Ajcc 8th edition

Ajcc 8th edition

1. Good morning

2. Union for International Cancer Control

3. INTRODUCTION Assigning the proper clinical and pathological stage is one of the key activities for clinicians caring for those afflicted with cancer. Staging is based on anatomic and non-anatomic criteria to assist in estimating prognosis and planning treatment.

4. Background on the AJCC Head and Neck Task Force

5. OVERVIEW Changes to the T categories in nasopharynx , oral cavity and skin(DOI & PNI) Alterations in N category in nasopharynx Addition of extra-nodal extension (ENE) by tumor in a metastatic lymph node (N category)

6. Changes to the T category The T category acknowledges the different biological behavior of deeply invasive but small tumors and incorporates depth of invasion (DOI) Recent data: DOI >>> tumor thickness 6 th edition – DOI has been recorded and available for analysis. DOI is distinct from tumor thickness.

7. Assessing DOI by clinical examination Clinicians will need to distinguish a thick, exophytic, but less invasive tumor from one that is ulcerated and deeply invasive through careful palpation, supplemented by radiographic assessment.

8. ….change Staging will no longer depend solely upon the greatest surface dimension. For every 5mm increase in DOI, both cT and pT categories will increase one level.

9. Pathologically, DOI is measured from the level of the basement membrane of the closest adjacent normal mucosa. A ‘PLUMB LINE’ is dropped from this plane to the deepest point of tumor invasion.

10. Key point Tumor thickness underestimates aggressive potential DOI is superior to tumor thickness

11. ENE in N categorization ENE has been added as a prognostic variable for regional lymph node metastases in addition to the number and size of metastatic lymph nodes.

12. ….problem with stage migration Current imaging modalities have significant limitations and lack sensitivity and specificity in their ability to identify early or minor ENE. What is Stage migration…..??

13. …. cENE positive status? Clinical staging of ENE is determined by physical examination: e.g. invasion of skin, infiltration of musculature/dense tethering to adjacent structures, or Dysfunction of cranial nerve, the brachial plexus, the sympathetic trunk, or phrenic nerve and supported by radiological evidence, should be present to assign a status of ENE-positive

14. …. pENE positive status? Pathological ENE is defined as extension of metastatic carcinoma from within a lymph node through the fibrous capsule and into the surrounding connective tissue , regardless of the presence of stromal reaction. Pathological ENE can be minor or major extension . Metastatic carcinoma that stretches the capsule but does not breach it does not constitute ENE Minor ENE ( ENEmi ) defined as extension of ≤2mm from the capsule Major ENE ( ENEma ) defined as either extension apparent to pathologist naked eye or > 2mm beyond the capsule microscopically.

15. Conclusion…….. The 8 th edition head and neck AJCC cancer staging manual incorporates significant changes which include: A separate staging algorithm for HPV- assosiated cancer of the oropharynx . Changes to the tumor T categories in the nasopharynx , oral cavity, and skin. And addition of tumor ENE to the lymph node category for most sites.

16. How good is this update? Inherent drawbacks of the TNM staging Future of cancer staging When applied to I ndian scenario ….!!

17. Drawbacks of TNM system Is it workable ?????– YES But the TNM system takes into consideration only the anatomic factors of the tumor, and not patient related factors such as smoking, alcohol, pulmonary status, general medical condition (life style and comorbidities) It is a static system and stages patients only at the time of initial diagnosis The TNM system does not include ‘response to therapy’ and thus is not dynamic .

18. Future directions Incorporation of TNM and other tumor parameters such as histo -morphological features, molecular markers, Non-anatomic prognostic factors, life style and comorbidities response to therapy. Dynamic Personalized P rognostic Nomograms

19. Staging It is a continuously evolving and dynamic process incorporating new and valid information to improve accuracy and predictive power. Frequency of revision: previous update -2010 Too frequent revisions: Not be able to generate comparative data, to show outcomes of the disease and therapy On the other hand new discoveries and new knowledge must be incorporated to continually improve Compromise between ‘ideal’ and ‘practical’

20. References Lydiatt , W., Patel, S., O'Sullivan, B., Brandwein , M., Ridge, J., Migliacci , J., Loomis, A. and Shah, J. (2017). Head and neck cancers-major changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA: A Cancer Journal for Clinicians, 67(2), pp.122-137 . Groome P, Schulze K, Boysen M, Hall S, Mackillop W. A comparison of published head and neck stage groupings in carcinomas of the oral cavity. Head & Neck. 2001;23(8):613-624 . Pai P, Tuljapurkar V, Dhar H, Mishra A, Chakraborti S, Chaturvedi P. The Indian scenario of head and neck oncology - Challenging the dogmas. South Asian Journal of Cancer. 2016;5(3):105.

21. Thank you …………