Arnold, Dominik

Dislich, Bastian

Erdem, Suna

Kröll, Dino

Langer, Rupert

Noser, Laura

Seiler, Christian A.

Storni, Federico Lorenzo

Zlobec, Inti

Bern Open Repository and Information System (BORIS)

BACKGROUND AND AIMSMATERIALS AND METHODS RESULTSCONCLUSIONLaura Noser1,2*, Dino Kröll2*, Suna Erdem2, Federico Storni2, Dominik Arnold1,2, Bastian Dislich1, Inti Zlobec1, Christian A. Seiler2, Rupert Langer11Institute of Pathology, Department of Clinical Pathology, University of Bern, Switzerland;                                   2Department of Visceral Surgery and Medicine, Inselspital Bern, University of Bern, Switzerland *equal contributionThe 8th edition of the AJCC TNM staging system showes slightly improved, but still not perfect prognostication for esophageal carcinomastreated by neoadjuvant therapy followed by surgeryThe 8th edition of the UICC/AJCC TNM stagingsystem (TNM8) provides slight, but simplifying changescompared to the preceding 7th edition (TNM7) Inaddition, the AJCC presents for the first time aspecific staging system for esophageal carcinomastreated with neoadjuvant therapy followed bysurgery. We compared the prognostic value of thisnovel staging system of AJCC TNM8 with TNM7.Histology work up The whole macroscopically detectable tumor bed was embedded. HE staining was performed for routine histopathological analysis. In cases without viable tumor in the first sections, additional deeper sections were performed. The ypT, ypN and M categories were recorded from the pathology files, or obtained from the original slides if the information in the original report was unclear Staging Tumor stage were classified according to TNM7 and TNM8. TNM7 staging was expanded by the additional introduction of a „stage 0“ in cases of ypT0N0M0 tumors which would have been reserved for ypTis tumors in the original staging systems. Cases with lymph node or distant metastases without evidence of residual cancer in the primary tumor site (i.e. ypT0N>0/M>0) were classified according to the lowest T category in the respectiveThe 8th edition of the AJCC TNM classification allows for the first time accurate staging esophageal carcinomas treated by neoadjuvant therapy. Prognostication has slightly improved as compared to the preceding TNM7, but still appears not perfect. Stage Distribution in TNM7 and TNM8: Complete regression of the primary tumor was observed in 50 cases (25.25%). The cases were included into stage I (ypT0N0M0; n=42), stage IIIA (ypT0N1M0; n=6) stage IVA (ypT0N3M0; n=1) and stage IVB (ypT0N0M1; n=1) in TNM8. Besides the 42 cases with complete regression of the primary tumor and without metastases, 24 cases of TNM7 stage IA and 20 cases of TNM7 stage IB tumors were incorporated into the newly defined yTNM8 stage I group. yTNM8 stage II is equal to TNM7 stage IIA, and yTNM8 stage IIIA is equal to TNM7 stage IIB. In yTNM8 stage IIIB there are tumors with TNM7 stage IIIA and IIIB now collapsed, meaning a simplification of stages but not literally a stage migration. TNM7Stage pT pN pMIA 1 0 0IB 2 0 0IIA 3 0 0IIB 1, 2 1 0IIIA 4a 0 03 1 01, 2 2 0IIIB 3 2 0IIIC 4a 1,2 04b Any 0Any 3 0IV Any Any 1yTNM8Stage ypT ypN ypMI 0-2 0 0II 3 0 0IIIA 0-2 1 0IIIB 0-3 2 03 1 04a 0 0IVA Any 3 04a 1-2 04b Any 0IVB Any Any 1Patients: Out of 272 patients who consecutively underwent surgery due to esophageal malignancy between 2001 and 2016 in the Department of Visceral Surgery at the Inselspital Bern, we selected all 198 cases with esophageal carcinomas (144 adeno; 54 squamous cell carcinomas) treated with neoadjuvant radiochemotherapy (n= 147) or chemotherapy (n= 51). Treatment: Preoperative radiation was performed with at least 40Gy. Chemotherapy was 5-FU and Cisplatin/Carboplatin based. For surgery, a transmediastinal esophagectomy with a radical bilateral mediastinal en-bloc lymphadenectomy (TME) was performed in most cases. Mean number of resected lymph nodes was 26. In 180 cases, complete tumor resection was achieved. In 7 cases, no esophagectomy was performed (evidence of distant metastases during surgery), however, these cases were classified as stage IV (TNM7) or IVB (TNM8)Survival Analysis Mean survival was 172 months (95%CI 45-300). There was no significant difference between adeno- and squamous cell carcinomas (p=0.71). Higher pT category (p<0.001), pN category (p<0.001), resection status (p=0.003)  and in trend presence of distant metastases (p=0.090) were associated with worse overall survival.Tumor staging in TNM7 showed highly significant prognostic impact (p<0.001). However, stage IIB tumors (pT1/pT2N1) had better prognosis compared to stage IA (ypT1N0), IB (pT2N0) and IIA (pT3N0) tumors. For TNM8, a similar prognostic value was observed when using the novel proposed ypTNM classification (p<0.001), and, likewise stage IIIA tumors (ypT0-2N1) were better than stage II (ypT3N0)yTNM8TotalStage I Stage II Stage IIIA Stage IIIB Stage IVA Stage IVB„Stage 0“ 42 0 0 0 0 0 42Stage IA 24 0 0 0 0 0 24Stage IB 20 0 0 0 0 0 20Stage IIA 0 21 0 0 0 0 21TNM7 Stage IIB 0 0 24 0 0 0 24Stage IIIA 0 0 0 27 0 0 27Stage IIIB 0 0 0 13 0 0 13Stage IIIC 0 0 0 0 11 0 11Stage IV 0 0 0 0 0 16 16Total 86 21 24 40 11 16 198Comparison of TNM7 and yTNM8 Using AIC and SBC as parameters for goodness-of-fit, TNM8 was slightly superior regarding prognostication (TNM7 AIC=1593.239; SBC=1619.088; TNM8 AIC=1589.331; SBC=1605.487: lower values of AIC and SBC indicate superior model fit with the “better” model showing the lowest values for both). A simplified staging with collapsed stages (i.e. stages IIA and IIB collapsed to stage II) did not improve AIC or SBC values. Similar results were seen for adenocarcinomas and squamous cell carcinomas if analyzed separately

The 8th edition of the AJCC TNM staging system shows slightly improved, but still not perfect prognostication for esophageal carcinomas treated by neoadjuvant therapy followed by surgery

https://boris.unibe.ch/109127/1/Poster_Laura.pdf

The 8th edition of the AJCC TNM staging system shows slightly improved, but still not perfect prognostication for esophageal carcinomas treated by neoadjuvant therapy followed by surgery

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