J Gastric Cancer.  2011 Jun;11(2):78-85.

Evaluation of the 7th UICC TNM Staging System of Gastric Cancer

• Kwon SJ

Abstract

Since January of 2010, the seventh edition of UICC tumor node metastasis (TNM) Classification, which has recently been revised, has been applied to almost all cases of malignant tumors. Compared to previous editions, the merits and demerits of the current revisions were analyzed. Many revisions have been made for criteria for the classification of lymph nodes. In particular, all the cases in whom the number of lymph nodes is more than 7 were classified as N3 without being differentiated. Therefore, the coverage of the N3 was broad. Owing to this, there was no consistency in predicting the prognosis of the N3 group. By determining the positive cases to a distant metastasis as TNM stage IV, the discrepancy in the TNM stage IV compared to the sixth edition was resolved. In regard to the classification system for an esophagogastric (EG) junction carcinoma, it was declared that cases of an invasion to the EG junction should follow the classification system for esophageal cancer. A review of clinical cases reported from Asian patients suggests that it would be more appropriate to follow the previous editions of the classification system for gastric cancer. In addition, in the classification of the TNM stages in the overall cases, the discrepancy in the prognosis between the different stages and the consistency in the prognosis between the same TNM stages were achieved to a lesser extent as compared to that previously. Accordingly, further revisions are needed to develop a purposive classification method where the prognosis can be predicted specifically to each variable and the mode of the overall classification can be simplified.

Keyword

Stomach neoplasms; Neoplasm staging; Lymphnodes

MeSH Terms

Asian Continental Ancestry Group
Esophageal Neoplasms
Humans
Lymph Nodes
Neoplasm Metastasis
Neoplasm Staging
Prognosis
Stomach Neoplasms

Reference

1. Sayegh ME, Sano T, Dexter S, Katai H, Fukagawa T, Sasako M. TNM and Japanese staging systems for gastric cancer: how do they coexist? Gastric Cancer. 2004. 7:140–148.

2. Ha TK, Kim HJ, Kwon SJ. Does the New UICC/AJCC TNM Staging System (7th Edition) Improve Assessing Prognosis in Gastric Cancer Compared to the Old System (6th Edition)? J Korean Gastric Cancer Assoc. 2009. 9:159–166.

3. Huang B, Zheng X, Wang Z, Wang M, Dong Y, Zhao B, et al. Prognostic significance of the number of metastatic lymph nodes: is UICC/TNM node classification perfectly suitable for early gastric cancer? Ann Surg Oncol. 2009. 16:61–67.

4. Qiu MZ, Wang ZQ, Zhang DS, Liu Q, Luo HY, Zhou ZW, et al. Comparison of 6th and 7th AJCC TNM staging classification for carcinoma of the stomach in China. Ann Surg Oncol. 2011. 01. 19. [Epub ahead of print].

5. Deng J, Liang H, Sun D, Wang D, Pan Y. Suitability of 7th UICC N stage for predicting the overall survival of gastric cancer patients after curative resection in China. Ann Surg Oncol. 2010. 17:1259–1266.

6. Deng J, Liang H, Wang D. The feasibility of N stage of the 7th edition TNM for gastric cancer. Ann Surg Oncol. 2011. 18:1805–1806.

7. Bae JM, Kim SW, Kim SW, Song SK. Evaluation of prognostic values according to the new TNM classification in gastric cancer. J Korean Surg Soc. 2011. 80:23–28.

8. Deng JY, Liang H, Sun D, Zhan HJ, Wang XN. The appropriate cutoffs of positive lymph nodes to evaluate the prognosis of gastric cancer patients. J Surg Oncol. 2008. 98:343–348.

9. Bunt AM, Hermans J, Smit VT, van de Velde CJ, Fleuren GJ, Bruijn JA. Surgical/pathologic-stage migration confounds comparisons of gastric cancer survival rates between Japan and Western countries. J Clin Oncol. 1995. 13:19–25.

10. Hundahl SA, Phillips JL, Menck HR. The National Cancer Data Base Report on poor survival of U.S. gastric carcinoma patients treated with gastrectomy: fifth edition American Joint Committee on Cancer staging, proximal disease, and the "different disease" hypothesis. Cancer. 2000. 88:921–932.

11. Barbour AP, Rizk NP, Gonen M, Tang L, Bains MS, Rusch VW, et al. Lymphadenectomy for adenocarcinoma of the gastroesophageal junction (GEJ): impact of adequate staging on outcome. Ann Surg Oncol. 2007. 14:306–316.

12. Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes NC, Stemmermann GN, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001. 345:725–730.

13. Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006. 355:11–20.

14. Strong VE, Song KY, Park CH, Jacks LM, Gonen M, Shah M, et al. Comparison of gastric cancer survival following R0 resection in the United States and Korea using an internationally validated nomogram. Ann Surg. 2010. 251:640–646.

15. Fukuda N, Sugiyama Y, Midorikawa A, Mushiake H. Prognostic significance of the metastatic lymph node ratio in gastric cancer patients. World J Surg. 2009. 33:2378–2382.

16. Persiani R, Rausei S, Biondi A, Boccia S, Cananzi F, D'Ugo D. Ratio of metastatic lymph nodes: impact on staging and survival of gastic cancer. Eur J Surg Oncol. 2008. 34:519–524.

17. Marchet A, Mocellin S, Ambrosi A, Morgagni P, Garcea D, Marrelli D, et al. The ratio between metastatic and examined lymph nodes (N ratio) is an independent prognostic factor in gastric cancer regardless of the type of lymphadenectomy: results from an Italian multicentric study in 1853 patients. Ann Surg. 2007. 245:543–552.

18. Moug SJ, Saldanha JD, McGregor JR, Balsitis M, Diament RH. Positive lymph node retrieval ratio optimizes patient staging in colorectal cancer. Br J Cancer. 2009. 100:1530–1533.

19. Peschaud F, Benoist S, Julié C, Beauchet A, Penna C, Rougier P, et al. The ratio of metastatic to examined lymph nodes is a powerful independent prognostic factor in rectal cancer. Ann Surg. 2008. 248:1067–1073.

20. van der Wal BC, Butzelaar RM, van der Meij S, Boermeeste MA. Axillary lymph node ratio and total number of removed lymph nodes: predictors of survival in stage I and II breast cancer. Eur J Surg Oncol. 2002. 28:481–489.

21. Lemmens VE, Dassen AE, van der Wurff AA, Coebergh JW, Bosscha K. Lymph node examination among patients with gastric cancer: Variation between department of pathology and prognostic impact of lymph node ratio. Eur J Surg Oncol. 2011. 37:488–496.

22. Ha TK, Kwon SJ. Subclassification of stage IV gastric cancer according to the presence of distant metastasis (IVa and IVb). J Korean Gastric Cancer Assoc. 2006. 6:173–180.

23. Park JM, Park SS, Mok YJ, Kim CS. pN3M0 gastric cancer: the category that allows the sub-classification of stage IV gastric cancer (IVa and IVb). Ann Surg Oncol. 2007. 14:2535–2542.

24. Li C, Yan M, Chen J, Xiang M, Zhu ZG, Lin YZ. Prognostic influence of sub-stages according to pTNM categories in patients with stage IV gastric cancer. J Surg Oncol. 2009. 99:324–328.

25. An JY, Ha TK, Noh JH, Sohn TS, Kim S. Proposal to subclassify stage IV gastric cancer into IVa, IVb, and IVM. Arch Surg. 2009. 144:38–45.

26. Kodera Y, Nakanishi H, Ito S, Nakao A. Clinical significance of isolated tumor cells and micrometastases in patients with gastric carcinoma. Gan To Kagaku Ryoho. 2007. 34:817–823.

27. Fukagawa T, Katai H, Saka M, Morita S, Sasajima Y, Taniguchi H, et al. Significance of lavage cytology in advanced gastric cancer patients. World J Surg. 2010. 34:563–568.

28. Badgwell B, Cormier JN, Krishnan S, Yao J, Staerkel GA, Lupo PJ, et al. Does neoadjuvant treatment for gastric cancer patients with positive peritoneal cytology at staging laparoscopy improve survival? Ann Surg Oncol. 2008. 15:2684–2691.

29. Nath J, Moorthy K, Taniere P, Hallissey M, Alderson D. Peritoneal lavage cytology in patients with oesophagogastric adenocarcinoma. Br J Surg. 2008. 95:721–726.

30. Washington K. 7th edition of the AJCC cancer staging manual: stomach. Ann Surg Oncol. 2010. 17:3077–3079.

31. Hassan HA, Sharma VK, Raufman JP. Changing trends in gastric carcinoma at a university medical center: a twelve-year retrospective analysis. J Clin Gastroenterol. 2001. 32:37–40.

32. Clark GW, Smyrk TC, Burdiles P, Hoeft SF, Peters JH, Kiyabu M, et al. Is Barrett's metaplasia the source of adenocarcinomas of the cardia? Arch Surg. 1994. 129:609–614.

33. Dolan K, Sutton R, Walker SJ, Morris AI, Campbell F, Williams EM. New classification of oesophageal and gastric carcinomas derived from changing patterns in epidemiology. Br J Cancer. 1999. 80:834–842.

34. Rüdiger Siewert J, Feith M, Werner M, Stein HJ. Adenocarcinoma of the esophagogastric junction: results of surgical therapy based on anatomical/topographic classification in 1,002 consecutive patients. Ann Surg. 2000. 232:353–361.

35. Kusano C, Gotoda T, Khor CJ, Katai H, Kato H, Taniguchi H, et al. Changing trends in the proportion of adenocarcinoma of the esophagogastric junction in a large tertiary referral center in Japan. J Gastroenterol Hepatol. 2008. 23:1662–1665.

36. Strong VE, Song KY, Park CH, Jacks LM, Gonen M, Shah M, et al. Comparison of gastric cancer survival following R0 resection in the United States and Korea using an internationally validated nomogram. Ann Surg. 2010. 251:640–646.

37. Kim HJ, Kwon SJ. Analysis of clinicopathologic difference between type II and type III cancers in Siewert classification for adenocarcinoma of the cardia. J Korean Gastric Cancer Assoc. 2004. 4:143–148.

38. Jang JH, Beron RI, Ahn HS, Kong SH, Lee HJ, Kim WH, et al. Clinicopathological features of upper third gastric cancer during a 21-year period (single center analysis). J Gastric Cancer. 2010. 10:212–218.

39. Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer. 2011. Published online: 15 May 2011.

40. Rausei S, Dionigi G, Boni L, Rovera F, Dionigi R. How does the 7th TNM edition fit in gastric cancer management? Ann Surg Oncol. 2010. 09. 29. [Epub ahead of print].