Understanding Esophageal Cancer Staging. Thomas W. Rice MD

Transcription

1 Understanding Esophageal Cancer Staging Thomas W. Rice MD

2 Purposes of Staging Treatment planning Prognostication Research Communication

3 TNM

4 Pierre Denoix ( ) Cancer Institute Gustave-Roussy conceived TNM

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6 1 ST Edition Stage Groupings 1977 T IS T1 T2 T3 N0 I I II III N1 III III III III M1 III III III III

7 2 nd Edition Stage Groupings 1983 Stage 0 Tis N0 M0 Stage IV Any T Any N M1

8 3rd 6th Edition T and N Classifications

9 3 rd 6 th Edition Stage Grouping T1 T2 T3 T4 N0 I IIA IIA III N1 IIB IIB III III

10 4 th Edition Stage Groupings 1997 M1 Sub-classifications M1a M1b Stage IV Sub-groupings IVA IVB

11 2010 AJCC/UICC 7 th Edition Staging

12 AJCC Requests If possible Data driven staging of esophageal cancer Addition of non-anatomic (non-tnm) cancer characteristics Harmonization of esophageal and gastric staging

13 WECC

14 The Data

15 Data for Stage Groupings Dataset n = 7,885 Subset for staging Surgery alone n = 4,723 No preoperative chemo and/or radiotherapy No postoperative chemo- or radiotherapy Mucosal cancers only ptnm

16 Demographics Age Men White Asian Other Rice TW, et al. Dis of the Eso 2009;22:1-8.

17 Histopathologic Cell Type Adenocarcinoma 60% Squamous Cell Carcinoma 40% Undifferentiated.15%

18 Histologic Grade G1 32% G2 33% G4.18% G3 35%

19 Esophageal Location Lower Third 69% Upper Third 4% Middle Third 27%

20 pt % Tis T1 T2 T3 T4

21 pn % N0 N+

22 Positive Lymph Nodes % >7

23 pm M0 92% M1 8%

24 Survival Univariable Correlates

25 Survival % Years Rice TW, et al. Dis of the Eso 2009;22:1-8.

26 Survival (%) Survival - Cell Type Undifferentiated Adenocarcinoma Squamous Years

27 Survival (%) Survival Histologic Grade G4 G1 G2 G Years

28 Survival (%) Survival - Location Lower Middle Upper Years

29 Survival (%) Survival - pt ptis pt pt2 pt Years pt4

30 Survival (%) Survival - Positive Lymph Nodes > Years

31 Survival (%) Survival - pm pm pm1a pm1b Years

32 The Results

33 Summary of Changes Cancer location Simplified EGJ/cardia/subcardia added and harmonization with gastric Rice TW, et al. Cancer 2010;16:

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35 Survival - Location % Lower Middle Upper Years

36 Summary of Changes Non-anatomic cancer features H (histopathologic type) G (histologic grade)

37 Survival - Histopathologic Cell Type % Adenocarcinoma 20 Undifferentiated Squamous Years

38 Survival (%) Survival Histologic Grade G4 G1 G2 G Years

39 Summary of Changes T Tis redefined T4 subclassified

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41 Summary of Changes N Regional lymph node redefined N subclassified by number of positive nodes

42 Survival (%) Survival - Positive Lymph Nodes > Years

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44 Summary of Changes M Redefined

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46 Site-specific Factors Distance to proximal edge of tumor from incisors Distance to distal edge of tumor from incisors Number of regional lymph nodes with extracapsular

47 Additional Descriptors and Treatment Decision Descriptor LVI Residual tumor (R) Treatment Planning Clinical stage used National guidelines used

48 Final Stage Groupings Esophageal Adenocarcinoma

49 Additional Non-TNM Characteristics

50 Adenocarcinoma G1-2 G 3 T1 T2 N0 IA IB IB IIA

51 Adenocarcinoma G1-2 G 3 N0 T4 T1 T2 T3 a b IIB IIIA IIIC N1 IIB IIB IIIA IIIC IIIC N2 IIIA IIIA IIIB IIIC IIIC N3 IIIC IIIC IIIC IIIC IIIC

52 Adenocarcinoma G1-2 G 3 N0 N1 T4 T1 T2 T3 a b IA IB IB IIA IIB IIIA IIIC IIB IIB IIIA IIIC IIIC N2 IIIA IIIA IIIB IIIC IIIC N3 IIIC IIIC IIIC IIIC IIIC

53 Survival - Adenocarcinoma 100 % IA IB IIA Years IIB IIIA IIIB IIIC

54 Squamous Cell Carcinoma T1 G1 IA G2-3 IB

55 Squamous Cell Carcinoma T2-T3 G1 IB IIA Cancer Location Lower Upper Middle G2-3 IIA IIB

56 Squamous Cell Carcinoma T4 T1 T2 T3 a b N0 IIIA IIIC N1 IIB IIB IIIA IIIC IIIC N2 N3 IIIA IIIA IIIB IIIC IIIC IIIC IIIC IIIC IIIC IIIC

57 Survival - Squamous cell % IA 0 IB IIA IIB IIIA IIIB IIIC Years ca AJCC

58 8 th Edition AJCC/UICC Esophageal and EGJ Cancer Staging

59 AIM 1 Refine and expand staging AJCC

60 Refine and Expand Staging A) Obtaining better homogeneity of Stage 0 and Stage IV. This requires abandoning the restrictive definitions of these stage groupings and changing composition of adjacent Stage IA and Stage IIIC

61 Survival Homogeneity (%) Adenocarcinoma IA IB IIA IIB IIIA IIIB IIIC

62 Survival Homogeneity (%) Squamous Cell Carcinoma IA IB IIA IIB IIIA IIIB IIIC

63 Refine and Expand Staging B) Improving homogeneity of Stage IIB adenocarcinoma and Stage IIA and IIB squamous cell cancer. This requires expanding our database of these less common cancers.

64 Survival Homogeneity (%) Adenocarcinoma IA IB IIA IIB IIIA IIIB IIIC

65 Survival Homogeneity (%) Squamous Cell Carcinoma IA IB IIA IIB IIIA IIIB IIIC

66 Refine and Expand Staging C) Adding staging classifications clinical (cstage) post-induction clinical and postdefinitive nonsurgical clinical (ycstage) post-induction pathologic (ypstage) staging This requires expanding the data analysis.

67 Refine and Expand Staging D) Assessing other non-anatomic tumor characteristics that affect survival. This requires expanding data elements beyond histopathologic cell type, histologic grade and cancer location.

68 Refine and Expand Staging E) Adding non-esophagectomy survival data endoscopic treatment in Stage 0, IA palliative therapy in Stage IV. This requires partnering with nonsurgical specialties and professional associations and groups.

69 Refine and Expand Staging F) Adding cancer of the cervical esophagus. This requires partnering and harmonizing with the head and neck task force, mirroring the process used with the gastric cancer task force in the 7th edition.

70 AIM 2 Develop clinical decision-making model Decision Model DEC

71 Decision Model A) Construct validated models for cancer recurrence death Based on variables known at the time of treatment decision making patient characteristics clinical stage (cstage and ycstage) additional cancer characteristics

72 Decision Model B) Estimate probability of downstaging clinical classifications (ctnm and yctnm) and stage groupings (cstage and ycstage) by various types, schedules, and combinations of preoperative adjuvant therapy.

73 Decision Model C) Program a smart phone-based strategic decision support tool based on clinical stage (cstage and ycstage) to estimate time-related cancer recurrence and death for different treatment options.

74 AIM 3 Create a personalized, patient-specific prognostic tool Prognostic Model PROG

75 Prognostic Model A) Construct validated models for cancer recurrence death Based on variables known at the time of treatment patient characteristics refined post treatment stage (ycstage) or pathologic stage (pstage or ypstage) additional cancer characteristics

76 Prognostic Model B) Program a smart phone-based strategic personalized prognostic tool based on post-treatment stage (ycstage, pstage and ypstage) and treatment received to estimate cancer recurrence and death for individual patients.

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78 AJCC DEC PROG Bridge Tango Malbec Beef Football

79 WECC

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