. Critical evaluation of 8th edition staging, intensive data collection,
in-depth analyses, and further consensus appraisal are necessary to proceed
from the 8th to the 9th edition.References 1) American Joint Committee on
Cancer Staging Manual. 8th ed. In press. 2) TNM classifications of malignant
tumors. International Union Against Cancer. 8 th ed. In press. 3) Edge SB,
Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. American
Joint Committee on Cancer Staging Manual. 7th ed. New York: Springer-
Verlag; 2010. 4) Sobin LH, Gospodarrowicz MK, Wittekind C, editors. TNM
classifications of malignant tumors. International Union Against Cancer. 7th
ed. Oxford, England: Wiley-Blackwell; 2009. 5) Rice TW, Chen L-Q, Hofstetter
WL, et al. Worldwide Esophageal Cancer Collaboration: pathologic staging
data. Dis Esophagus. In press. 6) Rice TW, Lerut TEMR, Orringer MB, et al.
Worldwide Esophageal Cancer Collaboration: neoadjuvant pathologic staging
data. Dis Esophagus. In press. 7) Rice TW, Apperson-Hansen C, DiPaola LM,
et al. Worldwide Esophageal Cancer Collaboration: clinical staging data.
Dis Esophagus. In press. 8) Rice TW, Ishwaran H, Hofstetter WL, Kelsen DP,
Blackstone EH. Recommendations for pathologic staging (pTNM) of cancer of
the esophagus and esophagogastric junction for the 8th edition AJCC/UICC
staging manuals. Dis Esophagus. In press. 9) Rice TW, Ishwaran H, Kelsen DP,
Hofstetter WL, Blackstone EH. Recommendations for neoadjuvant pathologic
staging (ypTNM) of cancer of the esophagus and esophagogastric junction for
the 8th edition AJCC/UICC staging manuals. Dis Esophagus. In press. 10)Rice
TW, Ishwaran H, Blackstone EH, Hofstetter WL, Kelsen DP. Recommendations
S16 Journal of Thoracic Oncology • Volume 12 Issue S1 January 2017