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TN Categorization for Rectal and Colon Cancers Based on National Survival Outcome Data

TN Categorization for Rectal and Colon Cancers Based on National Survival Outcome Data. LL Gunderson 1 , JM Jessup 2 , DJ Sargent 3 , FL Greene 4 , A Stewart 5 for the AJCC Hindgut Taskforce (HTF). 1 Mayo Clinic Cancer Center – Arizona; Scottsdale, AZ

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TN Categorization for Rectal and Colon Cancers Based on National Survival Outcome Data

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  1. TN Categorization for Rectal and Colon Cancers Based on National Survival Outcome Data LL Gunderson1, JM Jessup2, DJ Sargent3, FL Greene4, A Stewart5 for the AJCC Hindgut Taskforce (HTF) 1Mayo Clinic Cancer Center – Arizona; Scottsdale, AZ 2National Cancer Institute, Rockville, MD 3Mayo Clinic Cancer Center – Rochester; Rochester, MN 4Carolinas Medical Center; Charlotte, NC 5American College of Surgeons; Chicago, IL

  2. Colorectal Cancer – TN CategorizationBackground • AJCC 6th Edition:Added outcomes-based substaging • Stage II subdivided: IIA (T3N0M0) and IIB (T4N0M0) • Stage III subdivided: IIIA (T1-2N1), IIIB (T3-4N1), IIIC (TanyN2) • Rectal Pooled Analyses:Outcomes supported revised substaging of Stage III • T1-2N2 cancers - survival and relapse similar to T4N0 (IIB) or T3N1 (IIIA) • T4N1 cancers – survival and relapse similar to T3N2 and T4N2

  3. Colorectal CA – Rectal Pooled AnalysisImpact of NT Category on Survival and Relapse

  4. Colorectal CA – Rectal Pooled AnalysisImpact of NT Category on Survival

  5. Colorectal CA –Rectal Pooled AnalysisImpact of NT Category on Relapse*

  6. Colorectal CA – Rectal Pooled AnalysisSurvival and Relapse Rates by Risk for Relapse Category^

  7. Colorectal Cancer – TN CategorizationBackground • AJCC 6th Edition:Added outcomes-based substaging • Stage II subdivided: IIA (T3N0M0) and IIB (T4N0M0) • Stage III subdivided: IIIA (T1-2N1), IIIB (T3-4N1), IIIC (TanyN2) • Rectal Pooled Analyses:Outcomes supported revised substaging of Stage III • T1-2N2 cancers - survival and relapse similar to T4N0 (IIB) or T3N1 (IIIA) • T4N1 cancers – survival and relapse similar to T3N2 and T4N2 • AJCC Hindgut Taskforce - sought validation in a population-based dataset that depth of invasion interacts with nodal status to affect survival

  8. Colorectal CA – SEER Population-Based Analysis Methods – Patient Group/Tumor Stratification • SEER Population-based data:Jan 1, 1992 to Dec, 2004 • Patient Group:Rectal CA – 35,829 patients, Colon CA – 109,953 patients • Tumor Stratification • Extent of disease:T4N0 stratified by • ‘Tumor penetrates the surface of visceral peritoneum’ (T4a) vs. • ‘Tumor invades or is adherent to adjacent organs or structures’ (T4b) • Number of positive nodes(+ LN) • N1a (1 LN+) vs. N1b (2-3 LN+) • N2a (4-6 LN+) vs. N2b (≥7 LN+)

  9. Colorectal CA – TN Categorization, SEER Analysis Methods – Survival Analysis Observed 5-year survival(~ overall survival, OS) obtained for each TN category for both rectal and colon cancer patients Relative 5-year survival(survival corrected by age-related morbidity) obtained for each TN category

  10. Colorectal CA – TN Categorization, SEER AnalysisSurvival Results – Rectal Cancer

  11. Colorectal CA – TN Categorization, SEER AnalysisSurvival Results – Colon Cancer

  12. Colon CA – TN Categorization, SEER AnalysisSurvival Results by TN Category, # LN+, # LN Examined

  13. Colon CA – TN Categorization, SEER AnalysisSurvival Results by TN Category, # LN+, # LN Examined

  14. Rectal CA – TN Categorization, SEER AnalysisSurvival Results by TN Category, # LN+, # LN Examined

  15. Rectal CA – TN Categorization, SEER AnalysisSurvival Results by TN Category, # LN+, # LN Examined

  16. Rectal CA – TN Categorization, SEER AnalysisSurvival by Expanded TN Category, TNM Stg I-IIIA

  17. Rectal CA – TN Categorization, SEER AnalysisSurvival by Expanded TN Category, TNM Stg IIIB-IIIC

  18. Colon CA – TN Categorization, SEER AnalysisSurvival by Expanded TN Category, TNM Stg I-IIIA

  19. Colon CA – TN Categorization, SEER AnalysisSurvival by Expanded TN Category, TNM Stg IIIB-IIIC

  20. Colorectal CA – TN Categorization, SEER AnalysisSurvival by Expanded TN Category, Rectum vs Colon

  21. Rectal CA – Survival by TN Category, Pooled/SEER AnalysesProposed Changes – AJCC Staging, 6thvs. 7th Edition

  22. Colon CA – Survival by TN Category, SEER AnalysesProposed Changes – AJCC Staging, 6thvs. 7th Edition

  23. Colorectal CA – Survival by TN Category, SEER AnalysesProposed Changes – AJCC Staging, 7th Edition

  24. Colorectal CA – TN Categorization, SEER AnalysisSummary of 5-yr Observed Survival by TN Category • T4a lesions have better prognosis than T4b • Rectal 5-yr Obs Surv: N0, 55.7 vs. 44.7% ; N1, 48.2 vs. 24.3% • Colon 5-yr Obs Surv: N0, 60.6 vs. 45.7% ; N1, 47.0 vs. 27.9% • T1-2N2 lesions have better prognosis than T3-4N2 • Rectal 5-yr Obs Surv: 56.1% vs. 37.5% (T3N2) & 26.4% (T4N2) • Colon 5-yr Obs Surv: 61.5% vs. 38.1% (T3N2) & 21.7% (T4N2) • T4bN1 cancers have prognosis more akin to T4N2 than T4aN1 • Rectal 5-yr Obs Surv: 24.3 vs. 26.4 (T4N2) vs. 48.2% (T4aN1) • Colon 5-yr Obs Surv: 27.9 vs. 21.7 (T4N2) vs. 47.0% (T4aN1) • Prognosis by nodal status: Related to both number of LN+ andnumber of LN examined

  25. Colorectal CA – TN Categorization, SEER AnalysisConclusions • SEER population-based analyses validates Rectal Pooled Analysis • Supports shift of T1-2N2 lesions from IIIC to IIIA/IIIB • Supports shift of T4bN1 from IIIB to IIIC • SEER outcomes support sub-staging of T4, N1 and N2 • T4a has better prognosis than T4b for N0, N1, N2 categories • N1a (1 LN+) has better prognosis than N1b (2-3 LN+) • N2a (4-6 LN+) has better prognosis than N2b (> 7 LN+) • SEER outcomes support revised substaging of Stg II & III • Subdivide current IIB into IIB(T4aN0) or IIC(T4bN0) • Shift more favorable TN2 categories to earlier stages • IIIA – T1N2a • IIIB – T1N2b, T2N2a-b, T3N2a, T4aN2a • Survival Outcomes by TN category • More similar for rectal and colon cancer than expected • Suggest a complex biological interaction between depth of invasion and nodal status

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