What are the new AJCC Staging System changes, and how will they affect my patients? Emily Y. Chu, M.D., Ph.D. Assistant Professor of Dermatology & Pathology and Laboratory Medicine University of Pennsylvania February 17, 2017 AAD Annual Meeting San Diego, CA
DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Emily Y. Chu, MD PhD S047: Managing Patients with Melanoma or Other Melanocytic Neoplasms DISCLOSURES I do not have any relevant relationships with industry.
Overview AJCC Staging System 7 th Edition (most recent, until December 31, 2017) 8 th Edition (January 1, 2018 present) Considerations beyond AJCC Staging
Why do we care about staging?
AJCC (American Joint Committee on Cancer) Creates cancer staging system Stratify patients according to survival 7 th edition (most recent system up until December 31, 2017) from 2009 27,000+ patients with melanoma confined to the skin (Stage I and II melanoma) Melanoma-specific survival
AJCC Staging System, 7 th Edition Thickness Ulceration 10-year survival Stage IA 1mm - and <1 mitosis 95% Stage IB Stage IIA Stage IIB 1mm + or 1 mitosis 1 2mm - 1 2mm + 2 4mm - 2 4mm + >4mm - 87% 68% 57% Stage IIC >4mm + 40%
AJCC Staging System, 7 th Edition Thickness Ulceration 10-year survival Stage IA 1mm - and <1 mitosis 95% Stage IB Stage IIA Stage IIB 1mm + or 1 mitosis 1 2mm - 1 2mm + 2 4mm - 2 4mm + >4mm - 87% 68% 57% Stage IIC >4mm + 40%
2002 2009
2002 2009 2018
Changes for 2018 Different data set Include patients treated after the introduction of sentinel lymph node biopsy procedure Ten different centers around the world contributed data Different committee members
7 th Edition AJCC Staging System Thickness Ulceration Stage IA 1mm - and <1 mitosis Stage IB Stage IIA Stage IIB 1mm + or 1 mitosis 1 2mm - 1 2mm + 2 4mm - 2 4mm + >4mm - Stage IIC >4mm +
7th Edition AJCC Staging System Thickness Ulceration Stage IA 1mm - and <1 mitosis Stage IB Stage IIA Stage IIB 1mm + or 1 mitosis 1 2mm - 1 2mm + 2 4mm - 2 4mm + >4mm - Stage IIC >4mm +
Changes for 2018 Mitoses are no longer included Instead, for lesions <1mm, thickness of 0.8mm is used for stratification Stage IA: no ulceration, <0.8mm Stage IB: ulceration OR 0.8 1mm
Changes for 2018 Mitoses are no longer included Instead, for lesions <1mm, thickness of 0.8mm is used for stratification Stage IA: no ulceration, <0.8mm Stage IB: ulceration OR 0.8 1mm <0.8mm, -ulceration = IA <0.8mm, +ulceration = IB 0.8-1mm (regardless of ulceration) = IB
Mitoses are still important, though Among patients with clinically node-negative (cn0) primary melanoma in the 8th edition database, increasing mitotic rate was significantly associated with decreasing MSS in univariate analysis Gershenwald et al, Ca Cancer J Clin 2017
2018 AJCC Staging System Thickness Ulceration Stage IA <0.8mm - Stage IB Stage IIA Stage IIB <0.8mm + 0.8-1mm +/- 1 2mm - 1 2mm + 2 4mm - 2 4mm + >4mm - Stage IIC >4mm +
Changes for 2018 Thickness reported to one decimal place rather than two 0.6 mm rather than 0.63 mm Gershenwald et al, Ca Cancer J Clin 2017
AJCC Staging System AJCC Staging System has strengths that are also limitations Designed for worldwide use Aim is simplicity and usability But does not capture all that we know
AJCC Staging System Limitations/Strengths: Can only include information that ALL pathologists can determine Limited number of characteristics TNM system: only includes tumor characteristics
SEX
SEX MEN WOMEN
SEX WORSE MEN BETTER WOMEN
ANATOMIC SITE (From Balch et al, Cutaneous Melanoma, 3 rd Ed.)
ANATOMIC SITE AXIAL EXTREMITIES
ANATOMIC SITE WORSE AXIAL BETTER EXTREMITIES
AGE YOUNGER OLDER
AGE BETTER YOUNGER WORSE OLDER
Patient characteristics Sex (male is worse) Body site (axial is worse) Age (older is worse) Balch CM, JCO 2001
Microscopic Features
Vertical Growth Phase
Regression
Tumor Infiltrating Lymphocytes (TILs) Melanoma Lymphocytes
Lymphovascular Invasion
Looking Beyond Thickness Survival Penn Pigmented Lesion Group stratification system
Penn Pigmented Lesion Group stratification system Vertical growth phase Thickness Mitotic rate Tumor-infiltrating lymphocytes Regression Sex Body site Lymphovascular invasion, ulceration, age
Penn Pigmented Lesion Group stratification system
Looking Beyond Thickness: Survival Penn System stratifies patients into 3 different groups Higher-risk patients get more frequent exams and may get screening imaging
Don t forget Second primary melanoma risk may also play a role in developing a management plan Personal factors Age/Co-morbidity Patient preference
Summary AJCC changes in 2018 for Stage I/II are only in Stage IA and IB 0.8mm as a factor instead of mitoses But mitoses are still important (and should still be reported) Other clinical and histopathologic factors also important
Penn Multidisciplinary Melanoma Program Medical Dermatology Medical Oncology Michael Ming Lynn Schuchter Rose Elenitsas Ravi Amaravadi Brian Capell Tara Gangadhar Dermatopathology Surgical Oncology Rose Elenitsas Giorgos Karakousis David Elder Derm Surgery George Xu Chris Miller Medical Genetics Joseph Sobanko Kate Nathanson Thuzar Shin Jeremy Etzkorn
Thank you! emily.chu@uphs.upenn.edu