Rhabdomyosarcoma: the Stanford experience using a TNM staging system

Seventy-four patients with rhabdomyosarcoma were initially staged according to the Intergroup Rhabdomyosarcoma Study (IRS) grouping classification and then retrospectively using a TNM staging system based on the initial clinical extent of disease. The TNM system includes T1, tumor confined to site or organ of origin; T2, regional extension beyond the site of origin; N0, normal lymph nodes; N1, lymph nodes containing tumor; M0, no evidence of metastases; and M1, distant metastases. All patients received combination chemotherapy, and more than 90% received radiation therapy as part of their initial treatment program with curative intent. Fifty-three of 74 patients (72%) were group III according to the IRS system, indicating unresectable or gross residual tumor. A more uniform distribution was achieved using the TNM system. Freedom from relapse (FFR) was 43% and the actuarial survival rate was 47% for the entire study group at 10 years. All but one relapse occurred within 3 years of initial diagnosis, and only three of 38 relapsed patients were salvaged. All TNM stage I patients are surviving disease free. Among patients having stages II, III, and IV disease by the TNM system, FFR was 53%, 26%, and 11%, and the survival rates were 47%, 36%, and 33%, respectively. Thirty-two of 74 patients (43%) had evidence of lymph node involvement at presentation, and 28 (88%) of these had primary lesions that extended beyond the site of origin (T2 primary). Histologic subtype and primary site had little impact on outcome in a multivariate analysis, and T stage was identified as the single most significant covariate correlated with survival; a model composed of both T stage and M stage was the best one for predicting relapse. The presented data support a study using a prospectively assigned TNM staging system based on the initial clinical extent of disease for use in future therapeutic trials.     

Comparison of TNM staging systems for nasopharyngeal carcinoma,and proposal of a new staging system

Background:

There are few systematic evaluations regarding the sixth and seventh editions of the UICC/AJCC TNM Staging System (TNM6th, TNM7th) and Chinese 2008 Staging System (TNMc2008) for nasopharyngeal carcinoma (NPC).

Methods:

We classified 2333 patients into intensity-modulated radiotherapy (IMRT) cohort (n=941) and conventional radiotherapy (CRT) cohort (n=1392). Tumour staging defined by TNM6th, TNM7th and TNMc2008 was compared based on Akaike information criterion (AIC) and Harrell''s concordance index (c-index).

Results:

For T-classification, TNM6th (AIC=2585.367; c-index=0.6390385) had superior prognostic value to TNM7th (AIC=2593.242; c-index=0.6226889) and TNMc2008 (AIC=2593.998; c-index=0.6237146) in the IMRT cohort, whereas TNMc2008 was superior (AIC=5999.054; c-index=0.623547) in the CRT cohort. For N-classification, TNMc2008 had the highest prognostic value in both cohorts (AIC=2577.726, c-index=0.6297874; AIC=5956.339, c-index=0.6533576). Similar results were obtained when patients were stratified by chemotherapy types, age and gender. Using staging models in the IMRT cohort, we failed to identify better stage migrations than TNM6th T-classification and TNMc2008 N-classification. We therefore proposed to combine these categories; resultantly, stage groups of the proposed staging system showed superior prognostic value over TNM6th, TNM7th and TNMc2008.

Conclusion:

TNM6th T-classification and TNMc2008 N-classification have superior prognostic value in the IMRT era. By combining them with slight modifications, TNM criteria can be unified and its prognostic value be improved.     

TNM staging of testis cancer

Of one-thousand patients with testicular cancer treated mainly at the Memorial Sloan-Kettering Cancer Center from 1949 to 1974, 304 patients with pure seminoma and 659 patients with either embryonal carcinoma (329), teratocarcinoma (310) or pure choriocarcinoma (20), were staged clinicopathologically according to the TNM Classification. Paratesticular structures were involved (T_2–4) in 7% of all germinomas; para-aortic lymph nodes (N_1–3) in 15% of seminomas and 31 % of carcinomas; juxtaregional lymph nodes (N₄) in 6% of seminomas and 8% of carcinomas; and distant organs (M₁) in 4% of seminomas and 23% of carcinomas. Five year survivals were 80% in T₁ and 77% in t_2–4 pure seminomas, and 46% in T₁ and 34% in T_2–4 germinal carcinomas. The 5-year survival rates in pure seminoma versus germinal carcinomas, were 88% versus 76% in N₀M₀ 64% versus 36% in N_1–3, 53% versus 30% in N₄, and 27% versus 11% in M₁ tumors. Cancer recurrence in 5 or more years was 28% in T₁ and 18% in T_2–4 pure semnomas, and 58% in T₁ and 70% in T_2–4 germinal carcinomas. The recurrence rates in pure seminoma versus germinal carcinomas, were 17% versus 29% in N₀M₀ 55% versus 67% in N_1–3, 53% versus 74% in N₄, and identically 91% in M₁ tumors.     

Clinical relevance of TNM staging system according to breast cancer subtypes

BackgroundThere has been reported that the association between nodal spread and tumor size was disrupted in triple-negative breast cancer (TNBC) and it showed characteristically early relapse. The TNM (tumor–node–metastasis) staging system might not be equally effective as a prognostic indicator for all subtypes. The aim of our study was to evaluate the usefulness of the staging according to subtypes.Patients and methodsWe conducted a retrospective analysis of invasive breast cancer patients who received curative surgery at Samsung Medical Center from 2000 to 2004. Relapse-free survivals (RFS) by stage were analyzed.ResultsThousand eight hundred and seventy-nine patients who were available clinicopathologic data were included. These patients were divided into three subtypes: hormone receptor (HR)+, human epidermal growth factor receptor 2+, and triple negative groups. As the stage became more advanced, the slope of each stage of the RFS curves of patients with HR+ and HER2+ steadily increased. In contrast, RFS curves intermingled and showed overlap from stage 1 to 3A in TNBC patients. There was only wide separation of RFS curves between stage 1-3A and 3B-3C in TNBC.ConclusionsThe current TNM staging system might not be enough for encompassing the tumor biology and for predicting outcomes to make therapeutic decisions for all BCs, especially for TNBC patients.     

新TNM分期系统对评价手术切除肝癌预后的意义

背景与目的2002年国际抗癌联盟对原第5版肝癌TNM(以下简称TNM5)分期进行了修订,提出了新的第6版TNM(以下简称TNM6)分期标准,目前应用TNM6分期评估手术切除肝癌患者预后的报道较少。本研究探讨TNM6分期对评价手术切除肝癌预后的价值及TNM6分期在我国临床应用的可行性和合理性。方法根据我院1993年1月至1998年12月施行的478例肝细胞肝癌切除病例资料和随访结果,分别按TNM5分期及TNM6分期进行生存分析,比较各期的生存率,并将TNM5分期和TNM6分期作相互比较,分析TNM6分期的优缺点。结果按TNM5分期标准各期病例数分别为Ⅰ期12例(2.5%),Ⅱ期224例(46.8%),ⅢA期95例(19.9%),ⅢB期8例(1.7%)和ⅣA期139例(29.1%);各期患者5年生存率分别为81.8%、41.5%、17.0%、0.0%和10.2%。Ⅰ期与Ⅱ期、ⅢB与ⅣA期患者生存率无统计学差异;Ⅱ、ⅢA、ⅢB期患者间在预后上有显著差别。按TNM6分期标准各期病例数分别为Ⅰ期234例(48.9%),Ⅱ期41例(8.6%),ⅢA期96例(20.1%),ⅢB期88例(18.4%)和ⅢC期19例(4.0%);各期患者5年生存率分别为43.3%、20.2%、13.1%、13.0%和0。Ⅰ期与Ⅱ期患者生存率有统计学差异,Ⅱ期、ⅢA期与ⅢB期患者互相之间生存率均无显著差异。结论肝癌TNM6分期较TNM5分期有重要进步,参数较少,且简便易用,但仍有一定局限性,临床应用于预后估计还不十分准确,并不完全适用于我国绝大多数合并肝硬化的肝癌患者。     

Modified staging system for pulmonary carcinoids on the basis of lung cancer TNM system

Background

Pulmonary carcinoids are being staged along the lines of lung cancer American Joint Committee on Cancer (AJCC) staging system. The current study evaluated the prognostic value of a modified staging system for patients with pulmonary carcinoid.

Patients and methods

Surveillance, Epidemiology and End Results (SEER) database (2004–2014) was searched through SEER*Stat program. Through recursive partitioning analysis and subsequent decision tree formation, suggested stages were constructed. Overall survival analyses were performed through Kaplan–Meier analysis. The cancer-specific Cox regression hazard (adjusted for age, gender, race, sub-site and surgery) was calculated and pairwise comparisons of hazard ratios were conducted.

Results

A total of 6395 pulmonary carcinoid patients were recruited in the period from 2004–2014. Pairwise hazard ratio comparisons among different AJCC 8th stages were conducted and all comparisons were non-significant except for stage IIB vs. stage IIIA and stage IIIA vs. stage IIIB. Pairwise hazard ratio comparisons among different modified staging system stages were conducted and all comparisons were significant except for stage III vs. stage IV. C-statistic (using death from pulmonary carcinoid as the dependent variable) for AJCC 8th staging system was: 0.794 (SE 0.013; 95% CI 0.769–0.818); for AJCC 7th staging system was: 0.789 (SE 0.013; 95% CI 0.764–0.815), while c-statistic for the modified staging system was: 0.802 (SE 0.012; 95% CI 0.778–0.827).

Conclusion

The proposed modified staging system provided a simpler yet prognostically more relevant classification of pulmonary carcinoids compared to AJCC staging systems (both 7th and 8th editions).

     

TNM staging system for renal-cell carcinoma: current status and future perspectives

The Tumour, Nodes, and Metastasis (TNM) staging system is a method of stratifying patients with cancer and is based on data obtained from large multicentre studies that involved large numbers of patients, and have a good level of evidence. However, despite continual revisions to the methodology to incorporate evidence from new clinical studies, the optimum stratification of patients with renal-cell carcinoma (RCC) using the TNM staging system remains controversial and further revisions, in our opinion, are needed. Revision of the TNM staging system for renal-cell cancer could also result in the simultaneous update of the integrated prognostic systems that are currently used along side this traditional method of staging. These integrated systems could become key instruments for guiding patient counselling, for appropriate follow up strategies, for patient selection for clinical trials, and for appropriate assessment of results if the perception that they are complex is overcome. This perception is driven by the presence of more than one system, the heterogeneity of clinical and pathological variables included in the methodology, and the need for robust comparative studies between the various systems. Therefore, in everyday clinical practice, the TNM system is regarded as a more reliable method of staging. In this Essay, we aim to highlight the problems associated with the current version of the TNM staging system and highlight areas in which this grading instrument can be improved in future to become a more refined and standardised method of communication between all clinicians involved in clinical management of RCC.     

鼻咽癌分期的研究—评’92福州分期标准

研究鼻咽癌分期。材料与方法首次放疗前经ＣＴ扫描检查的鼻咽癌２０４例，１９７９年长沙分期法和１９９２年福州分期法进行评价。结果本组随访率为９４．６％，５年生存率为５２．２％。按’９２福州分期法本组各项分布是：Ⅰ期２．５％，Ⅱ期２２．１％，Ⅲ期４８．５％，Ⅳ期２４．０％，Ⅳｂ期２．９％：各期５年生存率分别是８０％，７６．２％，５２．７％，４３．７％和０％。结论作者建议：（１）将原发肿瘤局限在鼻咽腔者列为Ｔ１。（２）将Ⅳ期分为Ⅳ。期（Ｔ４或Ｎ３）和Ⅳｂ期（任何Ｔ，任何Ｎ，Ｍ１）。     

Pathologic staging of renal cell carcinoma: significance of tumor classification with the 1997 TNM staging system

BACKGROUND: The TNM staging system for renal cell carcinoma was revised by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC) in 1997. The 1997 TNM staging system for renal cell carcinoma reclassifies tumors using criteria for size and for extent of renal vein/vena cava involvement that are different from the criteria used in the 1987 staging system. The current study investigated the prognostic significance of tumor classification and other factors using the new staging system. METHODS: Records from 1547 renal cell carcinoma patients (1039 males and 508 females; mean age, 63.4 years; mean follow-up, 7.1 years) who underwent surgical resection between 1970 and 1998 were analyzed retrospectively. Tumors were staged using the 1987 and 1997 TNM criteria, and Kaplan-Meier estimates of survival and disease recurrence were compared for both staging systems. The Peto-Peto log rank test and the generalized Wilcoxon test were used to assess univariate significance of prognostic factors on survival. Cox proportional hazards regression analysis was then completed to assess the significance of the revised staging system. RESULTS: Tumor classification using the 1987 TNM staging system (P = 0.0001) and the 1997 TNM staging system (P = 0.0001) was a significant predictor of cause specific survival. Using 1997 TNM staging criteria, 641 patients were reclassified from the T2 classification to the T1 classification, 114 patients were reclassified from the T3c classification to the T3b classification, 11 patients were reclassified from the T4b classification to the T3c classification, and 3 patients were reclassified from the T4b classification to the T3b classification. Patients with reclassified tumors had outcomes similar to patients with tumors that remained in the same tumor classification. Patient stratification was improved using the new staging system. Prognostic discrimination for cause specific survival at 10 years was noted for the 1987 and 1997 TNM classifications (T1, 97% vs. 91%; T2, 84% vs. 70%; T3a, 53% vs. 53%; T3b, 48% vs. 42%; and T3c, 29% vs. 43%). CONCLUSIONS: The revised classification of renal cell carcinoma was a significant predictor of cause specific survival for the cohort of patients described in this report. Using the new system, the stratification of patients was improved. Patients who had their tumors reclassified as a result of the new staging system had outcomes similar to those of patients who had tumors that remained in the same classification. Based on an analysis of this cohort, tumor classification is valid, and the T1 subclassification is warranted. However, additional revision may be required to optimize staging.     

TNM staging of cancer of the colon

There are several kinds of proposals for the staging of colon cancer with TNM factors in the world. By comparisons with each survival rates on these staging groups, based on 698 curative resected colon cancer at our hospital between 1962 and 1985, we have evaluated the usefulness of their staging systems. There were no significant differences of survival rates between 3rd and 4th stage groups of J.J.C. classification II and III stage groups of I.C.C. -p-TNM, and Ib and II stage groups of A.J.C. -p-TNM. As far as the resected cases, the degree of spreading of serosal involvement is more affective factor influencing to the prognosis than the one of lymph nodes involvement. Extent of the area of resection and clearance of regional lymph nodes, curative or non curative, is also important prognostic factor. There seems to be still, much room for discussion and revision on the staging of the colon cancer.     

Tumor registrar's role in TNM staging.

The role of the tumor registrar in TNM staging has not been clearly defined. This paper shows how this can be clarified in individual hospital cancer programs and how the tumor registrar serves as a key member of the cancer team in implementing physician TNM staging.     

A STUDY OF THE TNM STAGING SYSTEM FOR NASOPHARYNGEAL CARCINOMA (NPC)

ＡＳＴＵＤＹＯＦＴＨＥＴＮＭＳＴＡＧＩＮＧＳＹＳＴＥＭＦＯＲＮＡＳＯＰＨＡＲＹＮＧＥＡＬＣＡＲＣＩＮＯＭＡ（ＮＰＣ）ＬｉＣｈａｎｇｑｉｎｇ；李长青ＬｉａｏＬｉｎｇｘｉａ；廖玲霞（ＨｕｂｅｉＣａｎｃｅｒＨｏｓｐｉｔａｌ，Ｗｕｈａｎ，４３００７０）Ａｂｓ...