The American Joint Committee on Cancer (AJCC) staging manual has become the benchmark for classifying patients with cancer, defining prognosis, and determining the best treatment approaches. Many view the primary role of the tumor, lymph node, metastasis (TNM) system as that of a standardized classification system for evaluating cancer at a population level in terms of the extent of disease, both at initial presentation and after surgical treatment, and the overall impact of improvements in cancer treatment. The rapid evolution of knowledge in cancer biology and the discovery and validation of biologic factors that predict cancer outcome and response to treatment with better accuracy have led some cancer experts to question the utility of a TNM-based approach in clinical care at an individualized patient level. In the Eighth Edition of the AJCC Cancer Staging Manual, the goal of including relevant, nonanatomic (including molecular) factors has been foremost, although changes are made only when there is strong evidence for inclusion. The editorial board viewed this iteration as a proactive effort to continue to build the important bridge from a "population-based" to a more "personalized" approach to patient classification, one that forms the conceptual framework and foundation of cancer staging in the era of precision molecular oncology. The AJCC promulgates best staging practices through each new edition in an effort to provide cancer care providers with a powerful, knowledge-based resource for the battle against cancer. In this commentary, the authors highlight the overall organizational and structural changes as well as "what's new" in the Eighth Edition. It is hoped that this information will provide the reader with a better understanding of the rationale behind the aggregate proposed changes and the exciting developments in the upcoming edition. CA Cancer J Clin 2017;67:93-99. 2017 American Cancer Society.
Evidence-based anatomic staging is the critical factor to understanding cancer and treating patients. New breakthroughs in oncologic, radiologic, pathologic, and molecular science are opening up ever-more promising possibilities for precisely defining a prognosis and recommending a treatment based on a patient's individual data.
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The American Joint Committee on Cancer (AJCC) has created a set of resource materials designed to provide in-depth information for doctors, medical professionals staging cancer patients, and cancer registrars abstracting cancer cases.
The 8th Edition Cancer Staging Manual brings together all the currently available knowledge on staging of cancer at various anatomic sites. This can be purchased as a hardcover or as a Kindle e-book.
The American Joint Committee on Cancer (AJCC) was established in 1959 to formulate and publish systems of classification of cancer, including staging and end-results reporting, that will be acceptable to and used by the medical profession for selecting the most effective treatment, determining prognosis, and continuing evaluation of cancer control measures. The AJCC is composed of 18 member organizations, and its activities are administered by the Chicago-based American College of Surgeons.
The American Joint Committee on Cancer (AJCC) recently released the eighth edition of the AJCC Cancer Staging Manual. This edition incorporates significant changes in a manual that is now approximately 1,000 pages in length. The AJCC member organizations worked together to devise a comprehensive format revision to provide consistency throughout an expanded list of chapters, and new organ sites have been added to the text, as well. Several chapters introduce additional non-anatomic prognostic variables into staging schemes to increase the relevancy of the stage with regard to prognosis and defining optimal therapy.
Coordinating the implementation for a new staging system is critically important to ensure that all partners in patient care and cancer data collection are working in synchrony. Implementation was originally scheduled for January 1, 2017. However, to ensure that the cancer care community has the necessary infrastructure in place to successfully implement the new standards, compliance with the eighth edition cancer staging system has been delayed until January 1, 2018. The decision to delay implementation resulted from discussions between the AJCC Executive Committee, the National Cancer Institute, Centers for Disease Control and Prevention, the College of American Pathologists, the National Comprehensive Cancer Network, the National Cancer Database, and the Commission on Cancer.
The eighth edition attempts to more fully synthesize stage groupings with relevant variables identified from multiple data sets based on registries and clinical trials. For example, after reviewing hundreds of publications, the Breast Expert Panel decided to include estrogen receptor and progesterone receptor status, HER-2 status, and grade into the creation of a prognostic stage, combined with traditional tumor, node, and metastases (TNM) variables as defined in Anatomic Stage. Information from multi-gene panels was incorporated for patients with T1-2N0M0, ER-positive, HER2-negative tumors. With these eight variables (T, N, M, grade, ER, PR, HER-2, and multi-gene panel score), the complexity of staging increased, creating several hundred possible combinations. Other noteworthy changes included the elimination of lobular carcinoma in situ as a breast cancer diagnosis.
Cancer staging provides critical information for patients and treating physicians to battle against cancer, predict prognosis, and guide treatment decisions. The American Joint Committee on Cancer (AJCC) staging system uses a tumor, node, metastasis (TNM) scoring algorithm and is the foremost classification system for adult cancers. This system is updated every 6 to 8 years to allow sufficient time for implementation of changes and for relevant examination and discussion of data validating those changes in staging.
The 8th edition of the American Joint Committee on Cancer (AJCC) Staging Manual has been in use for approximately 3 years.1 Developed by the joint efforts of AJCC and the Union for International Cancer Control, this newest edition is a compendium of all available information for staging adult cancers of clinically important anatomic sites, representing the standard of defining prognosis, determining treatment approaches, and providing basis for understanding population cancer incidence changes. Like its previous versions, the 8th edition continues to use the tumor, node, metastasis (TNM) scoring system, where the size and extent of primary tumor (T), involvement of regional lymph nodes (N), and the presence or absence of distant metastases (M) are basic measurements to stratify cancer stages.2 Those parameters are modified in response to updated clinical and pathologic data, improved understanding of cancer biology, or newly identified biologic factors affecting prognosis. Thus, refining and revising those factors to provide the best possible staging system is a never-ending process. Dedicated efforts from all health professionals are continuously validating those changes while investigating new measurements that can better predict cancer outcome and treatment response.
Hepato-pancreato-biliary (HPB) cancers are relatively rare. The complex anatomy surrounding those organs often requires technically demanding surgery. Improving the cancer staging system is particularly critical, correlating directly with high-quality surgery, accurate pathologic analysis, and reliable follow-up after treatment.3 For HPB cancer, the revisions are largely based on single-institution series from centers of excellence in both surgery and pathology, some of which have been validated at other centers of excellence. A big and unified change in the 8th edition is the harmonized N category for cancers of gallbladder, perihilar bile ducts, distal bile duct, ampulla, and exocrine pancreas, where N1 is now uniformly defined as metastasis to 1 to 3 lymph nodes and N2 as metastasis to 4 or more lymph nodes. In addition, subjective measurements such as size of tumor, depth of invasion (DOI), vascular invasion, and involvement of large vessels are generally given more distinguishing power on staging purposes compared with the previous editions. Are those changes implemented better in practice? The aim of this review is to provide a concise summary of changes/updates from the 8th edition of the AJCC staging manual in HPB cancers and review literature that validates those changes after 3 years' application in practice.
Hepatocellular carcinoma (HCC) is the most common primary malignancy in the liver, the fifth most common malignancy worldwide, and the third most common cause of cancer-related deaths globally.4,5 Current treatment choices include hepatic resection, liver transplantation, radiofrequency ablation, and transcatheter arterial chemoembolization, yet optimal management remains controversial owing to the heterogeneity of HCC and underlying diseases attributable to different risk factors such as viral hepatitis, metabolic disorders, or toxins.6,7 Given the considerable geographic and institutional variations, there are currently many different staging and scoring systems developed for HCC,8 among which the AJCC TNM staging system is widely accepted and is the most frequently used.
Currently AJCC cancer staging for all solid tumors is based on anatomic measurements. Molecular information is not yet incorporated. A recent study identified differentially expressed stage-specific genes in HCC, which may enhance our understanding of the molecular determinants of HCC progression and serve as biomarkers that potentially underpin diagnosis as well as pinpointing therapeutic targets.14
Gallbladder cancer (GBC) is the most common biliary tract malignancy, relatively rare in Western countries but a substantial health issue in certain regions of the world.40 It usually presents at a late stage, as there are no specific symptoms in its early stages. The 5-year survival rate is estimated to be 5%.40,41 Compared with other HPB cancers, the 8th edition AJCC cancer staging system for GBC did not change dramatically, but continued to use the layer-based approach for T classification, with slight changes for T2, where tumors involving the perimuscular tissue on the peritoneal side are T2a and those on the hepatic side are T2b, as the latter were found to be associated with lower survival rates.41,42 For N category, the 8th edition adopted the unified number-based approach,43 where N1 is designated as metastasis in 1 to 3 lymph nodes and N2 as metastasis in 4 or more lymph nodes (Table 5). Metastases to celiac, superior mesenteric, and peripancreatic lymph nodes, previously N2 in the 7th edition, are now considered distant metastasis (M1) in the 8th edition. To avoid underestimation of disease stage, especially in node-positive patients, a minimum of 6 lymph nodes to be harvested for histologic evaluation is recommended. be457b7860
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