1. Overview of New AJCC Cancer Staging
Jason P. Wilson, MD, MBA, FACS
Morton Plant Mease Grand Rounds
April 3, 2018

2. No financial disclosures

3. Updates?

4. Objectives Define AJCC and its role in staging
Describe the rationale, types, and elements of cancer staging
Provide historical perspective on staging
Highlight changes to recent guidelines for staging and rationale

5. The First Question Revisited

6. The First Question Revisited
What is my stage?

7. Goals of Cancer Staging
Describe the amount and severity of cancer
Define prognosis based on prior outcomes
Aid treatment and clinical trial planning
Provide a common lexicon

8. AJCC American Joint Committee on Cancer Established in 1959
Works with the Union for International Cancer Control (UICC)
To develop, promote, and maintain evidence based systems for classification and management of cancer

9. AJCC 22 member organizations
Surgical Representation
Radiology Representation
Medical and Radiation Oncology Representation
Pathology Representation
Managed by the American College of Surgeons

10. Historical Perspective
1st Edition: 1977
2nd Edition:
3rd Edition:
4th Edition:
5th Edition:
6th Edition:
7th Edition 2009
8th Edition 2016

11. Historical Perspective
Based on data from multiple databases:
NCDB: National Cancer Database from Commission on Cancer (70%) ACS/ACS
SEER: Surveillance, Epidemiology, and End Results from Nat’l Cancer Institute
Other population-based registries

12. Four Types of Cancer Staging
Clinical: based on exam, imaging, and pathology
Pathologic: combination of clinical findings and surgical pathology
Post-therapy or Post-neoadjuvant therapy:
pathologic/clinical staging after treatment; prior to surgery
Restaging: the extent of disease in the setting of recurrence

13. Elements of Staging Location of primary tumor/organ of origin
Tumor size/extent - T
Lymph node involvement - N
Presence or absence of distant metastasis - M
Non-anatomic elements
Stage is determined by the treating physician

14. Case 1
55 yo female is seen for routine physical examination by her physician
He appreciates a mass in the inner breast
Mammogram evaluation confirms a 2.4 cm mass

15. Case 1

16. Case 1 Pathology: Invasive Duct Carcinoma Grade 3
Triple Negative (ER-, PR-, HER-2-)
Ki-67: 65%

17. Case 1
Stage: IIA (T2N0M0)
Given location seen for neoadjuvant chemotherapy
Adriamicin, CytoxanTaxol and Carboplatin
Some response clinically

18. Case 1 Partial mastectomy/Sentinel node Pathology:
3 negative nodes
Invasive Carcinoma grade 3
Margins negative
ypT2N0cM0 (IIA)
Goes on to adjuvant radiation
Metastatic disease within 5 months

19. Case 2
55 yo female presents for screening mammogram with tomosynthesis
3.3 cm mass noted

20. Case 2

21. Case 2 Stage: IIA (T2N0M0) ER+, PR+, HER-2-
Underwent Lumpectomy/Sentinel Node
Pathology:
30 mm cancer, grade II
Margins widely negative
Two negative Sentinel nodes
Tumor Board recommended Genomic profile

22. Case 2: Genomic profile low risk of recurrence
97.8% chance of being disease free at 5 years only with endocrine therapy

23. Why?

24. Subtypes Luminal A (typically hormone+, low proliferation)
Luminal B (typically hormone low, high proliferation)
Her-2 (her-2 positive cancers)
Basal Like (triple negative cancers)

25. Purpose
“First and foremost, staging provides patients with cancer and their physicians the critical benchmark and standards for defining prognosis, the likelihood of overcoming the cancer once diagnosed, and for determining the best treatment approach for the disease.” AJCC 8th edition page ix

26. Staging Manual 8th Edition
Staging guidelines
Guidance for ordering tests i.e. what imaging tests and when tests appropriate
Provides level of evidence for guidelines

27. New Staging Systems
Cervical Lymph Nodes and Unknown Primary Tumors of H&N
Pharynx
Cutaneous Squamous Cell of H & N
Thymus
Bone
Sarcoma
Parathyroid
Leukemia

28. New Paradigms
Human papillomavirus: oropharyngeal staging based on HPV status
Separate staging systems for neoadjuvant therapy of esophagus and stomach
Bone and sarcoma (separate staging systems based on anatomic sites)
Introduction of an H category for heritable cancer trait in retinoblastoma

29. Breast Cancer Staging
From one page table to 5 pages

30. Breast Cancer Staging Two stage group options
Anatomic: where biomarkers not available
Prognostic: for use in all U.S.A. patients
Inclusion of grade, HER2, ER, PR
Inclusion of multigene panels

31. Breast Cancer Staging Lobular carcinoma in situ removed from Tis
1% or greater stain for ER & PR considered positive
HER2 “equivocal” is considered negative

32. Breast Cancer Staging Multigene panels
For use only with ER/PR+, HER2 negative, node negative tumors less than/= 5 cm
Mammoprint, Oncotype DX, Endopredict,PAM50, Breast Cancer Index
Only low risk scores considered
All Stage IA despite size (T)

33. Prognostic Stage Groups for Breast
Based on populations of patients that have been offered and mostly treated with appropriate endocrine and /or systemic therapy
40% of the anatomic stages changed to a different stage based on inclusion of the prognostic factors and grade

34. Examples of Stage Changes
T3 N1-2 M0 Stage III in 7th edition
Same TNM with grade 1, triple positive: prognostic stage IB in 8th edition
T1 N0 M0 Stage I in 7th edition
Same TNM, grade 2, triple negative: prognostic stage IIA in 8th edition
As measured by outcomes

35. Cases Revisited with AJCC 8
Both T2N0M0
Case 1 (2 cm Triple Negative):
IIA (Basal type)
Case 2 (2 cm Hormone Positive):
IA (Luminal A)

37. Melanoma Important T changes Mitotic rate not long used
Melanoma <0.8 without ulceration T1a
Melanoma <1.0 with ulceration T1b
Melanoma without ulceration T1b

38. Melanoma Important N changes a=clinically occult b=clinically detected
c=microsatellites, satellites and in-transit disease

39. Case 3 51 yo patient who had a spot on his thigh
Started to change while on a cruise
Case review showed 1.95 mm melanoma mitotic rate 0-1, no ulceration

40. Case 3
Wide excision of left leg
Sentinel node left groin

41. Case 3 Pathology: No residual melanoma SLN: 1.5 mm metastasis
Stage pT2aN1a cM0 Pathologic IIIA

42. Melanoma

43. Melanoma

44. Melanoma

45. Changes to Improve Patient Care
Sparing some systemic therapy
More accurate staging based on prognosis which is really what patients want

46. Summary Most recent changes to cancer staging took effect January 2018
AJCC is the governing body for standardized cancer staging in USA
New staging contains both anatomic and prognostic factors
Multiple upstaging/downstaging based on clinical outcomes

47. For more information
AJCC website:
Cancerstaging.org

48. Questions?