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1. Ajcc 8th Edition Staging Forms
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Oct 19, 2017 - In the United States, colorectal cancer (CRC) is the third most common. Time in the 5th edition of the AJCC Cancer Staging Manual, classifying. The 7th edition of the AJCC Cancer Staging Manual (AJCC-7) includes substantial changes for colon cancer (CC), which are particularly complex in patients with stage II and III disease. We used a national cancer database to determine if these changes improved prediction of survival. AJCC CANCER STAGING MANUAL 8TH EDITION. •Comprehend & define basic AJCC cancer staging. Only 5 regional LN removed at colon resection & all are.

AIM: To verify that the T stage has greater weight than the N stage in the staging of colorectal cancer. METHODS: Open data from the Surveillance, Epidemiology, and End Results program were reviewed and analyzed according to the T stage, N stage, and patients’ observed survival (OS). The relative weights of the T and N stages were calculated by multiple linear regressions based on their impact on survival. Risk scores for 25 TN categories were then calculated from the T and N stage relative weights, and a rearranged tumor node metastasis (TNM) staging system was proposed via a cluster analysis of the TN scores. RESULTS: Both T and N stages significantly affect the OS of patients with colorectal cancer. Moreover, the T stage has greater weight than the N stage in the TNM staging system of colorectal cancer.

For colon cancer, the relative T and N stage weights were 0.58 and 0.42, respectively, and for rectal cancer, the relative T and N stage weights were 0.61 and 0.39, respectively. On the basis of cluster analysis of the TN scores, T1N1a was classified to stage I, and T2N1a-1b and T1N1b-2a were classified to stage II in our revised TNM staging system for both colon and rectal cancer. For colon cancer, T4bN0 was classified to stage IIIa, but for rectal cancer, it was classified to stage IIIb. CONCLUSION: As the T stage affects colorectal cancer survival more significantly than the N stage, the TNM staging should be revised by relative T stage weight. Core tip: The 7 th edition of the American Joint Committee on Cancer (AJCC) tumor node metastasis (TNM) staging system for colorectal cancer can not predict survival linearly by stage.

We propose that the T stage has greater weight than the N stage, more especially in rectal cancer than in colon cancer. Moreover, in this article, we propose a revised scheme for the 7 th edition of the AJCC TNM staging system. In our revised scheme, T4bN0 is classified to stage IIIa in colon cancer, but to stage IIIb in rectal cancer. This is the first attempt to revise the established TNM staging system for colorectal cancer by shaking the keystone of present classification based on the lymph nodes status. INTRODUCTION The American Joint Committee on Cancer (AJCC) tumor node metastasis (TNM) staging system is widely used to predict the prognosis for patients with colorectal cancer and to guide adjuvant therapy after potentially curative surgery. The 7 th edition of the AJCC TNM staging system was published in 2010.

Ajcc 8th Edition Staging Forms

Patients with colorectal cancer, which directly invades or is adherent to other organs or structures, have poorer prognoses. As a result, stage T4 was stratified to T4a and T4b, and patients with T4bN0 lesions were reclassified from stage IIb to IIc. Similarly, T1-2N2 was moved from stage IIIc to IIIa/IIIb.

These changes reflect the fact that the T stage affects survival in colorectal cancer patients more significantly than previously believed. The most obvious drawback of the AJCC TNM staging system is that the relative weighting of the N stage is over-estimated. Except for patients in stage IV, all patients with lymph node involvement are defined as stage III. However, data from the Surveillance, Epidemiology, and End Results (SEER) program has shown that the 5-year observed survival (OS) of stage IIIa patients (T1-2N1 and T1N2a) matches that of stage I patients,.

On the other hand, stage IIc patients have a poorer prognosis, equivalent to that of stage IIIb patients (Figure ). In other words, the 7 th edition of the AJCC TNM staging system fails to predict survival linearly by stage. In a study in which survival data for 1165 Japanese colorectal cancer patients were calculated according to 7 th edition of the AJCC TNM staging system, it was found that after stage I, patients in stage IIIa unexpectedly showed the best prognosis.

Figure 1 Relationship between survival of colorectal cancer patients and stages of the American Joint Committee on Cancer 7 th edition tumor node metastasis staging system. A: The 5-year observed survival rate of colorectal cancer patients according to 25 combinations of T and N stages of the American Joint Committee on Cancer (AJCC) 7 th edition tumor node metastasis (TNM) staging system; B: The median 5-year observed survival rate of colorectal cancer patients for overall stages (I, II, IIIa, IIIb and IIIc) according to the 7 th edition of the AJCC TNM staging system.

Colon cancer is represented by the solid black grids. Rectal cancer is represented by the white grids (Surveillance, Epidemiology, and End Results open data). As we were concerned that the T stage may have a greater impact on the survival of colorectal cancer patients following potentially curative surgery than that proposed in the updated 7 th edition of the AJCC TNM staging system, we analyzed open SEER data further to clarify the impact of different T and N stage weights on survival. In doing so, we propose a revised scheme for the 7 th edition of the AJCC TNM staging system. MATERIALS AND METHODS Open SEER population-based data from 1992 to 2004 were reviewed, and data on colon cancer and rectal cancer were analyzed separately.

Patients with stage 0 and IV disease were excluded from the study. 5-year OS rate data were extracted according to 25 combinations of the T stage (1 = T1, 2 = T2, 3 = T3, 4 = T4a, and 5 = T4b) and N stage (0 = N0, 1 = N1a, 2 = N1b, 3 = N2a, and 4 = N2b). Stage N1c (tumor deposit) was also excluded from the study because no data were available. As T and N stage scores are independent variables, and 5-year OS rates are dependent variables, three-dimensional (3D) scatter plots were constructed to demonstrate the relationships of the T stage, N stage and OS. In addition, multiple linear regressions were calculated to elucidate the quantitative relationships of these parameters.

For example: OS = (c-b 1× T - b 2× N) × 100% where c is the survival constant, and b 1 and b 2 are the mean coefficients of regression of T and N. According to the coefficients of regression, we get: αOS/αT = b 1, αOS/αN = b 1 This means that when the T stage changes by one unit, the relative influence on OS is b 1, and when the N stage changes by one unit, the relative influence on OS is b 2. Therefore, the relative influence on OS of the T stage and N stage is b 1:b 2. Since OS is only influenced by 2 indicators, T and N, according to the relative influence on OS of T and N, we can calculate the normalization weights of the indicators T and N.

For example, the weight of T is: WT = b 1/(b 1 + b 2) × 100% and the weight of N is: WN = 1 - WT. The scores of TN combinations are the scores of each stage multiplied by its weight. For example, TN scores for T4aN0 = WT × 4 + WN × 0, and TN scores for T2N2b = WT × 2 + WN × 4 (WT is the weight of T, and WN is the weight of N). This concept was derived from a comprehensive evaluation of all the available data, which balances the various indicators. Using this method, the scores of 25 TN combinations of T stage and N stage were calculated. Subsequently, we used cluster analysis (also called group analysis; a statistical analysis method for studying the classification of samples or indicators) of the TN scores to rearrange the TNM staging system. Multiple linear regressions of T stage, N stage and OS Both T and N stages significantly affect the OS of patients with colorectal cancer.

The 3D scatter plots of T and N stages and 5-year OS for colon cancer are shown in Figure and B. The multiple regression equation for colon cancer is: OS = (97.432 - 10.56T - 7.812N) × 100%. The relative weight of T = 0.58, and the relative weight of N = 0.42. These calculations indicate that the T stage affects colon cancer survival more significantly than the N stage.

Figure 2 Scatter plots for T stage, N stage and the 5-year observed survival of colorectal cancer patients. A: Highlight of the T stage of colon cancer; B: Highlight of the N stage of colon cancer; C: Highlight of the T stage of rectal cancer; D: Highlight of the N stage of rectal cancer.

The 3D scatter plots of T and N stages and 5-year OS for rectal cancer are shown in Figure and D. The multiple regression equation for rectal cancer is: OS = (99.108 - 11.356T - 7.194N) × 100%. The relative weight of T = 0.61 and the relative weight of N = 0.39. Thus, the T stage appears to have greater weight in rectal cancer than in colon cancer. TN scores and cluster analysis The 25 combinations of T and N stages and the corresponding 5-year OS of colon cancer and rectal cancer are shown in Tables and, respectively. According to the TN scores, the TNM staging system can be rearranged to stage I (TN score ≤ 1.0), stage II (1.0 4.0). The proposed TNM staging system according to these TN scores fits well with the 5-year OS of colorectal cancer patients after potentially curative surgery (Figures and ).

The summary of our proposed TNM staging system is shown in Table. Figure 3 Relationship between survival of colon cancer patients and stages of the revised tumor node metastasis staging system. A: The 5-year observed survival rate of colon cancer patients for combinations of T and N stages according to TN scores. The observed survival rate is represented by the solid black grids. TN scores are represented by the white grids; B: The median 5-year observed survival rate of colon cancer patients for the proposed tumor node metastasis (TNM) staging system according to TN scores. Figure 4 Relationship between survival of rectal cancer patients and stages of the revised tumor node metastasis staging system.

A: The 5-year observed survival rate of rectal cancer patients for combinations of T and N stages according to TN scores. The observed survival rate is represented by the grey grids. TN scores are represented by the white grids; B: The median 5-year observed survival rate of rectal cancer patients for the proposed tumor node metastasis (TNM) staging system according to TN scores. DISCUSSION The present study and Mori’s report both found that the 7 th edition of the AJCC TNM staging system cannot accurately predict the survival of patients with colorectal cancer, especially for stages IIc and IIIa.

It is easy to misinterpret the prognosis of IIc as being better than that of IIIa. This defect of the current TNM staging system originates from the inherent notion that lymph node metastases (N stage) affect the prognosis more significantly than local invasion (T stage), and this opinion is reflected in the current classification of stages II and III colorectal cancer. Although patients with T4bN0 have a lower 5-year survival rate than many stage IIIa/b patients, they are still currently classified as stage IIc. Recent data have shown that adjuvant chemotherapy improves both the progression-free survival and overall survival of patients with stage II colon cancer, implying that there must be some problems with the existing staging system, especially in the identification of stages II and III. There are 2 considerations that may be the root of the problem. Firstly, the TNM staging system traditionally relies on anatomical staging.

The current system omits survival benefit because of the advances in surgery and adjuvant therapy in recent decades. As is well known, chemotherapy with oxaliplatin and fluorouracil and adjuvant radiotherapy have significantly improved the prognosis of patients with stage II/III colorectal cancer. The data on which the 7 th edition of the AJCC staging system for colorectal cancer were based were derived from the SEER outcome data of 1998-2002, well before the findings of adjuvant trials in stages II and III became available, and they certainly do not reflect current practice and prognosis,. Secondly and more importantly, our data indicate that the weight of the N stage has been over-estimated, and that this has been accompanied by an under-estimation of the T stage. This traditional concept needs to be reconsidered and correlated with contemporary survival data. The widespread application of complete mesocolic excision (CME) and total mesorectal excision (TME) standardized colorectal cancer surgery, with their greater lymph node yields, has reduced loco-regional recurrences and thereby improved survival rates,.

On the other hand, patients with locally advanced (especially T4) tumors have a higher risk of local recurrence and peritoneal and distant metastases, resulting in poorer outcomes. The findings of the present study support the hypothesis that the weight of T stage has been under-estimated in colorectal cancer patients. The relative weights of the T and N stages were 0.58 and 0.42, respectively, in colon cancer, and 0.61 and 0.39, respectively, in rectal cancer. Kubota b14 manuals for sale.

To confirm that the T stage should carry more weight in the TNM staging system, our study calculated 25 categories of TN scores according to different T/N weightings. The survival rate decreased with increasing TN scores with good linear relationships. In addition, the proposed rearrangement of TNM stages according to the TN scores also showed good linear relationships with survival. Consequently, the traditional classification system, which relied more on the N stage, needs to be revised to place more emphasis on the T stage. It is worth noting that the T stage has even greater weight in rectal cancer than in colon cancer, which probably indicates a higher risk and worse local recurrence consequences in rectal cancer.

As a result, we propose that T4bN0 should be reclassified to stage IIIa for colon cancer, but to stage IIIb for rectal cancer. In addition, T1N1a should be reclassified to stage I, rather than stage IIIa in the 7th edition of the AJCC TNM staging system, and T2N1a-1b and T1N1b-2a should be reclassified to stage II, rather than stage IIIa in the 7 th edition of the AJCC TNM staging system.

Our proposed rearrangement of the TNM staging system reflects the significance of the T stage in colorectal cancer and abandons the rigid classification by lymph node status, similar to the TNM staging system for gastric cancer. It should be noted, however, that there may be potential biases arising from the SEER database, because the survival of patients can also be affected by factors such as surgical procedures, adjuvant therapies, and the number of lymph nodes, etc. Consequently, the reliability of our findings should be validated not only with regard to individual SEER data and other datasets, but also with regard to other staging systems, such as the 5 th edition of the TNM staging system, which is used in Europe,.

As mentioned above, patients who previously were classified as stage IIIa (T1-2N1 and T1N2a) should now be reclassified as stage I or II. As the use of adjuvant therapy remains problematic for patients with colon cancer, information on treatment approaches was omitted in our study. In this regard, there are 2 factors to be considered. Firstly, stage IIIa patients receive adjuvant therapy to improve their prognosis.

Secondly, patients who have a good prognosis do not need either adjuvant therapy or intensive adjuvant therapy. Considering that patients with both stages II and III rectal cancer previously received adjuvant radiochemotherapy, some stage IIIa patients still have a better prognosis than those in stage II. It is speculated that some stage IIIa colorectal cancer patients have a naturally good prognosis, no matter which treatment is offered.

As stage III patients traditionally receive adjuvant therapy, this issue should be clarified in future trials. The question as to how to classify tumor deposits was not considered in this study. Peri-tumor deposits first emerged as prognostic indicators in the 5 th edition of the AJCC TNM staging system in 1997. A tumor nodule 3 mm in diameter in the perirectal or pericolic adipose tissue, without histologic evidence of residual lymph node tissue, is classified as a regional lymph node metastasis (N category). A tumor nodule up to 3 mm in diameter is classified within the T category. These definitions are called the 3 mm rule. In the 6th edition of the AJCC TNM staging system published in 2002, the 3 mm rule was replaced by the contour rule.

A tumor nodule without histologic evidence of a residual lymph node is now classified within the N category if the nodule has the form and smooth contour of a lymph node. If the nodule has an irregular contour, it is classified within the T category. In the 7 th edition of the AJCC TNM staging system, the definition of tumor deposits is left to the discretion of the pathologist. Colorectal cancer with an adjacent tumor deposit but no lymph node metastasis is now classified as N1c.

The definition and classification of tumor deposits have kept changing in recent editions of TNM staging systems on the basis of expert consensus instead of high level evidence. There is some evidence to support the view that the 5 th edition of TNM staging system is the best choice to define peri-tumoral tumor deposits in colorectal cancer,. The average number of lymph nodes within the SEER dataset was not well defined.

Of the 109953 colon cancer cases in the SEER dataset, 13 or more lymph nodes were harvested in 37% of patients. As a result, it is easy to see how understaging can occur within the SEER dataset, especially for stage II patients. However, in terms of the average number of lymph nodes, the SEER dataset is equivalent to other databases.

For example, in US hospital data, more than 60% of hospitals (792/1296) failed to archive a compliance benchmark for the 12-node measure. A nationwide population-based study in the Netherlands showed that the median number of lymph nodes harvested in colon cancer was only 8. However, the latest study based on SEER data shows that the detection of fewer lymph nodes does not result in understaging. Although the proportion of patients with 12 or more lymph nodes has increased over the period 1988 to 2008 (from 34.6% in 1988-1990 to 73.6% in 2006-2008, P. Background The American Joint Committee on Cancer (AJCC) TNM staging system is widely used to predict the prognosis for patients with colorectal cancer and to guide adjuvant therapy after potentially curative surgery. The 7 th edition of the AJCC TNM staging system for colorectal cancer, which was published in 2010, cannot predict survival linearly by stage.

For example, the 5-year observed survival of stage IIIa patients (T1-2N1 and T1N2a) matches that of stage I patients. On the other hand, stage IIc patients have a poorer prognosis, equivalent to that of stage IIIb patients. Innovations and breakthroughs Authors found that for colon cancer, the relative T and N stage weights were 0.58 and 0.42, respectively, and for rectal cancer, the relative T and N stage weights were 0.61 and 0.39, respectively.

It appears that T stage has greater weight in rectal cancer than in colon cancer (which would be consistent with the greater risk of local recurrence seen with rectal cancer). Moreover, the authors propose a revised scheme for the 7 th edition tumor node metastasis (TNM) staging system.

Consequently, T4bN0 is classified to IIIa in colon cancer, but to IIIb in rectal cancer. It is the first try to revise established TNM staging system for colorectal cancer by shaking the keystone of lymph nodes status (N stage). Peer review The authors analyzed the relationship between the survival and stages of colorectal cancer using AJCC 7 th edition TNM staging system. They found the 7 th edition TNM staging system for colorectal cancer cannot predict survival linearly by stage, but the relative weight of T stage has more impact on patients survival based on multiple linear regression analysis.

Even the criteria used in the TNM system have varied over time according to the different editions that AJCC and UICC have released, one aim for adopting a global standard is to give an indication of prognosis and assist in the evaluation of the results of treatment. To predict the survival of colorectal cancer more accurate, more and new factors should be introduced into the evaluation system. The authors found the relative weight of T/N stage is a factor that could predict survival effectively. It is novel for TNM staging system.

TNM is the most widely used system for classifying the anatomic extent of cancer spread. The fifth edition is now completed and appears in two English language versions., In this most recent edition, most of the tumor sites have remained unchanged from the fourth edition or contain only minor changes, following the basic philosophy of maintaining stability in classification over time.

The changes and additions reflect new data on prognosis as well as new methods for assessing prognosis. Some of the changes have appeared in the TNM Supplement 1993 as proposals. Subsequent support warranted their incorporation into the classification. The major changes are as follows. The classification of nasopharyngeal carcinoma has been revised to reflect the needs of radiation oncologists, and in fact is the result of an international collaborative effort with a number of specialists in Asia who have a great deal of experience with this disease. The revision makes the classification more relevant to treatment outcome for different patient subgroups.

There is a new classification of ethmoid sinus tumors and modifications in the classifications of hypopharyngeal and salivary gland tumors. Changes in classification in malignancies of the digestive tract include an expansion in the M category of esophageal tumors, a change from location to number of involved lymph nodes in the gastric tumor classification, the elimination of the N3 category of the large intestine, and changes in the T categories of pancreatic carcinoma and the T4 classification of liver tumors. The T4 and M1 categories of lung tumors as well as the stage grouping have changes. The T categories of soft tissue sarcomas have been divided into superficial and deep tumors.

A category termed T1mic (microinvasion) has been added to the breast tumor classification. The testis tumor classification has been revised to incorporate prognostic serum markers into the stage grouping in a manner that preserves the identity of the anatomic factors while increasing the prognostic value of the classification. It also may serve as a model of how to utilize nonanatomic prognostic factors without obscuring the original building blocks of TNM. It also was the result of an international study group. Today, patients with this disease are not managed without attention to the levels of serum markers. The prognostic categories within each stage have great significance in terms of patient survival. There are changes in the classifications of prostate, kidney, and bladder tumors, and a new classification of transitional cell carcinoma of the prostatic urethra.

A new classification of gestational trophoblastic tumors uses human chorionic gonadotropin levels and duration of disease to modify the anatomic factors in determining the final 'stage.' It is the result of an International Federation of Gynecology and Obstetrics (FIGO) study.

A new fallopian tube classification is included and is identical to the FIGO classification. Furthermore, modifications by FIGO to the classifications for the vulva and cervix uteri have been adopted in the continuing effort to keep FIGO and TNM classifications identical.

Ajcc 8th Edition Staging Breast

The classification of brain tumors adopted in the fourth edition has been deleted in this edition because it has not proved to be particularly useful as a predictor of outcome. Tumor size (T) appears to be much less important than tumor histology and location. Patient age, function and neurologic status, and extent of resection also are considered strong prognostic factors. The classification of pediatric tumors has been excluded because of the variety of approaches to classify these tumors. The classifications used by cooperative research groups are available for those interested in the subject.

As with the fourth edition of TNM, the entire International Union Against Cancer classification (criteria, notation, and stage grouping) is identical to that published by the American Joint Committee on Cancer. This is the result of the intent to have only one standard and reflects the collaborative efforts made by all national TNM committees to achieve uniformity in this field. Furthermore, the chapters on gynecologic tumors contain the same classification criteria and stage grouping as those formulated by FIGO. To avoid ambiguity, the authors encourage users to cite the year of the TNM publication they have used in their list of references.