You Want ME

to Stage that Case???

What’s New in the AJCC 8th Edition

Jayne Holubowsky, CTR, Director, Virginia Cancer Registry2nd DelMarVa-DC Regional Conference

October 11, 2018

Objectives

• Explain fundamental changes to disease site chapters

• Explain New Principles of Cancer Staging Chapter

• Learn rule changes for AJCC 8th edition

8th Edition DedicationThe AJCC Cancer Staging Manual, 8th Edition is dedicated to all CANCER REGISTRARS in recognition of their:• Education and unique commitment to the recording and

maintenance of data that are so vital for the care of the cancer patient;

• Professionalism in the collection of factors that are fundamental to sustaining local, state, and national cancer registries;

• Dedication to the cataloging of information crucial to cancer research;

• Leadership, support, and promulgation of the principles of cancer staging;

• AND THEIR POSITIVE IMPACT ON CANCER PATIENT OUTCOMES.

Fundamental Changes to Disease Site Chapters

• New & revised chapters

• Reorganization of chapters

• New features

• Chapters updated to keep pace with medical advances

• Chapter Summary– Cancers Staged Using This Staging System– Cancers Not Staged Using This Staging System– Summary of Changes– ICD-O-3 Topography Codes– WHO Classification of Tumors

• Introduction• Anatomy

– Primary site(s)– Regional Lymph Nodes– Metastatic Sites

• Rules for Classification– Clinical Classification– Imaging– Pathological Classification

Chapter “Layout”

• Prognostic Factors– Prognostic Factors Required for Stage Grouping– Additional Factors Recommended for Clinical Care

• Risk Assessment Models• Definitions of AJCC TNM

– Definition of Primary Tumor (T)– Definition of Regional Lymph Nodes (N)– Definition of Distant Metastasis (M)

• AJCC Anatomic & Prognostic Stage Groups• Registry Data Collection Variables• Histologic Grade• Histopathologic Type• Survival Data• Bibliography

Chapter “Layout”

Prognostic Factors• AJCC expanded the use of nonanatomic prognostic

factors & biomarkers in assigning stage groups

‐ Each chapter has a Prognostic Factors section

Prognostic Factors Required for Stage Grouping Additional Factors Recommended for Clinical Care Registry Data Collection Variables

• Levels of Evidence provided for the use ofprognostic factors used to determine the stagegroup

• Emerging Factors for Clinical Care

Imaging Core

• Provides guidance for physicians when ordering tests

‐ Which imaging tests are most appropriate

‐ Temporal order of tests

‐ Specific T, N and/or M that can be derived from tests

‐ Structured reporting is promoted

Online Content

• Staging forms available • Supplemental Information

‐ Risk Assessment models‐ Emerging Factors for Clinical Care‐ Recommendations for Clinical Trial

Stratification‐ Illustrations

• References, Recommended reading

• New Chapters

– Cervical Nodes & Unknown Head & Neck Primary

– Thymus

– Parathyroid

– Leukemia

– Pediatric Hematologic Malignancies

Other New Paradigms

• Some Chapters Split

– Thyroid• Differentiated & Anaplastic

• Medullary

– Pharynx• Oropharynx, HPV-Mediated (p16+) & (p16 neg)

• Nasopharynx

• Hypopharynx

– Pancreas• Exocrine

• Neuroendocrine

– Bone & STS are separated based on anatomic site

Other New Paradigms

• Some Chapters Merged

– Ovary, Fallopian Tube & Primary Peritoneal

• Some Chapters Deleted

– Cutaneous Non-melanoma skin cancers

• Separate staging systems for patients with neoadjuvant therapy

– Esophagus and Stomach

Other New Paradigms

Assigning Stage – the Role of the Managing Physician

• Staging is a Collaborative Effort

‐ Pathologist

‐ Radiologist

‐ Surgeon

‐ Medical Oncologist

‐ Cancer Registrar

• The Managing Physician has the ultimate responsibility to document the stage

Chapter 1 Staging Rules• Expansion of Chapter 1 rules

Explains the basics of staging

Clarifies terminology

Describes timeframe & criteria for each classification

• Some new rules based on changes in medical practice

• Detailed rules for clinical & pathological classifications

Guidance for T, N, and M for both classifications

• Detailed rules for stage groups

• Rules generally apply across all disease sites

Chapter 1 Staging Rules

• New Terminology

‐ T, N, M are categories

• T, N or M may have subcategories such as T1a or N2b

‐ Prognostic and Anatomic Stage Groups

‐ Staging Classifications

Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is Timing is Everything (April 2016) AJCC website.

• 14 general rules for the application of T, N, and M categories for all anatomic sites and classifications

• Exceptions are listed in specific disease site chapters

– Example: Must have a prostatectomy for pathological stage for Prostate

• Rules repeated all through the 1st chapter

Chapter 1 Staging Rules

General Staging Rules

1. Microscopic confirmation necessary

A. In rare clinical situations, pts may have positive cytology or clinical evidence that is not in doubt

B. Must be evaluated separate from microscopically confirmed cohort

General Staging Rules2. Timeframe/staging window for

determining clinical stage

A. From date of dx before initiation of 1 of the following, which ever is shorter:

1) 4 months after dx

2) To the date of cancer progression

General Staging Rules3. Timeframe/staging window for pathological

stageA. All clinical information plus information from

surgical resection & exam of resected specimen if surg is performed before RT or systemic tx –from the date of dx:

1) Within 4 mo after dx

2) To the date of cancer progression if the cancer progresses before the end of the 4-mo window

3) Includes any information obtained about the extent of cancer through the completion of definitive surgery as part of the primary treatment if that surgery occurs later than 4 mo after dx & the cancer has not clearly progressed

4. Timeframe/staging window for staging post neoadjuvant treatment or post therapy

A. After completion of neoadjuvant therapy, patients should be staged as:

1) yc: post therapy clinical

2) yp: post therapy pathological

B. The timeframe should be such that the post neoadjuvant surgery & staging occur within a time frame that accommodates disease-specific circumstances described in the specific chapters & relevant guidelines

General Staging Rules

5. Progression of disease

6. Uncertainty among T, N, or M categories and/or stage groups – rules for clinical decision making A. Lower of 2 possibilities is assigned for TNM

or Prognostic stage group

B. Based on clinical decision of managing physician

C. Unknown or missing information for T, N, M or stage group is never assigned to the lower category, subcategory or group

General Staging Rules

7. Uncertainty Rules do NOT apply to cancer registry data

A. If info is not available to the CTR for documentation to a sub-category, the main category should be assigned

B. If the specific info is not available to the CTR the stage group should not be assigned but should be documented as unknown

General Staging Rules

8. Prognostic Factor Category is unavailableA. Use X; or

B. If the prognostic is unavailable, default to assigning the anatomic stage using clinical judgement

9. GradeA. The recommended histologic grade system for

each disease site and/or cancer type, if applicable, is specified in each chapter.

B. The CTR will document grade according to the coding structure in the relevant disease site chapter

General Staging Rules

10. Synchronous Primary Tumors in a Single Organ: (m) suffix

A. If mult tumors of the same histology are present in 1 organ:

1) The tumor with the highest T category is classified

2) The m suffix is useda) pT3(m) N0 M0

3) If the # of synchronous tumors is important, an acceptable alternative designation is to specify the # of tumorsa) pT3(4) N0 M0

General Staging Rules

11. Synchronous Primary Tumors in Paired Organs

A. Cancer occurring at the same time in each of a paired organ are staged as separate cancers

1) For tumors of the thyroid, liver & ovary, multiplicity is a T-category criterion, thus, multiple synchronous tumors are not staged independently

12.Metachronous Primary Tumors

A. 2nd or subsequent primary cancers occurring in the same organ or different organs outside the staging window are staged independently

General Staging Rules

13.Unknown Primary or No Evidence of Primary TumorA. If there is no evidence of a primary tumor or the

site of the primary tumor is unknown, staging may be based on the clinical suspicion of the organ site of the tumor

1) Characterize as T0

B. T0 is NOT used for H/N SCC sites1) Pt’s with an involved LN are staged as unk primary

cancers using the “Cervical LN’s & Unknown Primary Tumors of the Head & Neck” chaptera) T0 remains valid for HPV & EBV associated oropharyngeal

& nasopharyngeal cancers

General Staging Rules

14.Date of Diagnosis

A. “The date of diagnosis is the date the physician determines that the patient has cancer. It may be the date of a diagnostic biopsy or other microscopic confirmation or of clear evidence on imaging. This rule varies by disease site & shares similarities of the earlier discussion on microscopic confirmation”

General Staging Rules

• Additional staging descriptors & guidelines

– Tis• In situ neoplasia core or incisional bx is assigned cTis

• In situ tumor with + LN’s is still Tis

– N Suffixes• Sentinel nodes (sn)

• FNA or core biopsy (f)

• ITC’s are N0(i+)

– Node positive for melanoma & Merkel cell carcinoma

– M Suffixes• Positivie CTC’s or DTC’s

– M0(i+)

General Staging Rules

– LVI

• Coding structure with new options– L0 to L9

– Distinguishes between lymphatic, small and/or large vessel involvement

– Residual tumor & surgical margins

• Microscopic vs macroscopic residual – RX Presence of residual tumor cannot be assessed

– R0 No residual tumor

– R1 Microscopic residual tumor

– R2 Macroscopic residual at the primary site or regional LNs

General Staging Rules

SIGNIFICANT RULE CHANGES

AJCC 8th Edition

• Melanoma

– Primary tumor thickness measured to the nearest 0.1mm

• Was 0.01mm in 7th edition

– Should be recorded per the CAP protocol

• If tumors are </= 1mm in thickness – record to the nearest 0.1mm

Rule Changes

• Example

– Wide excision of melanoma – path reports tumor thickness as 0.85

• Registrar records thickness as 0.9

• If pathologist reports in smaller units, you must round

• 0 – 4, round down; 5 – 9 round up

Rule Changes

• In situ and noninvasive papillary CA

– Reported from core bx, TUR or incisional bx

• Record cTis for urothelial carcinoma

• Record cTa for papillary urothelial carcinoma

– Surgical resection with no residual disease

• Record pTis or pTa

Rule Changes

• In Situ Changes

– Diagnosis of in situ NEVER made based on imaging alone

– Positive LN’s with an in situ tumor

• Record the Tis and N+

• There will not be a stage

Rule Changes

• Example

– CT guided lung bx – squamous cell ca in situ. Segmental lung resection showed squamous cell ca in situ, no LNs resected.

– Clinical stage

• cTis cN0 cM0

– Pathological stage

• pTis cN0 cM0o Do not need pathologicial confirmation of LN’s for in situ

pathological staging

Rule Changes

• Example

– Pt had TURB with noninvasive papillary ca. CT scan showed positive LN’s. Lap removal of 4 regional LN’s reported as 1 perivesicalLN+ & 1 external iliac LN +

• Clinical Staging– cTa cN2 cM0

• Pathological Staging– cTa pN2 cM0

Rule Changes

• Extranodal Extension

– Extension through LN capsule into adjacent ti

• Standardized as ENE to eliminate confusion– Extranodal instead of extracapsular

– Extension instead of spread

» Preferred terminology

– Descriptions that may indicate ENE

• Matted

• Fixed – not moveable or mobile

• Terminology will vary by physician

Rule Changes

– Regional LN extending into distant structure or organ

• Categorized as ENE

• NOT considered distant metastatic disease

• Head & Neck specific ENE Rules

– Stringent criteria for both clinical & pathological staging

Rule Changes

• Example

– Phys palpated 2 LT inguinal LNs in a pt with penile ca. Node resection showed ENE

• Clinical N assigned as cN2– cN2 palpable mobile >/= 2 unilateral inguinal LNs or

bilateral inguinal LNs

– If nodes were fixed it would have been stated

• Pathological N assigned as pN3– pN3 ENE of LN metastases or pelvic LN mets

– Evidence of ENE found on tissue examination

Rule Changes

Rule Changes

• Assigning pStage w/Incomplete Information

– Managing phys may combine clinical & pathological T & N categories

– Does NOT represent actual TNM stage

– Do NOT use to assign a path stage group

– Registry does NOT record combined clinical & pathological T and N categories

• Caution with incomplete stage– Critical for phys to use to plan pt care

– Essential for pt to understand their prognosis

– Skews data analysis

• How to use incomplete stage information– Do not record T, N or M category when it breaks

staging rules

– Do NOT record stage group with categories missing – always record accurate information

– Use blanks & unknown stage groups when accurate

Rule Changes

• H&P – imaging of lung shows T1b N0 M0

• Broncoscopy – lesion RUL near MSB

• Tumor Board – poss T2a, but not sure

• Mediastinoscopy – hilar LNs, no mediastinal LNs

– Record cT1b N1 M0

• Do NOT use presumptive stage information

• Combine all info prior to treatment

• Cannot use just one source

Rule Changes

• If the largest dimension of a tumor is <1mm (between 0.1 and 0.9 mm), record size as 001 (do not round down to 000). If tumor size is > 1 mm, round tenths of mm’s to whole mm & round tenths of mm in the 5- 9 range up to the nearest whole mm

• Breast cancer does NOT use the rounding rule

– So as not to classify tumors between 1 and 1.5mm as T1mi, tumors >1mm and <2mm should be rounded to 2mm

Rule Changes

ABSTRACTING HINTS

AJCC 8th Edition

• Read the chapter before you stage, make sure you have the most recent errata

Abstracting Hint #1

• Keep up to date with changes on the NAACCR 2008 Implementation Information website

– There are links to manuals with notification of changes and updates

– https://www.naaccr.org/2018-implementation/

Abstracting Hint #2

• Use the correct tables when assigning a stage

– Breast has multiple tables

Abstracting Hint #3

• Support your stage assignments with text

– Do NOT just record the stage – record HOWyou arrived at your stage

Abstracting Hint #4