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

doi:10.1016/j.jaad.2010.08.033

Journal of the American Academy of Dermatology

Volume 64, Issue 6, June 2011, Pages 1051-1059

https://doi.org/10.1016/j.jaad.2010.08.033 Get rights and content

Background

The incidence of cutaneous squamous cell carcinoma (cSCC) is increasing. Although most patients 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.

Section snippets

Methods

In 2006, the AJCC executive committee established the NMSC staging committee under the direction of Dr Arthur Sober. The committee was charged with responsibility of establishing new staging systems for MCC and cSCC separate from the existing NMSC staging system because of their metastatic potential. The MCC staging system is described and the NMSC chapter will be discontinued from the AJCC classification. There were two main objectives for the new cSCC staging system that is included in the

Results

The 6th edition¹⁰ (Table I) relied on the TNM staging system, classifying patients into primary tumor (T), regional lymph nodes (N), and distant metastasis (M). Although histopathologic grade (G) was recognized as significant and included in the characterization, this feature was not included in final stage grouping because the importance of grade was not established for all types of NMSC. In the 7th edition,⁹ the overall TNM staging concept is maintained but the G designation is eliminated

Discussion

cSCC poses a significant health concern because of its metastatic potential. cSCC is thought to claim approximately 2500 lives per year in the United States, almost a third the number of Americans who die from melanoma each year.³ Although prognosis and survival-based outcomes have been studied for over 25 years for melanoma, comparatively little is known in terms of the prognostic variables affecting cSCC survival. The incidence of aggressive or advanced cSCC may be increasing for several

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Perineural invasion is a poor prognostic factor for sinonasal squamous cell carcinoma
2024, Oral Oncology
In this study, our primary objective is to elucidate the correlation between sinonasal squamous cell carcinoma (SCC) and perineural invasion (PNI), a topic that has received limited attention in prior literature. Furthermore, we have undertaken an examination of various other clinicopathological factors.
We retrospectively reviewed the medical records of patients aged ≥ 20 years with newly diagnosed sinonasal cancer and received treatment and care at a tertiary medical center. We excluded patients who did not have an SCC diagnosis, those who underwent palliative surgery, and individuals with insufficient follow-up data at the study endpoint. Ultimately, a total of 49 eligible participants were included in our further analysis.
PNI and advanced T staging were associated with increased risk of local recurrence (LR). Furthermore, PNI was significantly associated with an adverse prognosis in terms of LR-free survival. Participants with PNI had significantly worse overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS). Patients with LR had significantly worse OS, DFS, and DSS.
PNI is associated with an elevated risk of LR and reduced OS, DFS, and DSS in patients with sinonasal SCC. These findings can facilitate the formulation of more targeted and effective treatment strategies for sinonasal SCC in clinical practice.
Defining and quantifying histopathologic risk factors for regional and distant metastases in a large cohort of vulvar squamous cell carcinomas
2023, Journal of the American Academy of Dermatology
Vulvar squamous cell carcinoma (vSCC) is a rare tumor with a good prognosis when treated at a localized stage. However, once regional/distant metastasis occurs, vSCC can be rapidly fatal. Thus, it is important to identify tumor prognostic features so that high-risk cases can be prioritized for further diagnostic workup and treatment.
To estimate the risk of regional/distant metastasis at presentation and sentinel lymph node status for vSCC based on histopathologic characteristics.
A retrospective cohort study of 15,188 adult vSCC cases from the National Cancer Database diagnosed from 2012 to 2019.
We provide specific estimates of the risk of clinically positive nodes and metastatic disease at presentation and sentinel lymph node positivity according to tumor size, moderate/poor tumor differentiation, and lymph-vascular invasion. These histopathologic factors were all significantly associated with the tested clinical outcomes in a multivariable analysis. Moderate (hazard ratio, 1.190; P < .001) and poor differentiation (hazard ratio, 1.204; P < .001) and lymph-vascular invasion (hazard ratio, 1.465; P < .001) were also associated with significantly poorer overall survival.
Data on disease-specific survival not available in the data set.
We demonstrate the association of the histopathologic characteristics of vSCC with clinically important outcomes. These data may provide individualized information when discussing diagnostic/treatment recommendations, particularly regarding sentinel lymph node biopsy. These data may also guide future staging and risk stratification efforts for vSCC.
Non-melanoma skin cancers: physio-pathology and role of lipid delivery systems in new chemotherapeutic treatments
2022, Neoplasia (United States)
Non-melanoma carcinoma has high incidence rates and has two most common subtypes: basal cell carcinoma and squamous cell carcinoma. This type of carcinoma is usually not fatal; however, it can destroy sensory organs such as the nose, ears, and lips. The treatment of these injuries using non-invasive methods is thus strongly recommended. Some treatments for non-melanoma carcinoma are already well defined, such as surgery, cryosurgery, curettage and electrode section, and radiotherapy; however, these conventional treatments cause inflammation and scarring. In the non-surgical treatment of non-melanoma carcinoma, the topical administration of chemotherapeutic drugs contributes for an effective treatment with reduced side effects. However, the penetration of anticancer drugs in the deeper layers of the skin is required. Lipid delivery systems (liposomes, solid lipid nanoparticles, nanostructured lipid carriers) have been developed to overcome epidermal barrier of the skin and to allow the drugs to reach tumor cells. These lipid nanoparticles contribute to control the release profile of the loaded chemotherapeutic drugs, maintaining their stability and increasing death of tumor cells. In this review, the characteristics of non-melanoma carcinoma will be discussed, describing the main existing treatments, together with the contribution of lipid delivery systems as an innovative approach to increase the effectiveness of topical therapies for non-melanoma carcinomas.
Factors predicting outcomes of patients with high-risk squamous cell carcinoma treated with Mohs micrographic surgery
2021, Journal of the American Academy of Dermatology
There is limited literature on the long-term outcomes and prognostic factors of high-risk cutaneous squamous cell carcinomas (hrSCC) treated with Mohs micrographic surgery (MMS).
To determine the rates of local recurrence, metastatic disease, and disease-specific death in hrSCCs treated with MMS and patient or tumor factors associated with poor outcomes.
Single-institution, retrospective cohort analysis of hrSCC treated with MMS alone and MMS with adjuvant therapy.
A total of 882 cases of hrSCC treated with MMS were identified, of which 842 were treated with MMS alone, with a median follow-up time of 2.4 years. The rate of local recurrence was 2.5%, of metastatic disease was 1.9%, and of disease-specific death was 0.57%. Perineural invasion, poor differentiation, and immunosuppression were significantly associated with poor outcomes. In propensity score–matched case patients treated with adjuvant therapy and control patients treated with Mohs alone, there was no significant difference in progression-free survival, but matching was imperfect.
Single-institution, retrospective review.
MMS remains an effective treatment for hrSCC. Current SCC staging systems may be limited by inconsistent inclusion of poor differentiation. Immunosuppression, especially transplant, should be considered a high-risk clinical feature. Further study is needed on the effect of adjuvant treatment.
Integrating depth of invasion in T classification improves the prognostic performance of the American Joint Committee on Cancer primary tumor staging system for cutaneous squamous cell carcinoma of the head and neck
2021, European Journal of Cancer
The last revision of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual included a specific system for cutaneous squamous cell carcinoma (CSCC) of the head and neck. Here, we assessed the prognostic performance of six candidate modified T-classification models in head and neck CSCC patients.
Analysis of 916 patients with head and neck CSCC given treatment with curative intent at The University of Texas MD Anderson Cancer Center between 1995 and 2019 was performed. The main outcome was disease-specific survival (DSS), and the impact of depth of invasion (DOI) was analyzed using multivariable regression models. Candidate models were developed using the optimal DOI cut points for each AJCC T classification based on goodness of fit of the model and the simplicity of the model. Staging systems were compared using Harrell's concordance index.
Median age was 70 years (range, 19–97years) and median follow-up time of 22 months (range, 1–250months). The median DOI was 6.0 mm (range, 0.1–70.0 mm). The five-year DSS rate was 80.7% (95%CI, 77.4–83.7%). We found significant association between DOI (hazard ratio, 1.21 [95%CI: 1.01–1.43]) and DSS on multivariable analysis. Based on a low Akaike information criterion score, improvement in the concordance index, and Kaplan–Meier curves, model 6 surpassed the AJCC staging system.
Incorporation of DOI in the current AJCC staging system improves discrimination of T classifications in head and neck CSCC patients.
The current staging system for head and neck cutaneous squamous cell carcinoma demonstrates wide prognostic variability and provides suboptimal risk stratification. Incorporation of depth of invasion in the T-classification system improves risk prediction and patient counseling.
We propose improved head and neck cutaneous squamous cell carcinoma T staging that will include depth of invasion and should be considered in future versions of the American Joint Committee on Cancer after external validation.
Comparison of the eighth edition of the TNM and Brigham Women's Hospital staging systems for cutaneous squamous cell carcinoma of the head and neck: a six-year review
2020, British Journal of Oral and Maxillofacial Surgery
This study was undertaken with the aim to compare the T stages in a series of cutaneous squamous cell carcinoma (cSCC) patients using both the eighth edition of the Union for International Cancer Control (UICC) TNM Classification of Malignant Tumours (TNM8) and Brigham and Women’s Hospital (BWH) staging systems. This would allow comparison of the two to determine suitability with regards to T stage and the effect on local recurrence and nodal disease. This was a six-year retrospective cohort study of patients with primary invasive cSCC of the head and neck who were diagnosed and treated at Western Sussex Hospitals Trust in the United Kingdom between 2007 and 2012. The TNM8 and BWH staging systems were applied to these primary cSCCs. A total of 695 invasive cSCCs treated in 604 patients over six years were identified. Most patients were male (76%), with a mean (range) age of 81 (50-103) years. The most common location for local recurrence was the scalp (n = 26, 58%). Regional metastasis occurred most commonly in the parotid gland (n = 20, 63%). All tumours were classified using both staging systems. Specifically, 432 tumours remained in the same T stage (61%), and 192 were downstaged (27%) and 71 upstaged using the BWH (10%). The median (SD) follow-up time was 23 (28) months (range 1-123). The BWH alternative staging system overlapped with the TNM8 in high-stage and low-stage tumour assignment. The highest percentage of local recurrence and regional metastasis occurred in T2b tumours.

View all citing articles on Scopus

: Dr Liégeois is supported with a Career Development Award from the Dermatology Foundation.

: Disclosure: Dr Liégeois is president and founder of Meridian Skin Care Limited. The rest of the authors have no conflict of interest to declare.

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

Background

Objective

Methods

Results

Limitations

Conclusions

Section snippets

Methods

Results

Discussion

J Am Acad Dermatol

J Am Acad Dermatol

Oral Oncol

Pathol Res Pract

J Plast Reconstr Aesthet Surg

Lancet Oncol

Am J Surg

J Am Acad Dermatol

J Am Acad Dermatol

Lancet

Surg Clin North Am

J Am Acad Dermatol

The epidemiology of skin cancer

Br J Dermatol

UV dose determines key characteristics of nonmelanoma skin cancer

Cancer Epidemiol Biomarkers Prev

Cancer statistics, 2007

CA Cancer J Clin

Cutaneous squamous-cell carcinoma

N Engl J Med

Evaluation of the American Joint Committee on Cancer staging system for cutaneous squamous cell carcinoma and proposal of a new staging system

Dermatol Surg

Problems in the current TNM staging of nonmelanoma skin cancer of the head and neck

Head Neck

The need for a better prognostic staging system in patients with metastatic cutaneous squamous cell carcinoma of the head and neck

Curr Opin Otolaryngol Head Neck Surg

Chapter 29: Cutaneous squamous cell carcinoma and other cutaneous carcinomas

Chapter 23: Carcinoma of the skin (excluding eyelid, vulva, and penis)

Incidence rates of skin cancer in Townsville, Australia

Int J Cancer

Squamous cell carcinoma: a population-based incidence study in Rochester, Minn

Arch Dermatol

Metastases from squamous cell carcinoma of the skin in southern Australia

Dermatology

Desmoplastic squamous cell carcinoma of skin and vermilion surface: a highly malignant subtype of skin cancer

Cancer

Prognostic factors for metastasis in squamous cell carcinoma of the skin

Dermatol Surg

High-risk cutaneous squamous cell carcinoma of the head and neck: results from 266 treated patients with metastatic lymph node disease

Cancer

Cutaneous head and neck squamous cell carcinoma metastatic to parotid and cervical lymph nodes

Head Neck

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