Diagnostic & Stagging

SARCOMA
Adly S561908001
Based on review of patient data in case conferences
over time, it hypothesized that clinically relevant
data are omitted in routine soft tissue sarcoma
staging to criteria of the AJCC 6th (2002) and 7
(2010) staging systems and examined their clinical
outcomes.
Relapse-free survival decreases with increasing
primary tumor size in four categories, versus two
categories used in AJCC 6 and 7 staging. Disease-
specific survival decreases over three categories.
Conversely, omission of tumor depth as a prognostic
factor in version 7 appears supported, since tumor
depth is not an independent risk factor for disease-
specific survival by multivariate analysis.
Patients with nodal disease and no other metastases
fare better than patients with other metastases, but
have inferior outcomes compared to patients with
large high-grade tumors without nodal metastasis.
Multivariate analysis identified size, site, grade,
age, nodal metastatic disease and other metastatic
disease as independent risk factors for disease-
specific survival.
The 8th edition AJCC (2018) staging for soft tissue
sarcomas of the trunk/extremities divides T-stage
into 4 categories and upstages nodal disease to
stage IV. We used the NCDB to evaluate the
prognostic power of the new system. Including T3
(10cm>x>15cm) and T4 (>15cm) categories resulted
in an increased number of patients classified as
stage III.
Improved patient risk assessment may be achieved
by staging using a larger number of size categories.
Staging system refinements come at the cost of a
larger number of staging categories. Histology or
site-specific staging systems may provide more
accurate means to assess clinical outcomes.
The AJCC 8th edition uses T stage to more
accurately stratify overall survival in patients with
large, high-grade tumors (T3/4) as compared to
those with T2 tumors, which facilitates risk
assessment. The distinction between T3 and T4 may
not be clinically significant. Patients with
metastatic nodal disease have a survival outcome
intermediate to those with stage III and stage IV
disease.
AJCC 6
Sarcoma
Stagging
System (2002)
AJCC 7
Sarcoma
Stagging
System (2010)
Difference between AJCC 7th Edition (2010) and
AJCC 8th Edition (2018) on Soft Tissue Sarcoma
AJCC 7th Edition
Site groups for soft tissue sarcoma include soft
tissue sarcoma of head and neck, soft tissue
sarcoma of extremity and superficial trunk, soft
tissue sarcoma of gastrointestinal, soft tissue
sarcoma of genitourinary, soft tissue sarcoma of
visceral retroperitoneal, soft tissue sarcoma of
gynecologic, soft tissue sarcoma of breast, lung,
pleura, mediastinum, other
Rules of classification consist of Clinical Staging,
Pathologic Staging, Definition of T, Depth, Nodal
Disease, Grade, FNCLCC Grading, Restaging of
Recurrent Tumors
AJCC 8th Edition
Site groups for soft tissue sarcoma include soft
tissue sarcoma of head and neck, soft tissue
sarcoma of trunk and extremities, soft tissue
sarcoma of abdomen and thoracic visceral organ,
soft tissue sarcoma of unusual histologies and
sites, soft tissue sarcoma of retroperitoneum with
more detail informations each site group
Times of Classification include cTNM or TNM
(Clinical Classification), pTNM (Pathological
Classification), ycTNM (Posttheraphy Clinical
Classification), ypTNM (Posttheraphy Pathological
Classification), rTNM (Recurrence or Retreatment
Classification), aTNM (Autopsy Classification)
Difference between AJCC 7th Edition and AJCC 8th Edition on Soft
Tissue Sarcoma
AJCC 7th Edition AJCC 8th Edition
Prognostic Features include Neurovascular and Prognostic stage group depend this is a new
Bone invasion, Molecular Markers, Validation classification that needs data collection before
defining a stage group for soft tissue sarcoma,
always refers to specific chapter for rules on
clinical and pathological classification of this
disease
Definition of TNM general for all soft tissue Definition of TNM based on each site group of soft
sarcoma tissue sarcoma (next slide)
Difference between AJCC 7th Edition and
AJCC 8th Edition on Soft Tissue Sarcoma

AJCC 7th Edition AJCC 8th Edition

Prognostic Stage Groups depend on each site group
of soft tissue sarcoma refers to specific chapter for
rules on clinical and pathological classification of
the disease (next slides)
Difference between AJCC 7th Edition and AJCC 8th Edition on
Soft Tissue Sarcoma
AJCC 7th Edition AJCC 8th Edition
 Difference between AJCC 7th Edition and AJCC 8th
Edition on Soft Tissue Sarcoma
AJCC 7th Edition AJCC 8th Edition
Histopathologic Type There is no additional information of histopatologic
Tumors included in the soft tissue category are type
listed below as per the 2002 World Health
Organization classifi cation of tumors:
-Adipocytic Tumors
-Fibroblastic/Myofi broblastic Tumors
-So-called Fibrohistiocytic Tumors
-Smooth Muscle Tumors
-Skeletal Muscle Tumors
-Vascular Tumors
-Tumors of Peripheral Nerves Malignant
peripheral nerve sheath tumor
-Chondro-osseous Tumors
-Tumors of Uncertain Differentiation
There is no additional information of registry More information of registry data collection
data collection variables variables depend on each site of group soft tissue
sarcoma (next slides)
 Difference between AJCC 7th Edition and AJCC
8th Edition on Soft Tissue Sarcoma
AJCC 7th Edition AJCC 8th Edition
There is no additional information of More information of lymphovascular invasion (LVI)
lymphovascular invasion (LVI)
AJCC 8 Sarcoma
Stagging System
Soft Tissue Sarcoma of
The Head and Neck

AJCC 7 Sarcoma Stagging System

AJCC 8 Sarcoma
Stagging System
Soft Tissue Sarcoma of
The Head and Neck

AJCC 7 Sarcoma Stagging System

 AJCC 8 Sarcoma Stagging System
Soft Tissue Sarcoma of The Head and Neck
AJCC 8 Sarcoma
Stagging System
Soft Tissue Sarcoma of
the Trunk and Extremities

AJCC 7 Sarcoma Stagging System

AJCC 8 Sarcoma
Stagging System
Soft Tissue Sarcoma
of the Trunk and
Extremities

AJCC 7 Sarcoma Stagging System

 AJCC 8 Sarcoma Stagging System
Soft Tissue Sarcoma of the Trunk and Extremities
AJCC 8 Sarcoma
Stagging System
Soft Tissue Sarcoma of the
Abdomen and Thoracic
Visceral Organ

AJCC 7 Sarcoma Stagging System

AJCC 8 Sarcoma
Stagging System
Soft Tissue Sarcoma of
the Abdomen and
Thoracic Visceral Organ

AJCC 7 Sarcoma Stagging System

 AJCC 8 Sarcoma Stagging System
Soft Tissue Sarcoma of the Abdomen and Thoracic Visceral
Organ
 AJCC 8 Sarcoma
Stagging System
Soft Tissue Sarcoma of
the Retroperitoneum

AJCC 7 Sarcoma Stagging System

AJCC 8 Sarcoma
Stagging System
Soft Tissue Sarcoma of
the Retroperitoneum

AJCC 7 Sarcoma Stagging System

 AJCC 8 Sarcoma Stagging System
Soft Tissue Sarcoma of the Retroperitoneum
 AJCC 8 Sarcoma
Stagging System
Soft Tissue Sarcoma-
Unsual Histology and Sites

AJCC 7 Sarcoma Stagging System

 AJCC 8 Sarcoma Stagging System
Soft Tissue Sarcoma- Unsual Histology and Sites
WHO Classification of Soft Tissue Tumor:
Histologic Grading French System (FNCLCC)

French Grading System A 3-Grade System with 3 Parameters

 Differentiation (1,2,3)
 Mitotic Index (1,2,3)
 Necrosis (0,1,2)

 Total
Grade 1 : 2-3
Grade 2 : 4-5
Grade 3 : 6-7-8
French Grading System Differentiation
 Histologic type/subtype -+ differentiation
Scores
1: Sarcoma closely resembling normal adult tissue
2: Sarcoma for which histologic typing is certain
3: Embryonal and poorly differentiated sarcoma,synovial sarcoma, PNET,
osteosarcoma, pleomorphic rhabdomiosarcoma, pleimorphic liposarcoma,
round cell liposarcoma
French Grading System Mitotic Index
 in 10 successive HPF (.1734 mm2), in the most mitotic area
Scores
1: 0 to 9/10 HPF
2: 10 to 19/10 HPF
3: more than 19/10 HPF

French Grading System Rules for Counting Mitoses

 early and adequate fixation of tumor
 good macroscopic sampling
 sections of good quality
 adequate sampling at microscopic levels
 take your time
French Grading System Necrosis
 Extension of tumor necrosis at histologic,macroscopic, radiologic levels
 Scores
0: no necrosis
1: <50% of tumor necrosis
2: >50% of tumor necrosis