Revised points and disputed matters in the eighth edition of the TNM staging system for gastric cancer.

The American Joint Committee on Cancer and the Union for International Cancer Control have now released the eighth edition of the cancer staging system, which incorporates some major revisions concerning gastric cancer. First, grouping of pathological stages has been revised in accordance with a proposal from the International Gastric Cancer Association. That revision was based on analysis of survival of more than 25 000 patients worldwide who had undergone curative gastrectomy without neoadjuvant therapy. Stratification of survival in Stage III subgroups has been improved by subdividing N3 into N3a and N3b. Second, a simplified grouping of clinical stages that differs completely from grouping of pathological stages has been proposed. Pre-treatment depth of tumour invasion is now categorized as T1/T2, T3/T4a or T4b, and lymph node status is simply categorized as N0 or N+. Additionally, a 'yp-stage' for specimens resected after neoadjuvant therapy has been newly proposed. These clinical and post-neoadjuvant stages were considered useful now that neoadjuvant chemotherapy is increasingly being administered to patients with potentially resectable gastric cancer. Third, staging of oesophagogastric junction tumours has been modified; Siewert type 3 tumours are now classified as gastric tumours and are staged according to the gastric, rather than the oesophageal, system. More appropriate staging of gastric cancers treated with neoadjuvant therapy, and/or new staging systems incorporating variables other than T/N/M, such as biological or genomic markers, are likely future developments.

Evolution of lymphoma staging and response evaluation: current limitations and future directions.

The accurate detection and precise assessment of therapeutic responses is critical to the optimal management of patients with lymphoma. Over the past 50 years, dramatic advances in technology have established imaging as the cornerstone of disease evaluation. However, the appropriate application of current techniques requires acknowledgement of their strengths and weaknesses, and appreciation of the full diversity of lymphoid neoplasms. The role of anatomical and functional imaging in detection, treatment escalation/de-escalation and prognostication of patients with lymphoma can be misinterpreted. The development of disease assessment criteria, without an appreciation of the limitations of current imaging technologies, reflects a potential overreach of imaging science. Furthermore, the introduction of various novel therapies adds to the complexity of disease monitoring. In this Perspectives, the authors evaluate the available evidence in this rapidly evolving field and propose a reporting framework, named 'Specialist Integrated Haematological Malignancy Imaging Reporting' (SIHMIR), with a goal of providing a robust and adaptable system for lymphoma assessment. We predict a future model of multimodal disease assessment using novel molecular and imaging techniques, and highlight the key outstanding research questions in this field.

Sentinel Lymph Node Biopsy: Evolution of the Technique Since the Original Description by Morton et al. in 1992.

Donald Morton was a truly amazing man: a remarkable scientist and an outstanding, inspirational surgical oncologist. For those of us who had the great fortune to know him personally, it was an experience that we will always remember with warmth and gratitude. Hundreds of thousands, possibly millions, of patients in the future will also be grateful to him when they benefit from his original but simple idea that has so dramatically improved the surgical approach to patients with cancers that may metastasize to regional lymph nodes: the sentinel lymph node biopsy concept.

Principles of Cancer Staging for Clinical Obstetrics and Gynecology.

Cancer represents a complex group of diseases characterized by uncontrolled growth and the ability to metastasize. Cancer may affect any part of the body, and within the female reproductive systems, there exist a variety of cancers each associated with different presenting symptoms, clinical course, etiology, and natural history of disease. The essential features of each cancer include the presenting site of disease (topography), the histopathologic (morphology), molecular and genetic tumor profile, and the anatomic disease extent (stage). Without knowing these features, it is impossible to discuss investigation, treatment, and prognosis in cancer.

Evolution of sentinel lymph node biopsy in breast cancer, in and out of vogue?

Sentinel lymph node biopsy (SLNB) was introduced 2 decades ago and thereafter validated for routine surgical management of breast cancer, including cases treated with neoadjuvant chemotherapy. As the number of lymph nodes for staging has decreased, pathologists have scrutinized SLN with a combination of standard hematoxylin and eosin, levels, immunohistochemistry (IHC), and molecular methods. An epidemic of small-volume metastases thereby arose, leading to modifications in the American Joint Committee on Cancer staging to accommodate findings such as isolated tumor cells (ITC) and micrometastases. With the goal of determining the significance of these findings, retrospective followed by prospective trials were performed, showing mixed results. The ACOSOG Z10 and NSABP B-32 trials both independently showed that ITC and micrometastases were not significant and thus discouraged the use of levels and IHC for detecting them. However, the Surveillance Epidemiology and End Results database showed that patients with micrometastases had an overall decreased survival. In addition, the MIRROR (Micrometastases and ITC: Relevant and Robust or Rubbish?) trial, showed that patients with ITC and micrometastases treated with adjuvant therapy had lower hazard ratios compared with untreated patients. Subsequently, the ACOSOG Z0011 trial randomized patients with up to 2 positive SLN to axillary lymph node dissection (ALND) or not, all treated with radiation and chemotherapy, showing no difference in survival or recurrence rates between the 2 groups and causing a shift from ALND. As the rate of ALND has declined, the necessity of performing levels, IHC, frozen section, and molecular studies on SLN needs to be revisited.

Historical perspectives: The evolution of the thymic epithelial tumors staging system.

Thymic epithelial tumors (thymomas, thymic carcinomas and neuroendocrine tumors - NETs) are rare primary mediastinal neoplasms, recently classified as orphan diseases. Their rarity might explain the fact that currently, no official staging system has been defined by the Union Internationale Contre le Cancer (UICC) and the American Joint Commission on Cancer (AJCC). However, the appropriate staging of these tumors has been matter of debate and several proposals have been published over the years, but very few have received a clinical validation. Recently an international database for thymic malignancies has been provided by the International Thymic Malignancy Interest Group (ITMIG); one of its aims is to accomplish a new and evidence based staging system, to allow progress in clinical management in thymic tumors. This paper will review the history of proposed staging systems, comparing resemblances and differences, being a sort of starting point for the development of a new widely accepted clinical staging system.

Esophageal cancer staging: past, present, and future.

TNM cancer staging, conceived 70 years ago, was first applied to the esophagus in 1977. Prior staging was neither data-driven nor harmonized with stomach cancer. Machine-learning analysis of worldwide data addressed these shortcomings in the 7th edition. The 8th edition considers 6 problems in attempting to advance esophageal cancer staging.

History of small-cell lung cancer.

The history of small-cell lung cancer (SCLC) is one of the more fascinating stories of medicine, a story of hope and disappointment that characterizes it as 1 of the most elusive cancers. Its history can be divided into 3 intervals. The first interval encompassed the 30 years after the initial reports from Bernard in 1926 during which SCLC was characterized. The second interval, from the 1960s-1980s, introduced advances in staging and treatment of SCLC and the advent of chemotherapy and radiation therapy (RT) as the primary forms of therapy. The final interval covers the past 25 years, which is considered a dormant period, although there are some shimmers of hope from the emergence of several new active drugs that are currently undergoing clinical trials.

Improvements in population-based survival of patients presenting with metastatic rectal cancer in the south of the Netherlands, 1992-2008.

We analysed population-based treatment and survival data of patients who presented with metastatic rectal cancer. All patients diagnosed with primary synchronous metastatic rectal cancer between 1992 and 2008 in the Eindhoven Cancer Registry area were included. Date of diagnosis was divided into three periods (1992-1999, 2000-2004, 2005-2008) according to the availability of chemotherapy type. We assessed treatment patterns and overall survival according to period of diagnosis. The proportion of patients diagnosed with stage IV disease increased from 16% in 1992-1999 to 20% in 2005-2008 (P < 0.0001). Chemotherapy use increased from 5% in 1992 to 61% in 2008 (P < 0.0001). Resection rates of the primary tumour decreased from 65% in 1992 to 27% in 2008 (P < 0.0001), while metastasectomy rates remained constant since 1999 (9%). Median survival increased from 38 weeks (95% confidence interval (CI) 32-44) in 1992-1999 to 53 weeks (95% CI 48-61) in 2005-2008. Among patients not receiving chemotherapy median survival remained approximately 30 weeks. Multivariable analysis confirmed the lower risk of death among patients diagnosed in more recent years. Increased use of chemotherapy went together with improved median survival among patients with metastatic rectal cancer in the last two decades. Stage migration as an effect of more effective imaging procedures is likely to be partly responsible for this improved survival.

Clinicopathological staging of colorectal cancer: Evolution and consensus-an Australian perspective.

In 1991 this journal published the report of an international working party to the World Congress of Gastroenterology regarding the clinicopathological staging of colorectal cancer. Since that time staging has continued to evolve as further prognostic factors in colorectal cancer have been elucidated in studies of increasingly large databases in several countries. This review summarizes several of the key issues that have arisen during this evolutionary process and raises matters which still remain controversial in staging at the present time.

Recent advances in mesothelioma staging.

Lack of a consensus staging system for malignant pleural mesothelioma has had a profound impact on clinical practice and research, which necessarily relies on comparison of outcomes across multiple institutions and studies for reliable prognostic information. Some lack of agreement arises from the difficulty of conforming this particular cancer to existing staging systems because of its unique biology. The heterogeneous prognosis of patients with differing tumor histology and constant search for new more effective therapies also play a role. Periodic data-driven refinement of staging criteria, based on careful pathologic analysis of histologically homogeneous cohorts, is mandated to provide clinicians with the optimal ability to stratify patients according to survival and select treatments most appropriate for the patient's individual tumor biology.

History of the FIGO cancer staging system.

The main objectives of any good staging system - essential to an evidence-based approach to cancer - are: to aid the clinician in planning treatment; to provide indication of prognosis; to assist the physician in evaluating the results of treatment; to facilitate the exchange of information between treatment centers, thus disseminating knowledge; and to contribute to continuing investigations into human malignancies. A good staging system must have 3 basic characteristics: it must be valid, reliable, and practical. The first staging system for gynecological cancers appeared around the turn of the 20th century and applied to the carcinoma of the cervix uteri-the most common cancer affecting women in high income countries at that time. The classification and staging of the other gynecological malignancies was not put forward until the 1950s. Over the years, these staging classifications - with the exception of cervical cancer and gestational trophoblastic neoplasia - have shifted from a clinical to a surgical-pathological basis. This paper reviews the history of the International Federation of Gynecology and Obstetrics (FIGO) cancer staging system, how it was developed, and why.

[The history of radical dissection of cervical lymph nodes--in centenary of George Crile publication]. / Historia operacji radykalnej wezlów chlonnych szyi--w 100-lecie publikacji George'a Crile'a.

The history of surgical management of cervical lymph nodes metastases evolved from the XIX century period, when the lymph nodes metastases in head and neck cancer had been recognized as a stage of disease above the limits of rational surgical treatment. Among the Pioneers of surgery of that time was Franciszek Jawdynski. The second period dated from 1906 publication of George Crile, who postulated the necessity of surgical resection of primary tumor as well as regional head and neck lymph nodes and defined a procedure of radical block dissection of cervical lymph nodes ended, when Hughes Martin and his contemporaries established a comprehensive radical neck dissection as a universal standard procedure of head and neck surgery. At present, not forgetting the value of radical neck dissection in treatment of cervical lymph nodes metastases, we return back to less mutilating surgical procedures, with preservation of non lymphatic structures and selective resections of regional group of nodes, due to the progress in non surgical treatment modalities (radiotherapy and chemotherapy) and new techniques of imaging and pathology.

Staging of renal cell carcinoma: past, present, and future.

Tumor stage, which describes the anatomic extent of disease, is a powerful determinant of prognosis and survival for patients with renal cell carcinoma (RCC). Stratification of patients based on prognostic outcomes derived from staging systems facilitates therapeutic decision-making, disease surveillance, and clinical research. Staging for RCC has evolved from the Robson classification into the TNM system, developed by the International Union Against Cancer and the American Joint Committee on Cancer. The most recent revisions of the TNM system for RCC introduced in 1997 and 2002 further subdivided organ-confined tumors, reclassified tumors with venous involvement, and clarified the staging of tumors that invade the perisinus fat. Most studies suggest that these revisions have substantially improved prognostication for RCC. Nevertheless, additional modifications have been proposed that would alter the subclassification of organ-confined disease, integrate various levels of venous involvement with other aspects of local tumor aggressiveness, and upgrade the classification of adrenal involvement. The data in support of each of these proposals will be discussed, and the current limitations of clinical and radiographic staging for RCC will be reviewed. Finally, a glimpse into the future of staging of RCC will be offered with a discussion of integrated staging and prognostic systems.