1 / 52

New Staging of Esophageal Caner - based on the 7 th edition of the AJCC Cancer Staging

New Staging of Esophageal Caner - based on the 7 th edition of the AJCC Cancer Staging. Hyun-Sung Lee, MD, PhD Center for Lung Cancer Research Institute and Hospital National Cancer Center, Korea. Disclosure. No financial disclosures

tyra
Download Presentation

New Staging of Esophageal Caner - based on the 7 th edition of the AJCC Cancer Staging

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. New Staging of Esophageal Caner- based on the 7th edition of the AJCC Cancer Staging • Hyun-Sung Lee, MD, PhD • Center for Lung Cancer • Research Institute and Hospital • National Cancer Center, Korea

  2. Disclosure • No financial disclosures • The presentation on a new AJCC staging is based on the AJCC Cancer Staging Manual 7th Edition • Presentation slides were kindly provided by Dr. Young Tae Kim, Seoul National University in 2009 Esophageal Cancer Symposium(held in National Cancer Center)

  3. 과거 6차 AJCC/UICC staging system • 식도암의 병기는 단순히 T, N, M 병기 분류에 따른 해부학적 진행 정도에 따라 정하여 졌기 때문에 실제 임상에서의 생존율과 병기에 따른 생존율의 구분이 명확하지 않았다 • 병리조직학적 분류, 암의 생물학적 양상, 위치 등도 반영되지 않았다 • 식도-위경계부암(EGJ cancer)과 관련되어 위암의 병기와 조화롭게 분류되지 않았다

  4. 새로운 병기 시스템 • AJCC Lung and Esophageal Task Force • 임상자료들을 기반으로 하는 새로운 병기를 구상 • Worldwide Esophageal Cancer Collaboration (WECC) • 3개 대륙의 13개 센터의 임상자료들을 근간 • 7차 AJCC/UICC 식도암 병기를 제안

  5. Worldwide EsophagealCancer Collaboration (WECC) • USA(14) • Cleveland Clinic(T. W. Rice) Fox Chase CC(W.J. Scott) Indiana U(K. A. Kesler) MD Anderson(W. Hofstetter, S.G. Swisher) MGH(H. A. Gaissert, D. J. Mathisen) Mayo Clinic(M. S. Allen) Medical U South Carolina(C. E. Reed) Memorial Sloan-Kettering(V. W. Rusch) Oregon Health & Science U(J. G. Hunter) U Alabama at Birmingham(R. Cerfolio) U Michigan(M. B. Orringer) U Pennsylvania(J. C. Kucharczuk) U Pittsburgh Medical Center(J. D. Luketich) U Rochester(T. J. Watson) • Europe(2) Helsinki U(J. A. Salo) U Z Leuven, Belgium(T. E.M.R. Lerut) • Orient(2) Fourth Hospital of Hebei Medical U, China(Long-Qi Chen) U Hong Kong(Simon Law, John Wong) • Canada(2) Toronto GH(G. Darling) U Montreal(A. Duranceau)

  6. 제7차 AJCC/UICC staging system • 식도암 또는 식도-위경계부암 환자 • 수술만 시행 받고 수술 전 혹은 수술 후 보조치료를 받지 않은 환자 • 사망 여부 및 사망 원인이 확실히 밝혀진 4,627명의 환자들의 임상데이터 • Risk-adjusted random-survival-forest analysis

  7. Patient characteristics T.W. Rice, Worldwide esophageal cancer collaboration, Diseases of the Esophagus 2009;22:1-8

  8. Cancer characteristics (1) ‡ pT1a in 262 and pT1b in 244 among 506 in whom this distinction was made. § pM1a in 104 and pM1b in 122 of 226 in whom this distinction was made. T.W. Rice, Worldwide esophageal cancer collaboration, Diseases of the Esophagus 2009;22:1-8

  9. Cancer characteristics (2) T.W. Rice, Worldwide esophageal cancer collaboration, Diseases of the Esophagus 2009;22:1-8

  10. Overall survival 30 days 98% 1 year 78% 5 year 42% 10 year 31% T.W. Rice, Worldwide esophageal cancer collaboration, Diseases of the Esophagus 2009;22:1-8

  11. Slide from YT Kim

  12. Survival stratified by pathologic classification N M

  13. Slide from YT Kim

  14. 새로운 식도암 병기 변경 요약 • 종양의 위치를 단순화 • Esophagogastric junction(EGJ) 과 stomach 근위부 5cm 이내의 병변을 포함 • Tis 에 대한 재정의(再定義) • T4를 T4a/T4b로 세분화 • Regional lymph node의 재정의(再定義) • N 병기를 전이된 regional lymph node 수에 따라 분류 • M 병기의 재정의(再定義) : (기존 M1a/M1b 개념 소실) • Squamous cell carcinoma 와 adenocarcinoma 의 병기 설정을 구분하여 표기 • 초기 병기에서는 분화도(Grade)를 병기 설정 요소로 도입

  15. Primary site of esophageal cancer based on proximal edge of tumor

  16. SurvivalUpper extent of cancer in the esophagus

  17. Esophageal wall • Mucosal layer • Epithelium(m1) • Lamina propria(m2) • Muscularis mucosae(m3) • Submucosal layer • Inner(sm1), middle(sm2), outer thirds(sm3) • Muscularis propria layer • Inner circular &outer longitudinal muscle layer • No serosa

  18. T descriptor

  19. T4 lesion • T4a; 식도암이 직접 침범한 경우에도 절제가 가능한 구조물 • pleura, peritoneum, pericardium, diaphragm • T4b; 완전 절제가 불가능한구조물 • aorta, carotid vessels, azygos vein, trachea, left main bronchus, vertebral body

  20. Lymphatics • Intramural network • longitudinal하게 전파되는 특징 • 림프계가 submucosa에 집중되어 있기는 하지만, lymphatic channel은 mucosal layer의 lamina propria에도 존재하기 때문에 mucosa에만 국한된 암이라도 하더라도 림프절 전이가 일어날 수 있다

  21. N descriptor

  22. LN mapping

  23. Supraclavicular Highest mediastinal Lower paratracheal Upper paratracheal Posterior mediastinal Upper periesophageal

  24. Tracheal bifurcation Subcarinal Lower Peri- esophageal Caudal margin of Inferior pulmonary vein

  25. Right cardial Left cardial Lesser curvature Common hepatic Celiac Left gastric

  26. Recurrent laryngeal lymph node chain Right upper paratracheal LNs Left upper paratracheal LNs Innoinate a. Trachea retraction

  27. Common hepatic & celiac LNs

  28. Left gastric LNs

  29. Optimum lymphadectomy for esophageal cancer • 7차 AJCC/UICC staging system에서는 각각의 T 병기에 따라 • pT1의 경우 10개 • pT2의 경우 20개 • pT3, pT4에서는 30개 이상의 림프절 절제가 최대 생존율을 보장할 수 있음을 제안 • 이러한 림프절 절제술은 결국 환자의 morbidity와 근치적 절제술 여부 등을 고려하여 그 범위가 결정되어야 할 것이다 Rizk NP, et al. Annals of Surgery 2010;251:46-50

  30. Distant metastatic sites • 이전의 pM1a 및 pM1b 분류가 없어지고 • 원격 장기에 전이가 있는 경우 pM1으로 분류

  31. Survival according to histopathologic cell type

  32. Slide from YT Kim

  33. Stage T N M G Location 0 is (HGD) 0 0 1 Any IA 1 0 0 1 Any IB 1 0 0 2-3 Any 2-3 0 0 1 Lower IIA 2-3 0 0 1 Upper, middle 2-3 0 0 2-3 Lower IIB 2-3 0 0 2-3 Upper, middle 1-2 1 0 Any Any IIIA 1-2 2 0 Any Any 3 1 0 Any Any 4a 0 0 Any Any IIIB 3 2 0 Any Any IIIC 4a 1-2 0 Any Any 4b Any 0 Any Any Any N3 0 Any Any IV Any Any 1 Any Any Staging system; Squamous cell carcinoma

  34. Slide from YT Kim

  35. Staging system; Adenocarcinoma Stage T N M G 0 is (HGD) 0 0 1 IA 1 0 0 1-2 IB 1 0 0 3 2 0 0 1-2 IIA 2 0 0 3 IIB 3 0 0 Any 1-2 1 0 Any IIIA 1-2 2 0 Any 3 1 0 Any 4a 0 0 Any IIIB 3 2 0 Any IIIC 4a 1-2 0 Any 4b Any 0 Any Any N3 0 Any IV Any Any 1 Any

  36. Slide from YT Kim

  37. Stage T N M Histology Grade Location 0 is(HGD) 0 0 Any Any Any I A 1 1 0 0 0 0 SqCC Adenoca G1 G1-2 Any Any B 1 1 2-3 2 0 0 0 0 0 0 0 0 SqCC Adenoca SqCC Adeno G2-3 G3 G1 G1-2 Any Any Lower Any II A 2-3 2-3 2 0 0 0 0 0 0 SqCC SqCC Adenoca G1 G2-3 G3 Upper, middle Lower Any B 2-3 1~2 3 0 1 0 0 0 0 SqCC Any Adenoca G2-3 Any Any Upper, middle Any Any III A 1~2 3 4a 2 1 0 0 0 0 Any Any Any Any Any Any Any Any Any B 3 2 0 Any Any Any C 4a 4b Any 1-2 Any 3 0 0 0 Any Any Any Any Any Any Any Any Any IV Any Any 1 Any Any Any New Staging Grouping

  38. Application of newly proposed staging system for Esophageal Squamous Cell Carcinoma National Cancer Center, Korea

  39. Patients • March 2001 ~ April 2010 • 592 esophagectomy for esophageal cancer • Exclusion criteria - neoadjuvant treatment - cervical esophageal cancer • Cohort of 492 patients in this study

  40. Patient characteristics(1)

  41. Patient characteristics(2)

  42. Overall survival 30 days 97.3% 1 year 93.2% 5 year 50.8%

  43. Overall survival (T factor) Tis T1 T2 T3 T4a T4b

  44. Overall survival (N factor) N0 N1 N2 N3

  45. Overall survival (Location) p=0.124 Lower Mid Upper N3

  46. Overall survival (Grade) p=0.085 WD MD PD N3

  47. Stage grouping Stage 0 Stage IA Stage IB Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC Stage IV

  48. Conclusion 1 • New staging system in which the number of lymph node metastasis is the important prognostic factor revealed the discrete survival curves among stage III esophageal cancer • Stage IA and IIA had the low proportions in the new staging system. Also, there was no significant differences between IB and IIA/B, which lead the overlay of the survival curves

  49. Conclusion 2 • However, subgroup analysis of the survival according to the grade or location in early esophageal squamous cell carcinoma did not show the significant differences • New staging system has the merit to discriminate the stage III system in esophageal squamous cell carcinoma. However, system is too complex d/t five characteristics. It seems that new staging system is not yet perfect

  50. Limitation of the new staging system • 수술 전후 항암이나 방사선치료가 없이 식도절제술을 시행한 식도암의 pT, pN, pM 병기를 근간으로 하였기 때문에, 수술을 시행하지 않은 환자나 수술에 따른 위험도가 높아 수술이 불가능하였던 환자, 근치적 수술 없이 개흉술만 시행한 환자들은 이 자료에서는 제외 • 특히 pT4 또는 pM1 병기를 보이는 환자에서 다른 치료 없이 수술만 시행 받은 환자는 굉장히 선택된경우 • T1a/T1b data; incomplete • Uncertain if celiac nodes included • Cervical esophageal cancers: Not represented

More Related