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. 2024 Oct 10;10(12):1627-1635.
doi: 10.1001/jamaoncol.2024.4354. Online ahead of print.

Ninth Version of the AJCC and UICC Nasopharyngeal Cancer TNM Staging Classification

Jian-Ji Pan  1   2   3 , Hai-Qiang Mai  4 , Wai Tong Ng  5 , Chao-Su Hu  6 , Jin-Gao Li  7 , Xiao-Zhong Chen  8 , James C H Chow  9 , Edwin Wong  10 , Victor Lee  5   11 , Ling-Yu Ma  5 , Qiao-Juan Guo  1 , Qin Liu  11 , Li-Zhi Liu  4 , Ting-Ting Xu  6 , Xiao-Chang Gong  7 , Meng-Yun Qiang  8 , Kwok-Hung Au  9 , Tsz-Chim Liu  10 , Chi Leung Chiang  5   11 , You-Ping Xiao  1 , Shao-Jun Lin  1 , Yun-Bin Chen  1 , Shan-Shan Guo  4 , Charlene H L Wong  11 , Lin-Quan Tang  4 , Zhi-Yuan Xu  5 , Yi-Zhen Jia  5 , Wen-Sa Peng  6 , Li-Ping Hu  7 , Tian-Zhu Lu  7 , Feng Jiang  8 , Cai-Neng Cao  8 , Wei Xu  12 , Jun Ma  3   4 , Pierre Blanchard  3   13   14 , Michelle Williams  3 , Christine M Glastonbury  3 , Ann D King  3   15 , Snehal G Patel  16   17 , Raja R Seethala  16   18 , A Dimitrios Colevas  3   19 , Dai-Ming Fan  20 , Melvin L K Chua  3   13   21 , Shao Hui Huang  12   13   16 , Brian O'Sullivan  12   13   16 , William Lydiatt  16   22 , Anne W M Lee  3   5   13
Affiliations

Ninth Version of the AJCC and UICC Nasopharyngeal Cancer TNM Staging Classification

Jian-Ji Pan et al. JAMA Oncol. .

Erratum in

  • Error in Figure 2.
    [No authors listed] [No authors listed] JAMA Oncol. 2024 Dec 1;10(12):1736. doi: 10.1001/jamaoncol.2024.6231. JAMA Oncol. 2024. PMID: 39699607 Free PMC article. No abstract available.

Abstract

Importance: Accurate staging is a fundamental step in treating patients with nasopharyngeal carcinoma (NPC) worldwide; this is crucial not only for prognostication, but also for guiding treatment decisions. The American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) tumor-node-metastasis (TNM) system is the global language for clinicians, researchers, and cancer registries. Continual improvement that aligns with contemporary pattern of care is essential.

Objective: To improve the prognostic accuracy and clinical applicability of the eighth edition (TNM-8) for NPC.

Design, setting, and participants: This multicenter study analyzed patients with NPC with detailed tumor features during January 2014 and December 2015 and was reviewed by experienced radiologists. The data analysis was completed in December 2023. The findings were further confirmed with internal and external validation. Statistical analyses and clinical considerations were reviewed by the AJCC/UICC multidisciplinary head and neck panels and attained consensus. The recommendations were evaluated by the AJCC Evidence-Based Medicine Committee before final endorsement as the ninth version (TNM-9).

Main outcomes and measures: The primary end point was overall survival. Adjusted hazard ratios of different subgroups were then assessed for confirmation of optimal stage grouping.

Results: Of the 4914 patients analyzed, 1264 (25.7%) were female and 3650 (74.3%) were male; the median (SD) age was 48.1 (12.0) years. Advanced radiological extranodal extension (with involvement of adjacent muscles, skin, and/or neurovascular bundles) was identified as an independent adverse factor for all end points: this was added as a criterion for N3. Patients with nonmetastatic disease were regrouped into stages I to III instead of TNM-8 stages I to IVA. Significant hazard discrimination was achieved by grouping T1-2N0-1 as stage I, T3/N2 as stage II, and T4/N3 as stage III. Although the T1-2N0-1 subgroups had comparable 5-year overall survival, subdivisions into IA (T1-T2N0) and IB (T1-T2N1) were recommended due to the distinction in adjusted hazard ratios following adjustment for chemotherapy use. Metastatic disease was exclusively classified as stage IV, and prognostication was further refined by subdivision into IVA (M1a, ≤3 lesions) and IVB (M1b, >3 lesions). TNM-9 demonstrated superiority compared with TNM-8 in major statistical aspects.

Conclusion and relevance: The results of this diagnostic study suggest that the ninth version of TNM staging for NPC, based on robust analyses and a comprehensive review by the AJCC/UICC staging committees, provides an improved staging system for global application and a framework for future incorporation of nonanatomical factors. This will be launched for global application in January 2025.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Williams reported grants from Bayer outside the submitted work. Dr Patel reported a patent for US20190046665A1 licensed to Summit Biomedical LLC, a patent for US20190090750A1 issued, a patent for US20210121569A1 issued, a patent for US20150182118A1 issued, and a patent for US-10940216-B2 issued. Dr Lydiatt reported being the chair of the head and neck core group for the American Joint Committee on Cancer. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Tumor-Node-Metastasis (TNM) Grouping Pattern
Corresponding distribution of stages by TNM eighth edition and TNM ninth version for the whole series.
Figure 2.
Figure 2.. Prognostication on Overall Survival Stage of Tumor-Node-Metastasis (TNM) Eighth Edition and TNM Ninth Version for the Whole Series
NA indicates not applicable.
See this image and copyright information in PMC

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