Original article
Comparing the eighth and the seventh editions of the American Joint Committee on Cancer staging system and the Brigham and Women's Hospital alternative staging system for cutaneous squamous cell carcinoma: Implications for clinical practice

https://doi.org/10.1016/j.jaad.2018.06.060Get rights and content

Background

The new eighth edition of the American Joint Committee on Cancer staging system (AJCC-8) incorporates changes regarding cutaneous squamous cell carcinoma (CSCC).

Objectives

We aimed to compare the AJCC-8 staging system with the previous seventh edition of the AJCC staging system (AJCC-7) and the Brigham and Women's Hospital (BWH) alternative staging system to identify their usefulness and the utility of their risk factors in defining prognostic groups in CSCC.

Methods

A series of 186 CSCCs of the head and neck were retrospectively collected. All 3 staging systems were compared from the standpoint of their ability to predict poor prognosis. Binary logistic regression models were built to determine which risk factors were most relevant.

Results

Poor prognosis was mainly associated with stage T2 of the AJCC-7, with stages T2b/T3 of the BWH system, and with stage T3 of the AJCC-8. The AJCC-8 and the BWH staging systems displayed overlap with each another in predicting poor prognosis, and both were superior to the AJCC-7. The new risk factors incorporated into the AJCC-8 and the poor degree of differentiation were independently associated with poor outcome.

Limitations

Retrospective study and few cases with bone invasion.

Conclusions

The AJCC-8 is more distinctive, monotonous, and homogeneous than the AJCC-7 and shows some overlap with the BWH system in stratification of tumors.

Section snippets

Patients and variables

We evaluated a retrospectively collected cohort of 186 CSCCs located in the H&N. The study included 103 male and 83 female patients with a median age of 85.5 years (range, 47-105) and a median follow-up of 79 months (range, 18.5-190.2). The data used were derived from a database of 2391 CSCCs registered from January 2008 to December 2016 at the University Hospital of Salamanca, Spain. Tumors other than those from the H&N (n = 430), recurrent tumors (n = 20), and tumors of the H&N with missing

T-stage classification using the AJCC-7, AJCC-8, and BWH staging systems

The characteristics of our cohort are described in Table I. First, the tumors were classified according to both the AJCC-7 and the AJCC-8. Some tumors were staged the same with use of both systems, but for other tumors the T stage was either upgraded or downgraded with use of the AJCC-8. Specifically, 71 of the 186 tumors (38.2%) remained in the same T stage with use of both systems, 95 tumors (51.1%) were up-staged with use of the AJCC-8, and 20 tumors (38.7%) were down-staged with use of the

Discussion

In 2010, the AJCC-7 incorporated some high-risk factors and built a completely new T stage,11 but it was found to exhibit limitations.8, 9 Recently, the AJCC-8 emerged as an upgraded classification system.2 Here, it has been shown that the AJCC-8 is better than the AJCC-7 in terms of prognosis stratification.

The vast majority of CSCC tumors associated with DSPO in the AJCC-7 were staged as T2 in our cohort, which included tumors with a heterogeneous prognosis (which is a weak point that others

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      Most respondents believed that HNcSCC should not have the same pN categorization as HNmSCC owing to the distinct biological characteristics of both malignancies, that immunosuppression should be included in the staging system, and that the frequency of ENE makes it poor prognostic strati fier in HNcSCC. AJCC8 pT categories have been reported to demonstrate greater homogeneity, distinctiveness, and monotonicity compared with AJCC7.18 However, further refinement is essential to increase the utility and prognostic implications of the T stage.

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    Dr Moyano-Bueno and Dr Viñolas-Cuadros contributed equally to this article.

    Funding sources: Dr Cañueto is partially supported by a grant (GRS 1342/A/16) from the Regional Health Office of Castile and Leon and by the program INT/M/16/17 from the Regional Health Office of Castile and Leon. Dr Pérez-Losada was partially supported by FEDER and the MICINN (grants SAF2014-56989-R and SAF2017-88854-R), the Instituto de Salud Carlos III (PIE14/00066), and the We Can Be Heroes Foundation.

    Conflicts of interest: None disclosed.

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