New staging system for cutaneous SCC

Hi All

The AJCC (see abstract below) has come out with the first ever staging system for cutaneous SCC on its own. Previously it was staged with other non-melanoma skin cancers. Of course they have not actually defined what an SCC is; as some of you may be aware there is still great controversy about early SCC vs solar keratosis and keratoacanthoma versus SCC

The salient points for us are the T part of the TMN system which gives us an idea of the important local prognostic factors, some of which I did not realise. The depth is actually a Breslow depth which I did not know could be used for SCC.

T Classification

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor <2 cm in greatest dimension with< 2 high-risk features*

T2 Tumor > 2 cm in greatest dimension with or without one additional high-risk feature, or any size with >2 high-risk features

T3 Tumor with invasion of maxilla, mandible, orbit, or temporal bone

T4 Tumor with invasion of skeleton (axial or appendicular) or perineural invasion of skull base

High-risk features include depth (>2-mm thickness; Clark level >IV); perineural invasion; location (primary site ear; primary site nonglabrous lip); and differentiation (poorly differentiated or undifferentiated).

 

A new American Joint Committee on Cancer staging system for cutaneous squamous cell carcinoma: Creation and rationale for inclusion of tumor (T) characteristics

Sharifeh Farasat, BS,a Siegrid S. Yu, MD,b Victor A. Neel, MD, PhD,c Kishwer S. Nehal, MD,d Thomas Lardaro, BSc,a Martin C. Mihm, MD,e David R. Byrd, MD,f Charles M. Balch, MD,g,h,i Joseph A. Califano, MD,j Alice Y. Chuang, MD,i William H. Sharfman, MD,h,i Jatin P. Shah, MD, PhD,k Paul Nghiem, MD, PhD,l Clark C. Otley, MD,m Anthony P. Tufaro, DDS, MD,n Timothy M. Johnson, MD,o Arthur J. Sober, MD,c and Nanette J. Li_egeois, MD, PhDh,j,n Baltimore, Maryland; San Francisco, California; Boston, Massachusetts; New York, New York; Seattle,Washington; Rochester, Minnesota; and Ann Arbor, Michigan

Background: The incidence of cutaneous squamous cell carcinoma (cSCC) is increasing. Although mostpatients achieve complete remission with surgical treatment, those with advanced disease have a poor prognosis. The American Joint Committee on Cancer (AJCC) is responsible for the staging criteria for all

cancers. For the past 20 years, the AJCC cancer staging manual has grouped all nonmelanoma skin cancers,including cSCC, together for the purposes of staging. However, based on new evidence, the AJCC has determined that cSCC should have a separate staging system in the 7th edition AJCC staging manual.

Objective: We sought to present the rationale for and characteristics of the new AJCC staging system specific to cSCC tumor characteristics (T).

Methods: The Nonmelanoma Skin Cancer Task Force of AJCC reviewed relevant data and reached expert consensus in creating the 7th edition AJCC staging system for cSCC. Emphasis was placed on prospectively accumulated data and multivariate analyses. Concordance with head and neck cancer staging system was also achieved.

Results: A new AJCC cSCC T classification is presented. The T classification is determined by tumor diameter, invasion into cranial bone, and high-risk features, including anatomic location, tumor thickness and level, differentiation, and perineural invasion.

Limitations: The data available for analysis are still suboptimal, with limited prospective outcomes trials and few multivariate analyses.

Conclusions: The new AJCC staging system for cSCC incorporates tumor-specific (T) staging features and will encourage coordinated, consistent collection of data that will be the basis of improved prognostic systems in the future. ( J Am Acad Dermatol 2011;64:1051-9.)

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  1. #1 by Dr Ian Katz on June 22, 2011 - 8:21 am

    Jeff Keir wrote:
    Theres a couple of interesting links:

    A link to the 7th edition AJCC staging referred to:
    http://www.cancerstaging.org/staging/PDFs/lardaro-cscc.pdf

    A link to an article expressing concerns re: the omission of certain staging criteria, including host immune status:
    http://www.hindawi.com/journals/jsc/2011/156391/

  2. #2 by Hein Vandenbergh on June 22, 2011 - 11:15 am

    So Clark level has been reinstated just when for melanoma it is no longer prognostically useful.
    Which – perversely – fits-in with Jeff’s last comment, i.e. ‘host immune status’.

    ‘Perversely’, as to me tumour staging is a ‘now’ situation of tumour, not of host organism, an accurate description of what we have here and now, from which certain future statistical behavioral characteristics [‘prognosis’] can be derived. However, they all relate to the tumour itself. By introducing host immune status, a non-tumour prognostic statistical confounder is introduced.

    Was that not the situation with Clark-levels and melanoma? It SEEMED to be relevant, but was not, and so confounded the purity of Breslow thickness.

    I think host immune status is on a par with, say, late diagnosis or interventional delay. For obvious reasons these DO affect outcome, as does impaired immunity – but have nothing to do with the tumour per se, as staged at a certain point in time.

    Sorry, a bit hard to explain, but we are mixing aetiological risk factors in with purity of staging.

    Just some late night musings after a first day of country general practice with some humdinger tumours: melanoma on back > 2 cm….. and only a few pointy-eared banjo-tocklers [vide ‘Deliverance’] for light relief, cannot wait till tomorrow!!

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