You Want ME to Stage that Case???

You Want ME to Stage that Case??? Jayne Holubowsky, CTR, Director, Virginia Cancer Registry 2 nd DelMarVa-DC Regional Conference October 11, 2018 What s New in the AJCC 8 th Edition

Objectives Explain fundamental changes to disease site chapters Explain New Principles of Cancer Staging Chapter Learn rule changes for AJCC 8 th edition

8 th Edition Dedication The AJCC Cancer Staging Manual, 8 th 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 Layout 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

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 of prognostic factors used to determine the stage group 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

Other New Paradigms New Chapters Cervical Nodes & Unknown Head & Neck Primary Thymus Parathyroid Leukemia Pediatric Hematologic Malignancies

Some Chapters Split Thyroid Other New Paradigms 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

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.

Chapter 1 Staging Rules 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 1 st chapter

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 Rules 2. 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 Rules 3. Timeframe/staging window for pathological stage A. 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

General Staging Rules 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 diseasespecific 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 unavailable A. Use X; or B. If the prognostic is unavailable, default to assigning the anatomic stage using clinical judgement 9. Grade A. 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 used a) pt3(m) N0 M0 3) If the # of synchronous tumors is important, an acceptable alternative designation is to specify the # of tumors a) 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. 2 nd 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 Tumor A. 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 sites 1) Pt s with an involved LN are staged as unk primary cancers using the Cervical LN s & Unknown Primary Tumors of the Head & Neck chapter a) 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

Additional staging descriptors & guidelines Tis General Staging Rules 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+)

LVI General Staging Rules 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

AJCC 8 th Edition SIGNIFICANT RULE CHANGES

Melanoma Rule Changes Primary tumor thickness measured to the nearest 0.1mm Was 0.01mm in 7 th edition Should be recorded per the CAP protocol If tumors are </= 1mm in thickness record to the nearest 0.1mm

Example Rule Changes 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

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 Rule Changes cn0 cm0 o Do not need pathologicial confirmation of LN s for in situ pathological staging

Example Pt had TURB with noninvasive papillary ca. CT scan showed positive LN s. Lap removal of 4 regional LN s reported as 1 perivesical LN+ & 1 external iliac LN + Clinical Staging Rule Changes 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

Example Rule Changes 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 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

Rule Changes 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

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 Rule Changes 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

AJCC 8 th Edition ABSTRACTING HINTS

Abstracting Hint #1 Read the chapter before you stage, make sure you have the most recent errata

Abstracting Hint #2 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 #3 Use the correct tables when assigning a stage Breast has multiple tables

Abstracting Hint #4 Support your stage assignments with text Do NOT just record the stage record HOW you arrived at your stage