Ajcc esophageal cancer staging manual

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Of the American Joint Committee on Cancer. The Eighth Edition of the AJCC Cancer Staging Manual published in October is a compendium of all currently available information on the staging of adult cancers for all clinically important anatomic sitesIt builds on a rich historical legacy of dynamic vision international synergy and the robust principles of cancer.

However, staging for the 7th edition used Random Forest RF analysis, a machine-learning technique that focuses on predictiveness for future patients. RF analysis first isolated cancer characteristics of interest from other factors influencing survival by generating risk-adjusted survival curves for each patient. Unlike previous approaches that began by placing cancer characteristics into proposed groups, RF analysis produced distinct groups with monotonically decreasing risk-adjusted survival without regard to cancer characteristics.

Then anatomic and nonanatomic cancer characteristics important for stage group composition were identified within these groups. Homogeneity within groups guided both amalgamation and segmentation of cancer characteristics between adjacent groups to arrive at the proposed stage groups. T classification has been changed for Tis and T4 cancers Table 1.

Tis is now defined as high-grade dysplasia and includes all noninvasive neoplastic epithelium that was previously called carcinoma-in-situ. T4, tumors invading local structures, have been subclassified as T4a and T4b.

T4a tumors are resectable cancers invading adjacent structures such as pleura, pericardium, or diaphragm. T4b tumors are unresectable cancers invading other adjacent structures, such as aorta, vertebral body, and trachea. A regional lymph node has been redefined to include any paraesophageal node extending from cervical nodes to celiac nodes Table 1. Distant metastases are simply designated M0, no distant metastasis, and M1, distant metastasis.

Nonanatomic classifications identified as important for stage grouping were histopathologic cell type, histologic grade, and tumor location Table 1.

The difference in survival between adenocarcinoma and squamous-cell carcinoma was best managed by separate stage groupings for stages I and II. Increasing histologic grade was associated with incrementally decreasing survival for early-stage cancers. For adenocarcinoma, the distinction of G1 and G2 well and moderately differentiated from G3 poorly differentiated was important for stage I and stage IIA cancers. Tumor location upper and middle thoracic vs.

Stage groupings and corresponding risk-adjusted survival curves are presented in Tables 2 and 3 and Figs. T is categorized as Tis: high-grade dysplasia HGD. T1 is cancer that invades the lamina propria, muscularis mucosae, or submucosa and is subcategorized into T1a cancer that invades the lamina propria or muscularis mucosae and T1b cancer that invades the submucosa ; T2 is cancer that invades the muscularis propria; T3 is cancer that invades the adventitia; T4 is cancer that invades the local structures and is subcategorized as T4a cancer that invades adjacent structures such as the pleura, pericardium, azygos vein, diaphragm, or peritoneum and T4b cancer that invades the major adjacent structures, such as the aorta, vertebral body, or trachea.

N is categorized as N0 no regional lymph node metastasis , N1 regional lymph node metastases involving one to two nodes , N2 regional lymph node metastases involving three to six nodes , and N3 regional lymph node metastases involving seven or more nodes. M is categorized as M0 no distant metastasis and M1 distant metastasis. Regional lymph nodes N , which are found in the adventitia periesophageal tissue from the upper esophageal sphincter to the celiac artery, are clarified in a new map Fig.

The seventh edition map was problematic because it included lung lymph node stations, some of which were not regional esophageal nodes. Lymph node maps for esophageal cancer. Regional lymph node stations for staging esophageal cancer from the left A , right B , and anterior C. The nonanatomic cancer category grade is important for pathologic staging pTNM of early-stage cancers see Table 1.

Undifferentiated cancers require additional analyses to expose a histopathologic cell type. If glandular origin can be determined, the cancer is staged as a grade 3 adenocarcinoma; if a squamous origin can be determined or if the cancer remains undifferentiated after full analysis, it is staged as a grade 3 squamous cell carcinoma see Table 1.

Cancer location is not important for adenocarcinoma staging, but in conjunction with grade it is necessary to subgroup pT3N0M0 squamous cell carcinoma. The definition of the esophagogastric junction is revised such that cancers involving it with epicenters no more than 2 cm into the gastric cardia are staged as adenocarcinomas of the esophagus and those with more than 2-cm involvement of the gastric cardia are staged as stomach cancers Fig.

This was considered by the AJCC Upper Gastrointestinal Expert Panel as a placeholder until comprehensive genomic analysis could identify cell of origin rather than arbitrary measurement locations. Location of esophageal cancer primary site, including typical endoscopic measurements of each region measured from the incisors. Exact measurements depend on body size and height. Location of cancer primary site is defined by cancer epicenter.

Historically, pathologic stage grouping after esophagectomy alone has been the sole basis for all cancer staging. Today, pathologic staging is losing its clinical relevance for advanced-stage cancer as postneoadjuvant therapy replaces esophagectomy alone.

However, it remains relevant for early-stage cancers and as an important staging and survival reference point. Stage subgroups increased from nine in the seventh edition to 10 in the eighth Fig. A Pathologic stage groups pTNM : adenocarcinoma. B Pathologic stage groups pTNM : squamous cell carcinoma. In the eighth edition, there is no net change in the number of stage subgroups; there is, however, significant rearrangement and renaming Fig.

New to the eighth edition is stage grouping of patients with esophageal cancers who have undergone postneoadjuvant therapy and had pathologic review of the resection specimen Fig. Drivers of this addition include absence of equivalent pathologic pTNM categories for the peculiar postneoadjuvant pathologic categories ypT0NM0 and ypTisNM0 , dissimilar stage group compositions, and markedly different survival profiles. Postneoadjuvant pathologic stage groups ypTNM : adenocarcinoma and squamous cell carcinoma.

The groups are identical for both histopathologic cell types. Grade is not included in postneoadjuvant pathologic staging. Ann Cardiothorac Surg. Thomas W. Rice , 1 Deepa T. Patil , 2 and Eugene H. Blackstone 1, 3. Deepa T. Eugene H. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Correspondence to: Thomas W. Rice, MD.

Email: gro. Received Dec 8; Accepted Mar 7. Copyright Annals of Cardiothoracic Surgery. All rights reserved. This article has been cited by other articles in PMC. Keywords: Clinical stage, pathologic stage, postneoadjuvant stage, decision-making, prognostication, precision cancer care.

Table 1 Cancer staging categories for cancer of the esophagus and esophagogastric junction. Prominent keratinization with pearl formation and a minor component of nonkeratinizing basal-like cells. Tumor cells are arranged in sheets, and mitotic counts are low G2 Moderately differentiated.

Variable histologic features, ranging from parakeratotic to poorly keratinizing lesions. Consists predominantly of basal-like cells forming large and small nests with frequent central necrosis.

Open in a separate window. Table 2 Clinical cTNM stage groups. Applications of 8th edition clinical staging cTNM to clinical practice Clinical staging is limited by resolution of imaging methods.

Location cL Assessment of cancer location cL made during esophagoscopy is crucial 1. Histologic cell type Biopsy is mandatory and is the principal means of determining cell type. Box 1 Registry data collection variables. Clinical staging: decision-making Clinical staging facilitates decision-making and has the potential to provide precision cancer care. Table 3 Pathologic pTNM stage groups. Applications of 8th edition pathologic staging pTNM to clinical practice Resection Before resection, the surgeon or endoscopist must confirm the epicenter of the cancer pL.

Handling of resection specimen Accurate pathologic staging requires careful examination of the gross specimen for cancer size, shape, configuration, location, distance from margins proximal, distal, and radial , and nodal dissection. Pathologic staging: decision-making Theoretically, pathologic staging could facilitate decision-making and has the potential to provide precision cancer care in the post-esophagectomy period.

Pathologic staging: prognostication Survival according to pTNM stage group was the best distributed of all classifications, with monotonically decreasing survival with increasing subgroup and group, except for stage group 0, which by AJCC definition was limited to pTis.

Table 4 Postneoadjuvant therapy ypTNM stage groups. Applications of 8th edition postneoadjuvant staging ypTNM to clinical practice Resection Just as for pTNM, adequate resection with preservation of margins and adequate lymphadenectomy are essential.

Handling of resection specimen Gross appearance of a cancer may vary depending on response to neoadjuvant therapy. Postneoadjuvant staging: decision-making The role of ypTNM in additional treatment planning is currently limited. Postneoadjuvant staging: prognostication With the introduction of 8th edition ypTNM cancer staging, prognostication is specific for patients undergoing neoadjuvant therapy and is not shared with any other classification. Acknowledgements None.

Footnotes Conflicts of Interest: The authors have no conflicts of interest to declare. References 1. Esophagus and esophagogastric junction. New York: Springer, Worldwide Esophageal Cancer Collaboration : pathologic staging data. Dis Esophagus ; 29 Worldwide Esophageal Cancer Collaboration : clinical staging data. Worldwide Esophageal Cancer Collaboration : neoadjuvant pathologic staging data.

Dis Esophagus ; Cancer Genome Atlas Research Network Comprehensive molecular characterization of gastric adenocarcinoma.

Nature ; Oesophageal adenocarcinoma and gastric cancer: should we mind the gap? Nat Rev Cancer ; 16 Squamous cell carcinoma of the oesophagus. Lyon: International Agency for Research on Cancer, Adenocarcinoma of the oesophagus. Signet-ring cell or mucinous histology after preoperative chemoradiation and survival in patients with esophageal or esophagogastric junction adenocarcinoma. Clin Cancer Res ; 11 A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma.

Gut ; 49 Ann Surg ; Endoscopic ultrasound predicts outcomes for patients with adenocarcinoma of the gastroesophageal junction. J Am Coll Surg ; Prospective comparison of endosonography, computed tomography, and histopathological stage of junctional oesophagogastric cancer. Clin Radiol ; 63 High-frequency endoscopic ultrasonography in the evaluation of superficial esophageal cancer.

Endoscopy ; 35 ; discussion Staging accuracy of esophageal cancer by endoscopic ultrasound: a meta-analysis and systematic review. World J Gastroenterol ; 14 T2N0M0 esophageal cancer.

J Thorac Cardiovasc Surg ; Treatment of clinical T2N0M0 esophageal cancer. Ann Surg Oncol ; 21 Correlation between endoscopic forceps biopsies and endoscopic mucosal resection with endoscopic ultrasound in patients with Barrett's esophagus with high-grade dysplasia and early cancer.

Surg Endosc ; 31 Endoscopy ; 47 Endoscopic submucosal dissection for Barrett's early neoplasia: a multicenter study in the United States. Gastrointest Endosc Principles of Cancer Staging. Quality control of endoscopic ultrasound in preoperative staging of esophageal cancer. Endoscopy ; 39 Diagnosis and staging of carcinoma of the esophagus and gastroesophageal junction, and detection of postoperative recurrence, by computed tomography.

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